OTHERS_CITABLE Background: Laparoscopic sleeve gastrectomy (LSG) has become popular both as a definitive and a staged procedure for morbid obesity. Gastroesophageal reflux disease (GERD) is a common co-morbid disease in bariatric patients. Objectives: The aim of this study was to evaluate the efficacy of LSG and hiatal hernia repair (HHR) to treat obesity, complicated by hiatus hernia (HH). Patients and Methods: The participants in the study were twenty patients, 14 women and 6 men, with a mean body mass index of 43.4 ± 1.9 kg/m2 and mean age of 47 years. All the subjects were eligible for LSG and eight were found to have esophagitis at preoperative endoscopy. Patients with Barrett’s esophagus were excluded. GERD symptom questionnaire, 24-hour esophageal pH-metry, and manometry were employed as Preand post-procedure assessments. The mean follow-up period was eight months. Clinical outcomes were also evaluated in terms of GERD symptoms improvement or resolution, interruption of antireflux medication, and X-ray evidence of HH recurrence. Results: Symptomatic HH was diagnosed preoperatively in 18 patients. In the other two patients, HH was asymptomatic and was diagnosed intra-operatively. Prosthetic reinforcement of crural closure was performed in two symptomatic cases with an HH > 5 cm. Mortality was nil and no complications occurred. After a mean follow-up of seven months, GERD symptoms resolution occurred in nine patients, while the other patients reported an improvement of reflux. Body mass index had fallen from 43.4 to 36.2 kg/m2 . Conclusions: A laparoscopic hiatal repair with or without commercially available onlay reinforcement biologic mesh and a sleeve gastrectomy performed at the same time, was successful in controlling the reflux symptoms and reducing body weight. http://annbsurg.iums.ac.ir/article-1-255-en.pdf 2012-11-15 0 0 10.5812/jmiss.5171 Laparoscopy Hernia Hiatal Gastrectomy Ayman M. Soliman 1 1 Department of General Surgery, Ain Shams University Hospital, Cairo, Egypt 2 Department of General Surgery, Dr. Suliman Fakeeh Hospital, Jeddah, Saudi Arabia 3 Department of General Surgery, Al Mouwasat Hospital, Dammam, Saudi Arabia AUTHOR Hesham Maged 2 1 Department of General Surgery, Ain Shams University Hospital, Cairo, Egypt AUTHOR Ahmed M. Awad 3 1 Department of General Surgery, Ain Shams University Hospital, Cairo, Egypt AUTHOR Osama El-Shiekh 4 1 Department of General Surgery, Ain Shams University Hospital, Cairo, Egypt AUTHOR

OTHERS_CITABLE Background: Deep Venous Thrombosis (DVT) is a major risk of morbidity and mortality in morbid obese patients underwent bariatric surgery. There are some controversies in different kind of prophylactic strategies for DVT in laparoscopic bariatric surgeries. Unfractionated heparin (UFH) is an available and reversible anticoagulant used for DVT prophylaxis. Objectives: This study aimed to compare clinical results of two different dosage regimes of unfractionated heparin for short term prophylaxis of DVT after bariatric surgery. Patients and Methods: 139 patients with morbid obesity who underwent laparoscopic bariatric surgery (laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding) were evaluated in two groups: group A received 5000 IU unfractionated heparin q12h and group B received the same dose but q8h ( preliminary dose received before induction of anesthesia followed by 2 or 3 times daily). All patients were evaluated by physical examination and Doppler ultra sound for DVT before and 10 days after surgery. Results: There was no statistically significant difference between two groups in venous thrombosis. No thrombotic events were observed before and after operations. There were no heparin induced thrombocytopenia and no meaningful difference between two groups in postoperative bleeding. Conclusions: This study showed that in combination with non-pharmacologic methods for prevention of thromboembolic events, both regimes of UFH prophylaxis had similar clinical effects. http://annbsurg.iums.ac.ir/article-1-254-en.pdf 2012-11-15 0 0 10.5812/jmiss.4991 Heparin Obesity Bariatric Surgery Venous Thrombosis Farzane Ebrahimifard 1 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran , IR Iran 2 Surgical Department, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran AUTHOR Abdolreza Pazouki 2 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran , IR Iran AUTHOR , Masoud Solaymani Dodaran 3 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran , IR Iran AUTHOR Mohammad Vaziri 4 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran , IR Iran AUTHOR

OTHERS_CITABLE http://annbsurg.iums.ac.ir/article-1-253-en.pdf 2012-11-15 0 0 10.5812/jmiss.4688 Gastrectomy Obesity Hormones Thiow Kong Ti 1 1 National University Hospital, Singapore AUTHOR

CASE_STUDY In this study we present successful management of an inflamed branchial cyst by strip- ping the inner lining thus providing a safe and definitive treatment. We believe that this is the first report of this technique in the literature. http://annbsurg.iums.ac.ir/article-1-252-en.pdf 2012-11-15 0 0 10.5812/jmiss.4991 Branchioma Cystectomy Inflammation Costa Healy 1 Department of Paediatric Surgery, Royal Alexandra Children’s Hospital, Brighton, UK AUTHOR Anies Mahomed 2 Department of Paediatric Surgery, Royal Alexandra Children’s Hospital, Brighton, UK AUTHOR

OTHERS_CITABLE http://annbsurg.iums.ac.ir/article-1-250-en.pdf 2012-11-15 0 0 10.5812/jmiss.3677 Laparoscopy Proctocolectomy Restorative Adenomatous Polyposis Coli Iliostomy Fabio Guilherme Campos 1 1 Gastroenterology Department, Colorectal Unit, Hospital das Clinicas, Medical School, University of Sao Paulo, Sao Paulo, Brazil AUTHOR

OTHERS_CITABLE The incidence of obesity has been increasing steadily, with approximately 10% of the world’s population meeting the criteria (1). The limited success of lifestyle and pharmaceutical interventions has resulted in an increased interest in bariatric surgery, as it is the only proven modality for achieving sustainable weight loss, and impacting survival in the clinically severe obese (BMI ≥ 40 or ≥ 35 with severe co-morbid disease) (2). In general, bariatric surgical intervention involves either a restrictive or mal-absorptive mechanism, to achieve weight loss. The two most renowned and successful procedures are; the Roux-en-Y gastric bypass and the biliopancreatic diversion with duodenal switch, and these use both routes. However, both of these procedures have potentially life threatening post-operative complications, mainly entailing leakage at anastomoses sites, thus making them less than ideal interventions. Gastric banding, sleeve gastrectomy and now recently gastric plication, are other bariatric surgeries that are essentially restrictive procedures, which are becoming more popular (3). Of the restrictive procedures, Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Total Gastric Vertical Plication (LTGVP) are relatively similar. Both involve decreasing the greater curvature of the stomach, and creating a gastric reservoir resembling a vertical tube (3). In general, LSG accomplishes this goal with staple lines and removal of a gastric section, while LTGVP achieves it with suture lines, without the need for a gastric section. The advantages of both procedures consist of; not introducing a foreign object into the body, preserving the stomach’s pylorus, and avoiding dumping syndrome (2). However, there are some advantages enjoyed only by plication. Since LTGVP does not involve the removal of gastric material, it has the ability to be reversible, which could make it a more ideal surgical procedure for some patients (4). Another reported benefit of LTGVP is that it decreases the risk of fistula formation at the gastroesophageal junction. It is important to recognize that these stated surgical advantages of LTGVP rely on the operator’s competency at minimally invasive techniques, in this case to perform manual laparoscopic suturing (4). This article highlights the promise that LTGVP has shown in achieving significant weight loss and reduction of comorbid conditions. Golpaie et al. have produced a well-organized study design that involved a multidisciplinary team. The drawbacks of this study were that; only http://annbsurg.iums.ac.ir/article-1-249-en.pdf 2012-11-15 0 0 10.5812/jmiss.4587 Obesity Bariatric Surgery Weight Loss Noah Switzer 1 1 Center for the Advancement of Minimally Invasive Surgery, Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Canada AUTHOR Kourosh Sarkhosh 2 1 Center for the Advancement of Minimally Invasive Surgery, Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Canada AUTHOR Shahzeer Karmali 3 1 Center for the Advancement of Minimally Invasive Surgery, Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Canada AUTHOR

CASE_STUDY Appendicitis after age 40 is unusual, and appendicitis two days after laparoscopic hysterectomy is very rare and has not been reported to date. We describe a 44-year-old woman who had abdominal pain two days after laparoscopic hysterectomy. The pathology report indicated early appendicitis and the pain disappeared after appendectomy. In our opinion, the cause of appendicitis may have been related to the use of monopolar and bipolar coagulation during laparoscopic hysterectomy, although the coincidence of appendicitis and laparoscopic surgery may be accidental. http://annbsurg.iums.ac.ir/article-1-248-en.pdf 2012-11-15 0 0 10.5812/jmiss.2289 Appendicitis Electrosurgery Hysterectomy Laparoscopy Fariba Almassinokiani 1 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran 2 Department of Gynecology and Obstetrics, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Mohammadali Ghoraian 2 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Hossein Akbari 3 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Alireza Almasi 4 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran3 Department of Radiology, Firoozgar Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Abdolreza Pazouki 5 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Mohammadkazem Shahmoradi 6 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Mahboubeh Saberifard 7 1 Minimally Invasive Surgery Research Center, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR

OTHERS_CITABLE Background: There are several methods for the ligation of structures during minimally invasive operations. The hem-o-lok clip is a nonabsorbable polymer clip with a lock engagement feature. There are few reports about its use in minimally invasive general surgical procedures. Objectives: In this report, we describe our experience with the hem-o-lok clip during basic, minimally invasive, general surgery procedures and the adverse events during application of the hem-o-lok. Patients and Methods: We retrospectively reviewed all laparoscopic appendectomies (LAs), cholecystectomies (LCs), and splenectomies (LSs), performed by 6 general surgeons at a university-affiliated hospital over 4 years. Clip failure was defined as intraoperative or postoperative bleeding due to clip malfunction that necessitated placement of another clip, conversion to an open procedure, or postoperative re-exploration. Leakage from the cystic duct and appendiceal stump was also considered clip failure. A search of the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database using the appropriate keywords was performed on July 7, 2011. This online resource contains reports of adverse events involving medical devices. Results: Over a 4-year period, 856 laparoscopic operations, comprising 770 LC, 55 LS, and 31 LA, were performed. We did not observe any incidence of clip failure. There were 22 reports of hem-o-lok clip failure in the MAUDA database. Eighty-two percent (n = 18) of clip failures were reported during laparoscopic nephrectomy. There was no report of failure after LA. There were 2 reported clip failures after LC (with bile leakage) and 1 after LS (tearing of splenic vessels with intraoperative bleeding). There was also a report of migration of the hem-o-lok clip into the common bile duct, which occurred 4 years after a complicated LC. Conclusions: Hem-o-lok clips that are properly applied during basic laparoscopic procedures are a secure option for the ligation of the structures. Surgeons must be educated regarding the proper application technique. http://annbsurg.iums.ac.ir/article-1-247-en.pdf 2012-11-15 0 0 10.5812/jmiss.1885 Surgical Instruments Laparoscopy Surgical Procedures Minimally Invasive Cholecystectomy Appendectomy Splenectomy Nephrectomy Ali Aminian 1 1 Department of General Surgery, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Zhamak Khorgami 2 1 Department of General Surgery, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR

OTHERS_CITABLE Background: Surgeon’s depend to a large degree on the amount of blood loss and a clear view of the surgical field, when conducting endoscopic procedures in order to achieve satisfactory outcomes. The anesthesiologist’s choice of method for the induction and maintenance of anesthesia plays a major role in achieving this goal. Objectives: This study was performed in order to compare the two most well-known methods in this regard; total intravenous anesthesia (TIVA) and venous inhalational mixed anesthesia (VIMA). Patients and Methods: This study included the endoscopic management of 89 patients with cerebrospinal leakage (CSF leakage) covering a period of nine years (1999-2008) for whom a subarachnoid injection of fluorescein was first administered, and afterwards they were maintained under general anesthesia using two distinct methods; propofolremifentanil versus isoflurane–remifentanil (inhalational or intravenous). During the operation, hemodynamic indices, blood loss, and surgeon’s satisfaction, were assessed and compared between the two groups. Results: Endoscopic management and autografts were successful in repairing anterior skull defects in 90% of cases. Regarding the surgeon’s satisfaction level, and hemodynamic stability no significant difference between the two groups was observed (P > 0.01). Conclusions: Both isoflurane and propofol in combination with remifentanil afford optimal surgical conditions with regard to hemodynamic parameters and the satisfaction of the surgeon with the surgical field. http://annbsurg.iums.ac.ir/article-1-246-en.pdf 2012-11-15 0 0 10.5812/jmiss.1839 Cerebrospinal Fluid Propofol Remifentanil Isoflurane Endoscopy Valliolah Hassani 1 1 Department of Anesthesiology, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Mahzad Alimian 2 1 Department of Anesthesiology, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Mohammad Farhadi 3 1 Department of Anesthesiology, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Behrouz Zaman 4 1 Department of Anesthesiology, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR Masood Mohseni 5 1 Department of Anesthesiology, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, IR Iran AUTHOR

OTHERS_CITABLE http://annbsurg.iums.ac.ir/article-1-102-fa.pdf 2012-11-15 100 110 This brand new Journal finds the greatest part of its “Mission” in the never ending field of promotion of science. Human mind is inquisitive by nature and does not stop trying to find answers to unclear areas, and also by keeping open the lines for discovering new paths for our quality of life. The medical field is rich in this type of work and the surgical one is one of the most active at the moment. It is also a duty of all medical professionals, not only to keep up the updating in knowledge but also to permanently transmit the same knowledge and innovations. A particularity of the Journal of Minimally Invasive Surgical Sciences is to have a widening view for the scope of scientific interests and to be open to the acceptance of papers from other fields of medicine also practicing minimal invasive accesses. This includes any medical speciality technique with this kind of approach, be it cardiology, radiology, nursing or similar ones, either very recent or of more common use and alreadyimplanted; it is important to realise what is being done and to compare and evaluate its results. Minimally invasive Human mind is inquisitive by nature and does not stop trying to find answers to unclear areas, and also by keeping open the lines for discovering new paths for our quality of life. The medical field is rich in this type of work and the surgical one is one of the most active at the moment. It is also a duty of all medical professionals, not only to keep up the updating in knowledge but also to permanently transmit the same knowledge and innovations. A particularity of the Journal of Minimally Invasive Surgical Sciences is to have a widening view for the scope of scientific interests and to be open to the acceptance of papers from other fields of medicine also practicing minimal invasive accesses. This includes any medical speciality technique with this kind of approach, be it cardiology, radiology, nursing or similar ones, either very recent or of more common use and already implanted; it is important to realise what is being done and to compare and evaluate its results. Minimally invasive techniques encompass many specialities and have now became standard or gold choice of treatment for a great number of conditions; this, both in surgical areas and in other non surgical areas like interventional imagiology; being aware of what other specialities do will allow, sometimes, the transposition of techniques and solutions across medical areas. At the same time the field of medical support to surgical patients keeps having new and more satisfactory options to help; in the last issue of JACS (1), a review paper on the use of statins in surgical patients shows surprising results. Statins, being the most commonly medication prescribed to lowering cholesterol, have progressively shown, besides the expected protective effect in the cardiovascular system, to reduce preoperative mortality and to decrease complications in patients submitted to cardiac and vascular surgery Similar benefits have been shown in other surgical settings than those. These effects are related to the properties of statins as anti-inflammatory, antioxidant, immunomodulatory and fibrinolytic agents. Growing evidence is now showing also its benefits in abdominal surgery, this being confirmed by research and clinical studies. More work is required, but a very interesting point is risen, which can have great impact in the life of the many patients using regularly these drugs. This impact can extend to other patients, if the first results are confirmed. Also in other areas – in and out of minimally invasive surgery – scientific research and new options being given keep growing. Recently, an option for better management of controlling the liver remnant, in cases of major liver resections with surgeries in two steps for disseminated lesions, has been introduced in a much unexpected way (2). While performing a surgery in a patient with perihilar cholangiocarcinoma, Hans Schlitt, from Germany, realised that the liver remnant was too small to sustain the necessary liver function during the post-operative period. He decided to do a selective hepatico-jejunostomy to the left side and, in doing so, he divided the liver doing an in-situ split. He also decided to ligate the right portal vein in order to induce hypertrophy of segments II to III. One week after, out of curiosity, he asked for a CT scan; this showed a great growth of the left liver and he decided to remove the diseased right liver. The patient – only one week after tolerated surgery very well, having a stable liver function. This unexpected solution – now proved efficient in quite several patients – addresses an important and difficult issue of liver surgery: post-operative liver failure and efficient liver volume. The amount of hypertrophy induced is exceptional, works in record timing (one week) and is still exceptional after removal of the diseased liver. This technique started by being called “In-situ splitting” and was renamed shortly after “ALPPS” (associating liver partition and portal vein ligation for staged hepatectomy). These two examples show how active science new boundaries are reached everyday in all areas of medicine, and the fact is that, even today, things happen, out of the labs and outside lines of research. Inquisitive minds and attentive professionals are all which is necessary to bring under scrutiny positive facts out of the usual. Minimally invasive surgery and techniques are nowadays used all over the world in many places as routine and as chosen options. Many of us still remember the difficulties felt with the introduction of the technique; not only the true introducers, Muhe, Mouret, Perissat, Dubois and others had serious difficulties in seeing their work accepted by the international surgical community, but also, in many countries, the pioneers had to go through similar situations. The “established” surgical practice was not prepared to face such major change in technical approach and most surgical leaders preferred to follow the route of denial, sarcasm and refusal of acceptance. Laparoscopic techniques were already used regularly by Gynaecologists but this did not bring reasons for easier acceptance. Persistence by the international and national pioneers managed to obtain results and minimally invasive surgery started to have the right place in these communities; 25 years after, it is difficult to have the proper prospective of how things were then but, undeniable is the importance it now has. Laparoscopic surgery brought major and extremely important changes to the way surgery is faced, trained, learned and practiced in our days. Even more than the clinical impact it brought, the implications in the way surgery is viewed by the clinical community, the media and the population in general, has changed the general attitude towards it. Besides, Education and Training have also been tremendously influenced, with a completely new way of looking at the problem. No longer have some procedures to be practiced within the OR, sometimes, unfortunately, at the cost of patients; the paradigm of teaching has changed and education was removed from the OR and from the patients, in a broad sense. The recent introduction of new teaching tools has completed this major change in the paradigm of education. In togetherness with the change in mentality, this has really been “The second French Revolution” as dubbed by some! But, the beginning of laparoscopic surgery was doomed by an increase in iatrogenic lesions of the biliary tract, fruit of the conditions of introduction of the technique in an “explosive” way, in a non controlled spread of the practice and because of the paradigms of the times: see one, do one, teach one! Despite this, the impact and the benefits shown were such that it became soon the “gold standard” in many countries! The point to be made is that the surgical community cannot afford going through a repeat situation and some of the lessons from then must have been learned. The fact that almost everything is possible to be done through minimally invasive surgery shall not be an excuse to have everything being done anywhere by anyone, without peer control. Changes and Innovations in existing techniques, and introduction of novel approaches and of new techniques and technologies must be done under an appreciative eye and under due and properly set research protocols. Times are different and we must show that science goes step by step to prove results and outcomes and to explain the facts. In parallel we have seen the spread of science and the spread of techniques and technologies. Although we must recognise the benefits and improvements brought to clinical practice by many new types of equipment, we cannot ever forget that the progress of medical and surgical fields is done through science and not through technology; the second is a fruit of the first and should be always seen as such. No matter how amazing new technologies can be and impress, as surgeons, and scientists, we cannot let it be the most important issue. http://annbsurg.iums.ac.ir/article-1-102-en.pdf 2012-11-15 100 110 Surgical Procedures Operative Research Diffusion of Innovation Laparoscopy Education Jose M Schiappa 1 Clinic CUF Cascais and Hospital CUF Infante Santo, Lisbon, Portugal AUTHOR