BariatricsColonHerniaForegutSolid OrganEducation

 Bariatrics

In 1998, when open gastric bypass was still the standard, Emory general surgeons began refining and developing laparoscopic bariatric methods. In 2000, Dr. C. Daniel Smith, director of the Endosurgery Unit from 2001-2006, established the Emory Bariatric Center as a multidisciplinary team of healthcare professionals dedicated to treating obesity by tailoring an individualized approach to the patient using nutrition and exercise therapy, lifestyle education, pharmacotherapy, liquid meal replacement and either laparoscopic gastric bypass or lap band surgery. The center has become one of the leading programs of its type in the southeast and is directed by current Endosurgery Unit director Dr. Edward Lin.

The Endosurgery Unit's bariatric specialists are engaged in ongoing research both within the program as well as collaboratively across Emory departments and with such organizations as the Centers for Disease Control and Children’s Healthcare of Atlanta. The unit also offers a mini-fellowship in bariatric surgery as well as workshops in advanced laparoscopic bariatric surgical techniques through the unit's training program.

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 Colon

When unit surgeons began performing laparoscopic colon surgery in 1992, they observed reduced wound infections, earlier functional recovery and greater visualization of anatomic detail than that of traditional methods. Various international, high-profile studies also showed that laparosocopy for colorectal cancer significantly reduced recovery time, while other studies indicated that laparoscopic methods provided a survival advantage for certain cancer stages. In 2004, a National Cancer Institute-sponsored trial reported identical outcomes between laparoscopic and open surgery for cancer, with subsequent studies reporting that the recurrence rate following the laparoscopic approach was as low as that of open methods.

As of 2007, unit surgeons have performed hundreds of laparoscopic colorectal operations. However, the national surgical community has been slow in assimilating the procedure due to its reliance on such advanced laparoscopic skills as suturing, stapling and the ability to operate in more than one quadrant of the abdominal cavity with key-holes and telescopes. To facilitate propagation of the technique, unit surgeons offer workshops in laparoscopic colon surgery through the unit's training program.

Due to their extensive role in perfecting laparoscopic colon surgery, unit surgeons can now apply laparoscopic techniques to treat such benign and malignant conditions of the colon as:

• Bleeding lesions
  
  
• Colon cancer with liver metastasis: In certain cases where removing the liver tumor is the only possibility for curing the most advanced stage of colon cancer, unit surgeons perform simultaneous laparoscopic colon and liver resections.
  
  
• Colon disease in elderly patients with other medical problems involving the heart and lung: While any operation is stressful for this population, laparoscopic methods can reduce wound complications and lead to earlier ambulation and rehabilitation.
  
  
• Diverticulitis
  
  
• Inflammatory bowel disease
  
  
• Large pre-cancer polyps
  
  
• Rectal prolapse
  
  
• Other services: Colostomy formation, colostomy/ileostomy reversal, hemorrhoid stapling and screening and diagnostic colonoscopies.

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 Hernia

The unit established the second course in the nation for laparoscopic ventral hernia repair in 1994. By 1997, a survey conducted by the American College of Surgeons reported that 74% of all hernia repairs had been performed with mesh that year due to a significant improvement in outcomes. The trend continued unabated, and laparoscopic ventral hernia repair is now one of the most performed minimally invasive procedures in the country. With persistent reports on the shortcomings of popular open repairs, laparoscopic inguinal hernia repair is also gaining momentum.

Unit surgeons are involved in some of the largest multi-institutional studies for laparoscopic ventral and inguinal hernia repairs in the world, direct workshops in both methods through the unit's training program, and offer both procedures at the Emory Hernia Institute, a referral/consultation center for difficult hernia cases from throughout the southeastern US.

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 Foregut

The refinement of laparoscopic antireflux surgery has given patients an efficacious alternative to medical therapy that can provide definitive correction of gastroesophageal reflux disease (GERD). With recent population-based studies identifying a relationship between GERD and esophageal malignancy, further emphasizing the importance of durable correction of acid reflux rather than just symptom control with medications, laparoscopic antireflux surgery has become even more of an important option for the treatment of GERD. However, new endoluminal approaches to GERD being developed by unit surgeons are evolving to be a relevant alternative to traditional and even laparoscopic antireflux surgery.

Since the 1992 establishment of the Endosurgery Unit, its foregut program has become a leading gastroesophageal disease treatment center. Unit surgeons have compiled one of the largest foregut procedure and patient outcomes databases in the world; are developing and testing less invasive devices including endoluminal techniques; and regularly perform laparoscopic surgery for GERD, hiatal hernia, achalasia, esophageal tumors, Barrett's esophagus and redo procedures for failed attempts at operative treatment. In May 2004, Dr. Lin performed the first endoscopic plication for GERD to be done in the nation at Emory University Hospital Midtown. The unit is also developing and offering minimally invasive approaches for diagnosing GERD like catheterless/wireless esophageal pH testing, impedence motility and pH testing.

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 Solid Organ

The limitations on attaining any significant and reproducible experience with laparoscopic liver surgery are diminishing due to the development of new technologies in combination with Emory general surgeons' familiarity with modern surgical methods applied to the liver. Even when cirrhosis is a factor, laparoscopic nonanatomical resections and peripheral resections of up to two segments of the liver are now routinely performed at Emory, yielding such encouraging results as decreased length of postoperative hospital stay for most patients. Emory surgeons are also regularly employing laparoscopic techniques to manage liver cysts.

The growing trend of including formal right and left hepatic lobectomies in the laparoscopic armamentarium as well as the intensive focus on developing laparoscopic living-related donation of the liver so that donors can avoid an upper abdominal incision have stimulated further expansion of the unit's laparoscopic liver surgery endeavors. Emory is an ideal site for developing laparoscopic living-related liver donation because it is already a major center for the open method of live partial hepatectomy. Unit surgeon Dr. Juan Sarmiento is working on refining laparoscopic hepatectomy to the degree that it can become a viable alternative to the organ procurement for transplant.

When appropriate, Dr. Sarmiento and other unit surgeons are applying laparoscopy to pancreatic resections. Thus far, laparoscopic distal pancreatectomies have been observed to reduce postoperative pain and shorten hospitalization. An already successful endocrine service has also notably benefited from the addition of laparoscopic enucleation of insulinomas to its practice. At Emory, the laparoscopic approach for hepatic and pancreatic operations is fortified by classic training in hepatobiliary surgery, formal training in laparoscopic surgery, and a solid foundation of endocrine and transplantation capabilities in an interdivisional combination of talents.

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 Education

In 1992, the unit was the first program of its type to offer a fellowship program in minimally invasive surgery; now there are over 90 laparoscopic fellowships in the US. Over the years, hundreds of surgeons have enrolled in the unit's SAGES-endorsed training workshops for various laparoscopic techniques, including laparoscopic colon surgery, inguinal and ventral hernia repair and modern management of foregut diseases.

In 2003, then current Endosurgery Unit director Dr. C. Daniel Smith oversaw the formation of the Emory Simulation, Training and Robotics Center (ESTAR), a program for developing, validating and applying simulation-based educational tools and devices, curricula and robotics for use in medical education, training and patient care that has become a common resource for surgical training programs both within and outside Emory. Many of the training systems at the center involve the simulation of minimally invasive and laparoscopic procedures. Following Dr. Smith's 2006 departure from Emory, Dr. Lin stepped in as interim ESTAR director until October 2007, when Dr. John Sweeney, newly appointed chief of the division of general and gastrointestinal surgery, was appointed director.

ESTAR sponsors mandatory resident laparoscopic and endoscopic skills labs throughout the academic year that meet RRC training requirements. The workshops are made possible in part by an educational grant from Ethicon Endo-Surgery, Inc. Faculty and fellows of the Endosurgery Unit generously volunteer their time to direct these sessions, providing one-on-one teaching and feedback using endoscopy and laparoscopic simulators by Immersion Medical, laparoscopic trainers by Haptica and endoscopy equipment by Olympus America.

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