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Marco PUGA

Clinica Alemana
Santiago, Chile
MD
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Role of laparoscopy in treating ovarian cancer
Borderline ovarian tumors (BOTs) represent about 10 to 20% of all ovarian malignancies and differ from invasive ovarian cancers (IOCs) by many characters. The standard management of BOT is peritoneal washing cytology, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, complete peritoneal resection of macroscopic lesions; in case of mucinous BOTs, appendectomy should be performed. Because BOTs are often diagnosed at an earlier stage, in younger women and have a better prognosis and a higher survival rate than IOCs, fertility-sparing surgery is one of the options to preserve a childbearing capacity. However, conservative surgery is still controversial.
So far, postoperative chemotherapy, radiotherapy, and hormone therapy are not recommended. BOTs are characteristically difficult to diagnose using preoperative radiological methods, exhibit inconsistencies in expression of tumor markers, and are often inaccurately identified using frozen sections. In these slides, Dr. Marco Puga will discuss the controversial issues of BOTs and will present the management of BOTs.
Lecture
2 years ago
2697 views
167 likes
0 comments
31:15
Role of laparoscopy in treating ovarian cancer
Borderline ovarian tumors (BOTs) represent about 10 to 20% of all ovarian malignancies and differ from invasive ovarian cancers (IOCs) by many characters. The standard management of BOT is peritoneal washing cytology, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, complete peritoneal resection of macroscopic lesions; in case of mucinous BOTs, appendectomy should be performed. Because BOTs are often diagnosed at an earlier stage, in younger women and have a better prognosis and a higher survival rate than IOCs, fertility-sparing surgery is one of the options to preserve a childbearing capacity. However, conservative surgery is still controversial.
So far, postoperative chemotherapy, radiotherapy, and hormone therapy are not recommended. BOTs are characteristically difficult to diagnose using preoperative radiological methods, exhibit inconsistencies in expression of tumor markers, and are often inaccurately identified using frozen sections. In these slides, Dr. Marco Puga will discuss the controversial issues of BOTs and will present the management of BOTs.
Stepwise radical vaginal trachelectomy: Dargent’s operation
Up to 40% of early cervical cancers are diagnosed in young women who might desire fertility preservation. More than 1,000 cases of Radical Vaginal Trachelectomy (RVT) have been published so far, with over 450 pregnancies achieved. Oncological outcomes of this treatment are totally comparable with the ones obtained with radical hysterectomies for similar size lesions. Additionally, these results are similar or superior when compared to the other routes of trachelectomy.
The procedure is always combined with a laparoscopic pelvic lymphadenectomy to rule out the possibility of lymph node metastases.
This video demonstrates the technique of RVT. Interesting parts of the vaginal steps are shown along with their contemporary laparoscopic views for didactic purposes.
Surgical intervention
5 years ago
2979 views
86 likes
0 comments
09:21
Stepwise radical vaginal trachelectomy: Dargent’s operation
Up to 40% of early cervical cancers are diagnosed in young women who might desire fertility preservation. More than 1,000 cases of Radical Vaginal Trachelectomy (RVT) have been published so far, with over 450 pregnancies achieved. Oncological outcomes of this treatment are totally comparable with the ones obtained with radical hysterectomies for similar size lesions. Additionally, these results are similar or superior when compared to the other routes of trachelectomy.
The procedure is always combined with a laparoscopic pelvic lymphadenectomy to rule out the possibility of lymph node metastases.
This video demonstrates the technique of RVT. Interesting parts of the vaginal steps are shown along with their contemporary laparoscopic views for didactic purposes.
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
Surgical intervention
5 years ago
2019 views
35 likes
0 comments
03:00
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
Laparoscopic oophorectomy for solid ovarian mass
We present the case of a 28-year-old woman with no relevant previous surgical or medical history. The patient was addressed for the removal of a right ovarian mass. She presented with dysmenorrhea and occasional dyspareunia. There were no other symptoms. Her physical examination showed a right adnexal mass to the vaginal touch. Preoperative work-up included a pelvic ultrasound, which showed a tumor apparently originating from the right ovary, of solid homogeneous appearance. MRI confirmed the presence of the solid mass, measuring approximately 6cm. No other pathological findings were present in the rest of the abdominal cavity. Tumor markers were negative. The patient had not completed childbearing and desired a conservative surgical approach. The different aspects of the surgical management were explained, including the possibility of performing an oophorectomy if no healthy ovarian tissue could be identified.
Surgical intervention
5 years ago
5273 views
83 likes
0 comments
08:33
Laparoscopic oophorectomy for solid ovarian mass
We present the case of a 28-year-old woman with no relevant previous surgical or medical history. The patient was addressed for the removal of a right ovarian mass. She presented with dysmenorrhea and occasional dyspareunia. There were no other symptoms. Her physical examination showed a right adnexal mass to the vaginal touch. Preoperative work-up included a pelvic ultrasound, which showed a tumor apparently originating from the right ovary, of solid homogeneous appearance. MRI confirmed the presence of the solid mass, measuring approximately 6cm. No other pathological findings were present in the rest of the abdominal cavity. Tumor markers were negative. The patient had not completed childbearing and desired a conservative surgical approach. The different aspects of the surgical management were explained, including the possibility of performing an oophorectomy if no healthy ovarian tissue could be identified.
Laparoscopic segmental resection in a patient with deep infiltrating endometriosis
We present the case of a 33-year-old-woman suffering from deep infiltrating endometriosis. In her previous history, three laparoscopies had been performed due to endometriosis. In the first two laparoscopies, bilateral ovarian cystectomies had been carried out while the third laparoscopy had been indicated to puncture the ovaries after hormonal stimulation for in vitro fertilization (IVF), due to the impossibility of reaching follicles transvaginally.
The patient presented with dysmenorrhea, dyspareunia and dyschezia, as well as rectorrhagia and diarrhea. The patient’s physical examination demonstrated the presence of a retrouterine mass suggestive of adhesions. Preoperative work-up included MRI and colonoscopy. MRI showed an endometriotic nodule affecting the rectosigmoid junction and infiltrating its wall. A colonoscopy was performed and allowed to visualize the endometriotic nodule.
Surgical intervention
5 years ago
2645 views
31 likes
0 comments
18:50
Laparoscopic segmental resection in a patient with deep infiltrating endometriosis
We present the case of a 33-year-old-woman suffering from deep infiltrating endometriosis. In her previous history, three laparoscopies had been performed due to endometriosis. In the first two laparoscopies, bilateral ovarian cystectomies had been carried out while the third laparoscopy had been indicated to puncture the ovaries after hormonal stimulation for in vitro fertilization (IVF), due to the impossibility of reaching follicles transvaginally.
The patient presented with dysmenorrhea, dyspareunia and dyschezia, as well as rectorrhagia and diarrhea. The patient’s physical examination demonstrated the presence of a retrouterine mass suggestive of adhesions. Preoperative work-up included MRI and colonoscopy. MRI showed an endometriotic nodule affecting the rectosigmoid junction and infiltrating its wall. A colonoscopy was performed and allowed to visualize the endometriotic nodule.
Laparoscopic colposacropexy for the treatment of an apical defect in a patient with previous total hysterectomy
We present the case of a 69-year-old patient who suffered from an elytrocele. Previously, she had undergone a total hysterectomy with anterior and posterior colpoperineoplasty due to the presence of a grade 2 cystocele, without urinary incontinence. The management of genital prolapse requires a thorough knowledge of the anatomy and physiology of the female pelvic floor. This video outlines the main steps to follow for the repair of an apical defect with no true rectocele or cystocele. It also offers a very good insight of the specific issues to be considered when performing dissection and mesh fixation in specific situations, such as distortion of the normal anatomy due to the scarring process from a previous surgery and obesity. This surgery was performed and streamed live.
Surgical intervention
6 years ago
4468 views
77 likes
0 comments
18:00
Laparoscopic colposacropexy for the treatment of an apical defect in a patient with previous total hysterectomy
We present the case of a 69-year-old patient who suffered from an elytrocele. Previously, she had undergone a total hysterectomy with anterior and posterior colpoperineoplasty due to the presence of a grade 2 cystocele, without urinary incontinence. The management of genital prolapse requires a thorough knowledge of the anatomy and physiology of the female pelvic floor. This video outlines the main steps to follow for the repair of an apical defect with no true rectocele or cystocele. It also offers a very good insight of the specific issues to be considered when performing dissection and mesh fixation in specific situations, such as distortion of the normal anatomy due to the scarring process from a previous surgery and obesity. This surgery was performed and streamed live.
Lumbo-aortic lymphadenectomy: improving exposure with the T’lift™ device
Lymph node dissection in the lumbo-aortic area is a challenging procedure. The main concerns during surgery include the risk of major vascular injury and the potential lesion of other structures such as the ureter or the duodenum. A thorough surgical strategy and adequate exposure are mandatory to reduce the possibility of complications.
During this surgical demonstration, the most important aspects of the strategy are discussed. Special emphasis is put on exposure and the use of the T’lift™ device is shown. This simple technique allows for a fast and safe suspension of the peritoneum, improving the visualization of the operative field.
Surgical intervention
6 years ago
4285 views
59 likes
0 comments
15:01
Lumbo-aortic lymphadenectomy: improving exposure with the T’lift™ device
Lymph node dissection in the lumbo-aortic area is a challenging procedure. The main concerns during surgery include the risk of major vascular injury and the potential lesion of other structures such as the ureter or the duodenum. A thorough surgical strategy and adequate exposure are mandatory to reduce the possibility of complications.
During this surgical demonstration, the most important aspects of the strategy are discussed. Special emphasis is put on exposure and the use of the T’lift™ device is shown. This simple technique allows for a fast and safe suspension of the peritoneum, improving the visualization of the operative field.
Radical nerve-sparing hysterectomy (type C1)
This video demonstrates a nerve-sparing radical hysterectomy (type C1).
During type C Radical Hysterectomy (RH), the uterus is removed en bloc with its ligaments along with a vaginal margin of 15 to 20mm. The uterosacral ligaments are transected from the level of the rectum and the vesicouterine ligament at the level of the bladder. The ureter is dissected until it enters the bladder. It is mobilized completely to resect the lateral parametrium from the lateral wall.

Radical hysterectomy type C1 implies the preservation of the hypogastric inferior nerve and the bladder branch of the hypogastric plexus during the resection of the parametrium.
During the surgery, the components of the hypogastric plexus are identified: the inferior hypogastric nerve running from the lateral wall of the rectum and the splanchnic nerves from S2-S4. The deep uterine vein is an essential landmark because we can find the first splanchnic nerve underneath it. Consequently, during the resection of the posterior parametrium, the uterosacral ligament can be completely resected while conserving the inferior hypogastric nerve. Division of the lateral parametrium is pursued without including the splanchnic nerves. During the transection of the caudal part of the paracervix and the paracolpium, attention must be paid not to include the vesical branch of the inferior hypogastric plexus that runs parallel to paravaginal vessels.
Surgical intervention
6 years ago
8348 views
154 likes
0 comments
20:14
Radical nerve-sparing hysterectomy (type C1)
This video demonstrates a nerve-sparing radical hysterectomy (type C1).
During type C Radical Hysterectomy (RH), the uterus is removed en bloc with its ligaments along with a vaginal margin of 15 to 20mm. The uterosacral ligaments are transected from the level of the rectum and the vesicouterine ligament at the level of the bladder. The ureter is dissected until it enters the bladder. It is mobilized completely to resect the lateral parametrium from the lateral wall.

Radical hysterectomy type C1 implies the preservation of the hypogastric inferior nerve and the bladder branch of the hypogastric plexus during the resection of the parametrium.
During the surgery, the components of the hypogastric plexus are identified: the inferior hypogastric nerve running from the lateral wall of the rectum and the splanchnic nerves from S2-S4. The deep uterine vein is an essential landmark because we can find the first splanchnic nerve underneath it. Consequently, during the resection of the posterior parametrium, the uterosacral ligament can be completely resected while conserving the inferior hypogastric nerve. Division of the lateral parametrium is pursued without including the splanchnic nerves. During the transection of the caudal part of the paracervix and the paracolpium, attention must be paid not to include the vesical branch of the inferior hypogastric plexus that runs parallel to paravaginal vessels.
How to improve exposure in laparoscopy: organ suspension with the T-Lift™ device
Organ suspension using a T-lift™ device is a simple method to enhance exposure in laparoscopic surgery, providing adequate vision and operating space and allowing the assistant to focus on helping the surgeon, thus reducing operative times, without the need for difficult intra-abdominal needle manipulation as well as the risk of bowel and vascular injury associated with that approach.
Several examples of organ suspension with the T-lift™ are demonstrated in this video, including suspension of the ovaries, sigmoid colon or vagina in simple procedures, as well as in more complex procedures, for instance by holding the anterior rectal wall for bowel resection with transanal specimen extraction.
Surgical intervention
6 years ago
7653 views
466 likes
0 comments
07:12
How to improve exposure in laparoscopy: organ suspension with the T-Lift™ device
Organ suspension using a T-lift™ device is a simple method to enhance exposure in laparoscopic surgery, providing adequate vision and operating space and allowing the assistant to focus on helping the surgeon, thus reducing operative times, without the need for difficult intra-abdominal needle manipulation as well as the risk of bowel and vascular injury associated with that approach.
Several examples of organ suspension with the T-lift™ are demonstrated in this video, including suspension of the ovaries, sigmoid colon or vagina in simple procedures, as well as in more complex procedures, for instance by holding the anterior rectal wall for bowel resection with transanal specimen extraction.
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.
Surgical intervention
6 years ago
1769 views
24 likes
0 comments
32:41
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.