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Didier MUTTER

Hôpitaux Universitaires de Strasbourg
Strasbourg, France
MD, PhD, FACS
42.8K likes
1.1M view
236 comments
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Laparoscopic management of perforated ulcer of the stomach
A 43-year-old woman with a history of chronic use of NSAIDs was admitted to the emergency care unit for acute abdominal epigastric pain. CT-scan showed both free air and fluid in the peritoneal cavity with marked thickening and irregularity at the level of the gastric antrum and the duodenal bulb. The patient underwent emergency laparoscopy. A large amount of purulent fluid was found in the peritoneal cavity and evacuated. The gastric defect was identified at the level of the anterior wall of the gastric antrum. A 2/0 Vicryl suture is used to oversew the perforation. As an additional protection, an omental patch was brought in place and fixed against the sutured lesion. Abundant peritoneal lavage was performed. The patient was discharged on postoperative day 5. One month later, esophagogastroduodenoscopies (EGDs) with biopsies of the ulcer’s margins were performed.
X Untereiner, M Pizzicannella, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
3 days ago
162 views
1 like
0 comments
06:55
Laparoscopic management of perforated ulcer of the stomach
A 43-year-old woman with a history of chronic use of NSAIDs was admitted to the emergency care unit for acute abdominal epigastric pain. CT-scan showed both free air and fluid in the peritoneal cavity with marked thickening and irregularity at the level of the gastric antrum and the duodenal bulb. The patient underwent emergency laparoscopy. A large amount of purulent fluid was found in the peritoneal cavity and evacuated. The gastric defect was identified at the level of the anterior wall of the gastric antrum. A 2/0 Vicryl suture is used to oversew the perforation. As an additional protection, an omental patch was brought in place and fixed against the sutured lesion. Abundant peritoneal lavage was performed. The patient was discharged on postoperative day 5. One month later, esophagogastroduodenoscopies (EGDs) with biopsies of the ulcer’s margins were performed.
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
D Mutter, T Urade, J Marescaux
Surgical intervention
4 days ago
132 views
2 likes
0 comments
46:18
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
Laparoscopic Spigelian hernia repair
Spigelian hernia is a rare condition and it is difficult to diagnose it clinically. It has been estimated to account for 0.12% of abdominal wall hernias. The hernia ring is a well-defined defect in the transversus abdominis aponeurosis. The hernia sac, surrounded with extraperitoneal adipose tissue, often lies interparietally passing through the transversus abdominis and the internal oblique muscle aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique muscle. The laparoscopic repair is well-established. Most authors use a transperitoneal approach either by placing the mesh in an intraperitoneal position or by raising the peritoneal flap and placing the mesh in the extraperitoneal space. In this video, we demonstrate the laparoscopic repair of a Spigelian hernia through the transabdominal preperitoneal (TAPP) placement of a composite mesh.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
4 days ago
77 views
0 likes
0 comments
08:23
Laparoscopic Spigelian hernia repair
Spigelian hernia is a rare condition and it is difficult to diagnose it clinically. It has been estimated to account for 0.12% of abdominal wall hernias. The hernia ring is a well-defined defect in the transversus abdominis aponeurosis. The hernia sac, surrounded with extraperitoneal adipose tissue, often lies interparietally passing through the transversus abdominis and the internal oblique muscle aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique muscle. The laparoscopic repair is well-established. Most authors use a transperitoneal approach either by placing the mesh in an intraperitoneal position or by raising the peritoneal flap and placing the mesh in the extraperitoneal space. In this video, we demonstrate the laparoscopic repair of a Spigelian hernia through the transabdominal preperitoneal (TAPP) placement of a composite mesh.
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
S Morales-Conde, T Urade, D Mutter, J Marescaux
Surgical intervention
4 days ago
96 views
3 likes
1 comment
42:53
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.
B Dallemagne, T Urade, D Mutter, J Marescaux
Surgical intervention
4 days ago
94 views
1 like
0 comments
39:46
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.
Laparoscopic management of small bowel obstruction and ileo-ileal intussusception
Meckel’s diverticulum is the most common congenital anomaly of the digestive tract, found in 2 to 3% of the population. It is usually detected in children. In adults, symptoms vary, and diagnosis is therefore uneasy to establish. The most common infectious complications include obstructions and bleedings, which account for approximately one third of overall complications. Obstructions may be caused by intussusception or by a band.
This video demonstrates a case of a 49-year-old male patient, who necessitated an emergency surgical procedure for the management of a small bowel obstruction induced by the presence of Meckel’s diverticulum and intussusception. Due to an underlying necrosis, a resection and an anastomosis of the small bowel were performed.
D Kadoche, M Ignat, D Mutter, J Marescaux
Surgical intervention
4 days ago
63 views
0 likes
0 comments
08:22
Laparoscopic management of small bowel obstruction and ileo-ileal intussusception
Meckel’s diverticulum is the most common congenital anomaly of the digestive tract, found in 2 to 3% of the population. It is usually detected in children. In adults, symptoms vary, and diagnosis is therefore uneasy to establish. The most common infectious complications include obstructions and bleedings, which account for approximately one third of overall complications. Obstructions may be caused by intussusception or by a band.
This video demonstrates a case of a 49-year-old male patient, who necessitated an emergency surgical procedure for the management of a small bowel obstruction induced by the presence of Meckel’s diverticulum and intussusception. Due to an underlying necrosis, a resection and an anastomosis of the small bowel were performed.
ERCP in a patient with previous subtotal gastrectomy for cancer: hybrid approach with transjejunal access
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior gastric surgery (Roux-en-Y gastric bypass, partial or subtotal gastrectomy) is a challenging procedure. Despite technological advances in endoscopy, reaching the duodenum and entering the bile duct remains difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach in case of previous RYGB or through the proximal jejunum in case of gastric resection. The objective of this video is to demonstrate the hybrid approach in a patient with a previous subtotal gastrectomy for gastric cancer.
A D'Urso, Gf Donatelli, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
4 days ago
15 views
0 likes
0 comments
12:02
ERCP in a patient with previous subtotal gastrectomy for cancer: hybrid approach with transjejunal access
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior gastric surgery (Roux-en-Y gastric bypass, partial or subtotal gastrectomy) is a challenging procedure. Despite technological advances in endoscopy, reaching the duodenum and entering the bile duct remains difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach in case of previous RYGB or through the proximal jejunum in case of gastric resection. The objective of this video is to demonstrate the hybrid approach in a patient with a previous subtotal gastrectomy for gastric cancer.
Endoscopic internal drainage of gastric fistula after sleeve gastrectomy
Gastric fistula is a major adverse event after sleeve gastrectomy.
In this live instructional video, authors present the case of a 45-year-old woman with a complex postoperative course after sleeve gastrectomy due to a gastric leakage and a twisted stomach. The patient had already been managed with the endoscopic placement of a fully covered metal stent and a percutaneous drainage with no resolution of the fistula.
The first step of the procedure consists in the removal of a 16cm fully covered stent using a grasper. After contrast injection, the leakage and the gastric twist are visualized. Under fluoroscopic control, a 30mm pneumatic dilatation of the twist is obtained. Two double pigtail plastic stents are placed between the stomach and the abscess cavity in order to achieve internal drainage and facilitate the healing process. The percutaneous drainage will be removed one day after the procedure while the plastic stents will be removed after 3 months.
Gf Donatelli, S Perretta, M Ignat, M Pizzicannella, D Mutter, J Marescaux
Surgical intervention
4 days ago
19 views
1 like
0 comments
14:45
Endoscopic internal drainage of gastric fistula after sleeve gastrectomy
Gastric fistula is a major adverse event after sleeve gastrectomy.
In this live instructional video, authors present the case of a 45-year-old woman with a complex postoperative course after sleeve gastrectomy due to a gastric leakage and a twisted stomach. The patient had already been managed with the endoscopic placement of a fully covered metal stent and a percutaneous drainage with no resolution of the fistula.
The first step of the procedure consists in the removal of a 16cm fully covered stent using a grasper. After contrast injection, the leakage and the gastric twist are visualized. Under fluoroscopic control, a 30mm pneumatic dilatation of the twist is obtained. Two double pigtail plastic stents are placed between the stomach and the abscess cavity in order to achieve internal drainage and facilitate the healing process. The percutaneous drainage will be removed one day after the procedure while the plastic stents will be removed after 3 months.
Fully robotic Roux-en-Y gastric bypass
Roux-en-Y gastric bypass is becoming increasingly popular. The use of the surgical robot is developing rapidly, and this is especially true for digestive surgery. The aim of this video is to show that Roux-en-Y gastric bypass can be performed using a totally robotic approach. When using the robot, one follows the same steps as for a conventional intervention. The 3D vision and the degrees of freedom of the instruments facilitate the dissection, especially around the cardia, and for suturing procedures. The surgeon takes advantage of the console's user friendly set-up which does not put his/her shoulders or back in a vulnerable position, as they sometimes are when using a laparoscopic approach.
M Vix, B Seeliger, D Mutter, J Marescaux
Surgical intervention
2 months ago
1159 views
2 likes
0 comments
12:00
Fully robotic Roux-en-Y gastric bypass
Roux-en-Y gastric bypass is becoming increasingly popular. The use of the surgical robot is developing rapidly, and this is especially true for digestive surgery. The aim of this video is to show that Roux-en-Y gastric bypass can be performed using a totally robotic approach. When using the robot, one follows the same steps as for a conventional intervention. The 3D vision and the degrees of freedom of the instruments facilitate the dissection, especially around the cardia, and for suturing procedures. The surgeon takes advantage of the console's user friendly set-up which does not put his/her shoulders or back in a vulnerable position, as they sometimes are when using a laparoscopic approach.
Laparoscopic cholecystectomy: cystic duct stone management
This video demonstrates a laparoscopic cholecystectomy in a 69-year-old woman who had multiple episodes of biliary colic. Ultrasonography and MRI showed the presence of multiple gallbladder stones. MRI also showed a folded gallbladder infundibulum over the cystic duct, which is enlarged and contains a stone. The common bile duct is otherwise perfectly thin and free of stones. In this video, one can observe a stepwise cholecystectomy technique, with exposure, dissection of the serosa and of Calot’s triangle. Cystic artery division is first performed in order to allow complete cystic duct dissection obtaining the critical view of safety. The dissection of the dilated cystic duct is thoroughly demonstrated. A small stone is pushed back into the gallbladder; the cystic duct is opened and checked for residual stones, and the cystic duct convergence with the common bile duct is evidenced prior to clip positioning and duct division.
M Ignat, M Wehr, B Seeliger, D Mutter, J Marescaux
Surgical intervention
2 months ago
2553 views
9 likes
2 comments
10:44
Laparoscopic cholecystectomy: cystic duct stone management
This video demonstrates a laparoscopic cholecystectomy in a 69-year-old woman who had multiple episodes of biliary colic. Ultrasonography and MRI showed the presence of multiple gallbladder stones. MRI also showed a folded gallbladder infundibulum over the cystic duct, which is enlarged and contains a stone. The common bile duct is otherwise perfectly thin and free of stones. In this video, one can observe a stepwise cholecystectomy technique, with exposure, dissection of the serosa and of Calot’s triangle. Cystic artery division is first performed in order to allow complete cystic duct dissection obtaining the critical view of safety. The dissection of the dilated cystic duct is thoroughly demonstrated. A small stone is pushed back into the gallbladder; the cystic duct is opened and checked for residual stones, and the cystic duct convergence with the common bile duct is evidenced prior to clip positioning and duct division.
LIVE UNCUT SURGERY: laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy.
The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected.
After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe.
Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia.
This 20-minute live uncut video is a demonstration of a gold standard procedure.
D Mutter, G Philouze, B Seeliger, J Marescaux
Surgical intervention
2 months ago
7098 views
34 likes
9 comments
30:23
LIVE UNCUT SURGERY: laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy.
The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected.
After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe.
Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia.
This 20-minute live uncut video is a demonstration of a gold standard procedure.
Fully robotically assisted transabdominal left adrenalectomy for hypercortisolism due to two left adrenal adenomas
This video demonstrates the case of a female patient who had been followed up by endocrinologists for 6 years. The size of the left adrenal gland had increased and two nodules of 2.5cm were found. Serum chemistries showed a progressive increase in cortisol secretion with a pathological dexamethasone suppression test (DST). Mineralocorticoids and catecholamines were normal. Noriodocholesterol scintigraphy showed an exclusive fixation of the left adrenal gland. Surgery was indicated due to the hypersecretion of the left adrenal gland.
We now have a surgical robot (da Vinci Xi™ robotic surgical system, Intuitive Surgical) and we use it for most of the adrenalectomies we perform. It provides great stability of the operative field. The precise dissection is facilitated by the dexterity of the articulated instruments.
M Vix, B Seeliger, D Mutter, J Marescaux
Surgical intervention
2 months ago
183 views
0 likes
0 comments
13:06
Fully robotically assisted transabdominal left adrenalectomy for hypercortisolism due to two left adrenal adenomas
This video demonstrates the case of a female patient who had been followed up by endocrinologists for 6 years. The size of the left adrenal gland had increased and two nodules of 2.5cm were found. Serum chemistries showed a progressive increase in cortisol secretion with a pathological dexamethasone suppression test (DST). Mineralocorticoids and catecholamines were normal. Noriodocholesterol scintigraphy showed an exclusive fixation of the left adrenal gland. Surgery was indicated due to the hypersecretion of the left adrenal gland.
We now have a surgical robot (da Vinci Xi™ robotic surgical system, Intuitive Surgical) and we use it for most of the adrenalectomies we perform. It provides great stability of the operative field. The precise dissection is facilitated by the dexterity of the articulated instruments.
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
M Vix, B Seeliger, D Mutter, J Marescaux
Surgical intervention
2 months ago
519 views
2 likes
0 comments
13:25
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
Fully robotically assisted transabdominal right adrenalectomy for a right adrenal incidentaloma
This video presents the case of a female patient in whom a right adrenal incidentaloma was found. It was 40mm in size and was found incidentally during a pancreatitis treatment.
Endocrinologists controlled the absence of abnormal secretion. The size of the lesion increased slightly over a period of 6 months and allowed to establish an indication for surgery. Our team performs adrenalectomies using a transabdominal laparoscopic approach with the patient in a lateral decubitus position. In order to facilitate the intervention, we asked the Visible Patient company to use the CT-scan images to make a 3D model. This reconstruction allowed to better indentify the relationships of the gland, to improve resection, and confirm the operative strategy. During the intervention, the surgeon can use it to better understand the anatomy hidden by peri-adrenal adipose tissue and operate accordingly. We now have a surgical robot (da Vinci Xi™ robotic surgical system, Intuitive Surgical) and we use it for most of the adrenalectomies we perform. It provides great stability of the operative field. The precise dissection is facilitated by the dexterity of the articulated instruments.
M Vix, B Seeliger, L Soler, D Mutter, J Marescaux
Surgical intervention
2 months ago
956 views
0 likes
2 comments
02:55
Fully robotically assisted transabdominal right adrenalectomy for a right adrenal incidentaloma
This video presents the case of a female patient in whom a right adrenal incidentaloma was found. It was 40mm in size and was found incidentally during a pancreatitis treatment.
Endocrinologists controlled the absence of abnormal secretion. The size of the lesion increased slightly over a period of 6 months and allowed to establish an indication for surgery. Our team performs adrenalectomies using a transabdominal laparoscopic approach with the patient in a lateral decubitus position. In order to facilitate the intervention, we asked the Visible Patient company to use the CT-scan images to make a 3D model. This reconstruction allowed to better indentify the relationships of the gland, to improve resection, and confirm the operative strategy. During the intervention, the surgeon can use it to better understand the anatomy hidden by peri-adrenal adipose tissue and operate accordingly. We now have a surgical robot (da Vinci Xi™ robotic surgical system, Intuitive Surgical) and we use it for most of the adrenalectomies we perform. It provides great stability of the operative field. The precise dissection is facilitated by the dexterity of the articulated instruments.
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.
WJ Hyung, S Perretta, B Dallemagne, B Seeliger, D Mutter, J Marescaux
Surgical intervention
2 months ago
1300 views
3 likes
0 comments
04:27
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.
Laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy. The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected. After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe. Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia. This 20-minute live uncut video is a demonstration of a gold standard procedure.
D Mutter, G Philouze, B Seeliger, J Marescaux
How to
2 months ago
7068 views
32 likes
9 comments
00:30:23
Laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy. The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected. After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe. Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia. This 20-minute live uncut video is a demonstration of a gold standard procedure.
LIVE INTERACTIVE SURGERY: robotic low anterior resection for a local recurrence of rectal cancer
In this live interactive surgery, Dr. Parra-Davila demonstrates a robotic low anterior resection for a local recurrence of transanally excised rectal cancer. The operative technique shown includes a robotic oncological ‘en bloc’ resection and intracorporeal anastomosis. In the patient’s history, an ulcerated villous polyp too large for endoscopic removal was addressed to surgery. Preoperative biopsies had failed to detect malignancy. The surgical procedure consisted in a transanal full-thickness resection including partial TME for lymph node sampling. Since the operative specimen revealed a pT2N1a (1/8) rectal adenocarcinoma, the patient underwent adjuvant radiochemotherapy. The following year, a single hepatic metastasis was resected, complemented by postoperative chemotherapy. After 7 years of uneventful follow-up, an anastomotic recurrence was diagnosed. Following oncologic committee discussion, the patient was advised to undergo surgery.
E Parra-Davila, M Ignat, L Soler, B Seeliger, D Mutter, J Marescaux
Surgical intervention
3 months ago
1203 views
2 likes
0 comments
32:48
LIVE INTERACTIVE SURGERY: robotic low anterior resection for a local recurrence of rectal cancer
In this live interactive surgery, Dr. Parra-Davila demonstrates a robotic low anterior resection for a local recurrence of transanally excised rectal cancer. The operative technique shown includes a robotic oncological ‘en bloc’ resection and intracorporeal anastomosis. In the patient’s history, an ulcerated villous polyp too large for endoscopic removal was addressed to surgery. Preoperative biopsies had failed to detect malignancy. The surgical procedure consisted in a transanal full-thickness resection including partial TME for lymph node sampling. Since the operative specimen revealed a pT2N1a (1/8) rectal adenocarcinoma, the patient underwent adjuvant radiochemotherapy. The following year, a single hepatic metastasis was resected, complemented by postoperative chemotherapy. After 7 years of uneventful follow-up, an anastomotic recurrence was diagnosed. Following oncologic committee discussion, the patient was advised to undergo surgery.
LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient
In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.
S Morales-Conde, B Seeliger, D Mutter, J Marescaux
Surgical intervention
4 months ago
3894 views
7 likes
0 comments
43:25
LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient
In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
B Dallemagne, S Perretta, B Seeliger, D Mutter, J Marescaux
Surgical intervention
11 months ago
927 views
351 likes
0 comments
21:18
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
Laparoscopic ileocecal resection for unresectable appendix
This is the case of a 36-year-old woman who has had an exploratory laparoscopy in another institution 2 months earlier. Acute appendicitis was suspected, based on ultrasound exam. However, exploration has shown an inflammatory appendicular mass, impossible to dissect. The patient was administered antibiotics for a period of 3 weeks. A laparoscopic appendectomy was decided upon at an interval of 2 months. Work-up included CT-scan and colonoscopy, which did not demonstrate anything specific.
Laparoscopic exploration demonstrated important fibrotic and scarry tissues around the appendix and the cecum. Despite painstaking dissection, appendectomy was impossible. Ileocecal resection was decided upon. Operative steps, namely exposure, division of the last ileal loop, division of the meso, division of the right colon above the ampulla coli and the intracorporeal side-to-side stapled anastomosis are demonstrated. Pathological findings evidenced an endometriotic nodule. The postoperative course was uneventful.
D Mutter, M Ignat, J Marescaux
Surgical intervention
1 year ago
3117 views
326 likes
0 comments
08:23
Laparoscopic ileocecal resection for unresectable appendix
This is the case of a 36-year-old woman who has had an exploratory laparoscopy in another institution 2 months earlier. Acute appendicitis was suspected, based on ultrasound exam. However, exploration has shown an inflammatory appendicular mass, impossible to dissect. The patient was administered antibiotics for a period of 3 weeks. A laparoscopic appendectomy was decided upon at an interval of 2 months. Work-up included CT-scan and colonoscopy, which did not demonstrate anything specific.
Laparoscopic exploration demonstrated important fibrotic and scarry tissues around the appendix and the cecum. Despite painstaking dissection, appendectomy was impossible. Ileocecal resection was decided upon. Operative steps, namely exposure, division of the last ileal loop, division of the meso, division of the right colon above the ampulla coli and the intracorporeal side-to-side stapled anastomosis are demonstrated. Pathological findings evidenced an endometriotic nodule. The postoperative course was uneventful.
Laparoscopic appendectomy and fenestration of hemorrhagic ovarian cyst
This is the case of a 19-year-old female patient who was admitted to the emergency department for lower abdominal pain going on for 24 hours. No abdominal guarding was noted. Biological findings showed an inflammation with leukocytes at 16,000 and CRP levels at 112. CT-scan showed the presence of an enlarged appendix (9mm thick) along with a voluminous adnexal cyst, which may be suggestive of a tubo-ovarian abscess. Laparoscopic exploration is performed. Congestive appendicitis is confirmed, as well as the presence of a hemorrhagic right ovarian cyst. Laparoscopic appendectomy is performed and the hemorrhagic ovarian cyst is fenestrated.
M Ignat, D Mutter, J Marescaux
Surgical intervention
1 year ago
2960 views
407 likes
1 comment
04:57
Laparoscopic appendectomy and fenestration of hemorrhagic ovarian cyst
This is the case of a 19-year-old female patient who was admitted to the emergency department for lower abdominal pain going on for 24 hours. No abdominal guarding was noted. Biological findings showed an inflammation with leukocytes at 16,000 and CRP levels at 112. CT-scan showed the presence of an enlarged appendix (9mm thick) along with a voluminous adnexal cyst, which may be suggestive of a tubo-ovarian abscess. Laparoscopic exploration is performed. Congestive appendicitis is confirmed, as well as the presence of a hemorrhagic right ovarian cyst. Laparoscopic appendectomy is performed and the hemorrhagic ovarian cyst is fenestrated.
Laparoscopic appendectomy for recurrent appendicitis after medical treatment
Appendectomy is the only curative treatment of appendicitis. However, the management of patients with an appendiceal mass or abscess can be temporarily managed medically with intravenous antibiotic therapy and/or percutaneous drainage. And yet, there are many controversies over the non-operative management of acute appendicitis. In 2015, Fair et al. used data from the American College of Surgeons National Surgical Quality Improvement Project to evaluate 30-day morbidity and mortality of intervention (laparoscopic and open appendectomy) at different time periods. A delay of operative intervention longer than 48 hours was associated with a doubling of complication rates. Elective appendectomy can be performed after 6 to 8 weeks later, which proves successful in the vast majority of patients.
This is the case of an 83-year-old man who presented with an acute appendicitis treated medically in another hospital. The patient had a past medical history of arterial hypertension, cardiomyopathy, previous cerebral ischemia, and rectal polyp. A delayed appendectomy was planned. However, before the procedure, a total colonoscopy was performed because of the history of polyps. This elderly patient was hospitalized for colonoscopy. At admission, he presented with fever, right iliac fossa tenderness, and a biological inflammatory syndrome. A CT-scan was performed. It showed a recurrent acute appendicitis without mass, with a 2cm abscess on the tip of the appendix. An appendectomy was performed in this case.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
1 year ago
3028 views
336 likes
0 comments
05:00
Laparoscopic appendectomy for recurrent appendicitis after medical treatment
Appendectomy is the only curative treatment of appendicitis. However, the management of patients with an appendiceal mass or abscess can be temporarily managed medically with intravenous antibiotic therapy and/or percutaneous drainage. And yet, there are many controversies over the non-operative management of acute appendicitis. In 2015, Fair et al. used data from the American College of Surgeons National Surgical Quality Improvement Project to evaluate 30-day morbidity and mortality of intervention (laparoscopic and open appendectomy) at different time periods. A delay of operative intervention longer than 48 hours was associated with a doubling of complication rates. Elective appendectomy can be performed after 6 to 8 weeks later, which proves successful in the vast majority of patients.
This is the case of an 83-year-old man who presented with an acute appendicitis treated medically in another hospital. The patient had a past medical history of arterial hypertension, cardiomyopathy, previous cerebral ischemia, and rectal polyp. A delayed appendectomy was planned. However, before the procedure, a total colonoscopy was performed because of the history of polyps. This elderly patient was hospitalized for colonoscopy. At admission, he presented with fever, right iliac fossa tenderness, and a biological inflammatory syndrome. A CT-scan was performed. It showed a recurrent acute appendicitis without mass, with a 2cm abscess on the tip of the appendix. An appendectomy was performed in this case.
Laparoscopic appendectomy for appendicitis with peritonitis
This is the case of a 37-year-old male patient who presented with abdominal pain and fever at 39.4°C. The work-up demonstrated important inflammation with leukocytes at 16,000 and CRP levels at 169. CT-scan confirmed an acute appendicitis with an appendicolith at the base. The appendix is probably perforated as the CT-scan also demonstrated a pneumoperitoneum. Laparoscopic appendectomy is decided upon. The operative set-up is standard with an optical port placed at the umbilicus, a port in the left iliac fossa, and a suprapubic port. Exposure, appendectomy with stapling of the appendicular base, and cleansing of the peritoneal cavity are thoroughly demonstrated.
M Ignat, D Mutter, J Marescaux
Surgical intervention
1 year ago
3665 views
473 likes
0 comments
05:03
Laparoscopic appendectomy for appendicitis with peritonitis
This is the case of a 37-year-old male patient who presented with abdominal pain and fever at 39.4°C. The work-up demonstrated important inflammation with leukocytes at 16,000 and CRP levels at 169. CT-scan confirmed an acute appendicitis with an appendicolith at the base. The appendix is probably perforated as the CT-scan also demonstrated a pneumoperitoneum. Laparoscopic appendectomy is decided upon. The operative set-up is standard with an optical port placed at the umbilicus, a port in the left iliac fossa, and a suprapubic port. Exposure, appendectomy with stapling of the appendicular base, and cleansing of the peritoneal cavity are thoroughly demonstrated.
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
P Pessaux, R Memeo, J Hallet, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
1 year ago
6587 views
939 likes
0 comments
32:12
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
O Soubrane, P Pessaux, R Memeo, L Soler, D Mutter, J Marescaux
Surgical intervention
1 year ago
4067 views
566 likes
0 comments
51:19
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
Laparoscopic distal pancreatectomy with spleen resection
We reported a laparoscopic distal pancreatectomy with spleen resection for a mucinous cystic lesion. Four ports were positioned. The greater omentum was retracted to the superior part of the abdomen in order to detach the colon from the omentum and approach the lesser sac. The stomach was dissected. A tape was placed around the stomach through the abdominal wall, making it possible to retract the stomach at the level of the pyloric junction towards the upper part of the abdomen. A second tape was placed at the antral part in order to achieve a retraction towards the left hypochondrium at the superior part of the abdomen. The mesentericoportal axis was identified and dissected at the inferior border of the pancreas. The right gastroepiploic vein was one of the landmarks. The superior border of the pancreas was dissected in order to identify the splenic artery and a tape was positioned around it. The dissection was performed progressively at the anterior aspect of the mesentericoportal axis through an avascular channel. A tape was subsequently positioned around the pancreatic isthmus. The pancreas was divided with a stapler. The stapling was performed very progressively to avoid crushing the pancreas. The splenic vein was dissected in order to preserve the left gastric vein and a tape was positioned around it. The splenic artery was first divided between two clips on the remaining surface. The splenic vein was also divided. Dissection was pursued from the right to the left, making it possible to mobilize the pancreas. The inferior mesenteric vein was dissected and divided. Dissection of the posterior mesogastrium was initiated, making it possible to mobilize the splenopancreatic block. The dissection was performed anteriorly to the plane of Gerota’s fascia, anteriorly to the kidney. Since the posterior dissection was almost complete, our attention was turned to the superior part to complete the dissection of lesser sac adhesions at the superior border of the pancreas. It was necessary to divide the greater omentum by gradually dividing the short gastric vessels. Due to venous derivations linked to segmental portal hypertension, this dissection was performed through the application of the Endo GIA™ linear stapler. Since the entire specimen had been divided and freed, it was placed in a bag to be extracted through a suprapubic Pfannenstiel’s incision.
P Pessaux, X Untereiner, Z Cherkaoui, V Louis, D Mutter, J Marescaux
Surgical intervention
1 year ago
4604 views
602 likes
0 comments
45:34
Laparoscopic distal pancreatectomy with spleen resection
We reported a laparoscopic distal pancreatectomy with spleen resection for a mucinous cystic lesion. Four ports were positioned. The greater omentum was retracted to the superior part of the abdomen in order to detach the colon from the omentum and approach the lesser sac. The stomach was dissected. A tape was placed around the stomach through the abdominal wall, making it possible to retract the stomach at the level of the pyloric junction towards the upper part of the abdomen. A second tape was placed at the antral part in order to achieve a retraction towards the left hypochondrium at the superior part of the abdomen. The mesentericoportal axis was identified and dissected at the inferior border of the pancreas. The right gastroepiploic vein was one of the landmarks. The superior border of the pancreas was dissected in order to identify the splenic artery and a tape was positioned around it. The dissection was performed progressively at the anterior aspect of the mesentericoportal axis through an avascular channel. A tape was subsequently positioned around the pancreatic isthmus. The pancreas was divided with a stapler. The stapling was performed very progressively to avoid crushing the pancreas. The splenic vein was dissected in order to preserve the left gastric vein and a tape was positioned around it. The splenic artery was first divided between two clips on the remaining surface. The splenic vein was also divided. Dissection was pursued from the right to the left, making it possible to mobilize the pancreas. The inferior mesenteric vein was dissected and divided. Dissection of the posterior mesogastrium was initiated, making it possible to mobilize the splenopancreatic block. The dissection was performed anteriorly to the plane of Gerota’s fascia, anteriorly to the kidney. Since the posterior dissection was almost complete, our attention was turned to the superior part to complete the dissection of lesser sac adhesions at the superior border of the pancreas. It was necessary to divide the greater omentum by gradually dividing the short gastric vessels. Due to venous derivations linked to segmental portal hypertension, this dissection was performed through the application of the Endo GIA™ linear stapler. Since the entire specimen had been divided and freed, it was placed in a bag to be extracted through a suprapubic Pfannenstiel’s incision.
Transhepatic percutaneous biliary tract drainage
Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary strictures. It is a procedure which includes the cannulation of an intrahepatic biliary tree using image-guided wire and catheter manipulation, and placement of a tube or stent for external and/or internal drainage. This video shows this technique applied in a patient with a pancreatic tumor.
This is the case of an 80-year-old male patient with signs of jaundice and a diagnosis of intrahepatic and extrahepatic bile duct dilatation and pancreatic tumor.
A transhepatic percutaneous biliary tract drainage was the therapeutic strategy.
F Davrieux, ME Gimenez, EJ Houghton, M Palermo, D Mutter, J Marescaux
Surgical intervention
1 year ago
3407 views
591 likes
0 comments
20:25
Transhepatic percutaneous biliary tract drainage
Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary strictures. It is a procedure which includes the cannulation of an intrahepatic biliary tree using image-guided wire and catheter manipulation, and placement of a tube or stent for external and/or internal drainage. This video shows this technique applied in a patient with a pancreatic tumor.
This is the case of an 80-year-old male patient with signs of jaundice and a diagnosis of intrahepatic and extrahepatic bile duct dilatation and pancreatic tumor.
A transhepatic percutaneous biliary tract drainage was the therapeutic strategy.
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
D Mutter, J Marescaux
Surgical intervention
1 year ago
16283 views
1388 likes
1 comment
25:14
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
B Dallemagne, S Perretta, D Mutter, J Marescaux
Surgical intervention
1 year ago
1177 views
111 likes
0 comments
41:44
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
B Dallemagne, S Perretta, M Diana, F Longo, D Mutter, J Marescaux
Surgical intervention
1 year ago
5022 views
437 likes
0 comments
54:47
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
Laparoscopic equipment and instrumentation in 2017
This two-part presentation outlines the principles and methods of functioning of the main medico-technical devices required to perform laparoscopic surgery.
The first part deals with the laparoscopic unit components including the insufflator, light sources, the evolution of cameras and screens, as well as scopes used in laparoscopic surgery. For each component, operating principles, technological developments, malfunctions and their management are discussed.
The second part presents operating modalities based on novel innovative energy technologies which are used to control tissues. Their operating modalities, specific risks and prevention means are envisaged. This relates in the first place to the evolution of the use of high frequency currents delivering monopolar and bipolar currents within tissues. New ways of management of these currents with tissue vessel-sealing processes are also discussed. Finally, the principles, use and risks of the new means of dissection and tissue sealing with ultrasonic devices are addressed.
The operating principles and the specific risks of all these systems are not well known to surgeons. In case they are not correctly used, they represent new risks and surgeons should be aware of it.
In conclusion, ergonomic choices of conventional instrumentation in minimally invasive surgery are outlined.
D Mutter
Lecture
1 year ago
2983 views
562 likes
0 comments
06:01
Laparoscopic equipment and instrumentation in 2017
This two-part presentation outlines the principles and methods of functioning of the main medico-technical devices required to perform laparoscopic surgery.
The first part deals with the laparoscopic unit components including the insufflator, light sources, the evolution of cameras and screens, as well as scopes used in laparoscopic surgery. For each component, operating principles, technological developments, malfunctions and their management are discussed.
The second part presents operating modalities based on novel innovative energy technologies which are used to control tissues. Their operating modalities, specific risks and prevention means are envisaged. This relates in the first place to the evolution of the use of high frequency currents delivering monopolar and bipolar currents within tissues. New ways of management of these currents with tissue vessel-sealing processes are also discussed. Finally, the principles, use and risks of the new means of dissection and tissue sealing with ultrasonic devices are addressed.
The operating principles and the specific risks of all these systems are not well known to surgeons. In case they are not correctly used, they represent new risks and surgeons should be aware of it.
In conclusion, ergonomic choices of conventional instrumentation in minimally invasive surgery are outlined.
Laparoscopic postpartum right diaphragmatic hernia reduction
A 35-year-old patient was referred to our emergency department for acute abdominal pain and respiratory distress. The patient gave natural childbirth three days before the episode, a childbirth without immediate complications.
Clinically, the patient presented with tachypnea, tachycardia, and desaturation, nauseas and constipation, depressible abdomen with generalized pain on palpation. The absence of vesicular murmur and right lung dullness were noted.
Blood lab findings showed increased inflammatory parameters.
An abdominothoracic CT-scan with contrast was performed. It showed a voluminous right diaphragmatic hernia containing the omentum, a distended colon and liver segment VIII with signs of hypoperfusion.
A surgical procedure was performed. A laparoscopic approach was performed and the patient’s hiatal hernia was reduced by closing the defect with a non-absorbable suture and by placing a Vicryl mesh.
The patient recovered with no complications and was discharged on postoperative day 3.
A D'Urso, P Saleg, D Mutter, J Marescaux
Surgical intervention
1 year ago
1630 views
112 likes
0 comments
09:10
Laparoscopic postpartum right diaphragmatic hernia reduction
A 35-year-old patient was referred to our emergency department for acute abdominal pain and respiratory distress. The patient gave natural childbirth three days before the episode, a childbirth without immediate complications.
Clinically, the patient presented with tachypnea, tachycardia, and desaturation, nauseas and constipation, depressible abdomen with generalized pain on palpation. The absence of vesicular murmur and right lung dullness were noted.
Blood lab findings showed increased inflammatory parameters.
An abdominothoracic CT-scan with contrast was performed. It showed a voluminous right diaphragmatic hernia containing the omentum, a distended colon and liver segment VIII with signs of hypoperfusion.
A surgical procedure was performed. A laparoscopic approach was performed and the patient’s hiatal hernia was reduced by closing the defect with a non-absorbable suture and by placing a Vicryl mesh.
The patient recovered with no complications and was discharged on postoperative day 3.
Live interactive transanal TME (TaTME) with the TEO™ platform
Randomized clinical trials such as COLOR II, COREAN and CLASICC, have shown better results for laparoscopic total mesorectal excision (TME), in terms of short-term and long-term outcomes, when compared with open TME.
Laparoscopic TME presents some limitations such as low rectal cancer which has a high risk of leaving a positive circumferential resection margin (CRM) and a narrow pelvis. Conversion to open procedures remains unsatisfactory.
Transanal TME (taTME) has been proposed to give a new option in cases where laparoscopic TME is difficult.
In this video, we present the case of a transanal approach with the TEO™ platform for low rectal cancer.
A Melani, A D'Urso, D Mutter, J Marescaux
Surgical intervention
1 year ago
3341 views
324 likes
0 comments
45:51
Live interactive transanal TME (TaTME) with the TEO™ platform
Randomized clinical trials such as COLOR II, COREAN and CLASICC, have shown better results for laparoscopic total mesorectal excision (TME), in terms of short-term and long-term outcomes, when compared with open TME.
Laparoscopic TME presents some limitations such as low rectal cancer which has a high risk of leaving a positive circumferential resection margin (CRM) and a narrow pelvis. Conversion to open procedures remains unsatisfactory.
Transanal TME (taTME) has been proposed to give a new option in cases where laparoscopic TME is difficult.
In this video, we present the case of a transanal approach with the TEO™ platform for low rectal cancer.
Removal of large biliary stones
Biliary stones can be easy or difficult to remove, depending on their dimensions. Understanding bile ducts anatomy, choosing the appropriate devices/extraction technique, developing confidence with biliary lithotripsy, choosing the appropriate size of the sphincterotomy, performing large balloon biliary dilation in appropriate cases and management of failed stones extraction are the basic key issues in the management of biliary stones. Here, we present the case of a 96-year-old female patient who had an episode of cholangitis one week ago and ERCP was performed with a biliary precut to access the bile duct. Since the biliary stones were large, a biliary plastic stent was placed and after unintentional pancreatic duct cannulation, a pancreatic stent was also placed to prevent pancreatitis. ERCP was repeated. The biliary stent was removed since the stones were approximately 12mm in diameter. A biliary balloon dilation was carried out to facilitate the removal. At the end, the pancreatic stent was also removed.
I Boškoski, M Morar, RA Ciurezu, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
940 views
83 likes
0 comments
12:52
Removal of large biliary stones
Biliary stones can be easy or difficult to remove, depending on their dimensions. Understanding bile ducts anatomy, choosing the appropriate devices/extraction technique, developing confidence with biliary lithotripsy, choosing the appropriate size of the sphincterotomy, performing large balloon biliary dilation in appropriate cases and management of failed stones extraction are the basic key issues in the management of biliary stones. Here, we present the case of a 96-year-old female patient who had an episode of cholangitis one week ago and ERCP was performed with a biliary precut to access the bile duct. Since the biliary stones were large, a biliary plastic stent was placed and after unintentional pancreatic duct cannulation, a pancreatic stent was also placed to prevent pancreatitis. ERCP was repeated. The biliary stent was removed since the stones were approximately 12mm in diameter. A biliary balloon dilation was carried out to facilitate the removal. At the end, the pancreatic stent was also removed.
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
I Boškoski, I Crisan, M Morar, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
618 views
54 likes
0 comments
18:35
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
I Boškoski, RA Ciurezu, I Crisan, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
1367 views
67 likes
0 comments
09:31
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
I Boškoski, RA Ciurezu, M Morar, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
938 views
66 likes
0 comments
11:04
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
I Boškoski, M Morar, I Crisan, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
801 views
83 likes
0 comments
18:14
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.
I Boškoski, I Crisan, RA Ciurezu, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
478 views
92 likes
0 comments
09:17
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.
LIVE INTERACTIVE SURGERY: Interactive discussion around splenic flexure during laparoscopic sigmoidectomy for cancer
In this educational video, Professor Luc Soler gives a brief introduction of 3D reconstruction and modeling. Dr. Corcione introduces the main principles of trocar and port placement. He briefly demonstrates the technical aspects, main principles and key steps of laparoscopic sigmoidectomy for cancer in a 61-year-old male patient in a live interactive surgery. He highlights the technical aspects and main principles of lesser sac opening, vascular identification and division, splenic flexure mobilization, lateral mobilization, transection, suprapubic incision for specimen removal, and EEA anastomosis.
F Corcione, D Mutter, J Marescaux
Surgical intervention
1 year ago
6186 views
320 likes
0 comments
58:02
LIVE INTERACTIVE SURGERY: Interactive discussion around splenic flexure during laparoscopic sigmoidectomy for cancer
In this educational video, Professor Luc Soler gives a brief introduction of 3D reconstruction and modeling. Dr. Corcione introduces the main principles of trocar and port placement. He briefly demonstrates the technical aspects, main principles and key steps of laparoscopic sigmoidectomy for cancer in a 61-year-old male patient in a live interactive surgery. He highlights the technical aspects and main principles of lesser sac opening, vascular identification and division, splenic flexure mobilization, lateral mobilization, transection, suprapubic incision for specimen removal, and EEA anastomosis.
Laparoscopic appendectomy after appendicular phlegmon
Appendicitis is one of the main reasons for consultation and surgical interventions in the emergency departments around the world. If it is not diagnosed and treated timely, it can evolve towards an appendicular perforation, and as a result, it can become a peritonitis or an appendicular phlegmon. This latter case may occur in approximately 10% of cases.
Currently, the management of the appendicular phlegmon is controversial. Some authors prefer to perform an appendectomy immediately, and others are in favor of medical treatment using antibiotic therapy and percutaneous drainage if possible and delay appendectomy.
In this case, we present a patient presenting with an appendicular phlegmon in which a conservative management with percutaneous drainage and delayed surgery were decided upon.
P Saleg, A D'Urso, D Mutter, J Marescaux
Surgical intervention
1 year ago
7894 views
515 likes
1 comment
04:17
Laparoscopic appendectomy after appendicular phlegmon
Appendicitis is one of the main reasons for consultation and surgical interventions in the emergency departments around the world. If it is not diagnosed and treated timely, it can evolve towards an appendicular perforation, and as a result, it can become a peritonitis or an appendicular phlegmon. This latter case may occur in approximately 10% of cases.
Currently, the management of the appendicular phlegmon is controversial. Some authors prefer to perform an appendectomy immediately, and others are in favor of medical treatment using antibiotic therapy and percutaneous drainage if possible and delay appendectomy.
In this case, we present a patient presenting with an appendicular phlegmon in which a conservative management with percutaneous drainage and delayed surgery were decided upon.
Laparoscopic distal pancreatectomy with splenectomy
In this video, a laparoscopic distal pancreatectomy with a splenectomy is demonstrated. The colon is mobilized from the omentum and the splenic flexure is lowered completely. The dissection is completed towards the right side in order to access the pancreatic isthmus. The dissection is initiated at the level of the inferior pancreatic port in order to identify the mesentericoportal axis. The retropancreatic dissection is performed. The splenic vein and the splenic artery are dissected and taped. A tape is placed around the pancreas in order to facilitate the dissection thanks to the traction exerted. The pancreas is divided by means of a stapler, tan cartridge. The splenic vessels were divided through Hem-o-lok™ Polymer Locking Ligation Systems. The dissection is performed from the right to the left side of the retropancreatic region. The greater omentum is dissected in close contact with the greater curvature of the stomach. The short gastric vessels are progressively divided. The division of the posterior mesogastrium allows to completely free the specimen, which is then placed in a bag. The specimen is removed through a suprapubic Pfannenstiel’s incision.
P Pessaux, R Memeo, V De Blasi, D Mutter, J Marescaux
Surgical intervention
1 year ago
2134 views
159 likes
0 comments
21:51
Laparoscopic distal pancreatectomy with splenectomy
In this video, a laparoscopic distal pancreatectomy with a splenectomy is demonstrated. The colon is mobilized from the omentum and the splenic flexure is lowered completely. The dissection is completed towards the right side in order to access the pancreatic isthmus. The dissection is initiated at the level of the inferior pancreatic port in order to identify the mesentericoportal axis. The retropancreatic dissection is performed. The splenic vein and the splenic artery are dissected and taped. A tape is placed around the pancreas in order to facilitate the dissection thanks to the traction exerted. The pancreas is divided by means of a stapler, tan cartridge. The splenic vessels were divided through Hem-o-lok™ Polymer Locking Ligation Systems. The dissection is performed from the right to the left side of the retropancreatic region. The greater omentum is dissected in close contact with the greater curvature of the stomach. The short gastric vessels are progressively divided. The division of the posterior mesogastrium allows to completely free the specimen, which is then placed in a bag. The specimen is removed through a suprapubic Pfannenstiel’s incision.
Robotic pancreaticoduodenectomy for vaterian ampulloma
We report the case of a robot-assisted pancreaticoduodenectomy for vaterian ampulloma. The patient is positioned in the French position with the assistant between the legs and the robot at the head. Five trocars are used: the camera is introduced through the umbilical trocar. The operation begins with the exploration of the peritoneum and of the liver. The gastric antrum is divided. Each structure of the hepatic pedicle is skeletonized. The superior border of the pancreas is dissected, hence allowing to approach the mesentericoportal axis.
The surgeon proceeds to the inferior border of the pancreas in order to find the mesentericoportal axis and to achieve a retropancreatic passage, which is where the pancreas will be divided. The pancreas is divided using the Sonicision™ cordless ultrasonic dissection device. The first jejunal loop is divided with a stapler. The specimen is totally mobilized ‘en bloc’, and freed from the portal vascular axis with a dissection of the right border of the coeliac trunk. At the end of the dissection, the different arterial and venous structures are skeletonized with a lymph node resection. The reconstruction is performed with a pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy.
P Pessaux, R Memeo, V De Blasi, D Mutter, J Marescaux
Surgical intervention
1 year ago
2196 views
234 likes
0 comments
28:02
Robotic pancreaticoduodenectomy for vaterian ampulloma
We report the case of a robot-assisted pancreaticoduodenectomy for vaterian ampulloma. The patient is positioned in the French position with the assistant between the legs and the robot at the head. Five trocars are used: the camera is introduced through the umbilical trocar. The operation begins with the exploration of the peritoneum and of the liver. The gastric antrum is divided. Each structure of the hepatic pedicle is skeletonized. The superior border of the pancreas is dissected, hence allowing to approach the mesentericoportal axis.
The surgeon proceeds to the inferior border of the pancreas in order to find the mesentericoportal axis and to achieve a retropancreatic passage, which is where the pancreas will be divided. The pancreas is divided using the Sonicision™ cordless ultrasonic dissection device. The first jejunal loop is divided with a stapler. The specimen is totally mobilized ‘en bloc’, and freed from the portal vascular axis with a dissection of the right border of the coeliac trunk. At the end of the dissection, the different arterial and venous structures are skeletonized with a lymph node resection. The reconstruction is performed with a pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy.
Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
The presence of a single parathyroid adenoma accurately located using preoperative imaging is the best indication for minimally invasive surgery when dealing with primary hyperparathyroidism. It is certainly possible to search for several glands that may be suspicious of adenoma, but an extensive experience in video-assisted cervical surgery is required to find the anatomical structures allowing to explore the four parathyroid locations.
Patient and methods:
A 75-year-old obese woman is diagnosed with hypercalcemia, hypophosphoremia, and a high level of PTH during a work-up for joint pain.

Preoperative imaging includes a 3D-reconstructed cervico-mediastinal CT-scan —a computer program developed at the IRCAD-Strasbourg, named VrAnat™, Vr planning™, is used for that purpose. This 3D virtual reconstruction demonstrates three suspicious images respectively located at the right superior parathyroid territory, at the right latero-esophageal area, and at the left inferior parathyroid territory. A video-assisted cervical exploration, guided by this reconstruction, is decided upon. The objective is to find the three suspicious images and to explore the four parathyroid glands.

A 3cm median incision is carried out 2cm above the sternal notch. The right thyrotracheal groove is reached through a dissection performed laterally to the strap muscles and medially to the omohyoid muscle. A complete dissection of the lateral aspect of the thyroid lobe is obtained using blunt dissection and small instruments under endoscopic vision, which is provided by a 30-degree, 5mm scope (Storz, Tüttlingen, Germany). The recurrent laryngeal nerve is identified.

Dissection is now carried on above the inferior thyroid artery. It allows to rapidly identify a superior parathyroid adenoma, which will be resected. It exactly matches with one of the suspicious images.

Dissection is pursued anterior to the intersection between the artery and the nerve so as to find the right inferior parathyroid, which is healthy, underneath the capsule. The latero-esophageal image is now searched for. It is nothing but an anthracosic lymph node.

The left side is approached by dissecting the left jugulocarotid gutter. The left recurrent nerve is identified. The left inferior parathyroid is identified and looks healthy. The suspected image is nothing else but a nodule of the apex of the thyrothymic ligament. The left superior parathyroid, which is healthy, can be finally identified in a strictly orthotopic position, although partially hidden behind a Zuckerkandl’s nodule.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

Miccoli P, Materazzi G, Baggiani A, Miccoli M. Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 2011;34:473-80.
M Vix, D Mutter, J Marescaux
Surgical intervention
1 year ago
482 views
71 likes
0 comments
09:39
Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
The presence of a single parathyroid adenoma accurately located using preoperative imaging is the best indication for minimally invasive surgery when dealing with primary hyperparathyroidism. It is certainly possible to search for several glands that may be suspicious of adenoma, but an extensive experience in video-assisted cervical surgery is required to find the anatomical structures allowing to explore the four parathyroid locations.
Patient and methods:
A 75-year-old obese woman is diagnosed with hypercalcemia, hypophosphoremia, and a high level of PTH during a work-up for joint pain.

Preoperative imaging includes a 3D-reconstructed cervico-mediastinal CT-scan —a computer program developed at the IRCAD-Strasbourg, named VrAnat™, Vr planning™, is used for that purpose. This 3D virtual reconstruction demonstrates three suspicious images respectively located at the right superior parathyroid territory, at the right latero-esophageal area, and at the left inferior parathyroid territory. A video-assisted cervical exploration, guided by this reconstruction, is decided upon. The objective is to find the three suspicious images and to explore the four parathyroid glands.

A 3cm median incision is carried out 2cm above the sternal notch. The right thyrotracheal groove is reached through a dissection performed laterally to the strap muscles and medially to the omohyoid muscle. A complete dissection of the lateral aspect of the thyroid lobe is obtained using blunt dissection and small instruments under endoscopic vision, which is provided by a 30-degree, 5mm scope (Storz, Tüttlingen, Germany). The recurrent laryngeal nerve is identified.

Dissection is now carried on above the inferior thyroid artery. It allows to rapidly identify a superior parathyroid adenoma, which will be resected. It exactly matches with one of the suspicious images.

Dissection is pursued anterior to the intersection between the artery and the nerve so as to find the right inferior parathyroid, which is healthy, underneath the capsule. The latero-esophageal image is now searched for. It is nothing but an anthracosic lymph node.

The left side is approached by dissecting the left jugulocarotid gutter. The left recurrent nerve is identified. The left inferior parathyroid is identified and looks healthy. The suspected image is nothing else but a nodule of the apex of the thyrothymic ligament. The left superior parathyroid, which is healthy, can be finally identified in a strictly orthotopic position, although partially hidden behind a Zuckerkandl’s nodule.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

Miccoli P, Materazzi G, Baggiani A, Miccoli M. Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 2011;34:473-80.
Right and left adrenalectomy by transperitoneal approach
In this video, Professor Didier Mutter demonstrates different approaches for laparoscopic adrenalectomy. For a precise and fast dissection, the quality of camera and instruments is essential. Vascular landmarks are of paramount importance, Sometimes, there is a duplication of the adrenal vein, and any mistake in dissection can cause difficulty to control bleeding. 3D reconstruction helps to identify some original anatomical variations. In this lecture, Professor Mutter also discusses the robotic approach used to perform an adrenalectomy with 3D reconstruction for vascular exploration in order to prevent renal vascular damage. The laparoscopic approach is the gold standard for all types of glands. In some complicated cases, the procedure is converted to an open procedure. This does not mean that the technique has failed.
D Mutter
Lecture
2 years ago
3026 views
291 likes
1 comment
18:17
Right and left adrenalectomy by transperitoneal approach
In this video, Professor Didier Mutter demonstrates different approaches for laparoscopic adrenalectomy. For a precise and fast dissection, the quality of camera and instruments is essential. Vascular landmarks are of paramount importance, Sometimes, there is a duplication of the adrenal vein, and any mistake in dissection can cause difficulty to control bleeding. 3D reconstruction helps to identify some original anatomical variations. In this lecture, Professor Mutter also discusses the robotic approach used to perform an adrenalectomy with 3D reconstruction for vascular exploration in order to prevent renal vascular damage. The laparoscopic approach is the gold standard for all types of glands. In some complicated cases, the procedure is converted to an open procedure. This does not mean that the technique has failed.
Robot-assisted ultrasound-guided transgastric cystogastrostomy
We report the case of a 57-year-old woman with a voluminous pseudocyst in the lesser sac after several episodes of acute pancreatitis of biliary origin managed by a robot-assisted transgastric cystogastrostomy. The patient is lying supine, legs apart. Five ports are positioned. The intervention is begun with an anterior gastrotomy, which allows to introduce a balloon-tipped trocar transgastrically. A second gastrotomy is performed in the prepyloric region. It allows to introduce a second transgastric trocar. Finally, a third gastrotomy is performed at the level of the fundus to introduce a third transgastric balloon-tipped trocar. After transgastric insufflation, the trocars are connected to the robot, which is positioned at the patient’s head. A transgastric ultrasonography is performed to visualize the pseudocyst, which has a heterogeneous content, with fibrotic debris. The gastrotomy is initiated with Ultracision™ at the posterior aspect of the stomach. The cyst is multilocular. The gastric wall is controlled by means of a Doppler ultrasound in order not to pass through the gastric varices, which had been identified on endoscopic ultrasound. A second cavity with some more heterogeneous content is subsequently opened. This cavity presents some pancreatic necrosis. The cystogastrostomy is enlarged at its most. Trocars are then removed to proceed intraperitoneally. The three anterior gastrotomy incisions are then sutured using the robot. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
P Pessaux, R Memeo, V De Blasi, O Perotto, D Mutter, J Marescaux
Surgical intervention
2 years ago
1104 views
51 likes
0 comments
06:04
Robot-assisted ultrasound-guided transgastric cystogastrostomy
We report the case of a 57-year-old woman with a voluminous pseudocyst in the lesser sac after several episodes of acute pancreatitis of biliary origin managed by a robot-assisted transgastric cystogastrostomy. The patient is lying supine, legs apart. Five ports are positioned. The intervention is begun with an anterior gastrotomy, which allows to introduce a balloon-tipped trocar transgastrically. A second gastrotomy is performed in the prepyloric region. It allows to introduce a second transgastric trocar. Finally, a third gastrotomy is performed at the level of the fundus to introduce a third transgastric balloon-tipped trocar. After transgastric insufflation, the trocars are connected to the robot, which is positioned at the patient’s head. A transgastric ultrasonography is performed to visualize the pseudocyst, which has a heterogeneous content, with fibrotic debris. The gastrotomy is initiated with Ultracision™ at the posterior aspect of the stomach. The cyst is multilocular. The gastric wall is controlled by means of a Doppler ultrasound in order not to pass through the gastric varices, which had been identified on endoscopic ultrasound. A second cavity with some more heterogeneous content is subsequently opened. This cavity presents some pancreatic necrosis. The cystogastrostomy is enlarged at its most. Trocars are then removed to proceed intraperitoneally. The three anterior gastrotomy incisions are then sutured using the robot. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
Robotic partial splenectomy for cystic lesion of the spleen
We report the case of a 21-year-old woman with a cystic lesion of the spleen treated with a robotic partial splenectomy. The patient is placed in a right lateral decubitus position. Four ports are introduced into the left hypochondrium. The robot is placed at the level of the patient’s left shoulder. The intervention is begun with a lowering of the splenic flexure. Dissection is initiated at the upper pole of the spleen by retracting the stomach and by progressively dividing the different short vessels. It is decided to start the parenchymotomy approximately 1cm from the devascularized area. Transection is begun using an ultrasonic dissector. Hemostasis is subsequently achieved progressively. Transection is completed by means of a firing of the Endo GIA™ linear stapler. Hemostasis is further completed using the Aquamantys® system and bipolar sealers. The specimen is fully mobilized and placed in a bag. It is extracted by means of a small suprapubic Pfannenstiel’s incision. Pathological findings demonstrate the presence of an epidermoid cyst. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
P Pessaux, R Memeo, V De Blasi, N Ferreira, D Mutter, J Marescaux
Surgical intervention
2 years ago
1766 views
70 likes
0 comments
09:14
Robotic partial splenectomy for cystic lesion of the spleen
We report the case of a 21-year-old woman with a cystic lesion of the spleen treated with a robotic partial splenectomy. The patient is placed in a right lateral decubitus position. Four ports are introduced into the left hypochondrium. The robot is placed at the level of the patient’s left shoulder. The intervention is begun with a lowering of the splenic flexure. Dissection is initiated at the upper pole of the spleen by retracting the stomach and by progressively dividing the different short vessels. It is decided to start the parenchymotomy approximately 1cm from the devascularized area. Transection is begun using an ultrasonic dissector. Hemostasis is subsequently achieved progressively. Transection is completed by means of a firing of the Endo GIA™ linear stapler. Hemostasis is further completed using the Aquamantys® system and bipolar sealers. The specimen is fully mobilized and placed in a bag. It is extracted by means of a small suprapubic Pfannenstiel’s incision. Pathological findings demonstrate the presence of an epidermoid cyst. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy for pheochromocytoma
Laparoscopic adrenalectomy was first described by Gagner et al. in 1992. It has become the procedure of choice for most benign adrenal lesions since then because of decreased blood loss, shorter hospital stay, faster recovery, and lower morbidity as compared to open surgery.
The indications for laparoscopic adrenalectomy are the same as for open surgery, except in cases of confirmed adrenocortical carcinomas.
Absolute contraindications for laparoscopic adrenalectomy are as follows: severe cardiopulmonary disease, locally advanced tumors, medically untreated pheochromocytoma, and uncontrolled coagulopathies. This is a live demonstration of a left adrenalectomy recorded during the Minimally Invasive Endocrine Surgery Course, which was held at IRCAD in May 2016.
D Mutter, P Donepudi, J Marescaux
Surgical intervention
2 years ago
3756 views
333 likes
1 comment
28:17
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy for pheochromocytoma
Laparoscopic adrenalectomy was first described by Gagner et al. in 1992. It has become the procedure of choice for most benign adrenal lesions since then because of decreased blood loss, shorter hospital stay, faster recovery, and lower morbidity as compared to open surgery.
The indications for laparoscopic adrenalectomy are the same as for open surgery, except in cases of confirmed adrenocortical carcinomas.
Absolute contraindications for laparoscopic adrenalectomy are as follows: severe cardiopulmonary disease, locally advanced tumors, medically untreated pheochromocytoma, and uncontrolled coagulopathies. This is a live demonstration of a left adrenalectomy recorded during the Minimally Invasive Endocrine Surgery Course, which was held at IRCAD in May 2016.
Laparoscopic distal pancreatectomy for mucinous cystadenoma
This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.
F Costantino, M Shahbaz, D Mutter, J Marescaux
Surgical intervention
2 years ago
1906 views
94 likes
0 comments
12:01
Laparoscopic distal pancreatectomy for mucinous cystadenoma
This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
P Pessaux, R Memeo, V De Blasi, D Mutter, T Piardi, J Marescaux
Surgical intervention
2 years ago
655 views
17 likes
0 comments
16:09
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
P Pessaux, R Memeo, J Hargat, S Tzedakis, D Mutter, J Marescaux, L Soler
Surgical intervention
2 years ago
2022 views
42 likes
0 comments
08:07
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
P Pessaux, J Hallet, R Memeo, S Tzedakis, V De Blasi, D Mutter, J Marescaux, L Soler
Surgical intervention
2 years ago
1644 views
58 likes
0 comments
13:06
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.