Joseph NASSIF

In this key lecture, Dr. Joseph Nassif provides an overview of the management of borderline ovarian tumors.

After a keyed description of the material useful for suturing, Dr. Joseph Nassif exposes a global vision of suturing: what are the correct ergonomics and techniques to load the needle and to do extracorporeal and intracorporeal knots. This presentation provides a first good overview!

This lecture focuses on complications in laparoscopic surgery for endometriosis. First, the expert addresses how to define complications. Surgeons sometimes need to remove part of the adjacent structures such as bowel, vagina and ureter, which should be included in the surgery – to achieve a complete excision of the disease. Complications can always occur and the most important thing to be borne in mind is to know how to deal with them by laparoscopy.
Complications may include adhesions, bowel, ureter and vascular injuries. The rate of complications in rectal shaving ranges from 0.2 to 1.4%. In case of discoid bowel resection, the morbidity rate published in the literature is 13%. Regarding rectal segmental resection, the rate of complications in laparoscopy (4.25%) is similar to that of laparotomy (4.5%). The rate of rectovaginal fistula in case of rectal shaving is 8.3%, and in rectal segmental resection 3.1%, which is not associated with the distance between the anastomosis and the rectum. Voiding problems are frequent and the incidence of urinary retention ranges from 1 to 29% and depends on the interval of observation. Finally, in case of ureteral endometriosis, a double J catheter should be always placed in order to decrease the risk of ureteral fistula.

Standardization means: implementing guidelines or measurements in order to obtain solutions to a disorganized system. Laparoscopic sacrocolpopexy is a long and complete surgical procedure that requires good knowledge of the anatomy and of the surgical technique, as well as advanced suturing skills. Laparoscopic sacrocolpopexy is also the gold standard procedure for POP repair, and its standardization is justified by its difficulty.
This video demonstrates the standard technique for laparoscopic sacrocolpopexy with sub-total hysterectomy. It is called “the six-point technique” due to the six stitches used to fix the meshes.

A 56-year-old woman, G2P2 (vaginal deliveries), presented with a cystocele grade 3, a hysterocele grade 2 and a rectocele grade 1 during physical examination. She underwent a laparoscopic sacrocolpopexy with uterine preservation.

This is the case of a 34-year-old patient with secondary infertility and symptomatology of dyspareunia, chronic pelvic pain and dysmenorrhea. The MRI demonstrated the presence of pelvic endometriosis with a rectovaginal nodule.

A 71-year-old woman presented with a cystocele grade 4, a hysterocele grade 4 and a rectocele grade 2 during physical examination. As the patient did not want to perform a hysterectomy, she underwent a laparoscopic promontofixation with uterine preservation.

Some believe that laparoscopy is almost impossible to perform in cases of very big uterus or large adnexal masses that obstruct our view to the pelvis. However, if the same surgical steps are always followed and a specific strategy is determined, it is feasible and safe to choose laparoscopy even in the case of large organs. In this video, we present the case of a 45-year-old patient with a large fibromatous uterus, suffering from abdominal discomfort and bleeding. The patient was anemic and decision was made to perform a laparoscopic total hysterectomy. With the appropriate surgical steps and some safety tips, the operation took place quickly and with success. The weight of the specimen was 1300g.

Surgery is the treatment of choice for myomas. Myomectomy has undergone a dramatic evolution over the years. Laparoscopic myomectomy provides a preferable alternative to abdominal myomectomy for women with symptomatic fibroids who desire uterine preservation. It is also an excellent method for women who have infertility primarily related to fibroids. A lot of patients prefer myomectomy over hysterectomy even if they do not desire pregnancy. However, laparoscopic myomectomy is not easy and needs some practice. Together with the basic steps, some tips and tricks are provided to make this technique even more safe and feasible for surgeons. For good results, the use of a few technical tricks provides an optimal solution for all issues.

NOTES cholecystectomy in its hybrid format is a first step towards new methods and devices to explore the potentialities of this incisionless natural orifice transluminal endoscopic procedure. In this lecture, Dr. Silvana Perretta reports the follow-up of the first NOTES transvaginal cholecystectomy performed at the University of Strasbourg, France.

We report the clinical case of a 59-year-old patient with a previous obstetrical history of two normal deliveries and a previous surgical history of appendectomy, lobular breast cancer treated by breast-preserving surgery, radiation and hormone therapy.
This patient complains of vaginal bulge symptoms and of a mild Stress Urinary Incontinence.
On clinical examination, a cystocele stage III, uterine prolapse stage II, and rectocele stage I were found.
The urodynamic examination revealed no bladder instability, UCP: 89cm H20, normal compliance, and negative clinical stress test.

This video demonstrates the technique of a total laparoscopic hysterectomy with unilateral adnexectomy and the excision of a vesical endometriotic nodule.
This patient is a 46-year-old lady with a previous surgical history of one laparotomy for a hemoperitoneum (endometriotic ovarian cyst rupture) and 6 laparoscopies because of endometriosis, the last one 3 years ago with a segmental sigmoid resection. After this last surgery, the patient starts to complain of dysmenorrhea, chronic pelvic pain and dysuria. She has never had any urinary infection.
Because of urinary stress incontinence, she had botulinic toxin injection and underwent a cystoscopy, which revealed a bladder nodule.

In this video, we present the case of a late infectious complication after abdominal hysterectomy and sacral colpopexy using mesh interposition. We demonstrate the complete laparoscopic removal of the infected mesh, including excision of all the affected surrounding tissue. This is the case of a 57-year-old patient who had a total hysterectomy with bilateral adnexectomy and sacrocolpopexy in 2005. In 2009, she started to complain of an abundant, continuous and smelly vaginal discharge. The microbiological exam revealed a vaginal infection by Proteus mirabilis and the gynecologic examination showed a painful vaginal tumor with a drainage hole.

This video shows the excision of a persistent post-caesarean section hematoma located in the vesicouterine space. The case is that of a 25-year-old patient with a previous caesarean section due to twin pregnancy and HELLP syndrome, that was performed 2 years before the present surgery. She complained of pain when her bladder was full and of dyspareunia. During the ultrasound exam, the presence of a mass in the vesicouterine space was found. We therefore decided to perform a laparoscopy in order to diagnose and treat the vesicouterine mass.

In this video, we show a technique to excise a non-infiltrating endometriotic nodule of the bladder wall. After MRI study and cystoscopy, the decision to do a mucosal skinning is undertaken. Filling of the bladder, use of adequate energy and traction are the main features to perform mucosal skinning. The bladder serosa is then sutured.

Ureteral endometriosis is unfrequent and it is defined by the presence of endometrial glands in the ureteric or pre-ureteric tissue. The prevalence reported is less than 1% and usually confined to the lower one-third of the left ureter. This pathology generates a ureteral stenosis, with an extrinsic compression of the ureteral wall by the inflammatory response and fibrosis, or an intrinsic stenosis with the invasion of the uro-epithelium and submucosal layer of the ureteral wall. We present a short video describing the technique of the laparoscopic segmental ureteral resection followed by the re-anastomosis.

In this lecture, the preoperative assessment of endometriosis, especially bowel and bladder endometriosis, is discussed. The preoperative work-up facilitates the surgical management and defines any multidisciplinary approach, if needed. Physical exam, ultrasonography, Magnetic Resonance Imaging (MRI) and other tests are outlined. Evidence-based medicine conclusions are also cited for each method of evaluation.

In this case of severe deep infiltrative endometriosis, you will find the surgical approach for an anterior resection of a rectal endometriotic nodule, using a circular DST stapler. We will show you the different steps to perform this procedure, and a final rectoscopy to evaluate the results.

Development of new multifunctional devices for laparoscopic surgery is crucial for reducing operative time. This video demonstrates the application of a new grasper, the Robby-type, by Karl Storz (Tüttlingen, Germany) in uterosacral endometriotic nodule excision and cystectomy for endometrioma.

In this video, we show the indications, technique and contraindications of direct port entry in laparoscopic surgery. Although this way of entry is not popular, recent data show that there are no differences in terms of safety for a way of entry (i.e., Veress needle, open laparoscopy, Hasson's technique, direct entry, etc.) when compared to another. We also discuss some hints and tips and tricks to use when performing this entry technique.

Ovarian cancer usually affects women over age 50, but it can also occur in younger women. Its cause is unknown and is hard to detect early. We present a short video describing the technique of laparoscopic restaging for ovarian cancer with pelvic and lumbo-aortic lymphadenectomy.

This video shows a myomectomy in which uterine arteries and infundibulopelvic ligaments are clipped temporarily in order to reduce intraoperative blood loss.
In addition, the incision of the uterus used to extract the myoma is not typical as the myoma is partially intramural and partially in the broad ligament. The choice of this incision is driven by the aim of decreasing blood loss, obtaining good ergonomics and anatomical exposure.

The video "Laparoscopic total hysterectomy and bilateral pelvic lymphadenectomy for endometrial cancer" authored by A Wattiez, J Nassif, C Zacharopoulou is analysed by Dr. C Pomel, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

This video demonstrates the technique of a total laparoscopic hysterectomy with adnexectomy. Our patient is a 44-year-old lady with Tamoxifen-induced endometrial hyperplasia, which failed to respond to medical treatment.
Umbilical incision is made on the left internal border to give a more aesthetic scar.
Direct entry is performed. The assistant helps to lift the abdomen while the surgeon directs the trocar perpendicularly towards the rectus sheath first, then directs it towards the pelvis. The midline port is inserted: this should be at a slightly higher level than the lateral ports for better ergonomics. The uterine manipulator has a rotating ceramic valve for opening the vagina and a set of rings to maintain the pneumoperitoneum. The procedure is started by coagulating and cutting the round ligament on the left and opening the broad ligament. The broad ligament is opened parallel to the infundibulopelvic ligament for adnexectomy and a window is made over the grey area. The posterior leaf of the broad ligament is opened towards the left uterosacral ligament. The anterior leaf of the broad ligament is opened towards the vagina by dissecting the space and coagulating and cutting the tissues in between. The dissection is continued until the uterine artery is reached. The left infundibulopelvic ligament is coagulated and cut. The same procedure is done on the other side. Bladder dissection is performed with the help of the assistant holding up the bladder and entering the vesicovaginal space. The bladder is dissected away, beyond the valve of the manipulator. The left uterine artery is coagulated and cut. The left uterosacral ligament is coagulated and cut. The right uterine vessels are coagulated and cut followed by the uterosacral ligament. The vagina is now cut against the valve of the manipulator using a monopolar hook. Bleeding points are coagulated with a bipolar forceps. The vagina is sutured in two layers using extracorporeal knots. The procedure is now complete and hemostasis is confirmed. This patient had a favourable postoperative outcome and was discharged on postoperative day 1.