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Ronan CAHILL

Beaumont Hospital
Dublin, Ireland
MD, FRCS
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Single port laparoscopic-assisted ileocolic resection for recurrent Crohn's disease
Background: Here we demonstrate a single port laparoscopic ileocolic resection technique in a patient with Crohn’s disease and recurrent anastomotic stricturing despite prior ileocaecal resection and medication.
Procedure: The procedure is begun with a 3cm transumbilical incision. After safe peritoneal entry, a wound protector-retractor was placed into the wound and then sealed for laparoscopy with a surgical glove port. Thereafter, the operation proceeded using a 30-degree high definition laparoscope with sterile in-line cabling (EndoEYE™, Olympus Corporation) along with other standard, rigid instrumentation (primarily an atraumatic grasper and a LigaSure™ sealer-cutter, Covidien). The strictured anastomotic segment was cleared of an omental adhesion and mobilized laterally. The proximal colon was fully mobilized and the duodenum as well as right gonadal vessels and ureter were clearly preserved. After medialization of the diseased segment, the glove port was removed and the specimen extracted (without further fascial extension) via the single port access site. A side-to-side stapled anastomosis was performed in the usual fashion and re-laparoscopy done after return of the bowel into the peritoneum.
Comment: Single port laparoscopic-assisted surgery is applicable to the re-operative setting in selected patients. Its advantages particularly apply to young patients who value body image and reduced scarring.
Surgical intervention
5 years ago
2329 views
45 likes
0 comments
12:34
Single port laparoscopic-assisted ileocolic resection for recurrent Crohn's disease
Background: Here we demonstrate a single port laparoscopic ileocolic resection technique in a patient with Crohn’s disease and recurrent anastomotic stricturing despite prior ileocaecal resection and medication.
Procedure: The procedure is begun with a 3cm transumbilical incision. After safe peritoneal entry, a wound protector-retractor was placed into the wound and then sealed for laparoscopy with a surgical glove port. Thereafter, the operation proceeded using a 30-degree high definition laparoscope with sterile in-line cabling (EndoEYE™, Olympus Corporation) along with other standard, rigid instrumentation (primarily an atraumatic grasper and a LigaSure™ sealer-cutter, Covidien). The strictured anastomotic segment was cleared of an omental adhesion and mobilized laterally. The proximal colon was fully mobilized and the duodenum as well as right gonadal vessels and ureter were clearly preserved. After medialization of the diseased segment, the glove port was removed and the specimen extracted (without further fascial extension) via the single port access site. A side-to-side stapled anastomosis was performed in the usual fashion and re-laparoscopy done after return of the bowel into the peritoneum.
Comment: Single port laparoscopic-assisted surgery is applicable to the re-operative setting in selected patients. Its advantages particularly apply to young patients who value body image and reduced scarring.
The glove TEM port: the poor man's TEM
Objective: Single port laparoscopic tools and principles are transferable to transanal work. Initial experiences and small series have recently been reported with the use of commercially available singe port systems. In an effort to improve the ergonomic constraints as well as to reduce the costs associated with these commercially available ports, we have further evolved our personal experience with the glove port towards an access modality equivalent to Transanal Endoscopic Microsurgery (TEM) for the intraluminal management of rectal disease. Here we describe this new and cost-effective technique for transanal work in a short video.
Materials and Methods: The glove TEM port is constructed on table by using a circular anal dilator (CAD), a wound retractor-protector (ALEXIS®, Applied Medical) and a standard sterile surgical glove. The wound retractor-protector is inserted through the CAD and anchors itself at the anorectal junction. Sealing the outer ring of the wound retractor with the cuff of the surgical glove creates a workspace and airtight seal. Through the fingers of the glove, standard laparoscopic trocar sleeves are inserted (along with a gas insufflation channel) through which a conventional 30-degree videoscope along with straight rigid laparoscopic instruments are inserted. Excellent views can be obtained with the regular laparoscopic optics after the creation of a stable pneumorectum of 10-15mmHg. The same principles apply for the dissection and resection as with a conventional TEM. The flexibility of the glove provides enhanced instrument maneuverability in each of the horizontal, vertical and rotational planes as well as improved tip abduction and adduction especially useful for suturing.
Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument maneuverability and range of movement. Thereafter, all patients eligible for TEM have been offered the option to participate in our pilot study. With this new access modality, ten consecutive patients between October 2010 and January 2011 underwent resection of benign (n=6) or malignant (n=4) rectal tumors. Only one case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. The case we present here is a full-thickness excision of an early rectal cancer in an 87-year-old female patient who was unfit for the conventional radical rectal resection.
Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon-friendly, economically attractive, and universally applicable.
Surgical intervention
7 years ago
2615 views
30 likes
0 comments
08:10
The glove TEM port: the poor man's TEM
Objective: Single port laparoscopic tools and principles are transferable to transanal work. Initial experiences and small series have recently been reported with the use of commercially available singe port systems. In an effort to improve the ergonomic constraints as well as to reduce the costs associated with these commercially available ports, we have further evolved our personal experience with the glove port towards an access modality equivalent to Transanal Endoscopic Microsurgery (TEM) for the intraluminal management of rectal disease. Here we describe this new and cost-effective technique for transanal work in a short video.
Materials and Methods: The glove TEM port is constructed on table by using a circular anal dilator (CAD), a wound retractor-protector (ALEXIS®, Applied Medical) and a standard sterile surgical glove. The wound retractor-protector is inserted through the CAD and anchors itself at the anorectal junction. Sealing the outer ring of the wound retractor with the cuff of the surgical glove creates a workspace and airtight seal. Through the fingers of the glove, standard laparoscopic trocar sleeves are inserted (along with a gas insufflation channel) through which a conventional 30-degree videoscope along with straight rigid laparoscopic instruments are inserted. Excellent views can be obtained with the regular laparoscopic optics after the creation of a stable pneumorectum of 10-15mmHg. The same principles apply for the dissection and resection as with a conventional TEM. The flexibility of the glove provides enhanced instrument maneuverability in each of the horizontal, vertical and rotational planes as well as improved tip abduction and adduction especially useful for suturing.
Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument maneuverability and range of movement. Thereafter, all patients eligible for TEM have been offered the option to participate in our pilot study. With this new access modality, ten consecutive patients between October 2010 and January 2011 underwent resection of benign (n=6) or malignant (n=4) rectal tumors. Only one case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. The case we present here is a full-thickness excision of an early rectal cancer in an 87-year-old female patient who was unfit for the conventional radical rectal resection.
Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon-friendly, economically attractive, and universally applicable.
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
Surgical intervention
8 years ago
129 views
3 likes
0 comments
02:28
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
Optical coherence tomography (OCT) of the colon and its mesentery (including virtual sentinel node biopsy) by natural orifice transluminal endoscopic surgery
Optical coherence tomography (OCT) is capable of 2–3mm slicing in opaque samples and so provides real-time cross-sectional images from the specimen. OCT can also achieve resolutions approaching that of conventional histology (c. 2–5μm) as it employs very short wave near-infrared light with precise interferometric detection. Although now mainly used in ophthalmology, OCT has already been found to have clinical applications in dermatology, cardiology, neurology, gynecology and gastroenterology. Dr. Ronan Cahill have deployed a commercially available probe (NIRIS™, Imulax Corporation, Cleveland OH, USA) via the working channel of a gastroscope used as a N.O.T.E.S. peritoneoscope in an experimental model. By this means, high-resolution real-time images mesenteric sentinel nodes have been obtained. Placing such a probe on the surface of the node should provide examination of the tissue to a depth of 2mm. In this video, we show the application of this technique in an experimental model.
Surgical intervention
10 years ago
187 views
2 likes
0 comments
07:42
Optical coherence tomography (OCT) of the colon and its mesentery (including virtual sentinel node biopsy) by natural orifice transluminal endoscopic surgery
Optical coherence tomography (OCT) is capable of 2–3mm slicing in opaque samples and so provides real-time cross-sectional images from the specimen. OCT can also achieve resolutions approaching that of conventional histology (c. 2–5μm) as it employs very short wave near-infrared light with precise interferometric detection. Although now mainly used in ophthalmology, OCT has already been found to have clinical applications in dermatology, cardiology, neurology, gynecology and gastroenterology. Dr. Ronan Cahill have deployed a commercially available probe (NIRIS™, Imulax Corporation, Cleveland OH, USA) via the working channel of a gastroscope used as a N.O.T.E.S. peritoneoscope in an experimental model. By this means, high-resolution real-time images mesenteric sentinel nodes have been obtained. Placing such a probe on the surface of the node should provide examination of the tissue to a depth of 2mm. In this video, we show the application of this technique in an experimental model.
Gastric lymphatic mapping for sentinel node biopsy by natural orifice transluminal endoscopic surgery (NOTES)
This video demonstrates fully how NOTES can facilitate 'cherry-picking' of sentinel nodes from the perigastric lymph basins (including the retropyloric space) after gastroscopic lymphatic mapping of a site in the stomach in an experimental model. It is proposed that this could be partnered with advanced endoscopic resective techniques such as Submucosal Endoscopic Dissection (SED) in order to allow definitive endoscopic excision of early stage gastric cancers.
This video is reproduced here by kind permission of Surgical Endoscopy.
2008 Sep 24. [Epub ahead of print]. PMID: 18813997 [PubMed - as supplied by publisher]

Surgical intervention
10 years ago
222 views
3 likes
0 comments
07:16
Gastric lymphatic mapping for sentinel node biopsy by natural orifice transluminal endoscopic surgery (NOTES)
This video demonstrates fully how NOTES can facilitate 'cherry-picking' of sentinel nodes from the perigastric lymph basins (including the retropyloric space) after gastroscopic lymphatic mapping of a site in the stomach in an experimental model. It is proposed that this could be partnered with advanced endoscopic resective techniques such as Submucosal Endoscopic Dissection (SED) in order to allow definitive endoscopic excision of early stage gastric cancers.
This video is reproduced here by kind permission of Surgical Endoscopy.
2008 Sep 24. [Epub ahead of print]. PMID: 18813997 [PubMed - as supplied by publisher]

NOTES approach to lymphatic mapping in the sigmoid mesocolon
This video fully demonstrates all the technical aspects of performing sentinel node biopsy in the sigmoid mesocolon by NOTES. A transgastric access to the peritoneum allows a flexible gastroscope observe the lymphatic mapping in real-time and then to perform excisional nodal biopsy while magnetic retraction provides full exposure of the sigmoid mesentery. Such a totally NOTES procedure could be used to supplement colonoscopic intraluminal dissection (e.g. ESD) or prompt transmural localized resection (perhaps also by NOTES).

This video is reproduced here by kind permission of the Annals of Surgical Oncology and Springer Verlag.
Publication citation: Lymphatic mapping and sentinel node biopsy in the colonic mesentery by NOTES. RA Cahill, S Perretta, J Leroy, B Dallemagne, J Marescaux. Annals of Surgical Oncology 2008 Oct;15(10):2677-2683. Epub 2008 May 20.
Note: This work is also the subject of an invited editorial in the same issue: i.e. Takeuchi H, Kitagawa Y. Sentinel Node Biopsy Without Scars: Does Natural Orifice Transluminal Endoscopic Surgery Herald a New Era for Early GI Cancer? Ann Surg Oncol 2008 Oct;15(10):2639-40.
Surgical intervention
11 years ago
373 views
0 likes
0 comments
05:16
NOTES approach to lymphatic mapping in the sigmoid mesocolon
This video fully demonstrates all the technical aspects of performing sentinel node biopsy in the sigmoid mesocolon by NOTES. A transgastric access to the peritoneum allows a flexible gastroscope observe the lymphatic mapping in real-time and then to perform excisional nodal biopsy while magnetic retraction provides full exposure of the sigmoid mesentery. Such a totally NOTES procedure could be used to supplement colonoscopic intraluminal dissection (e.g. ESD) or prompt transmural localized resection (perhaps also by NOTES).

This video is reproduced here by kind permission of the Annals of Surgical Oncology and Springer Verlag.
Publication citation: Lymphatic mapping and sentinel node biopsy in the colonic mesentery by NOTES. RA Cahill, S Perretta, J Leroy, B Dallemagne, J Marescaux. Annals of Surgical Oncology 2008 Oct;15(10):2677-2683. Epub 2008 May 20.
Note: This work is also the subject of an invited editorial in the same issue: i.e. Takeuchi H, Kitagawa Y. Sentinel Node Biopsy Without Scars: Does Natural Orifice Transluminal Endoscopic Surgery Herald a New Era for Early GI Cancer? Ann Surg Oncol 2008 Oct;15(10):2639-40.