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Michele DIANA

Hôpitaux Universitaires de Strasbourg
Strasbourg, France
MD, PhD
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Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
Surgical intervention
10 months ago
4084 views
11 likes
0 comments
12:41
Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
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.
Surgical intervention
1 year ago
5873 views
441 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.
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.