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Leonardo GERARD

European School of Laparoscopic Surgery, Saint-Pierre University Hospital
Brussels, Belgium
MD
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Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.
Surgical intervention
2 years ago
2760 views
224 likes
1 comment
10:22
Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.
Laparoscopic prosthetic parastomal and perineal hernias repair after abdominoperineal resection
Background: In this video, the authors report the case of a 74-year-old woman who consulted for episodes of intestinal occlusions following an abdomino-perineal resection for rectal adenocarcinoma (pT2N0M0), performed 6 years earlier. Abdomino-pelvic CT-scan showed a parastomal hernia with migrated small bowel loops and a perineal hernia with transposition of the caecum and bowel loops into the pelvis. Preoperative work-up was negative for tumor recurrence, hence a laparoscopic treatment using a double dual face prosthesis was proposed.

Video: Three trocars were placed into the abdomen. After adhesiolysis and removal of the viscera herniated into the hernia, the parastomal defect was exposed and measured intracorporeally 6cm (cranio-caudally) and 4cm (latero-laterally). An intracorporeal suture was used to close the defect, and a dual face prosthesis of 15cm in length and 10cm in width (Surgimesh XB, Aspide Medical, Saint-Etienne, France) was fixed by means of absorbable tacks (Sorbafix, Bard Davol Inc., Warwick, RI, US), according to the Sugarbaker technique. Successively, the pelvis was freed from adhesions, and the superior pelvic opening appeared to be 8cm (antero-posteriorly) and 7cm (latero-laterally). A dual face circular prosthesis of 10cm (Surgimesh XB, Aspide Medical) was fixed using two running sutures around the superior pelvic opening.

Results: Operative time was 72 minutes for parastomal hernia and 95 minutes for perineal hernia. Operative bleeding was unsignificant. The patient was discharged after 3 days, and at visit consultations, she did not present with any recurrence.

Conclusion: Prosthetic parastomal and perineal hernias repair can be performed simultaneously using laparoscopy with the same port positioning, adding the advantages of minimally invasive surgery and avoiding a large laparotomy.
Surgical intervention
2 years ago
1176 views
117 likes
0 comments
07:20
Laparoscopic prosthetic parastomal and perineal hernias repair after abdominoperineal resection
Background: In this video, the authors report the case of a 74-year-old woman who consulted for episodes of intestinal occlusions following an abdomino-perineal resection for rectal adenocarcinoma (pT2N0M0), performed 6 years earlier. Abdomino-pelvic CT-scan showed a parastomal hernia with migrated small bowel loops and a perineal hernia with transposition of the caecum and bowel loops into the pelvis. Preoperative work-up was negative for tumor recurrence, hence a laparoscopic treatment using a double dual face prosthesis was proposed.

Video: Three trocars were placed into the abdomen. After adhesiolysis and removal of the viscera herniated into the hernia, the parastomal defect was exposed and measured intracorporeally 6cm (cranio-caudally) and 4cm (latero-laterally). An intracorporeal suture was used to close the defect, and a dual face prosthesis of 15cm in length and 10cm in width (Surgimesh XB, Aspide Medical, Saint-Etienne, France) was fixed by means of absorbable tacks (Sorbafix, Bard Davol Inc., Warwick, RI, US), according to the Sugarbaker technique. Successively, the pelvis was freed from adhesions, and the superior pelvic opening appeared to be 8cm (antero-posteriorly) and 7cm (latero-laterally). A dual face circular prosthesis of 10cm (Surgimesh XB, Aspide Medical) was fixed using two running sutures around the superior pelvic opening.

Results: Operative time was 72 minutes for parastomal hernia and 95 minutes for perineal hernia. Operative bleeding was unsignificant. The patient was discharged after 3 days, and at visit consultations, she did not present with any recurrence.

Conclusion: Prosthetic parastomal and perineal hernias repair can be performed simultaneously using laparoscopy with the same port positioning, adding the advantages of minimally invasive surgery and avoiding a large laparotomy.
Transumbilical single access laparoscopic right adrenalectomy with 1.8mm epigastric trocarless grasping forceps
Background: Single access laparoscopic adrenalectomy has been reported in supine and prone patient positioning. The authors report the technique with the patient in supine position, with the umbilicus as access site, and with all adopted material as reusable.

Video: A 43-year-old woman was admitted to the hospital for symptomatic primary hyperaldosteronism. A right-side adrenal adenoma was diagnosed, and surgery was proposed. The patient was placed in a supine position with a mild semi-lateral left-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope, in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany). The right liver lobe was retracted using the 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz Endoskope), inserted percutaneously under the 12th right rib. The procedure started with the adhesiolysis between the hepatic surface and right Gerota’s fascia. Then, after having identified the adrenal gland, it was dissected and the inferior adrenal arteries and veins were clipped between 5mm Hem-o-lok® clips (Teleflex Medical, Research Triangle Park, NC, US). The middle adrenal vein was clipped as well using the 5mm Hem-o-lok® ligation systems. Once the specimen was completely mobilized, a plastic bag (used for suction drain) was custom-made and introduced into the abdomen through the 11mm trocar. The specimen was removed transumbilically, and the procedure finished with the closure of the access site by absorbable figure of 8 sutures.

Results: Laparoscopic time was 98 minutes, estimated blood loss was 20cc, and the final scar length was 16mm. The patient was discharged from the hospital after 2 days.

Conclusions: Transumbilical single access laparoscopic right adrenalectomy is feasible and safe. With this technique, the cost of the procedure is not increased, the final scar length is minimal, and the working triangulation is established intrabdominally as well as externally.
Surgical intervention
5 years ago
1857 views
25 likes
0 comments
06:24
Transumbilical single access laparoscopic right adrenalectomy with 1.8mm epigastric trocarless grasping forceps
Background: Single access laparoscopic adrenalectomy has been reported in supine and prone patient positioning. The authors report the technique with the patient in supine position, with the umbilicus as access site, and with all adopted material as reusable.

Video: A 43-year-old woman was admitted to the hospital for symptomatic primary hyperaldosteronism. A right-side adrenal adenoma was diagnosed, and surgery was proposed. The patient was placed in a supine position with a mild semi-lateral left-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope, in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany). The right liver lobe was retracted using the 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz Endoskope), inserted percutaneously under the 12th right rib. The procedure started with the adhesiolysis between the hepatic surface and right Gerota’s fascia. Then, after having identified the adrenal gland, it was dissected and the inferior adrenal arteries and veins were clipped between 5mm Hem-o-lok® clips (Teleflex Medical, Research Triangle Park, NC, US). The middle adrenal vein was clipped as well using the 5mm Hem-o-lok® ligation systems. Once the specimen was completely mobilized, a plastic bag (used for suction drain) was custom-made and introduced into the abdomen through the 11mm trocar. The specimen was removed transumbilically, and the procedure finished with the closure of the access site by absorbable figure of 8 sutures.

Results: Laparoscopic time was 98 minutes, estimated blood loss was 20cc, and the final scar length was 16mm. The patient was discharged from the hospital after 2 days.

Conclusions: Transumbilical single access laparoscopic right adrenalectomy is feasible and safe. With this technique, the cost of the procedure is not increased, the final scar length is minimal, and the working triangulation is established intrabdominally as well as externally.
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
Surgical intervention
5 years ago
4186 views
77 likes
0 comments
07:50
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
Repair of distal esophageal perforation (Boerhaave’s syndrome) by left thoracoscopy with the patient in prone position
Background: Boerhaave’s syndrome is an emergency disease related to a high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation treated by left thoracoscopy in prone position.

Clinical case: A 44-year-old man was admitted to our emergency room following a 14-hour episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated with a pneumomediastinum. The patient underwent a left thoracoscopy in a prone position, after induction of general anesthesia using a Carlens-type double lumen tube. Three trocars of 5mm, 10mm, and 5mm, were placed in the 5th, 7th, and 10th intercostal spaces respectively. Exploration of the chest cavity revealed the presence of free liquid and fibrin, with no evidence of esophageal perforation. However, the esophageal perforation was demonstrated after dissection of the mediastinal pleura, and appeared to be 2cm in length. A nasogastric tube was advanced into the stomach under visual control, and an additional trocarless grasper was placed in the 10th intercostal space to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleansed and the 5mm trocar was replaced with a chest tube in the 10th intercostal space, with its tip close to the suture.

Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was admitted to hospital in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardial drain was placed after 16 days for pericardial tamponade. A gastrograffin swallow test on postoperative day 10 revealed a residual sinus at the site of the perforation. Another gastrograffin swallow test on postoperative day 20 was negative for leakage. The patient was discharged after 32 days.

Conclusions: Esophageal perforation can be treated by thoracoscopy with the patient placed in a prone position as access is facilitated by the effect of gravity on the cardiopulmonary organs. The success of the primary suture depends on the timing between the incident and the treatment; however, morbidity remains high.
Surgical intervention
6 years ago
3014 views
58 likes
0 comments
07:11
Repair of distal esophageal perforation (Boerhaave’s syndrome) by left thoracoscopy with the patient in prone position
Background: Boerhaave’s syndrome is an emergency disease related to a high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation treated by left thoracoscopy in prone position.

Clinical case: A 44-year-old man was admitted to our emergency room following a 14-hour episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated with a pneumomediastinum. The patient underwent a left thoracoscopy in a prone position, after induction of general anesthesia using a Carlens-type double lumen tube. Three trocars of 5mm, 10mm, and 5mm, were placed in the 5th, 7th, and 10th intercostal spaces respectively. Exploration of the chest cavity revealed the presence of free liquid and fibrin, with no evidence of esophageal perforation. However, the esophageal perforation was demonstrated after dissection of the mediastinal pleura, and appeared to be 2cm in length. A nasogastric tube was advanced into the stomach under visual control, and an additional trocarless grasper was placed in the 10th intercostal space to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleansed and the 5mm trocar was replaced with a chest tube in the 10th intercostal space, with its tip close to the suture.

Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was admitted to hospital in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardial drain was placed after 16 days for pericardial tamponade. A gastrograffin swallow test on postoperative day 10 revealed a residual sinus at the site of the perforation. Another gastrograffin swallow test on postoperative day 20 was negative for leakage. The patient was discharged after 32 days.

Conclusions: Esophageal perforation can be treated by thoracoscopy with the patient placed in a prone position as access is facilitated by the effect of gravity on the cardiopulmonary organs. The success of the primary suture depends on the timing between the incident and the treatment; however, morbidity remains high.
Transumbilical single access laparoscopic Toupet fundoplication
Background: Different procedures have been reported to be feasible and safe through single access laparoscopy (SAL). A transumbilical SAL Toupet fundoplication is demonstrated here.

Video: A young lady sought care for gastroesophageal reflux disease associated with grade B esophagitis, hiatal hernia and esophageal dyskinesia. The SAL procedure was performed by the opening of the umbilicus through Hasson’s technique. An 11mm reusable trocar was inserted for a 10mm, 30-degree angled, non-flexible, and standard length scope. Curved reusable instruments according to Dapri (Karl Storz Endoskope) were introduced through the same scar without trocars. The gastroesophageal junction was exposed thanks to the insertion of a 2mm wire under the xiphoid access. Crura repair and fundoplication were performed using intracorporeal knots, with a curved needle-holder. The umbilicus was finally closed in layers.

Results: No extra-umbilical trocar was necessary, and no intraoperative complications were registered. Operative time was 172 minutes and the final umbilical scar was 15mm. Postoperative pain was kept minimal, and the patient was discharged on the third postoperative day after a satisfying gastrograffin swallow.

Conclusions: Transumbilical SAL Toupet fundoplication is feasible. Use of curved and reusable instruments permits to avoid the conflict between the instruments’ tips intracorporeally or between the surgeons’ hands externally. Thanks to this technique, the cost of SAL is similar to multi-trocar laparoscopy.
Surgical intervention
6 years ago
2830 views
35 likes
0 comments
08:05
Transumbilical single access laparoscopic Toupet fundoplication
Background: Different procedures have been reported to be feasible and safe through single access laparoscopy (SAL). A transumbilical SAL Toupet fundoplication is demonstrated here.

Video: A young lady sought care for gastroesophageal reflux disease associated with grade B esophagitis, hiatal hernia and esophageal dyskinesia. The SAL procedure was performed by the opening of the umbilicus through Hasson’s technique. An 11mm reusable trocar was inserted for a 10mm, 30-degree angled, non-flexible, and standard length scope. Curved reusable instruments according to Dapri (Karl Storz Endoskope) were introduced through the same scar without trocars. The gastroesophageal junction was exposed thanks to the insertion of a 2mm wire under the xiphoid access. Crura repair and fundoplication were performed using intracorporeal knots, with a curved needle-holder. The umbilicus was finally closed in layers.

Results: No extra-umbilical trocar was necessary, and no intraoperative complications were registered. Operative time was 172 minutes and the final umbilical scar was 15mm. Postoperative pain was kept minimal, and the patient was discharged on the third postoperative day after a satisfying gastrograffin swallow.

Conclusions: Transumbilical SAL Toupet fundoplication is feasible. Use of curved and reusable instruments permits to avoid the conflict between the instruments’ tips intracorporeally or between the surgeons’ hands externally. Thanks to this technique, the cost of SAL is similar to multi-trocar laparoscopy.