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Michel VIX

Hôpitaux Universitaires de Strasbourg
Strasbourg, France
MD
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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.
Surgical intervention
8 months ago
1440 views
4 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.
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.
Surgical intervention
8 months ago
521 views
4 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.
Surgical intervention
8 months ago
830 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.
Surgical intervention
8 months ago
1264 views
2 likes
0 comments
11:41
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.
Bariatric and metabolic surgery
In this authoritative lecture, Dr. Michel Vix highlighted the indications related to metabolic and morbid obesity surgery. He presented key anatomical landmarks and operating room (OR) set-up depending on every patient. He briefly described the main principles of port placement and pneumoperitoneum, and demonstrated maneuvers, indications, and main key steps of morbid obesity procedures including LAGB, SBPD-DS, Scopinaro, RYGB, Mini Gastric Bypass, and Sleeve Gastrectomy, along with their technical aspects, mortality, morbidity, effectiveness, and results using different studies and meta-analyses. He also demonstrated the main principles and key steps of new trends and approaches in bariatric and metabolic surgery with complications and technical therapeutic aspects.
Lecture
1 year ago
1491 views
273 likes
0 comments
04:52
Bariatric and metabolic surgery
In this authoritative lecture, Dr. Michel Vix highlighted the indications related to metabolic and morbid obesity surgery. He presented key anatomical landmarks and operating room (OR) set-up depending on every patient. He briefly described the main principles of port placement and pneumoperitoneum, and demonstrated maneuvers, indications, and main key steps of morbid obesity procedures including LAGB, SBPD-DS, Scopinaro, RYGB, Mini Gastric Bypass, and Sleeve Gastrectomy, along with their technical aspects, mortality, morbidity, effectiveness, and results using different studies and meta-analyses. He also demonstrated the main principles and key steps of new trends and approaches in bariatric and metabolic surgery with complications and technical therapeutic aspects.
Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
Surgical intervention
2 years ago
1099 views
119 likes
1 comment
08:28
Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.
Surgical intervention
2 years ago
4623 views
316 likes
1 comment
25:34
PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.
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.
Surgical intervention
2 years ago
576 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.
The VERSA LIFTER BAND™: a new option for liver retraction in laparoscopic Roux-en-Y gastric bypass for morbid obesity
During laparoscopic bariatric procedures in morbidly obese patients, the surgeon's operative view is often obscured by the hypertrophic adipose left lobe of the liver.
To provide adequate operative views and working space, an appropriate retraction of the left liver lobe is required.
The use of a conventional liver retractor mandates an additional subxiphoid wound, resulting in patient discomfort for pain and scar formation, with the additional risk of iatrogenic liver injury during retraction maneuvers.
To overcome these limitations, we present the use of a simple, rapid, and safe technique for liver retraction using the VERSA LIFTER™ Band disposable liver suspension system or retractor.
Surgical intervention
3 years ago
1708 views
38 likes
0 comments
03:48
The VERSA LIFTER BAND™: a new option for liver retraction in laparoscopic Roux-en-Y gastric bypass for morbid obesity
During laparoscopic bariatric procedures in morbidly obese patients, the surgeon's operative view is often obscured by the hypertrophic adipose left lobe of the liver.
To provide adequate operative views and working space, an appropriate retraction of the left liver lobe is required.
The use of a conventional liver retractor mandates an additional subxiphoid wound, resulting in patient discomfort for pain and scar formation, with the additional risk of iatrogenic liver injury during retraction maneuvers.
To overcome these limitations, we present the use of a simple, rapid, and safe technique for liver retraction using the VERSA LIFTER™ Band disposable liver suspension system or retractor.
Laparoscopic Roux-en-Y gastric bypass: live demonstration and technical details
Roux-en-Y gastric bypass (RYGB) has become a common procedure for the management of morbid obesity. However, learning to perform such a procedure may be difficult as it is made up of very technical operative steps in complex cases of overweight patients with a great amount of adipose tissue. In order to prevent complications, an operative strategy should be adopted, allowing for an easy and rapid acquisition of the technique. Each step is perfectly mastered and outlined.
This video demonstrates a laparoscopic Roux-en-Y gastric bypass performed live, showing all the preoperative and operative patient settings. The surgical technique is thoroughly explained.
Surgical intervention
4 years ago
7335 views
197 likes
1 comment
28:09
Laparoscopic Roux-en-Y gastric bypass: live demonstration and technical details
Roux-en-Y gastric bypass (RYGB) has become a common procedure for the management of morbid obesity. However, learning to perform such a procedure may be difficult as it is made up of very technical operative steps in complex cases of overweight patients with a great amount of adipose tissue. In order to prevent complications, an operative strategy should be adopted, allowing for an easy and rapid acquisition of the technique. Each step is perfectly mastered and outlined.
This video demonstrates a laparoscopic Roux-en-Y gastric bypass performed live, showing all the preoperative and operative patient settings. The surgical technique is thoroughly explained.
Laparoscopic Roux-en-Y gastric bypass after gastric band removal
This video demonstrates the case of a 50-year-old woman with morbid obesity (BMI of 39). She had a gastric banding placed 7 years before, which became ineffective 3 years after the primary surgery, resulting in band removal 2 years ago.
A secondary bariatric surgery was scheduled, with the decision to perform a laparoscopic Roux-en-Y gastric bypass. This video shows the surgical technique, with special emphasis on dissection of the cardia and lesser curvature, where the anatomy is altered as a result of the previous band. An interesting technical point occurs during the creation of the jejunojejunostomy, where a perforation of the biliary loop is accidentally made during the EndoGIATM linear stapler introduction.
Surgical intervention
4 years ago
2183 views
59 likes
0 comments
32:11
Laparoscopic Roux-en-Y gastric bypass after gastric band removal
This video demonstrates the case of a 50-year-old woman with morbid obesity (BMI of 39). She had a gastric banding placed 7 years before, which became ineffective 3 years after the primary surgery, resulting in band removal 2 years ago.
A secondary bariatric surgery was scheduled, with the decision to perform a laparoscopic Roux-en-Y gastric bypass. This video shows the surgical technique, with special emphasis on dissection of the cardia and lesser curvature, where the anatomy is altered as a result of the previous band. An interesting technical point occurs during the creation of the jejunojejunostomy, where a perforation of the biliary loop is accidentally made during the EndoGIATM linear stapler introduction.
Robot-assisted Roux-en-Y gastric bypass after band removal
Patients ask for a new weight loss surgical procedure after gastric band removal due to a lack of efficiency or to complications. Although gastric banding is a reversible procedure, perigastric adhesions located mostly in the upper part of the stomach can make new approaches to this area difficult.
We report the case of a woman who benefited from a gastric banding in 2006. This gastric band was removed in 2010. The patient developed a left subphrenic abscess, which was drained under CT-scan control postoperatively.
Two years after this procedure, the patient wishes to benefit from a new weight loss surgical procedure as she gained 10Kg since her gastric band removal. She has a BMI of 40 and presents with respiratory and rheumatological co-morbidities.
The preoperative work-up was uneventful, and this is particularly true for the esogastroduodenal contrast exam and the gastroscopy.
During the procedure, multiple omental parietal adhesions were found, as well as tight adhesions between the liver, the stomach, and the left crus.
Dissecting the stomach using a conventional approach was made difficult by the presence of these adhesions, and we had to perform an upper pole gastrectomy of the greater curvature in order to clearly identify the gastroesophageal junction’s anatomy. A complete dissection of the left subcardial area is necessary in order to prevent the formation of an excessively large gastric pouch, which could lead to a regain in weight.
This video covers the whole procedure in detail and highlights dissection challenges, which can occur in patients who had their gastric band removed.
The postoperative outcome was uneventful in this woman, with a significant weight loss at one year.
Surgical intervention
4 years ago
1386 views
46 likes
0 comments
25:55
Robot-assisted Roux-en-Y gastric bypass after band removal
Patients ask for a new weight loss surgical procedure after gastric band removal due to a lack of efficiency or to complications. Although gastric banding is a reversible procedure, perigastric adhesions located mostly in the upper part of the stomach can make new approaches to this area difficult.
We report the case of a woman who benefited from a gastric banding in 2006. This gastric band was removed in 2010. The patient developed a left subphrenic abscess, which was drained under CT-scan control postoperatively.
Two years after this procedure, the patient wishes to benefit from a new weight loss surgical procedure as she gained 10Kg since her gastric band removal. She has a BMI of 40 and presents with respiratory and rheumatological co-morbidities.
The preoperative work-up was uneventful, and this is particularly true for the esogastroduodenal contrast exam and the gastroscopy.
During the procedure, multiple omental parietal adhesions were found, as well as tight adhesions between the liver, the stomach, and the left crus.
Dissecting the stomach using a conventional approach was made difficult by the presence of these adhesions, and we had to perform an upper pole gastrectomy of the greater curvature in order to clearly identify the gastroesophageal junction’s anatomy. A complete dissection of the left subcardial area is necessary in order to prevent the formation of an excessively large gastric pouch, which could lead to a regain in weight.
This video covers the whole procedure in detail and highlights dissection challenges, which can occur in patients who had their gastric band removed.
The postoperative outcome was uneventful in this woman, with a significant weight loss at one year.
Robot-assisted gastric band removal
Adjustable gastric banding (AGB) is one of the surgical treatment modalities for morbid obesity. Over the years, popularity for this treatment increased. It has been by far the most performed bariatric procedure for years in Europe and in the United States. Many gastric band removals are linked to complications and weight loss failure, indicating a new bariatric procedure for some of the patients. Complications after AGB are not uncommon and consist mainly of gastroesophageal reflux disease, pouch dilatation, slippage of the band, and intragastric migration. The failure of the gastric band is multifactorial. Gastric band removal does not preclude a new bariatric procedure (the most common procedure performed in our department is Roux en-Y gastric bypass), which is feasible in the same operative time but the 2-step approach is suitable. The new bariatric procedure offers adequate surgical outcomes and satisfactory results in terms of weight loss.
Surgical intervention
4 years ago
1086 views
36 likes
0 comments
08:14
Robot-assisted gastric band removal
Adjustable gastric banding (AGB) is one of the surgical treatment modalities for morbid obesity. Over the years, popularity for this treatment increased. It has been by far the most performed bariatric procedure for years in Europe and in the United States. Many gastric band removals are linked to complications and weight loss failure, indicating a new bariatric procedure for some of the patients. Complications after AGB are not uncommon and consist mainly of gastroesophageal reflux disease, pouch dilatation, slippage of the band, and intragastric migration. The failure of the gastric band is multifactorial. Gastric band removal does not preclude a new bariatric procedure (the most common procedure performed in our department is Roux en-Y gastric bypass), which is feasible in the same operative time but the 2-step approach is suitable. The new bariatric procedure offers adequate surgical outcomes and satisfactory results in terms of weight loss.
Perforated gastric pouch ulcer 4 years after gastric bypass surgery: laparoscopic diagnosis and treatment
The frequency of marginal ulcers is reported to range between 0.6% and 16% after laparoscopic Roux-en-Y gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H pylori infection, non-steroidal anti-inflammatory drugs use, and smoking [1, 2]. We present a rare case of a gastric pouch ulcer perforation occurring 4 years after a laparoscopic gastric bypass.
Bibliographic references:
1. Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Bramkamp M, Muller MK, Wildi S, Clavien PA, Weber M. Obes Surg 2006;16:1545-7.
2. Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Chin EH, Hazzan D, Sarpel U, Herron DM. Surg Endosc 2007;21:2110.
Surgical intervention
4 years ago
1363 views
28 likes
0 comments
10:13
Perforated gastric pouch ulcer 4 years after gastric bypass surgery: laparoscopic diagnosis and treatment
The frequency of marginal ulcers is reported to range between 0.6% and 16% after laparoscopic Roux-en-Y gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H pylori infection, non-steroidal anti-inflammatory drugs use, and smoking [1, 2]. We present a rare case of a gastric pouch ulcer perforation occurring 4 years after a laparoscopic gastric bypass.
Bibliographic references:
1. Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Bramkamp M, Muller MK, Wildi S, Clavien PA, Weber M. Obes Surg 2006;16:1545-7.
2. Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Chin EH, Hazzan D, Sarpel U, Herron DM. Surg Endosc 2007;21:2110.
Laparoscopic Roux-en-Y gastric bypass after gastric band removal with severe small bowel adhesions
After gastric band removal, a laparoscopic Roux-en-Y gastric bypass is rendered more difficult by the existence of adhesions between the liver, the superior part of the stomach, and potentially the spleen. This video describes how to handle difficulties in dissecting the superior part of the stomach. Dissection of the cardia and left crus are required to allow for an appropriate calibration of the gastric pouch. The difficulty is subsequently increased in this patient as there are dense small bowel adhesions related to a previous history of gynecologic peritonitis. The intervention has been entirely performed laparoscopically. Small bowel adhesions have been taken down in order to obtain a sufficient free length (approximately 2 meters) and perform a jejunojejunostomy in adequate conditions.
Surgical intervention
4 years ago
966 views
8 likes
0 comments
20:19
Laparoscopic Roux-en-Y gastric bypass after gastric band removal with severe small bowel adhesions
After gastric band removal, a laparoscopic Roux-en-Y gastric bypass is rendered more difficult by the existence of adhesions between the liver, the superior part of the stomach, and potentially the spleen. This video describes how to handle difficulties in dissecting the superior part of the stomach. Dissection of the cardia and left crus are required to allow for an appropriate calibration of the gastric pouch. The difficulty is subsequently increased in this patient as there are dense small bowel adhesions related to a previous history of gynecologic peritonitis. The intervention has been entirely performed laparoscopically. Small bowel adhesions have been taken down in order to obtain a sufficient free length (approximately 2 meters) and perform a jejunojejunostomy in adequate conditions.
Onset of internal hernia after Roux-en-Y gastric bypass: laparoscopic management
Laparoscopic Roux-en-Y gastric bypass (LRYGB) represents the gold standard of treatment for morbidly obese patients. While the laparoscopic approach offers many advantages in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, certain complications of this operation present difficult clinical problems. The most challenging complication to determine is internal hernia through one of the mesenteric defects.

Internal hernias occur more frequently in LRYGB than in the open procedure. This is a significant clinical problem since internal hernia is the most common cause of small bowel obstruction (SBO) after LRYGB, which can result in ischemia or infarction and often requires a reoperation.

The incidence of SBO after LGBP is reported to be between 1.8 and 9.7%. The most common site of internal hernia after LGBP is at Petersen’s space.
In this video, we present the laparoscopic management of a complete small bowel herniation at Petersen’s space.
Surgical intervention
4 years ago
1293 views
17 likes
0 comments
11:25
Onset of internal hernia after Roux-en-Y gastric bypass: laparoscopic management
Laparoscopic Roux-en-Y gastric bypass (LRYGB) represents the gold standard of treatment for morbidly obese patients. While the laparoscopic approach offers many advantages in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, certain complications of this operation present difficult clinical problems. The most challenging complication to determine is internal hernia through one of the mesenteric defects.

Internal hernias occur more frequently in LRYGB than in the open procedure. This is a significant clinical problem since internal hernia is the most common cause of small bowel obstruction (SBO) after LRYGB, which can result in ischemia or infarction and often requires a reoperation.

The incidence of SBO after LGBP is reported to be between 1.8 and 9.7%. The most common site of internal hernia after LGBP is at Petersen’s space.
In this video, we present the laparoscopic management of a complete small bowel herniation at Petersen’s space.
Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea)
The video entitled "Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition", authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea) is analyzed by Dr. Michel Vix, MD (Nouvel Hôpital Civil, Strasbourg, France), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Reply from Dr. Ji Yeon Park to the reviewer:
The South Korean surgeon in the current case, who originally was a gastric cancer surgeon, was extremely inexperienced in bariatric surgery at the time of the primary surgery in this patient. He applied “uncut” Roux-en-Y reconstruction for gastric cancer surgery to RYGB in this patient; it is a simple modification of Billroth II with Braun anastomosis with additional occlusion of the jejunogastric pathway with a non-bladed linear stapler. Consequently, sufficient distance between the gastrojejunostomy and the jejunojejunostomy was preserved in order to prevent bile reflux into the remnant stomach when staple-line recanalization occurs. However, intraoperative findings at reversal showed that the previously uncut staple line was found split apart, far from being recanalized. This consequently resulted in a long “true” blind loop at the distal end of the biliopancreatic limb. At reversal, we established a new jejunojejunal anastomosis between the distal end of the blind loop and the cut end of the proximal alimentary limb, and left the old jejunojejunostomy in situ. The operative procedure per se became much simpler by not dismantling the old jejunojejunostomy; as a result, the number of new anastomoses and the operating time could be reduced.
Surgical intervention
4 years ago
1291 views
20 likes
0 comments
17:41
Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea)
The video entitled "Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition", authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea) is analyzed by Dr. Michel Vix, MD (Nouvel Hôpital Civil, Strasbourg, France), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Reply from Dr. Ji Yeon Park to the reviewer:
The South Korean surgeon in the current case, who originally was a gastric cancer surgeon, was extremely inexperienced in bariatric surgery at the time of the primary surgery in this patient. He applied “uncut” Roux-en-Y reconstruction for gastric cancer surgery to RYGB in this patient; it is a simple modification of Billroth II with Braun anastomosis with additional occlusion of the jejunogastric pathway with a non-bladed linear stapler. Consequently, sufficient distance between the gastrojejunostomy and the jejunojejunostomy was preserved in order to prevent bile reflux into the remnant stomach when staple-line recanalization occurs. However, intraoperative findings at reversal showed that the previously uncut staple line was found split apart, far from being recanalized. This consequently resulted in a long “true” blind loop at the distal end of the biliopancreatic limb. At reversal, we established a new jejunojejunal anastomosis between the distal end of the blind loop and the cut end of the proximal alimentary limb, and left the old jejunojejunostomy in situ. The operative procedure per se became much simpler by not dismantling the old jejunojejunostomy; as a result, the number of new anastomoses and the operating time could be reduced.
Laparoscopic central pancreatectomy for insulinoma
We report the case of a 43-year-old male patient who was diagnosed with insulinoma and had a robotic enucleation of an isthmic pancreatic tumor in November 2012. However, the patient presents with clinical recurrences of hypoglycemia 18 months later. Re-evaluation studies demonstrated a local recurrence. A laparoscopic central pancreatectomy was indicated. The procedure started with the opening of the lesser sac. The splenic vessels were dissected and controlled. A retropancreatic passage along the venous mesenterico-portal axis was performed. Ultrasonography was carried out to assess the pancreatic recurrence area. The pancreas isthmus was transected. A pancreaticogastric anastomosis was performed at the posterior aspect of the stomach. The resected specimen confirms the recurrence of an insulinoma, which has been entirely removed.
Surgical intervention
4 years ago
1304 views
30 likes
0 comments
09:21
Laparoscopic central pancreatectomy for insulinoma
We report the case of a 43-year-old male patient who was diagnosed with insulinoma and had a robotic enucleation of an isthmic pancreatic tumor in November 2012. However, the patient presents with clinical recurrences of hypoglycemia 18 months later. Re-evaluation studies demonstrated a local recurrence. A laparoscopic central pancreatectomy was indicated. The procedure started with the opening of the lesser sac. The splenic vessels were dissected and controlled. A retropancreatic passage along the venous mesenterico-portal axis was performed. Ultrasonography was carried out to assess the pancreatic recurrence area. The pancreas isthmus was transected. A pancreaticogastric anastomosis was performed at the posterior aspect of the stomach. The resected specimen confirms the recurrence of an insulinoma, which has been entirely removed.
Laparoscopic and endoscopic treatment of a complicated candy cane syndrome after Roux-en-Y gastric bypass
A “Candy Cane” Roux syndrome represents an excessive length of non-functional Roux limb proximal to the gastrojejunostomy, which can cause abnormal upper gastrointestinal symptoms of postprandial epigastric discomfort that is relieved by vomiting. Symptoms of reflux, loss of satiety, and nausea are also common. The length of the blind loop is the essential factor to explain these symptoms, but the orientation of the gastrojejunal anastomosis is equally important to facilitate the emptying of the gastric pouch.
Scarce data can be found in the literature --a case report (1) and a case series (2) with a number of limitations. It is not possible to determine a critical excess length of Roux limb at which symptoms would become evident, nor were we able to determine whether all patients, or just a small minority, would develop symptoms, even with a seemingly excessive Roux limb.
Patients who underwent a gastric bypass technique with a gastrojejunal anastomosis using a circular stapler seem to be more likely to develop this anomaly. All 3 patients described by Cottam et al. (2) have their primary procedure performed by means of a circular stapler.
A long, non-functional Roux limb tip may cause persistent nausea, postprandial epigastric pain, and even a lack of satiety. Surgeons should attempt to minimize redundancy in the Roux limb during the primary procedure. Limiting the length and orientating the Roux limb to aid in gravity and drainage during the initial operation may prevent this syndrome.
References:
1. Dallal RM, Cottam D. "Candy cane" Roux syndrome--a possible complication after gastric bypass surgery. Surg Obes Relat Dis 2007;3:408-10.
2. Romero-Mejía C, Camacho-Aguilera JF, Paipilla-Monroy O. "Candy cane" Roux syndrome in laparoscopic gastric by-pass. Cir Cir 2010;78:347-51.
Surgical intervention
5 years ago
1505 views
10 likes
0 comments
05:57
Laparoscopic and endoscopic treatment of a complicated candy cane syndrome after Roux-en-Y gastric bypass
A “Candy Cane” Roux syndrome represents an excessive length of non-functional Roux limb proximal to the gastrojejunostomy, which can cause abnormal upper gastrointestinal symptoms of postprandial epigastric discomfort that is relieved by vomiting. Symptoms of reflux, loss of satiety, and nausea are also common. The length of the blind loop is the essential factor to explain these symptoms, but the orientation of the gastrojejunal anastomosis is equally important to facilitate the emptying of the gastric pouch.
Scarce data can be found in the literature --a case report (1) and a case series (2) with a number of limitations. It is not possible to determine a critical excess length of Roux limb at which symptoms would become evident, nor were we able to determine whether all patients, or just a small minority, would develop symptoms, even with a seemingly excessive Roux limb.
Patients who underwent a gastric bypass technique with a gastrojejunal anastomosis using a circular stapler seem to be more likely to develop this anomaly. All 3 patients described by Cottam et al. (2) have their primary procedure performed by means of a circular stapler.
A long, non-functional Roux limb tip may cause persistent nausea, postprandial epigastric pain, and even a lack of satiety. Surgeons should attempt to minimize redundancy in the Roux limb during the primary procedure. Limiting the length and orientating the Roux limb to aid in gravity and drainage during the initial operation may prevent this syndrome.
References:
1. Dallal RM, Cottam D. "Candy cane" Roux syndrome--a possible complication after gastric bypass surgery. Surg Obes Relat Dis 2007;3:408-10.
2. Romero-Mejía C, Camacho-Aguilera JF, Paipilla-Monroy O. "Candy cane" Roux syndrome in laparoscopic gastric by-pass. Cir Cir 2010;78:347-51.
Robot-assisted gastric band removal: any limitations?
Nowadays, indications for gastric band removal are well-standardized. In case of esophageal or gastric dilatation, migration or any injury related to the LAP-BAND® access port or tubing, the band and its access port should be removed. In rare specific cases, part of the LAP-BAND® system (either access port or band) may be preserved.
Before proceeding to the surgical band removal, a complete preoperative radiological and endoscopic work-up should be performed.
Here, we present the case of a 62-year-old woman who benefited from gastric band placement 10 years earlier. The band proved effective. However, for several weeks, she has been suffering from abdominal pain associated with vomiting and hematemesis.
After a work-up which included CT-scanning, water-soluble contrast swallow and gastroscopy, it was decided to remove the band.
Surgical intervention
5 years ago
763 views
11 likes
0 comments
08:36
Robot-assisted gastric band removal: any limitations?
Nowadays, indications for gastric band removal are well-standardized. In case of esophageal or gastric dilatation, migration or any injury related to the LAP-BAND® access port or tubing, the band and its access port should be removed. In rare specific cases, part of the LAP-BAND® system (either access port or band) may be preserved.
Before proceeding to the surgical band removal, a complete preoperative radiological and endoscopic work-up should be performed.
Here, we present the case of a 62-year-old woman who benefited from gastric band placement 10 years earlier. The band proved effective. However, for several weeks, she has been suffering from abdominal pain associated with vomiting and hematemesis.
After a work-up which included CT-scanning, water-soluble contrast swallow and gastroscopy, it was decided to remove the band.
Typical laparoscopic four-trocar transabdominal adrenalectomy for a 5cm right-sided pheochromocytoma
This is the case of a female patient presenting with a typical 5cm right-sided pheochromocytoma was operated on laparoscopically. Preoperative 3D MRI reconstruction allowed to precisely identify surgical landmarks. The procedure was carried out typically. Four ports were used, and dissection aimed to first mobilize the liver. Control of the main adrenal vein was achieved as the first operative step. Medial, superior, and inferior arteries were dissected and controlled successively. Total freeing of the gland was performed with no manipulation or effraction of the gland's capsule. The postoperative course was uneventful. Small-sized pheochromocytomas are excellent indications for a laparoscopic approach with early control of the vein.
Surgical intervention
6 years ago
3321 views
79 likes
0 comments
23:50
Typical laparoscopic four-trocar transabdominal adrenalectomy for a 5cm right-sided pheochromocytoma
This is the case of a female patient presenting with a typical 5cm right-sided pheochromocytoma was operated on laparoscopically. Preoperative 3D MRI reconstruction allowed to precisely identify surgical landmarks. The procedure was carried out typically. Four ports were used, and dissection aimed to first mobilize the liver. Control of the main adrenal vein was achieved as the first operative step. Medial, superior, and inferior arteries were dissected and controlled successively. Total freeing of the gland was performed with no manipulation or effraction of the gland's capsule. The postoperative course was uneventful. Small-sized pheochromocytomas are excellent indications for a laparoscopic approach with early control of the vein.
Robot-assisted mini gastric bypass in a patient with a huge liver
This video demonstrates our mini gastric bypass technique using the da Vinci™ robotic surgical system. This intervention may be suggested in all morbidly obese patients without any major gastroesophageal reflux. One of the interests of this film lies in that the patient has a huge liver requiring delicate dissection and division of the superior gastric pouch. The biliary loop typically measures 200cm, and we systematically close Petersen’s defect in order to prevent internal hernias. The use of the surgical robot allows to perform an easier hand-assisted gastrojejunostomy. None of the preparatory maneuvers rely on the surgical robot as it is currently not equipped with mechanical staplers.
Surgical intervention
6 years ago
2114 views
10 likes
0 comments
15:19
Robot-assisted mini gastric bypass in a patient with a huge liver
This video demonstrates our mini gastric bypass technique using the da Vinci™ robotic surgical system. This intervention may be suggested in all morbidly obese patients without any major gastroesophageal reflux. One of the interests of this film lies in that the patient has a huge liver requiring delicate dissection and division of the superior gastric pouch. The biliary loop typically measures 200cm, and we systematically close Petersen’s defect in order to prevent internal hernias. The use of the surgical robot allows to perform an easier hand-assisted gastrojejunostomy. None of the preparatory maneuvers rely on the surgical robot as it is currently not equipped with mechanical staplers.
Occurrence of a rare complication during laparoscopic sleeve gastrectomy
Nowadays, sleeve gastrectomy is a common procedure frequently performed laparoscopically in the management of morbid obesity. This intervention as proven to be efficient in comparison to laparoscopic Roux-en-Y gastric bypass (LRYGB) regarding weight loss and revision of obesity-related co-morbidities such as diabetes mellitus and high blood pressure. Today, in France, selection of the surgical technique (e.g., sleeve gastrectomy, LRYGB) depends on the patient should preoperative work-up be strictly normal. If not, the surgeon will have to make a decision as to which technique should be used. Postoperative complications related to bariatric surgery are currently well-known (fistula, bleeding, abscess) and are managed in a multidisciplinary way by radiologists, endoscopists and surgeons. Here, we present the case of a rare perioperative complication related to the incidental stapling of the nasogastric tube during gastric division. This complication mainly highlights shortcomings in the interaction between the surgical team and anesthesiologists during placement and retrieval of calibration and nasogastric tubes. In the present case, this complication was immediately demonstrated and it was managed laparoscopically.
Surgical intervention
6 years ago
2932 views
26 likes
0 comments
08:29
Occurrence of a rare complication during laparoscopic sleeve gastrectomy
Nowadays, sleeve gastrectomy is a common procedure frequently performed laparoscopically in the management of morbid obesity. This intervention as proven to be efficient in comparison to laparoscopic Roux-en-Y gastric bypass (LRYGB) regarding weight loss and revision of obesity-related co-morbidities such as diabetes mellitus and high blood pressure. Today, in France, selection of the surgical technique (e.g., sleeve gastrectomy, LRYGB) depends on the patient should preoperative work-up be strictly normal. If not, the surgeon will have to make a decision as to which technique should be used. Postoperative complications related to bariatric surgery are currently well-known (fistula, bleeding, abscess) and are managed in a multidisciplinary way by radiologists, endoscopists and surgeons. Here, we present the case of a rare perioperative complication related to the incidental stapling of the nasogastric tube during gastric division. This complication mainly highlights shortcomings in the interaction between the surgical team and anesthesiologists during placement and retrieval of calibration and nasogastric tubes. In the present case, this complication was immediately demonstrated and it was managed laparoscopically.