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surgical intervention video

Traitement d'un diverticule de Zenker par endoscopie flexible 

This video shows the case of a 68-year-old man who has had symptoms related to dysphagia, weight loss, and cough over a year. The patient presented with a clear cell renal cell carcinoma (ccRCC), and he recently ended adjuvant chemotherapy. Due to the patient’s condition, a flexible endoscopic treatment was offered and accepted by the patient. 

Note of the editors:

In this video, authors perform a simple division, without using any sutures or lateral clips, raising the following question: can this technique be recommended? It is known that some endoscopists (rarely enough) do not use clips, as there is an increased risk of complications. Why did the authors not use clips? 

Authors pointed out that the use of clips was not always necessary. Indeed, most of the times, they do not use it, considering that it is a "false diverticulum"; in addition, even when the mucosa is divided, the "third space" is not created, just as in a peroral endoscopic myotomy (POEM) or in submucosal dissections. This technique must be stopped in a distance of approximately 5 to 10mm before the very bottom of the diverticulum, since this maneuver prevents perforation. 

At present time, we would recommend the use of lateral clips for most of the procedures. Please read the following articles to improve your knowledge: Rodríguez-Luna MR, Pizzicannella M, Perretta S. Indication for the endoscopic treatment of Zenker’s diverticula. Ann Esophagus 2021;4:38.

Flexible endoscopic management of Zenker’s diverticulum. Experience in reference hospital and description of the surgical technique. Noé Zaragoza-Arias, Marco A. de la Mora-Romero, Francisco J. Martínez-Jiménez. Endoscopia. 2021;33:91-6.

Flexible endoscopic treatment of a Zenker's diverticulum

During radical resection of sigmoid and superior rectal cancer, ligation of the root of the inferior mesenteric artery is considered the oncologically acceptable treatment strategy aiming for an enlargedlymph node dissection. 

There is no consensus on the level of inferior mesenteric artery (IMA) ligation, but both high and low ligations are accepted in curative intention resections of upper rectal and sigmoid colon cancer. 

A few surgeons prefer a laparoscopic lymph node dissection technique with preservation of the IMA, left colic artery (LCA), and superior rectal artery (SRA) with selective sigmoid artery branch ligation. 

This lymphadenectomy is accomplished by peeling the vascular sheath and the lymph cellular tissue up to the root of the IMA, harvesting the apical lymph nodes at the IMA’s aortic origin and at the LCA’s origin. 

Sparing the IMA, LCA, and SRA should maintain good blood supply to the bowel, avoiding devascularization and potentially decreasing the incidence of anastomotic leakage. 

Since the number of lymph nodes retrieved is adequate, the lymph node dissection with vascular preservation is an oncologically acceptable treatment strategy in patients with upper rectal or sigmoid colon cancer. 

We present a case of a laparoscopic low anterior resection and lymph node dissection for adenocarcinoma. The IMA is skeletonized cephalad until its root with preservation of the LCA and SRA using selective sigmoid artery ligation. 

Starting from the IMA’s aortic origin, the lymphadenectomy is obtained by peeling the vascular sheath and the lymph cellular tissue around the vessel. This emphasized technique follows the course of the SRA until the hilum of Mondor. 

Note from the contributors: The terms "extreme" and "emphasized" have been deliberately chosen to underline the fact that the surgical technique does not involve the skeletonization of the lower mesenteric artery up to the hilum of Mondor. With those terms, the authors want to stress the concept of how much the dissection of the adventitia of the artery has been conducted beyond the usual standards commonly related to the technique. 

Laparoscopic low anterior rectal resection with inferior mesenteric artery preservation for rectal cancer: extreme vascular peeling

Résection rectale antérieure basse par laparoscopie avec préservation de l'artère mésentérique inférieure pour cancer du rectum : peeling vasculaire extrême

Authors present the case of a 78-year-old female patient who underwent elective surgery for a 5cm esophageal diverticulum. During the dissection, the vagus nerve and major blood vessels, as well as airway structures must be left intact. Non-selective lung intubation, especially in elderly patients, is well tolerated as it diminishes pulmonary complications and helps achieve early hospital discharge. 

Non-selective lung intubation in right thoracoscopy due to 5cm esophageal diverticulum (5 steps, wise approach)

Intubation pulmonaire non sélective lors d'une thoracoscopie droite en raison d'un diverticule œsophagien de 5 cm (5 étapes, approche préconisée)

We present the case of a 33-year-old female patient who was referred to our department for abdominal pain. In the imaging studies, an appendicular tumor was diagnosed. Consequently, a laparoscopic resection was decided upon. During surgery, decision was made to perform a cecectomy with mechanical suture since the appendicular base was thickened. Postoperative outcomes were uneventful. 

Laparoscopic resection for appendiceal mucinous neoplasms (mucocele): cecectomy

Néoplasmes mucineux appendiculaires (mucocèle) : cécectomie laparoscopique

Splenic flexure cancers account for up to 8% of all colon cancers. As they are relatively uncommon, several surgical alternatives are currently used. The surgical approach has yet to be standardized. The oncological resection of colon cancer requires the removal of the colon with an intact mesocolon, performing a complete mesocolic excision with central ligation of the feeding vessels to maximize an adequate lymphadenectomy. 

The different possible surgical approaches for splenic flexure tumors include extended right hemicolectomy, splenic flexure resection, and left hemicolectomy. At our center, we prefer and are going to show a video of the splenic flexure resection. 

This 2020 meta-analysis comparing the previously referred techniques includes 7 retrospective studies. No differences were found between groups regarding 5-year survival and 5-year disease-free survival. Also, no differences were found regarding anastomotic leak rate.

Focus on surgical management of GI diseases

Flexible endoscopic treatment of a Zenker's diverticulum

Non-selective lung intubation in right thoracoscopy due to 5cm esophageal diverticulum (5 steps, wise approach)

Laparoscopic low anterior rectal resection with inferior mesenteric artery preservation for rectal cancer: extreme vascular peeling

Laparoscopic resection for appendiceal mucinous neoplasms (mucocele): cecectomy

Surgery for splenic flexure tumors