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Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.
Y Aawsaj, I Ibrahim, A Mitchell, A Gilliam
Surgical intervention
1 month ago
279 views
6 likes
1 comment
10:08
Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, NS Gómez Peña-Alfaro
Surgical intervention
29 days ago
1414 views
10 likes
2 comments
12:40
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
Laparoscopic central hepatectomy for hepatoma using a Glissonian approach
Introduction: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic central hepatectomy remains a challenging and technically demanding procedure because it requires two transection planes. This video illustrates a useful technique for laparoscopic central hepatectomy, which was successfully performed in a cirrhotic patient with hepatoma. Method: We demonstrated a total laparoscopic central hepatectomy which was performed in a 65-year-old woman who had a centrally located hepatoma, and this tumor was in contact with the middle hepatic vein. The operative procedure was performed by using five ports with the patient placed in a low lithotomy position. Results: The technique was successfully performed without any complications. The operative time was 380 min. Intraoperative blood loss was 60mL. The length of hospital stay was 5 days. The pathological report was well-differentiated HCC and free surgical margins. Conclusions: Laparoscopic central hepatectomy for hepatoma by using a Glissonian approach is feasible and safe.
R Chanwat, C Bunchaliew
Surgical intervention
29 days ago
978 views
16 likes
2 comments
10:01
Laparoscopic central hepatectomy for hepatoma using a Glissonian approach
Introduction: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic central hepatectomy remains a challenging and technically demanding procedure because it requires two transection planes. This video illustrates a useful technique for laparoscopic central hepatectomy, which was successfully performed in a cirrhotic patient with hepatoma. Method: We demonstrated a total laparoscopic central hepatectomy which was performed in a 65-year-old woman who had a centrally located hepatoma, and this tumor was in contact with the middle hepatic vein. The operative procedure was performed by using five ports with the patient placed in a low lithotomy position. Results: The technique was successfully performed without any complications. The operative time was 380 min. Intraoperative blood loss was 60mL. The length of hospital stay was 5 days. The pathological report was well-differentiated HCC and free surgical margins. Conclusions: Laparoscopic central hepatectomy for hepatoma by using a Glissonian approach is feasible and safe.
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
F Signorini, HK Yang
Surgical intervention
29 days ago
479 views
2 likes
1 comment
10:02
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
S Greco, M Giulii Capponi, M Lotti, M Khotcholava
Surgical intervention
29 days ago
409 views
1 like
1 comment
14:14
A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Morbid obesity has reached epidemic proportions. Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective bariatric surgery procedure for weight loss. This procedure was first described by Scopinaro in 1979. It consisted of a horizontal gastrectomy, a transection of the bowel halfway from the ligament of Treitz and the ileocecal junction, and a Roux-en-Y reconstruction with a 50cm common channel. This was later modified: the duodenal switch was added and the gastrectomy was performed in a vertical sleeve fashion, thereby preserving the pylorus and increasing the common channel to 100cm. This modification greatly reduced the incidence of marginal ulceration, dumping, and nutritional deficiencies. However, this operation is still uncommon due to the perceived technical difficulty and risk of nutritional morbidity. This video demonstrates a standardized technique for this complex procedure.
RC Pullatt
Surgical intervention
29 days ago
748 views
4 likes
2 comments
13:00
Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Morbid obesity has reached epidemic proportions. Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective bariatric surgery procedure for weight loss. This procedure was first described by Scopinaro in 1979. It consisted of a horizontal gastrectomy, a transection of the bowel halfway from the ligament of Treitz and the ileocecal junction, and a Roux-en-Y reconstruction with a 50cm common channel. This was later modified: the duodenal switch was added and the gastrectomy was performed in a vertical sleeve fashion, thereby preserving the pylorus and increasing the common channel to 100cm. This modification greatly reduced the incidence of marginal ulceration, dumping, and nutritional deficiencies. However, this operation is still uncommon due to the perceived technical difficulty and risk of nutritional morbidity. This video demonstrates a standardized technique for this complex procedure.
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
F Corcione, M D'Ambra, U Bracale, S Dilillo, G Luglio
Surgical intervention
29 days ago
791 views
1 like
1 comment
23:20
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
P Agami, A Andrianov, M Baychorov, R Izrailov
Surgical intervention
29 days ago
630 views
6 likes
2 comments
17:23
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
Complex cases in laparoscopic recurrent and incisional hernia repair: multi-recurrence, infections, fistulas, difficult abdomen
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
3 months ago
5554 views
1 like
0 comments
03:00
Complex cases in laparoscopic recurrent and incisional hernia repair: multi-recurrence, infections, fistulas, difficult abdomen
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
Recurrent and incisional hernia repair: complex cases
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
A D'Urso, D Mutter, J Marescaux
State of the art
3 months ago
1075 views
4 likes
0 comments
00:00
Recurrent and incisional hernia repair: complex cases
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
L Taglietti, G Baronio, L Lussardi, R Cazzaniga, S Dester, A Zanoletti
Surgical intervention
4 months ago
1843 views
4 likes
1 comment
09:56
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
S Macina, L Baldari, E Cassinotti, M Ballabio, A Spota, M de Francesco, L Boni
Surgical intervention
4 months ago
2993 views
17 likes
0 comments
07:10
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.
E Soricelli, E Facchiano, L Leuratti, G Quartararo, N Console, P Tonelli, M Lucchese
Surgical intervention
4 months ago
2381 views
7 likes
0 comments
09:10
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.
Endoscopic full-thickness colonic resection for malignant polyp excision
This is the case of an 83-year-old woman who presented with per rectal bleeding. She had flexible sigmoidoscopy, which showed a 1.5 to 2cm flat polyp with central depression and non-lifting sign. CT-scan of the chest, abdomen, and pelvis was performed and showed no metastasis. The case was discussed with the multidisciplinary team and decision was made to perform an endoscopic full-thickness colonic resection. The case was performed using the colonic FTRD® set (OVESCO™). The procedure was completed successfully and the patient was discharged on postoperative day 1. During the postoperative follow-up, the resection margin was clear. This is the first case performed in the North-East of England to our knowledge. Since this case, we have performed another case.
Y Aawsaj, K Khan, M Hayat
Surgical intervention
4 months ago
623 views
2 likes
1 comment
05:30
Endoscopic full-thickness colonic resection for malignant polyp excision
This is the case of an 83-year-old woman who presented with per rectal bleeding. She had flexible sigmoidoscopy, which showed a 1.5 to 2cm flat polyp with central depression and non-lifting sign. CT-scan of the chest, abdomen, and pelvis was performed and showed no metastasis. The case was discussed with the multidisciplinary team and decision was made to perform an endoscopic full-thickness colonic resection. The case was performed using the colonic FTRD® set (OVESCO™). The procedure was completed successfully and the patient was discharged on postoperative day 1. During the postoperative follow-up, the resection margin was clear. This is the first case performed in the North-East of England to our knowledge. Since this case, we have performed another case.
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
WTL Chen, J Verde
Surgical intervention
4 months ago
1820 views
8 likes
0 comments
47:24
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
Laparoscopic cholecystectomy - Basic rules - Bile duct injury
There is twice as much risk of incidental biliary injuries in laparoscopic cholecystectomy than in open cholecystectomy.
About half of surgeons will cause a bile duct injury during their careers. In this lecture, Dr. Dallemagne provides key national data of bile duct injury and explains that the lack of surgical experience or visual misperception leads to an increase in the rate of incidental injuries, mentioning his own cases. Dr. Dallemagne also outlines the fundamental techniques to prevent injuries and use bailout procedures (partial and subtotal cholecystectomy) in laparoscopic cholecystectomy, according to the latest version of the Tokyo guidelines.
B Dallemagne
Lecture
5 months ago
4018 views
36 likes
2 comments
22:02
Laparoscopic cholecystectomy - Basic rules - Bile duct injury
There is twice as much risk of incidental biliary injuries in laparoscopic cholecystectomy than in open cholecystectomy.
About half of surgeons will cause a bile duct injury during their careers. In this lecture, Dr. Dallemagne provides key national data of bile duct injury and explains that the lack of surgical experience or visual misperception leads to an increase in the rate of incidental injuries, mentioning his own cases. Dr. Dallemagne also outlines the fundamental techniques to prevent injuries and use bailout procedures (partial and subtotal cholecystectomy) in laparoscopic cholecystectomy, according to the latest version of the Tokyo guidelines.
Bile duct injury: what to do?
In this key lecture, Dr. Soubrane outlines the various types of bile duct injuries and demonstrates how to manage them, classifying them into bile duct injuries during or after index surgery. When injuries are detected during index surgery, surgeons either have to add stitches combined with drainage in case of minor injuries or create an anastomosis in case of complete common bile duct division. When injuries are detected after index surgery, surgeons may either solve them with endoscopic stenting in case of minor injuries or have to wait at least 2 months in case of complete common bile duct division. As an example of major liver resection for severe bile duct injuries, Dr. Soubrane also shows a case of right liver resection for severe bile duct injury with concomitant arterial interruption and massive portal vein thrombosis after laparoscopic cholecystectomy.
O Soubrane
Lecture
5 months ago
1872 views
13 likes
1 comment
31:48
Bile duct injury: what to do?
In this key lecture, Dr. Soubrane outlines the various types of bile duct injuries and demonstrates how to manage them, classifying them into bile duct injuries during or after index surgery. When injuries are detected during index surgery, surgeons either have to add stitches combined with drainage in case of minor injuries or create an anastomosis in case of complete common bile duct division. When injuries are detected after index surgery, surgeons may either solve them with endoscopic stenting in case of minor injuries or have to wait at least 2 months in case of complete common bile duct division. As an example of major liver resection for severe bile duct injuries, Dr. Soubrane also shows a case of right liver resection for severe bile duct injury with concomitant arterial interruption and massive portal vein thrombosis after laparoscopic cholecystectomy.
Minimal access surgery approach to benign biliary disease
The laparoscopic biliary approach for benign diseases has been discussed for a quarter of a century. However, there were few articles in the literature about laparoscopic bilioenteric anastomoses, such as choledochoduodenostomy and hepatico/choledochojejunostomy which require advanced laparoscopic skills and experience. In this key lecture, Dr. Asbun demonstrates his own laparoscopic techniques for bilioenteric anastomoses. For choledochal cysts representative of benign biliary diseases, cyst excision is required. The difficulty lies in the fact that the cyst extends towards the intrapancreatic portion. Dr. Asbun demonstrates the techniques for complete exposure of the intrapancreatic bile duct portion in such cases. Finally, Dr. Asbun shows bile duct injury cases managed using a hepaticojejunostomy.
HJ Asbun
Lecture
5 months ago
794 views
5 likes
2 comments
24:34
Minimal access surgery approach to benign biliary disease
The laparoscopic biliary approach for benign diseases has been discussed for a quarter of a century. However, there were few articles in the literature about laparoscopic bilioenteric anastomoses, such as choledochoduodenostomy and hepatico/choledochojejunostomy which require advanced laparoscopic skills and experience. In this key lecture, Dr. Asbun demonstrates his own laparoscopic techniques for bilioenteric anastomoses. For choledochal cysts representative of benign biliary diseases, cyst excision is required. The difficulty lies in the fact that the cyst extends towards the intrapancreatic portion. Dr. Asbun demonstrates the techniques for complete exposure of the intrapancreatic bile duct portion in such cases. Finally, Dr. Asbun shows bile duct injury cases managed using a hepaticojejunostomy.
Laparoscopic Frey's procedure with management of intraoperative complication
This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.
After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards.
The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing.
Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure.
P Agami, A Andrianov, V Shchadrova, M Baychorov, R Izrailov
Surgical intervention
5 months ago
4826 views
19 likes
3 comments
12:28
Laparoscopic Frey's procedure with management of intraoperative complication
This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.
After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards.
The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing.
Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure.
Laparoscopic distal pancreatectomy for intraductal papillary mucinous neoplasm (IPMN)
This is the case of a 76-year-old female patient who was referred to our hospital because of intraductal papillary mucinous neoplasm (IPMN). The patient has a medical history of renal insufficiency, sleep apnea syndrome, type 2 diabetes mellitus (T2DM), and hypertension. She has also a history of previous total hysterectomy.
MRI findings showed that the patient’s IPMN affected secondary pancreatic ducts entirely.
The main pancreatic duct is dilated, especially in the distal part at 6mm, but there are no remarkable findings of cystic wall thickening or intracystic nodules. A laparoscopic distal pancreatectomy was planned.
The postoperative course was uneventful and the patient was discharged on postoperative day 8.
Pathological findings showed that the intraductal papillary mucinous neoplasm was without any malignant component.
P Pessaux, E Felli, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
5 months ago
2556 views
5 likes
0 comments
13:26
Laparoscopic distal pancreatectomy for intraductal papillary mucinous neoplasm (IPMN)
This is the case of a 76-year-old female patient who was referred to our hospital because of intraductal papillary mucinous neoplasm (IPMN). The patient has a medical history of renal insufficiency, sleep apnea syndrome, type 2 diabetes mellitus (T2DM), and hypertension. She has also a history of previous total hysterectomy.
MRI findings showed that the patient’s IPMN affected secondary pancreatic ducts entirely.
The main pancreatic duct is dilated, especially in the distal part at 6mm, but there are no remarkable findings of cystic wall thickening or intracystic nodules. A laparoscopic distal pancreatectomy was planned.
The postoperative course was uneventful and the patient was discharged on postoperative day 8.
Pathological findings showed that the intraductal papillary mucinous neoplasm was without any malignant component.
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
P Pessaux, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
5 months ago
1577 views
2 likes
0 comments
05:51
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
Laparoscopic left lateral sectionectomy for hepatocarcinoma in a cirrhotic patient
This video demonstrates a laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC) in a cirrhotic liver with hemochromatosis. This is the case of a 77-year-old patient who presented with a 40mm HCC located in Couinaud’s liver segment II and III. After left liver mobilization, parenchymal transection was initiated along the left side of the falciform ligament, mainly using the cavitron ultrasonic surgical aspirator (CUSA®). Tissue Select mode was used during the exposure of the vascular structure. The Glissonian pedicles of segments III and II were encircled and transected, and finally the suprahepatic vein was divided using an Endo GIA™ linear stapler. The specimen was extracted with a short suprapubic incision. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of a well-differentiated HCC.
P Pessaux, T Urade, T Wakabayashi, E Felli, A Mazzotta, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
5 months ago
1951 views
9 likes
0 comments
07:22
Laparoscopic left lateral sectionectomy for hepatocarcinoma in a cirrhotic patient
This video demonstrates a laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC) in a cirrhotic liver with hemochromatosis. This is the case of a 77-year-old patient who presented with a 40mm HCC located in Couinaud’s liver segment II and III. After left liver mobilization, parenchymal transection was initiated along the left side of the falciform ligament, mainly using the cavitron ultrasonic surgical aspirator (CUSA®). Tissue Select mode was used during the exposure of the vascular structure. The Glissonian pedicles of segments III and II were encircled and transected, and finally the suprahepatic vein was divided using an Endo GIA™ linear stapler. The specimen was extracted with a short suprapubic incision. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of a well-differentiated HCC.
Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor
In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter, at the pancreatic isthmus. Scintigraphy does not evidence any intense uptake.
The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall.
A postoperative pancreatic fistula grade B was reported. It was successfully managed. The presence of a well-differentiated neuroendocrine tumor was confirmed. The patient was discharged on postoperative day 22.
P Pessaux, E Felli, T Wakabayashi, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
5 months ago
2408 views
4 likes
3 comments
07:01
Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor
In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter, at the pancreatic isthmus. Scintigraphy does not evidence any intense uptake.
The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall.
A postoperative pancreatic fistula grade B was reported. It was successfully managed. The presence of a well-differentiated neuroendocrine tumor was confirmed. The patient was discharged on postoperative day 22.