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Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
P Pessaux, R Memeo, V De Blasi, D Mutter, T Piardi, J Marescaux
Surgical intervention
3 years ago
722 views
19 likes
0 comments
16:09
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
Robotic assisted thoracoscopic lingulectomy
A 67-year-old otherwise healthy woman presented to her primary care physician with complaints of dyspnea. Her primary care physician obtained a chest X-ray, which revealed a left upper lobe abnormality. A follow-up chest CT revealed a 16mm left upper lobe mass concerning for malignancy in the lingula. A bronchoscopy with brushings was performed and pathology was positive for a well-differentiated adenocarcinoma. As part of a clinical staging, a PET-CT was obtained and demonstrated no FDG avid disease in the thorax or elsewhere. Pulmonary function tests revealed an FEV1 of 2.28 L (122% predicted) and DLCO of 19.05 (112% predicted). The therapeutic objectives were to perform an oncologically sound anatomic lung resection and lymph node dissection for the patients early stage biopsy proven lung cancer. The robotic platform was used in this case and we aimed to demonstrate our approach to a robotic assisted thoracoscopic lingulectomy for lung cancer.
HJ Feldman, M Kent, J Wilson
Surgical intervention
4 years ago
483 views
16 likes
0 comments
10:55
Robotic assisted thoracoscopic lingulectomy
A 67-year-old otherwise healthy woman presented to her primary care physician with complaints of dyspnea. Her primary care physician obtained a chest X-ray, which revealed a left upper lobe abnormality. A follow-up chest CT revealed a 16mm left upper lobe mass concerning for malignancy in the lingula. A bronchoscopy with brushings was performed and pathology was positive for a well-differentiated adenocarcinoma. As part of a clinical staging, a PET-CT was obtained and demonstrated no FDG avid disease in the thorax or elsewhere. Pulmonary function tests revealed an FEV1 of 2.28 L (122% predicted) and DLCO of 19.05 (112% predicted). The therapeutic objectives were to perform an oncologically sound anatomic lung resection and lymph node dissection for the patients early stage biopsy proven lung cancer. The robotic platform was used in this case and we aimed to demonstrate our approach to a robotic assisted thoracoscopic lingulectomy for lung cancer.
Complex left upper lobectomy with lymphadenectomy using a full endoscopic robotic technique
This is the case of a 72-year-old woman, followed up for chronic lymphocytic leukemia treated with chemotherapy.
During her follow-up, a nodule in the left upper lobe as well as multiple bulky lymph nodes were discovered.
The multidisciplinary meeting proposed a wedge resection more or less associated with a lobectomy depending on the results of frozen section.
The difficulty of this procedure lies in bulky lymph nodes around the pulmonary artery.
Due to the complexity of the case, we prefer to use a RATS approach rather than a VATS approach, as it allows for a sharp dissection using a bipolar Maryland forceps.
JM Baste, B Bottet, C Peillon
Surgical intervention
4 years ago
1015 views
14 likes
0 comments
08:52
Complex left upper lobectomy with lymphadenectomy using a full endoscopic robotic technique
This is the case of a 72-year-old woman, followed up for chronic lymphocytic leukemia treated with chemotherapy.
During her follow-up, a nodule in the left upper lobe as well as multiple bulky lymph nodes were discovered.
The multidisciplinary meeting proposed a wedge resection more or less associated with a lobectomy depending on the results of frozen section.
The difficulty of this procedure lies in bulky lymph nodes around the pulmonary artery.
Due to the complexity of the case, we prefer to use a RATS approach rather than a VATS approach, as it allows for a sharp dissection using a bipolar Maryland forceps.
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
P Pessaux, J Hallet, R Memeo, JB Delhorme, D Mutter, J Marescaux
Surgical intervention
4 years ago
1398 views
28 likes
0 comments
12:38
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
Robotic subinguinal varicocelectomy
Purpose: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy.
Material and Methods: Ten patients with an average age of 28.4 years underwent 11 microscopic subinguinal varicocelectomies. Ten patients with an average age of 23.1 years underwent 11 robot-assisted varicocelectomies.
Results: The average operative time for microscopic inguinal varicocelectomy was 69.2 minutes, whereas the robot-assisted technique took 70.3 minutes. There were no difficulties in identifying and isolating vessels and the vas deferens with robotic-assisted subinguinal varicocelectomy. Hand tremor was eliminated with the robotic procedure. Robotic patients were able to resume daily activities on the day of surgery and full activities within two weeks. There were no complications or recurrences of varicocele.
Conclusions: From our experience, we believe that robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic surgery, with the added benefit of reducing hand tremor.
T Shu
Lecture
5 years ago
829 views
30 likes
0 comments
08:03
Robotic subinguinal varicocelectomy
Purpose: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy.
Material and Methods: Ten patients with an average age of 28.4 years underwent 11 microscopic subinguinal varicocelectomies. Ten patients with an average age of 23.1 years underwent 11 robot-assisted varicocelectomies.
Results: The average operative time for microscopic inguinal varicocelectomy was 69.2 minutes, whereas the robot-assisted technique took 70.3 minutes. There were no difficulties in identifying and isolating vessels and the vas deferens with robotic-assisted subinguinal varicocelectomy. Hand tremor was eliminated with the robotic procedure. Robotic patients were able to resume daily activities on the day of surgery and full activities within two weeks. There were no complications or recurrences of varicocele.
Conclusions: From our experience, we believe that robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic surgery, with the added benefit of reducing hand tremor.
Robot-assisted left upper lobectomy for T1N0M0 adenocarcinoma
This is the case of a robotic left upper lobectomy with lymphadenectomy in a woman aged 52 who has had 9 children and who was a regular smoker (50 packs per year). She is presenting with an isolated cT1N0M0 adenocarcinoma in the left upper pulmonary lobe. PET-scan was positive for the lesion without any other pathological finding in the mediastinum or far metastasis. Histology was obtained by CT-guided transthoracic needle aspiration biopsy.
This minimally invasive technique, assisted by the da Vinci® robotic surgical system, is sure, comfortable, and efficient to perform a pulmonary lobectomy with lymphadenectomy in the early stages of lung cancer.
3D vision and the accuracy of dissection appear to be better than in conventional VATS.
As in VATS lobectomy, hospital stay is reduced to 3-4 days and postoperative pain appears to be more acceptable.
N Santelmo, F Antonacci, G Massard
Surgical intervention
6 years ago
561 views
6 likes
0 comments
11:59
Robot-assisted left upper lobectomy for T1N0M0 adenocarcinoma
This is the case of a robotic left upper lobectomy with lymphadenectomy in a woman aged 52 who has had 9 children and who was a regular smoker (50 packs per year). She is presenting with an isolated cT1N0M0 adenocarcinoma in the left upper pulmonary lobe. PET-scan was positive for the lesion without any other pathological finding in the mediastinum or far metastasis. Histology was obtained by CT-guided transthoracic needle aspiration biopsy.
This minimally invasive technique, assisted by the da Vinci® robotic surgical system, is sure, comfortable, and efficient to perform a pulmonary lobectomy with lymphadenectomy in the early stages of lung cancer.
3D vision and the accuracy of dissection appear to be better than in conventional VATS.
As in VATS lobectomy, hospital stay is reduced to 3-4 days and postoperative pain appears to be more acceptable.
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.
M Vix, J Marescaux
Surgical intervention
6 years ago
2140 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.
Robot-assisted revision of stenotic gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass
This video presents the case of a 37-year-old woman who benefited from a laparoscopic Roux-en-Y gastric bypass with circular gastrojejunal anastomosis one year ago. An anastomotic stenosis rapidly occurred. It was managed conventionally by several endoscopic balloon dilatations without any stable results. It was found legitimate to offer the patient a revision of the gastrojejunostomy. Prior to performing the reintervention, a nasojejunal tube was placed in order to improve the patient’s enteral nutrition. Surgery consisted in the resection of the existing gastrojejunostomy and in the tailoring of a new manual anastomosis using the da Vinci™ robotic Surgical System. The postoperative outcome was uneventful. The patient no longer reports any dysphagia 3 months postoperatively.
M Vix, J Marescaux
Surgical intervention
6 years ago
1186 views
9 likes
0 comments
15:12
Robot-assisted revision of stenotic gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass
This video presents the case of a 37-year-old woman who benefited from a laparoscopic Roux-en-Y gastric bypass with circular gastrojejunal anastomosis one year ago. An anastomotic stenosis rapidly occurred. It was managed conventionally by several endoscopic balloon dilatations without any stable results. It was found legitimate to offer the patient a revision of the gastrojejunostomy. Prior to performing the reintervention, a nasojejunal tube was placed in order to improve the patient’s enteral nutrition. Surgery consisted in the resection of the existing gastrojejunostomy and in the tailoring of a new manual anastomosis using the da Vinci™ robotic Surgical System. The postoperative outcome was uneventful. The patient no longer reports any dysphagia 3 months postoperatively.
Robotic-assisted mini gastric bypass
Amongst bariatric procedures, mini gastric bypass has been described by Rutledge in 2001 with the objective of simplifying the gastric bypass technique (1). Mini gastric bypass only requires one anastomosis instead of 2 and should reduce complications related to the anastomosis at the foot of the loop in a conventional gastric bypass procedure. A few specificities should be pointed out. The gastric pouch is longer and more narrow. The landmark used to start the gastric division corresponds to the area separating the body of the stomach from the antrum at the level of the angulus. The biliary limb is also much longer and should reach 2cm in order to avoid the undiluted biliary fluid effects on the anastomosis. In this intervention, it is crucial to closue Petersen’s defect between the mounted loop and the transverse mesocolon. According to Himpens, this procedure could well reduce the incidence of hypoglycemias that might occur after a gastric bypass. This video outlines the different steps of the intervention. The use of a surgical robot allows to very easily perform a manual gastrojejunostomy.

(1). Rutledge, R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg 2001;11:276-80.
M Vix, KH Liu, J Marescaux
Surgical intervention
7 years ago
2182 views
49 likes
0 comments
15:41
Robotic-assisted mini gastric bypass
Amongst bariatric procedures, mini gastric bypass has been described by Rutledge in 2001 with the objective of simplifying the gastric bypass technique (1). Mini gastric bypass only requires one anastomosis instead of 2 and should reduce complications related to the anastomosis at the foot of the loop in a conventional gastric bypass procedure. A few specificities should be pointed out. The gastric pouch is longer and more narrow. The landmark used to start the gastric division corresponds to the area separating the body of the stomach from the antrum at the level of the angulus. The biliary limb is also much longer and should reach 2cm in order to avoid the undiluted biliary fluid effects on the anastomosis. In this intervention, it is crucial to closue Petersen’s defect between the mounted loop and the transverse mesocolon. According to Himpens, this procedure could well reduce the incidence of hypoglycemias that might occur after a gastric bypass. This video outlines the different steps of the intervention. The use of a surgical robot allows to very easily perform a manual gastrojejunostomy.

(1). Rutledge, R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg 2001;11:276-80.
Robot-assisted left adrenalectomy for Conn's adenoma
As laparoscopy is the standard approach to perform an adrenalectomy, robotic assistance is considered as an effective tool to perform this resection. Surgical steps follow those established for laparoscopy (i.e., mobilization of the spleen and of the pancreas in a patient placed in a lateral position, identification of the renal vein, control and division of the adrenal vein, successive freeing of the medial, external, inferior, and finally posterior aspects of the gland. The sealing devices such as ultrasonic dissectors are well adapted to perform this resection, and to safely control adrenal arteries. Robotic assistance takes full benefit from the degrees of freedom of the tips of the instruments and allows for an easy adrenal gland mobilization and removal.
D Mutter, L Soler, J Marescaux
Surgical intervention
7 years ago
1762 views
24 likes
0 comments
16:19
Robot-assisted left adrenalectomy for Conn's adenoma
As laparoscopy is the standard approach to perform an adrenalectomy, robotic assistance is considered as an effective tool to perform this resection. Surgical steps follow those established for laparoscopy (i.e., mobilization of the spleen and of the pancreas in a patient placed in a lateral position, identification of the renal vein, control and division of the adrenal vein, successive freeing of the medial, external, inferior, and finally posterior aspects of the gland. The sealing devices such as ultrasonic dissectors are well adapted to perform this resection, and to safely control adrenal arteries. Robotic assistance takes full benefit from the degrees of freedom of the tips of the instruments and allows for an easy adrenal gland mobilization and removal.
Gastric bypass after band removal: robotic-assisted gastrojejunostomy and linear-stapled jejunojejunostomy
Laparoscopic gastric bypass performed after gastric band removal requires the same surgical steps as a conventional gastric bypass. The presence of adhesions between the liver and the stomach makes the dissection of the superior gastric pouch more difficult. It is essential to correctly visualize the left crus during the dissection.
When the gastric pouch has been created, the other steps of the intervention remain conventional. Our team is currently evaluating the interest of using the Da Vinci™ surgical robot in morbid obesity surgery. As a result, we regularly perform a hand-assisted gastrojejunal anastomosis using the robot. The anastomosis is therefore easier to perform as the robot offers specific degrees of freedom. Consequently, the surgeon benefits from a more ergonomic position. In order to substantially increase surgical time, we opted for a conventional jejunojejunal anastomosis without the assistance of the surgical robot.
M Vix, J Marescaux
Surgical intervention
7 years ago
1218 views
4 likes
0 comments
20:14
Gastric bypass after band removal: robotic-assisted gastrojejunostomy and linear-stapled jejunojejunostomy
Laparoscopic gastric bypass performed after gastric band removal requires the same surgical steps as a conventional gastric bypass. The presence of adhesions between the liver and the stomach makes the dissection of the superior gastric pouch more difficult. It is essential to correctly visualize the left crus during the dissection.
When the gastric pouch has been created, the other steps of the intervention remain conventional. Our team is currently evaluating the interest of using the Da Vinci™ surgical robot in morbid obesity surgery. As a result, we regularly perform a hand-assisted gastrojejunal anastomosis using the robot. The anastomosis is therefore easier to perform as the robot offers specific degrees of freedom. Consequently, the surgeon benefits from a more ergonomic position. In order to substantially increase surgical time, we opted for a conventional jejunojejunal anastomosis without the assistance of the surgical robot.
Robot-assisted Roux-en-Y gastric bypass using Sonicision™ cordless ultrasonic dissection device
Gastric bypass is considered to be the gold standard in morbid obesity surgery.
If technical principles are well-established, there are several alternatives to apply them. Consequently, gastrojejunostomy can be performed in three different fashions: manual, linear, and circular. Manual anastomosis can be performed with the help of the robotic Da Vinci™ Surgical System. This robot is particularly suited for manual anastomosis thanks to the instruments’ articulated extremities. Operative steps that do not benefit from robotics are performed by means of conventional laparoscopy, and especially gastric pouch division. This video also demonstrates the combined use of ultrasonic wireless scissors developed by Covidien (i.e., the Sonicision™ cordless ultrasonic dissection device).
M Vix, KH Liu, J Marescaux
Surgical intervention
7 years ago
4792 views
4 likes
0 comments
17:20
Robot-assisted Roux-en-Y gastric bypass using Sonicision™ cordless ultrasonic dissection device
Gastric bypass is considered to be the gold standard in morbid obesity surgery.
If technical principles are well-established, there are several alternatives to apply them. Consequently, gastrojejunostomy can be performed in three different fashions: manual, linear, and circular. Manual anastomosis can be performed with the help of the robotic Da Vinci™ Surgical System. This robot is particularly suited for manual anastomosis thanks to the instruments’ articulated extremities. Operative steps that do not benefit from robotics are performed by means of conventional laparoscopy, and especially gastric pouch division. This video also demonstrates the combined use of ultrasonic wireless scissors developed by Covidien (i.e., the Sonicision™ cordless ultrasonic dissection device).