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Laparoscopic ileocecal resection for unresectable appendix
This is the case of a 36-year-old woman who has had an exploratory laparoscopy in another institution 2 months earlier. Acute appendicitis was suspected, based on ultrasound exam. However, exploration has shown an inflammatory appendicular mass, impossible to dissect. The patient was administered antibiotics for a period of 3 weeks. A laparoscopic appendectomy was decided upon at an interval of 2 months. Work-up included CT-scan and colonoscopy, which did not demonstrate anything specific.
Laparoscopic exploration demonstrated important fibrotic and scarry tissues around the appendix and the cecum. Despite painstaking dissection, appendectomy was impossible. Ileocecal resection was decided upon. Operative steps, namely exposure, division of the last ileal loop, division of the meso, division of the right colon above the ampulla coli and the intracorporeal side-to-side stapled anastomosis are demonstrated. Pathological findings evidenced an endometriotic nodule. The postoperative course was uneventful.
D Mutter, M Ignat, J Marescaux
Surgical intervention
2 years ago
6858 views
339 likes
6 comments
08:23
Laparoscopic ileocecal resection for unresectable appendix
This is the case of a 36-year-old woman who has had an exploratory laparoscopy in another institution 2 months earlier. Acute appendicitis was suspected, based on ultrasound exam. However, exploration has shown an inflammatory appendicular mass, impossible to dissect. The patient was administered antibiotics for a period of 3 weeks. A laparoscopic appendectomy was decided upon at an interval of 2 months. Work-up included CT-scan and colonoscopy, which did not demonstrate anything specific.
Laparoscopic exploration demonstrated important fibrotic and scarry tissues around the appendix and the cecum. Despite painstaking dissection, appendectomy was impossible. Ileocecal resection was decided upon. Operative steps, namely exposure, division of the last ileal loop, division of the meso, division of the right colon above the ampulla coli and the intracorporeal side-to-side stapled anastomosis are demonstrated. Pathological findings evidenced an endometriotic nodule. The postoperative course was uneventful.
Laparoscopic appendectomy for abscessed and necrotic appendix
This video of an emergency appendectomy demonstrates some of the advantages of the laparoscopic approach. Multiple abscess cavities are identified by a thorough exploration, including the necrotic appendix. Control of bleeding from the appendiceal artery and control of a gangrenous base of the appendix are clearly shown.

This male patient had emergency surgery after a 1-week history of diffuse abdominal pain with signs of inflammatory syndrome. CT showed a pelvic abscess.

The author begins the laparoscopic approach with a 1-cm incision just above the umbilicus and establishes pneumoperitoneum with the open technique. Dissection of the abscess must proceed cautiously. A suction device in tandem with a probe prove useful for continuing dissection to help mobilize the cecum.

As the appendix comes into view, the author identifies the mesoappendix to begin dissection. Significant edema makes it difficult to continue dissection with the blunt probe, so the author uses bipolar cautery to begin dissection of the mesoappendix.
A Rossini
Surgical intervention
13 years ago
10274 views
88 likes
0 comments
05:04
Laparoscopic appendectomy for abscessed and necrotic appendix
This video of an emergency appendectomy demonstrates some of the advantages of the laparoscopic approach. Multiple abscess cavities are identified by a thorough exploration, including the necrotic appendix. Control of bleeding from the appendiceal artery and control of a gangrenous base of the appendix are clearly shown.

This male patient had emergency surgery after a 1-week history of diffuse abdominal pain with signs of inflammatory syndrome. CT showed a pelvic abscess.

The author begins the laparoscopic approach with a 1-cm incision just above the umbilicus and establishes pneumoperitoneum with the open technique. Dissection of the abscess must proceed cautiously. A suction device in tandem with a probe prove useful for continuing dissection to help mobilize the cecum.

As the appendix comes into view, the author identifies the mesoappendix to begin dissection. Significant edema makes it difficult to continue dissection with the blunt probe, so the author uses bipolar cautery to begin dissection of the mesoappendix.
Laparoscopy and appendicitis
In this key lecture, Dr. Benoît Navez outlines the use of laparoscopy for the management of appendicitis, from diagnosis to surgical treatment, and postoperative complications of acute appendicitis.
He explains the best diagnostic modalities, providing an indication for each one. While performing a complete evaluation of the leading role of laparoscopy in this common entity and the advantages in challenge scenarios such as morbid obesity and pregnancy. Surgical technical pitfalls are pointed (e.g., standard trocar placement and best localization for additional port, types of mesoappendix control and its advantages, principal stump closure techniques such as endoloop and specific indications for stapler use, evidence-based recommendations to prevent stump appendicitis and avoid the risk of bacteremia during sepsis, evidence of intraperitoneal irrigation and its correlation with intra-abdominal postoperative abscess, and non-operative options such as Wait and See and interval appendectomy).

B Navez
Lecture
2 months ago
3813 views
59 likes
9 comments
29:19
Laparoscopy and appendicitis
In this key lecture, Dr. Benoît Navez outlines the use of laparoscopy for the management of appendicitis, from diagnosis to surgical treatment, and postoperative complications of acute appendicitis.
He explains the best diagnostic modalities, providing an indication for each one. While performing a complete evaluation of the leading role of laparoscopy in this common entity and the advantages in challenge scenarios such as morbid obesity and pregnancy. Surgical technical pitfalls are pointed (e.g., standard trocar placement and best localization for additional port, types of mesoappendix control and its advantages, principal stump closure techniques such as endoloop and specific indications for stapler use, evidence-based recommendations to prevent stump appendicitis and avoid the risk of bacteremia during sepsis, evidence of intraperitoneal irrigation and its correlation with intra-abdominal postoperative abscess, and non-operative options such as Wait and See and interval appendectomy).

Laparoscopic appendectomy for recurrent appendicitis after medical treatment
Appendectomy is the only curative treatment of appendicitis. However, the management of patients with an appendiceal mass or abscess can be temporarily managed medically with intravenous antibiotic therapy and/or percutaneous drainage. And yet, there are many controversies over the non-operative management of acute appendicitis. In 2015, Fair et al. used data from the American College of Surgeons National Surgical Quality Improvement Project to evaluate 30-day morbidity and mortality of intervention (laparoscopic and open appendectomy) at different time periods. A delay of operative intervention longer than 48 hours was associated with a doubling of complication rates. Elective appendectomy can be performed after 6 to 8 weeks later, which proves successful in the vast majority of patients.
This is the case of an 83-year-old man who presented with an acute appendicitis treated medically in another hospital. The patient had a past medical history of arterial hypertension, cardiomyopathy, previous cerebral ischemia, and rectal polyp. A delayed appendectomy was planned. However, before the procedure, a total colonoscopy was performed because of the history of polyps. This elderly patient was hospitalized for colonoscopy. At admission, he presented with fever, right iliac fossa tenderness, and a biological inflammatory syndrome. A CT-scan was performed. It showed a recurrent acute appendicitis without mass, with a 2cm abscess on the tip of the appendix. An appendectomy was performed in this case.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
2 years ago
6791 views
346 likes
1 comment
05:00
Laparoscopic appendectomy for recurrent appendicitis after medical treatment
Appendectomy is the only curative treatment of appendicitis. However, the management of patients with an appendiceal mass or abscess can be temporarily managed medically with intravenous antibiotic therapy and/or percutaneous drainage. And yet, there are many controversies over the non-operative management of acute appendicitis. In 2015, Fair et al. used data from the American College of Surgeons National Surgical Quality Improvement Project to evaluate 30-day morbidity and mortality of intervention (laparoscopic and open appendectomy) at different time periods. A delay of operative intervention longer than 48 hours was associated with a doubling of complication rates. Elective appendectomy can be performed after 6 to 8 weeks later, which proves successful in the vast majority of patients.
This is the case of an 83-year-old man who presented with an acute appendicitis treated medically in another hospital. The patient had a past medical history of arterial hypertension, cardiomyopathy, previous cerebral ischemia, and rectal polyp. A delayed appendectomy was planned. However, before the procedure, a total colonoscopy was performed because of the history of polyps. This elderly patient was hospitalized for colonoscopy. At admission, he presented with fever, right iliac fossa tenderness, and a biological inflammatory syndrome. A CT-scan was performed. It showed a recurrent acute appendicitis without mass, with a 2cm abscess on the tip of the appendix. An appendectomy was performed in this case.
Laparoscopic appendectomy and fenestration of hemorrhagic ovarian cyst
This is the case of a 19-year-old female patient who was admitted to the emergency department for lower abdominal pain going on for 24 hours. No abdominal guarding was noted. Biological findings showed an inflammation with leukocytes at 16,000 and CRP levels at 112. CT-scan showed the presence of an enlarged appendix (9mm thick) along with a voluminous adnexal cyst, which may be suggestive of a tubo-ovarian abscess. Laparoscopic exploration is performed. Congestive appendicitis is confirmed, as well as the presence of a hemorrhagic right ovarian cyst. Laparoscopic appendectomy is performed and the hemorrhagic ovarian cyst is fenestrated.
M Ignat, D Mutter, J Marescaux
Surgical intervention
2 years ago
5795 views
417 likes
0 comments
04:57
Laparoscopic appendectomy and fenestration of hemorrhagic ovarian cyst
This is the case of a 19-year-old female patient who was admitted to the emergency department for lower abdominal pain going on for 24 hours. No abdominal guarding was noted. Biological findings showed an inflammation with leukocytes at 16,000 and CRP levels at 112. CT-scan showed the presence of an enlarged appendix (9mm thick) along with a voluminous adnexal cyst, which may be suggestive of a tubo-ovarian abscess. Laparoscopic exploration is performed. Congestive appendicitis is confirmed, as well as the presence of a hemorrhagic right ovarian cyst. Laparoscopic appendectomy is performed and the hemorrhagic ovarian cyst is fenestrated.
Laparoscopic appendectomy for appendicitis with peritonitis
This is the case of a 37-year-old male patient who presented with abdominal pain and fever at 39.4°C. The work-up demonstrated important inflammation with leukocytes at 16,000 and CRP levels at 169. CT-scan confirmed an acute appendicitis with an appendicolith at the base. The appendix is probably perforated as the CT-scan also demonstrated a pneumoperitoneum. Laparoscopic appendectomy is decided upon. The operative set-up is standard with an optical port placed at the umbilicus, a port in the left iliac fossa, and a suprapubic port. Exposure, appendectomy with stapling of the appendicular base, and cleansing of the peritoneal cavity are thoroughly demonstrated.
M Ignat, D Mutter, J Marescaux
Surgical intervention
2 years ago
5396 views
477 likes
0 comments
05:03
Laparoscopic appendectomy for appendicitis with peritonitis
This is the case of a 37-year-old male patient who presented with abdominal pain and fever at 39.4°C. The work-up demonstrated important inflammation with leukocytes at 16,000 and CRP levels at 169. CT-scan confirmed an acute appendicitis with an appendicolith at the base. The appendix is probably perforated as the CT-scan also demonstrated a pneumoperitoneum. Laparoscopic appendectomy is decided upon. The operative set-up is standard with an optical port placed at the umbilicus, a port in the left iliac fossa, and a suprapubic port. Exposure, appendectomy with stapling of the appendicular base, and cleansing of the peritoneal cavity are thoroughly demonstrated.
Laparoscopic appendectomy after appendicular phlegmon
Appendicitis is one of the main reasons for consultation and surgical interventions in the emergency departments around the world. If it is not diagnosed and treated timely, it can evolve towards an appendicular perforation, and as a result, it can become a peritonitis or an appendicular phlegmon. This latter case may occur in approximately 10% of cases.
Currently, the management of the appendicular phlegmon is controversial. Some authors prefer to perform an appendectomy immediately, and others are in favor of medical treatment using antibiotic therapy and percutaneous drainage if possible and delay appendectomy.
In this case, we present a patient presenting with an appendicular phlegmon in which a conservative management with percutaneous drainage and delayed surgery were decided upon.
P Saleg, A D'Urso, D Mutter, J Marescaux
Surgical intervention
2 years ago
9952 views
526 likes
0 comments
04:17
Laparoscopic appendectomy after appendicular phlegmon
Appendicitis is one of the main reasons for consultation and surgical interventions in the emergency departments around the world. If it is not diagnosed and treated timely, it can evolve towards an appendicular perforation, and as a result, it can become a peritonitis or an appendicular phlegmon. This latter case may occur in approximately 10% of cases.
Currently, the management of the appendicular phlegmon is controversial. Some authors prefer to perform an appendectomy immediately, and others are in favor of medical treatment using antibiotic therapy and percutaneous drainage if possible and delay appendectomy.
In this case, we present a patient presenting with an appendicular phlegmon in which a conservative management with percutaneous drainage and delayed surgery were decided upon.
Low-cost laparoscopic appendectomy: how to teach
Laparoscopic appendectomy must be the gold standard. Nowadays, many centers still continue to go on with McBurney’s incisions. Why? Expensive devices may be a reason. Low cost appendectomy allows for a diagnostic laparoscopy and offers a therapeutic option with the lowest price.
On the other hand, residents must begin the learning curve in laparoscopy as soon as possible not only with a training center (training in cadaveric or animals) but they must also start practicing on humans with watchful surgeon/teacher’s eyes.
The aim of this video is to demonstrate that low-cost laparoscopic appendectomy is feasible not only for surgeons but also for residents operating with an expert.
S Rua, G Machado , P Mira
Surgical intervention
4 years ago
11087 views
580 likes
0 comments
08:49
Low-cost laparoscopic appendectomy: how to teach
Laparoscopic appendectomy must be the gold standard. Nowadays, many centers still continue to go on with McBurney’s incisions. Why? Expensive devices may be a reason. Low cost appendectomy allows for a diagnostic laparoscopy and offers a therapeutic option with the lowest price.
On the other hand, residents must begin the learning curve in laparoscopy as soon as possible not only with a training center (training in cadaveric or animals) but they must also start practicing on humans with watchful surgeon/teacher’s eyes.
The aim of this video is to demonstrate that low-cost laparoscopic appendectomy is feasible not only for surgeons but also for residents operating with an expert.
Laparoscopic interval appendectomy after conservative treatment of an appendiceal abscess
Appendectomy is the standard treatment for acute appendicitis in adults and children. However, more and more studies demonstrate that a conservative treatment with antibiotics and radiological drainage, if required, is effective and may be of importance in complicated cases and in older frail patients [1].
In the absence of randomized controlled trials, there is no consensus on whether an appendectomy at distance from the acute phase (interval appendectomy) is necessary for conservatively treated patients. A large observational study has shown that about 10% of these patients will require an appendectomy [2] over a period of several years. However, a histopathological study of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess concluded that more than half of the patients had strong histopathological changes in the appendix, thereby suggesting a high possibility of recurrence [3].
This is the case of a 58-year-old female patient presenting with a perforated appendix with an appendiceal abscess, treated by antibiotherapy and radiological drainage. She has a past history of uterine cancer treated by radiochemotherapy and total hysterectomy, complicated by bilateral ureteral stenoses after radiotherapy, treated by long-term pig-tail urinary catheters, as well as a postoperative abdominal hernia treated by means of an abdominal underlay mesh. Even though the initial non-surgical treatment of her complicated acute appendicitis was successful, an interval appendectomy was indicated because of persistent abdominal pain in the right lower quadrant (RLQ). The operation was performed laparoscopically with a simple postoperative course.
References:
1. Tannoury J. Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013;19:3942-50.
2. McCutcheon BA, Chang DC, Marcus LP, Inui T, Noorbakhsh A, Schallhorn C, Parina R, Salazar FR, Talamini MA. Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis. J Am Coll Surg 2014;218:905-13.
3. Otake S, Suzuki N, Takahashi A, Toki F, Nishi A, Yamamoto H, Kuroiwa M, Kuwano H. Histological analysis of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess. Surg Today 2014;44:1400-5.
D Ntourakis, D Mutter, J Marescaux
Surgical intervention
5 years ago
5555 views
171 likes
0 comments
12:12
Laparoscopic interval appendectomy after conservative treatment of an appendiceal abscess
Appendectomy is the standard treatment for acute appendicitis in adults and children. However, more and more studies demonstrate that a conservative treatment with antibiotics and radiological drainage, if required, is effective and may be of importance in complicated cases and in older frail patients [1].
In the absence of randomized controlled trials, there is no consensus on whether an appendectomy at distance from the acute phase (interval appendectomy) is necessary for conservatively treated patients. A large observational study has shown that about 10% of these patients will require an appendectomy [2] over a period of several years. However, a histopathological study of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess concluded that more than half of the patients had strong histopathological changes in the appendix, thereby suggesting a high possibility of recurrence [3].
This is the case of a 58-year-old female patient presenting with a perforated appendix with an appendiceal abscess, treated by antibiotherapy and radiological drainage. She has a past history of uterine cancer treated by radiochemotherapy and total hysterectomy, complicated by bilateral ureteral stenoses after radiotherapy, treated by long-term pig-tail urinary catheters, as well as a postoperative abdominal hernia treated by means of an abdominal underlay mesh. Even though the initial non-surgical treatment of her complicated acute appendicitis was successful, an interval appendectomy was indicated because of persistent abdominal pain in the right lower quadrant (RLQ). The operation was performed laparoscopically with a simple postoperative course.
References:
1. Tannoury J. Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013;19:3942-50.
2. McCutcheon BA, Chang DC, Marcus LP, Inui T, Noorbakhsh A, Schallhorn C, Parina R, Salazar FR, Talamini MA. Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis. J Am Coll Surg 2014;218:905-13.
3. Otake S, Suzuki N, Takahashi A, Toki F, Nishi A, Yamamoto H, Kuroiwa M, Kuwano H. Histological analysis of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess. Surg Today 2014;44:1400-5.
Monopolar laparoscopic appendectomy
The laparoscopic approach is the gold standard for acute appendicitis. There are several surgical devices to achieve hemostatic control of the appendicular artery (monopolar electrocautery, endoclip, endostapler, ultrasonic scalpel, and LigaSure™ vessel-sealing device), which vary widely according to the surgeon’s preference and availability in the institution. All devices are effective and safe, but monopolar electrocautery systems are the most cost-effective ones.
A 24-year-old woman was admitted to our emergency department with a 24-hour evolution of right iliac fossa pain. No other symptoms were noted. An abdominal ultrasound was suggestive of an acute appendicitis.
This full length surgical movie shows the feasibility and safety of monopolar electrocautery for meso-appendiceal dissection. The intra-abdominal procedure was achieved in 5 minutes 30 seconds.
No complications were observed and the patient was discharged home on the next postoperative day.
P Leão, A Goulart
Surgical intervention
5 years ago
10297 views
339 likes
1 comment
06:14
Monopolar laparoscopic appendectomy
The laparoscopic approach is the gold standard for acute appendicitis. There are several surgical devices to achieve hemostatic control of the appendicular artery (monopolar electrocautery, endoclip, endostapler, ultrasonic scalpel, and LigaSure™ vessel-sealing device), which vary widely according to the surgeon’s preference and availability in the institution. All devices are effective and safe, but monopolar electrocautery systems are the most cost-effective ones.
A 24-year-old woman was admitted to our emergency department with a 24-hour evolution of right iliac fossa pain. No other symptoms were noted. An abdominal ultrasound was suggestive of an acute appendicitis.
This full length surgical movie shows the feasibility and safety of monopolar electrocautery for meso-appendiceal dissection. The intra-abdominal procedure was achieved in 5 minutes 30 seconds.
No complications were observed and the patient was discharged home on the next postoperative day.