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Laparoscopic revision of stenotic colorectal anastomosis
Background: Colorectal anastomosis is usually performed using a circular stapler inserted transanally. Postoperative complications such as strictures are rare and related to various factors like ischemia, poor vascularization, and previous leak. This video shows a laparoscopic revision of a stenotic colorectal anastomosis, solved with a new hand-sewn anastomosis.

Video: A 51-year-old man underwent laparoscopic sigmoidectomy for symptomatic diverticulosis. At that time, a transanal circular mechanical end-to-end colorectal anastomosis was performed using a 29mm circular stapler. After 3 months of follow-up, a symptomatic stenotic colorectal anastomosis was evidenced, and endoscopic dilatation (repeated 3 times) remained unsuccessful. Preoperative barium enema showed a stenotic anastomosis and some residual diverticulosis. A laparoscopic 3-trocar revision was scheduled. On exploration of the abdominal cavity, the anastomosis appeared thickened and strictly adherent to the left ureter. After proper mobilization, a segmental colorectal resection was performed and a new anastomosis was fashioned in an end-to-end hand-sewn technique.

Results: The procedure was completed by laparoscopy without additional trocars. Operative time was 202 minutes and blood loss 20cc. The patient was allowed to be discharged on the 4th postoperative day, and after 6 months, he is fine, without intestinal trouble.

Conclusions: Postoperative complications of colorectal anastomosis, such as strictures, can be managed laparoscopically. A new hand-sewn anastomosis is feasible and it allows for control of the vascularization and openings of both colonic and rectal lumens.
G Dapri
Surgical intervention
7 years ago
1962 views
20 likes
0 comments
06:20
Laparoscopic revision of stenotic colorectal anastomosis
Background: Colorectal anastomosis is usually performed using a circular stapler inserted transanally. Postoperative complications such as strictures are rare and related to various factors like ischemia, poor vascularization, and previous leak. This video shows a laparoscopic revision of a stenotic colorectal anastomosis, solved with a new hand-sewn anastomosis.

Video: A 51-year-old man underwent laparoscopic sigmoidectomy for symptomatic diverticulosis. At that time, a transanal circular mechanical end-to-end colorectal anastomosis was performed using a 29mm circular stapler. After 3 months of follow-up, a symptomatic stenotic colorectal anastomosis was evidenced, and endoscopic dilatation (repeated 3 times) remained unsuccessful. Preoperative barium enema showed a stenotic anastomosis and some residual diverticulosis. A laparoscopic 3-trocar revision was scheduled. On exploration of the abdominal cavity, the anastomosis appeared thickened and strictly adherent to the left ureter. After proper mobilization, a segmental colorectal resection was performed and a new anastomosis was fashioned in an end-to-end hand-sewn technique.

Results: The procedure was completed by laparoscopy without additional trocars. Operative time was 202 minutes and blood loss 20cc. The patient was allowed to be discharged on the 4th postoperative day, and after 6 months, he is fine, without intestinal trouble.

Conclusions: Postoperative complications of colorectal anastomosis, such as strictures, can be managed laparoscopically. A new hand-sewn anastomosis is feasible and it allows for control of the vascularization and openings of both colonic and rectal lumens.
Laparoscopic colorectal resection for anastomotic stricture following reversal of Hartmann's procedure
Reversal of Hartmann's procedure is a major undertaking and due to its associated morbidity and mortality, many patients are left with permanent colostomy and many others elect not to have the reversal. The advances in laparoscopy and stapler anastomosis have made the reversal simpler and easier. The objective of this film is to show how to carry out a laparoscopic re-intervention of a stenosis of a colorectal anastomosis performed some months before for the restoration of the colorectal continuity after a laparoscopic reversal of Hartmann’s procedure that was performed to manage a perforated sigmoid diverticulitis.
J Leroy, J Marescaux
Surgical intervention
9 years ago
791 views
55 likes
0 comments
09:35
Laparoscopic colorectal resection for anastomotic stricture following reversal of Hartmann's procedure
Reversal of Hartmann's procedure is a major undertaking and due to its associated morbidity and mortality, many patients are left with permanent colostomy and many others elect not to have the reversal. The advances in laparoscopy and stapler anastomosis have made the reversal simpler and easier. The objective of this film is to show how to carry out a laparoscopic re-intervention of a stenosis of a colorectal anastomosis performed some months before for the restoration of the colorectal continuity after a laparoscopic reversal of Hartmann’s procedure that was performed to manage a perforated sigmoid diverticulitis.
Total laparoscopic Hudson’s procedure, pelvic and para-aortic node dissection, omentectomy with primary re-anastomosis and loop ileostomy
This patient previously underwent a right ovarian cystectomy for endometrioma with final histopathology confirming an endometrioid adenocarcinoma in association with endometriosis (at least FIGO 1C1). Preoperative MRI and CT-scan suggested endometriosis/disease in the rectouterine pouch, with no evidence of disease outside the pelvis. Completion surgery with a Hudson’s procedure and comprehensive surgical staging was planned as a laparoscopic intervention. On initial inspection, intravenous indocyanine green (ICG) was used to facilitate the identification of endometriosis disease in the pelvis. Following surgical staging, including ‘en bloc’ dissection of the uterus, tubes, ovaries, and rectosigmoid, the specimen was removed via the vagina with the aid of an Alexis wound retractor. For re-anastomosis, the distal descending colon was delivered through the vagina, the anvil applied, and the anastomosis completed laparoscopically. This anastomosis was then defunctioned via a loop ileostomy. ICG was used to confirm anastomotic perfusion. The ileostomy was successfully reversed after 10 days facilitating postoperative treatment with chemotherapy.
M Graham, E Craig, A Armstrong, C Wilson, I Harley
Surgical intervention
4 months ago
1992 views
16 likes
0 comments
25:31
Total laparoscopic Hudson’s procedure, pelvic and para-aortic node dissection, omentectomy with primary re-anastomosis and loop ileostomy
This patient previously underwent a right ovarian cystectomy for endometrioma with final histopathology confirming an endometrioid adenocarcinoma in association with endometriosis (at least FIGO 1C1). Preoperative MRI and CT-scan suggested endometriosis/disease in the rectouterine pouch, with no evidence of disease outside the pelvis. Completion surgery with a Hudson’s procedure and comprehensive surgical staging was planned as a laparoscopic intervention. On initial inspection, intravenous indocyanine green (ICG) was used to facilitate the identification of endometriosis disease in the pelvis. Following surgical staging, including ‘en bloc’ dissection of the uterus, tubes, ovaries, and rectosigmoid, the specimen was removed via the vagina with the aid of an Alexis wound retractor. For re-anastomosis, the distal descending colon was delivered through the vagina, the anvil applied, and the anastomosis completed laparoscopically. This anastomosis was then defunctioned via a loop ileostomy. ICG was used to confirm anastomotic perfusion. The ileostomy was successfully reversed after 10 days facilitating postoperative treatment with chemotherapy.
Robotic assisted ovary preserving excision of a benign serous cystadenoma in a prepubertal symptomatic girl
Symptomatic ovarian cysts or larger incidentally diagnosed ovarian cysts require treatment. If features of malignancy can be reasonably ruled out, minimally invasive procedures can be offered to not only excise the lesion but also preserve the ovary at the same time.
A 10-year-old female child was referred to our department with complaints of right lower abdominal pain which lasted for 6 months. She had no history of vomiting. On examination, her abdomen was soft, non-tender, with no palpable mass, and not distended. Abdominal sonography revealed a 5 by 4.5cm simple cyst in the right adnexa with a 1.7mm wall thickness, with no solid component or septation. Her right ovary was not seen separately. Her left ovary and uterus showed no abnormalities. Malignancy work-up revealed nothing suspicious (Beta-HCG: 2.9 IU/L, AFP: 1.3ng/mL, CA125: 10.9, all within normal range). A robotic-assisted complete cyst excision with preservation of the ovary was performed using 3 arms of the Da Vinci Xi™ robotic surgical system. The patient resumed oral food intake the same evening. He was discharged the following day within 24 hours of the procedure on paracetamol only. The patient was healthy and well. The biopsy reported a benign serous cystadenoma. At a 1-year follow-up, the child is asymptomatic and ovarian preservation was confirmed on postoperative ultrasound. While oophorectomy is eminently feasible with a minimally invasive approach, ovary preservation in benign lesions is quite challenging using pure laparoscopy. Robotic assistance, with its 3D binocular high-definition vision, articulating instruments, and availability of simultaneous energy in both arms, provides better precision and a maximum range of movements. It also helps to preserve the ovary while removing the cyst completely. The case report with a stepwise video of the procedure is demonstrated.
S Kumaravel, A Shenoy
Surgical intervention
5 months ago
1013 views
10 likes
1 comment
05:24
Robotic assisted ovary preserving excision of a benign serous cystadenoma in a prepubertal symptomatic girl
Symptomatic ovarian cysts or larger incidentally diagnosed ovarian cysts require treatment. If features of malignancy can be reasonably ruled out, minimally invasive procedures can be offered to not only excise the lesion but also preserve the ovary at the same time.
A 10-year-old female child was referred to our department with complaints of right lower abdominal pain which lasted for 6 months. She had no history of vomiting. On examination, her abdomen was soft, non-tender, with no palpable mass, and not distended. Abdominal sonography revealed a 5 by 4.5cm simple cyst in the right adnexa with a 1.7mm wall thickness, with no solid component or septation. Her right ovary was not seen separately. Her left ovary and uterus showed no abnormalities. Malignancy work-up revealed nothing suspicious (Beta-HCG: 2.9 IU/L, AFP: 1.3ng/mL, CA125: 10.9, all within normal range). A robotic-assisted complete cyst excision with preservation of the ovary was performed using 3 arms of the Da Vinci Xi™ robotic surgical system. The patient resumed oral food intake the same evening. He was discharged the following day within 24 hours of the procedure on paracetamol only. The patient was healthy and well. The biopsy reported a benign serous cystadenoma. At a 1-year follow-up, the child is asymptomatic and ovarian preservation was confirmed on postoperative ultrasound. While oophorectomy is eminently feasible with a minimally invasive approach, ovary preservation in benign lesions is quite challenging using pure laparoscopy. Robotic assistance, with its 3D binocular high-definition vision, articulating instruments, and availability of simultaneous energy in both arms, provides better precision and a maximum range of movements. It also helps to preserve the ovary while removing the cyst completely. The case report with a stepwise video of the procedure is demonstrated.
Laparoscopic left hemicolectomy with manual intracorporeal anastomosis
The best surgical approach for splenic flexure tumors is not well defined yet.
The distal third of the transverse colon has an embryological origin in the hindgut, and the splenic flexure classically shows a dual lymphatic drainage, the proximal retropancreatic and the distal to the lymphatic pedicle of both the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV). Nakagoe et al. showed that the majority of positive nodes have distal lymphatic spread to the paracolic archway and up to the origin of the left colic artery. Lymph nodes of the middle colic artery and its left branch are positive in a small percentage (0 and 4.2% respectively).
As a result, a left segmental colectomy is a valid option for splenic flexure and distal transverse colon tumors because it allows vascular ligation at the root of the vessels, dissection along the embryological planes, and adequate bowel margins from the tumor. The preservation of the IMV should reduce impaired venous drainage of the sigmoid colon, which can be associated with anastomotic leakage, without compromising complete mesocolic excision.
An intracorporeal anastomosis for left colonic resection may have the same advantages as for a right hemicolectomy, but can be technically more challenging.
This video shows a laparoscopic left hemicolectomy with manual intracorporeal anastomosis and preservation of the IMV for a tumor of the distal transverse colon.
A Canaveira Manso, M Rosete, R Nemésio, M Fernandes
Surgical intervention
6 months ago
3074 views
27 likes
0 comments
16:43
Laparoscopic left hemicolectomy with manual intracorporeal anastomosis
The best surgical approach for splenic flexure tumors is not well defined yet.
The distal third of the transverse colon has an embryological origin in the hindgut, and the splenic flexure classically shows a dual lymphatic drainage, the proximal retropancreatic and the distal to the lymphatic pedicle of both the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV). Nakagoe et al. showed that the majority of positive nodes have distal lymphatic spread to the paracolic archway and up to the origin of the left colic artery. Lymph nodes of the middle colic artery and its left branch are positive in a small percentage (0 and 4.2% respectively).
As a result, a left segmental colectomy is a valid option for splenic flexure and distal transverse colon tumors because it allows vascular ligation at the root of the vessels, dissection along the embryological planes, and adequate bowel margins from the tumor. The preservation of the IMV should reduce impaired venous drainage of the sigmoid colon, which can be associated with anastomotic leakage, without compromising complete mesocolic excision.
An intracorporeal anastomosis for left colonic resection may have the same advantages as for a right hemicolectomy, but can be technically more challenging.
This video shows a laparoscopic left hemicolectomy with manual intracorporeal anastomosis and preservation of the IMV for a tumor of the distal transverse colon.
Gastrojejunal anastomosis resizing with Argon Plasma Coagulation (APC) and Apollo OverStitch™ endoscopic suturing system: live procedure
In 2004, a 57-year-old lady underwent a Roux-en-Y gastric bypass (RYGB) for morbid obesity. After the surgical intervention, she lost 13Kg and she started to regain weight back with a current BMI of 41.
During this live procedure, Professor Perretta performs a gastroscopy that shows a normal gastric pouch and a gastrojejunal anastomosis increased in caliber. The operator does an endoscopic resizing of the anastomosis with Argon Plasma Coagulation (APC) followed by the placement of an endoscopic suture with the Apollo OverStitch™ endoscopic suturing system.
S Perretta, M Pizzicannella, B Dallemagne
Surgical intervention
7 months ago
842 views
8 likes
3 comments
30:14
Gastrojejunal anastomosis resizing with Argon Plasma Coagulation (APC) and Apollo OverStitch™ endoscopic suturing system: live procedure
In 2004, a 57-year-old lady underwent a Roux-en-Y gastric bypass (RYGB) for morbid obesity. After the surgical intervention, she lost 13Kg and she started to regain weight back with a current BMI of 41.
During this live procedure, Professor Perretta performs a gastroscopy that shows a normal gastric pouch and a gastrojejunal anastomosis increased in caliber. The operator does an endoscopic resizing of the anastomosis with Argon Plasma Coagulation (APC) followed by the placement of an endoscopic suture with the Apollo OverStitch™ endoscopic suturing system.
Surgical technique of tubal reanastomosis
Many women who undergo tubal ligation surgery later decide to have children again. One option available to these women is tubal ligation reversal, or tubal reanastomosis. In this microsurgery, the two separated parts of a uterine tube are surgically reunited. It is ideally performed in younger women under 39 years of age with good ovarian reserve. Depending on the previously used tubal ligation method, it may be necessary to first perform a diagnostic laparoscopy to check the condition of the uterus, the uterine tubes, and the ovaries and to make sure that the tubal length is sufficient for reversal. Following the proper principles of microsurgery, this procedure can yield very good results and offer a more economical option to women desirous of childbearing if the tubal pathology related to tubal sterilization is the only cause of infertility.
H Grover, A Padmawar
Surgical intervention
1 year ago
3566 views
27 likes
0 comments
08:48
Surgical technique of tubal reanastomosis
Many women who undergo tubal ligation surgery later decide to have children again. One option available to these women is tubal ligation reversal, or tubal reanastomosis. In this microsurgery, the two separated parts of a uterine tube are surgically reunited. It is ideally performed in younger women under 39 years of age with good ovarian reserve. Depending on the previously used tubal ligation method, it may be necessary to first perform a diagnostic laparoscopy to check the condition of the uterus, the uterine tubes, and the ovaries and to make sure that the tubal length is sufficient for reversal. Following the proper principles of microsurgery, this procedure can yield very good results and offer a more economical option to women desirous of childbearing if the tubal pathology related to tubal sterilization is the only cause of infertility.
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
1 year ago
1296 views
8 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.
Percutaneous transhepatic cholangioplasty to treat biliary strictures after biliary-enteric anastomosis
This is the case of a 50-year-old female patient presenting with a bilio-enteric anastomosis stricture caused by a bile duct injury during a cholecystectomy 10 years ago. The patient presents with multiple episodes of cholangitis treated by antibiotics, causing multiple hospital admissions. Blood test assessment demonstrates high levels of alkaline phosphatase. Her magnetic resonance cholangiopancreatography showed a stricture at the level of the hepaticojejunal anastomosis as well as mild intrahepatic biliary duct dilatation. An endoscopic approach was not suitable for this patient, because of the anatomical disturbance induced by the bilio-enteric surgical reconstruction. A percutaneous balloon catheter dilatation strategy was adopted. After two previous cholangioplasty sessions, a final session is presented here. The total duration of the last procedure was less than 1 hour, and a final stricture dilatation was achieved. After 24 hours of the final procedure, the biliary catheter was removed and the patient was discharged home without any complications.
ME Gimenez, A Garcia
Surgical intervention
1 year ago
406 views
6 likes
0 comments
13:34
Percutaneous transhepatic cholangioplasty to treat biliary strictures after biliary-enteric anastomosis
This is the case of a 50-year-old female patient presenting with a bilio-enteric anastomosis stricture caused by a bile duct injury during a cholecystectomy 10 years ago. The patient presents with multiple episodes of cholangitis treated by antibiotics, causing multiple hospital admissions. Blood test assessment demonstrates high levels of alkaline phosphatase. Her magnetic resonance cholangiopancreatography showed a stricture at the level of the hepaticojejunal anastomosis as well as mild intrahepatic biliary duct dilatation. An endoscopic approach was not suitable for this patient, because of the anatomical disturbance induced by the bilio-enteric surgical reconstruction. A percutaneous balloon catheter dilatation strategy was adopted. After two previous cholangioplasty sessions, a final session is presented here. The total duration of the last procedure was less than 1 hour, and a final stricture dilatation was achieved. After 24 hours of the final procedure, the biliary catheter was removed and the patient was discharged home without any complications.
EUS gastrojejunal anastomosis with HOT AXIOS® stent after Whipple pancreatectomy, filling blind loop through percutaneous transhepatic biliary drainage
A 67-year-old woman underwent a Whipple pancreatectomy for cancer one year earlier. She was readmitted to hospital for abdominal pain and subocclusion with jaundice. CT-scan showed a dilatation of the jejunal stump with associated biliary tree dilatation. Percutaneous biliary transhepatic drainage (PBTHD) was performed and a stenosis was diagnosed in the afferent loop, accountable for subocclusion and secondary jaundice. Two double pigtails were delivered by the interventional radiologist through PBTHD across the jejunal stricture without resolution of symptoms. Biliary drainage was left in place causing patient discomfort. EUS gastrojejunal anastomosis (GJA) using the HOT AXIOS® stent was attempted in order to bypass the stricture. EUS allows to find the jejunal stump, detected by mechanical staple line visualization. Additionally, the blind loop was detected as it was filled up with liquid and contrast through the PBTHD. The HOT AXIOS® stent was delivered without any complications (VIDEO). Afterwards, flow of bile and liquid was observed through the lumen-apposing metal stent (LAMS). PBTHD was immediately removed. Recovery was uneventful and the patient was discharged on a normal diet with no pain on the following day. EUS-GJA via a LAMS is a well-described technique in experts’ hands (Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Itoi T, Baron TH, Khashab MA, et al. Dig Endosc 2017;29:495-502). Special skills and techniques are necessary in order to recognize the exact small bowel loop to puncture (Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Tyberg A, Perez-Miranda M, Sanchez-Ocaña R et al. Endosc Int Open 2016;4:E276-81). In that case, we show that filling this loop using a previous transhepatic access should be considered an alternative in case of alterated anatomy. Also direct EUS transgastric injection of contrast medium in the dilated biliary tree to fill up the jejunal stump could be considered an option to perform GJA by a single operator in a single session after safely recognizing the right loop. In addition, fluoroscopy helps to detect the exact loop puncture site. In conclusion, GJA using a LAMS is feasible, safe and useful, and transhepatic injection of liquid and contrast medium helps to adequately recognize the jejunal stump after biliopancreatic surgery.
Gf Donatelli, G Pourcher, D Fuks, S Perretta, B Dallemagne, M Pizzicannella
Surgical intervention
1 year ago
241 views
3 likes
0 comments
02:30
EUS gastrojejunal anastomosis with HOT AXIOS® stent after Whipple pancreatectomy, filling blind loop through percutaneous transhepatic biliary drainage
A 67-year-old woman underwent a Whipple pancreatectomy for cancer one year earlier. She was readmitted to hospital for abdominal pain and subocclusion with jaundice. CT-scan showed a dilatation of the jejunal stump with associated biliary tree dilatation. Percutaneous biliary transhepatic drainage (PBTHD) was performed and a stenosis was diagnosed in the afferent loop, accountable for subocclusion and secondary jaundice. Two double pigtails were delivered by the interventional radiologist through PBTHD across the jejunal stricture without resolution of symptoms. Biliary drainage was left in place causing patient discomfort. EUS gastrojejunal anastomosis (GJA) using the HOT AXIOS® stent was attempted in order to bypass the stricture. EUS allows to find the jejunal stump, detected by mechanical staple line visualization. Additionally, the blind loop was detected as it was filled up with liquid and contrast through the PBTHD. The HOT AXIOS® stent was delivered without any complications (VIDEO). Afterwards, flow of bile and liquid was observed through the lumen-apposing metal stent (LAMS). PBTHD was immediately removed. Recovery was uneventful and the patient was discharged on a normal diet with no pain on the following day. EUS-GJA via a LAMS is a well-described technique in experts’ hands (Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Itoi T, Baron TH, Khashab MA, et al. Dig Endosc 2017;29:495-502). Special skills and techniques are necessary in order to recognize the exact small bowel loop to puncture (Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Tyberg A, Perez-Miranda M, Sanchez-Ocaña R et al. Endosc Int Open 2016;4:E276-81). In that case, we show that filling this loop using a previous transhepatic access should be considered an alternative in case of alterated anatomy. Also direct EUS transgastric injection of contrast medium in the dilated biliary tree to fill up the jejunal stump could be considered an option to perform GJA by a single operator in a single session after safely recognizing the right loop. In addition, fluoroscopy helps to detect the exact loop puncture site. In conclusion, GJA using a LAMS is feasible, safe and useful, and transhepatic injection of liquid and contrast medium helps to adequately recognize the jejunal stump after biliopancreatic surgery.
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esophagojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esophagojejunal anastomosis.
WJ Hyung, S Perretta, B Dallemagne, B Seeliger, D Mutter, J Marescaux
Surgical intervention
1 year ago
3276 views
19 likes
0 comments
04:27
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esophagojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esophagojejunal anastomosis.
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
J Magalhães, L Matos, J Costa, J Costa Pereira, G Gonçalves, M Nora
Surgical intervention
1 year ago
3704 views
16 likes
5 comments
10:31
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
SAE Yeo
Surgical intervention
1 year ago
2397 views
5 likes
0 comments
15:36
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
SAE Yeo
Surgical intervention
2 years ago
18743 views
1103 likes
3 comments
13:33
Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
Segmental left colectomy: a modified caudal-to-cranial approach
Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.
M Milone, P Anoldo, M Manigrasso, F Milone
Surgical intervention
2 years ago
4609 views
505 likes
0 comments
09:27
Segmental left colectomy: a modified caudal-to-cranial approach
Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.