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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
6 years ago
1942 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
8 years ago
737 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.
Laparoscopic antrectomy and vagotomy for stenotic pyloric peptic ulcer
Peptic ulcer disease is the major cause of benign gastro-duodenal obstruction or gastric outlet obstruction (GOO) in the adult population. Patients often present with abdominal pain and distension, vomiting, dehydration, and weight loss. Previous studies have demonstrated that the incidence of GOO varies from 5% to 10% of all hospital admissions for ulcer-related complications.
Today surgeons are performing fewer elective ulcer surgeries, as H2 receptor blockers and the eradication of Helicobacter pylori represent a major step in the treatment of this disease. Nevertheless, patients with complications and those resistant to medical therapy can be offered surgical options. When surgery is required, a laparoscopic approach is possible with its well-known advantages.
Surgical procedures include highly selective vagotomy with some form of pyloroplasty, truncal vagotomy and antrectomy, and truncal vagotomy with gastroenterostomy. Proponents of highly selective vagotomy advocate an acceptably low recurrence rate (0 to 5% at follow-up of 24 to 90 months) and a relative paucity of post-gastrectomy sequelae. Those recommending vagotomy and antrectomy stress the superiority of the acid-reducing procedure, the virtual absence of recurrent ulceration, and the rarity of postoperative symptoms other than post-vagotomy diarrhea, which is usually a self-limited process. Finally, truncal vagotomy with gastroenterostomy avoids what can be a treacherous duodenal stump, but can result in higher ulcer recurrence rates.
We present the case of a young male patient not compliant to medical treatment who was referred to us for gastric outlet obstruction. The selected approach consisted in a laparoscopic Billroth II antrectomy and vagotomy using four ports.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
10 years ago
1525 views
160 likes
0 comments
12:58
Laparoscopic antrectomy and vagotomy for stenotic pyloric peptic ulcer
Peptic ulcer disease is the major cause of benign gastro-duodenal obstruction or gastric outlet obstruction (GOO) in the adult population. Patients often present with abdominal pain and distension, vomiting, dehydration, and weight loss. Previous studies have demonstrated that the incidence of GOO varies from 5% to 10% of all hospital admissions for ulcer-related complications.
Today surgeons are performing fewer elective ulcer surgeries, as H2 receptor blockers and the eradication of Helicobacter pylori represent a major step in the treatment of this disease. Nevertheless, patients with complications and those resistant to medical therapy can be offered surgical options. When surgery is required, a laparoscopic approach is possible with its well-known advantages.
Surgical procedures include highly selective vagotomy with some form of pyloroplasty, truncal vagotomy and antrectomy, and truncal vagotomy with gastroenterostomy. Proponents of highly selective vagotomy advocate an acceptably low recurrence rate (0 to 5% at follow-up of 24 to 90 months) and a relative paucity of post-gastrectomy sequelae. Those recommending vagotomy and antrectomy stress the superiority of the acid-reducing procedure, the virtual absence of recurrent ulceration, and the rarity of postoperative symptoms other than post-vagotomy diarrhea, which is usually a self-limited process. Finally, truncal vagotomy with gastroenterostomy avoids what can be a treacherous duodenal stump, but can result in higher ulcer recurrence rates.
We present the case of a young male patient not compliant to medical treatment who was referred to us for gastric outlet obstruction. The selected approach consisted in a laparoscopic Billroth II antrectomy and vagotomy using four ports.
Three trocar laparoscopic sigmoidectomy for diffuse diverticulosis with transanal specimen extraction: tips and tricks
The video demonstrates the case of a woman with recurrent diverticulitis, BMI 30. She has a background of a previous hysterectomy via a Pfannenstiel incision. A three-port sigmoidectomy with transanal excision was carried out.
Methods
The set up consisted of a 12mm umbilical optical port, a 12mm port in the right iliac fossa, and a 5mm operating port in the right flank. After initial peritoneoscopy, any abnormal adhesions were divided. The sigmoid colon mesentery was divided high, near the sigmoid colon in order to preserve the mesenteric vasculature. The mesentery was divided to the level of the rectum, which was then skeletonized. The proximal colon was mobilized free up to the level of the splenic flexure. The rectum was then ligated, washed out with betadine and transected. A Vicryl Loop was attached to the proximal stump which was then removed transanally. A colotomy was created above the level of the diverticula and the anvil of a circular stapler introduced into the proximal colon. The proximal sigmoid colon mesentery was divided and the sigmoid transected with a linear stapler. The specimen was then fully removed transanally. The anvil was then delivered through the colon via the fishing technique. The rectal stump was closed with a linear stapler. A colorectal anastomosis was fashioned with a circular stapler. After verifying that the colon was not twisted, an air test was performed.
Conclusion
The video demonstrates a three-port technique for laparoscopic sigmoidectomy with natural orifice specimen extraction (NOSE).
J Leroy, J Marescaux
Surgical intervention
7 years ago
2695 views
14 likes
0 comments
16:52
Three trocar laparoscopic sigmoidectomy for diffuse diverticulosis with transanal specimen extraction: tips and tricks
The video demonstrates the case of a woman with recurrent diverticulitis, BMI 30. She has a background of a previous hysterectomy via a Pfannenstiel incision. A three-port sigmoidectomy with transanal excision was carried out.
Methods
The set up consisted of a 12mm umbilical optical port, a 12mm port in the right iliac fossa, and a 5mm operating port in the right flank. After initial peritoneoscopy, any abnormal adhesions were divided. The sigmoid colon mesentery was divided high, near the sigmoid colon in order to preserve the mesenteric vasculature. The mesentery was divided to the level of the rectum, which was then skeletonized. The proximal colon was mobilized free up to the level of the splenic flexure. The rectum was then ligated, washed out with betadine and transected. A Vicryl Loop was attached to the proximal stump which was then removed transanally. A colotomy was created above the level of the diverticula and the anvil of a circular stapler introduced into the proximal colon. The proximal sigmoid colon mesentery was divided and the sigmoid transected with a linear stapler. The specimen was then fully removed transanally. The anvil was then delivered through the colon via the fishing technique. The rectal stump was closed with a linear stapler. A colorectal anastomosis was fashioned with a circular stapler. After verifying that the colon was not twisted, an air test was performed.
Conclusion
The video demonstrates a three-port technique for laparoscopic sigmoidectomy with natural orifice specimen extraction (NOSE).
Laparoscopic sigmoidectomy for T3N2M1 sigmoid cancer
Introduction:
This is the case of a 65-year-old gentleman who presented with blood per rectum (PR) and symptoms of subacute obstruction. He was diagnosed with a stenotic invasive adenocarcinoma at 15cm from the anal verge and with liver metastases. After discussion at our multidisclipinary meeting, he was recommended to undergo palliative chemotherapy in the form of FOLFIRI and Avastin. Unfortunately, his symptoms of subacute obstruction worsened and it was recommended that he undergo a palliative resection.

Methods:
He underwent a palliative Laparoscopic Anterior Resection (LAR). Professor Armondo Melani utilized a 4-port technique with a 10mm umbilical optical port and 3 by 5mm working ports (2 on the right-hand side and one on the left). He used a medial to lateral approach starting with the splenic flexure takedown. This was achieved by entering the retroperitoneal plane cephalad to the inferior mesenteric artery (IMA) and inferior to the inferior mesenteric vein (IMV). Once the correct plane has been entered, the IMV was skeletonized and divided with a Ligasure® vessel-sealing device. The lesser sac was then entered superior and cephalad to the IMV, superior to the pancreas and to the left of the middle colic vessels. This novel approach allowed for easy identification of the pancreas and retroperitoneal mobilization of the mesocolon from the pancreas. The lesser sac was then entered above the transverse colon, the omental attachments divided and splenic flexure mobilization completed. The retroperitoneal plane was then entered caudally to the IMA, which was subsequently skeletonized and divided after identification of the left ureter and gonadal vessels. The rectum was then mobilized to >5cm below the tumor, the mesorectum divided, the rectum transected with an articulating linear stapling device. The specimen was delivered through a Pfannenstiel incision (with a wound protector). The specimen was transected and the anvil of a circular stapler inserted into the proximal colon with a purse-string suture. The colon was returned to the abdomen and the colorectal anastomosis was completed with the insertion of the circular stapler transanally.
A Melani, J Marescaux
Surgical intervention
7 years ago
8597 views
129 likes
0 comments
28:38
Laparoscopic sigmoidectomy for T3N2M1 sigmoid cancer
Introduction:
This is the case of a 65-year-old gentleman who presented with blood per rectum (PR) and symptoms of subacute obstruction. He was diagnosed with a stenotic invasive adenocarcinoma at 15cm from the anal verge and with liver metastases. After discussion at our multidisclipinary meeting, he was recommended to undergo palliative chemotherapy in the form of FOLFIRI and Avastin. Unfortunately, his symptoms of subacute obstruction worsened and it was recommended that he undergo a palliative resection.

Methods:
He underwent a palliative Laparoscopic Anterior Resection (LAR). Professor Armondo Melani utilized a 4-port technique with a 10mm umbilical optical port and 3 by 5mm working ports (2 on the right-hand side and one on the left). He used a medial to lateral approach starting with the splenic flexure takedown. This was achieved by entering the retroperitoneal plane cephalad to the inferior mesenteric artery (IMA) and inferior to the inferior mesenteric vein (IMV). Once the correct plane has been entered, the IMV was skeletonized and divided with a Ligasure® vessel-sealing device. The lesser sac was then entered superior and cephalad to the IMV, superior to the pancreas and to the left of the middle colic vessels. This novel approach allowed for easy identification of the pancreas and retroperitoneal mobilization of the mesocolon from the pancreas. The lesser sac was then entered above the transverse colon, the omental attachments divided and splenic flexure mobilization completed. The retroperitoneal plane was then entered caudally to the IMA, which was subsequently skeletonized and divided after identification of the left ureter and gonadal vessels. The rectum was then mobilized to >5cm below the tumor, the mesorectum divided, the rectum transected with an articulating linear stapling device. The specimen was delivered through a Pfannenstiel incision (with a wound protector). The specimen was transected and the anvil of a circular stapler inserted into the proximal colon with a purse-string suture. The colon was returned to the abdomen and the colorectal anastomosis was completed with the insertion of the circular stapler transanally.