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Anterior and posterior laparoscopic mesh removal due to pelvic pain, subtotal hysterectomy, mesh replacement, and Burch procedure
This is the case of a 69-year-old woman presenting with pelvic pain after laparoscopic sacrocolpopexy. The patient has a history of one vaginal birth, laparoscopic sacrocolpopexy with uterine preservation combined with a transobturator tape (TOT) sling procedure performed in 2013.
The following symptoms appeared after surgery: invalidating pelvic pain, especially in an upright position, severe terminal constipation, worsening of a previously mild stress urinary incontinence.
On clinical examination, a high rectocele (grade 2/3), a cystocele, and elective pain at the level of the TOT sling were observed. MRI revealed a perineal inflammation between the anterior aspect of the vagina and the urethra, at the level of the lower third of the urethra. A fibrotic area can be noted at the level of the rectovaginal space.
Her TOT sling was partially resected in January 2014.
Cystoscopy ruled out the presence of mesh erosion. Hysteroscopy was normal.
Endometrial biopsy demonstrated an atrophic endometrium.
In this surgery, the anterior and posterior meshes are removed. A subtotal hysterectomy combined with the replacement of meshes were performed, followed by a Burch procedure.
A Wattiez, I Argay, F Asencio, J Faria, L Schwartz
Surgical intervention
4 years ago
1824 views
64 likes
0 comments
33:56
Anterior and posterior laparoscopic mesh removal due to pelvic pain, subtotal hysterectomy, mesh replacement, and Burch procedure
This is the case of a 69-year-old woman presenting with pelvic pain after laparoscopic sacrocolpopexy. The patient has a history of one vaginal birth, laparoscopic sacrocolpopexy with uterine preservation combined with a transobturator tape (TOT) sling procedure performed in 2013.
The following symptoms appeared after surgery: invalidating pelvic pain, especially in an upright position, severe terminal constipation, worsening of a previously mild stress urinary incontinence.
On clinical examination, a high rectocele (grade 2/3), a cystocele, and elective pain at the level of the TOT sling were observed. MRI revealed a perineal inflammation between the anterior aspect of the vagina and the urethra, at the level of the lower third of the urethra. A fibrotic area can be noted at the level of the rectovaginal space.
Her TOT sling was partially resected in January 2014.
Cystoscopy ruled out the presence of mesh erosion. Hysteroscopy was normal.
Endometrial biopsy demonstrated an atrophic endometrium.
In this surgery, the anterior and posterior meshes are removed. A subtotal hysterectomy combined with the replacement of meshes were performed, followed by a Burch procedure.
Laparoscopic resection of deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment
Renal function impairment is a rare condition when associated with endometriosis. This video shows the laparoscopic resection of a deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment. The left kidney has an almost silent pattern on scintigraphy. The therapeutic strategy consists of freeing the obstacle caused by the endometriotic nodule, placement of a double J (JJ) catheter and monitoring for renal function in the postoperative follow-up. Further laparoscopic nephrectomy is to be discussed if the renal function is not improved.
A Wattiez, J Nassif, I Miranda-Mendoza, J Marescaux
Surgical intervention
10 years ago
2228 views
42 likes
0 comments
07:56
Laparoscopic resection of deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment
Renal function impairment is a rare condition when associated with endometriosis. This video shows the laparoscopic resection of a deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment. The left kidney has an almost silent pattern on scintigraphy. The therapeutic strategy consists of freeing the obstacle caused by the endometriotic nodule, placement of a double J (JJ) catheter and monitoring for renal function in the postoperative follow-up. Further laparoscopic nephrectomy is to be discussed if the renal function is not improved.
Laparoscopic excision of urachal cyst - a minimally invasive approach of a rare cause of abdominal pain in adults
Congenital abnormalities of the urachus are rare, with an incidence of 2:300000 children and 1:5000 adults. The urachus is a fibrous remnant of the allantois, usually occluded in the 4-5th gestational months, with the descent of the bladder towards the pelvis. It lies in the space of Retzius, between the transverse fascia anteriorly and the peritoneum posteriorly. The absence of its obliteration can result in an urachal cyst in 36% of cases. The main complication of the cyst is focal infection with associated risks of rupture and intestinal involvement. Diagnosis relies on clinical history, abdominopelvic ultrasonography and CT-scan. The treatment consists in complete excision of abnormal tissue and a small portion of adjacent bladder wall, therefore reducing the risk of malignant degeneration of the entire remnant.
A twenty-year-old healthy woman was referred to the emergency department with localized discomfort and a foul smelling purulent discharge from the umbilicus with three days of evolution. The patient was afebrile with periumbilical inflammatory signs, without signs of peritoneal irritation on physical exam. Blood tests were all normal, apart from a raised C-reactive protein (2.52mg/dL). Abdominal ultrasound was suggestive of an infected urachal cyst with umbilical fistulization. Empirical treatment with antibiotics was started and an abdominopelvic CT-scan, made as outpatient surgery, showed a probable 26mm urachal cyst, posterior and adjacent to the umbilicus, without bladder attachment.
The patient was treated surgically with a laparoscopic excision of the remainder of the urachus, without intraoperative complications. A good clinical evolution was observed during the hospital stay, and the patient was discharged on the fourth postoperative day. On follow-up, the patient did not complain of anything.
This clinical case emphasizes the importance of the high index of diagnostic suspicion in the management and treatment of the rare causes of abdominal pain, often with the possibility of a minimally invasive approach.
A Tojal, AR Loureiro, B Prata, R Patrão, N Carrilho, C Casimiro
Surgical intervention
5 months ago
946 views
3 likes
0 comments
10:34
Laparoscopic excision of urachal cyst - a minimally invasive approach of a rare cause of abdominal pain in adults
Congenital abnormalities of the urachus are rare, with an incidence of 2:300000 children and 1:5000 adults. The urachus is a fibrous remnant of the allantois, usually occluded in the 4-5th gestational months, with the descent of the bladder towards the pelvis. It lies in the space of Retzius, between the transverse fascia anteriorly and the peritoneum posteriorly. The absence of its obliteration can result in an urachal cyst in 36% of cases. The main complication of the cyst is focal infection with associated risks of rupture and intestinal involvement. Diagnosis relies on clinical history, abdominopelvic ultrasonography and CT-scan. The treatment consists in complete excision of abnormal tissue and a small portion of adjacent bladder wall, therefore reducing the risk of malignant degeneration of the entire remnant.
A twenty-year-old healthy woman was referred to the emergency department with localized discomfort and a foul smelling purulent discharge from the umbilicus with three days of evolution. The patient was afebrile with periumbilical inflammatory signs, without signs of peritoneal irritation on physical exam. Blood tests were all normal, apart from a raised C-reactive protein (2.52mg/dL). Abdominal ultrasound was suggestive of an infected urachal cyst with umbilical fistulization. Empirical treatment with antibiotics was started and an abdominopelvic CT-scan, made as outpatient surgery, showed a probable 26mm urachal cyst, posterior and adjacent to the umbilicus, without bladder attachment.
The patient was treated surgically with a laparoscopic excision of the remainder of the urachus, without intraoperative complications. A good clinical evolution was observed during the hospital stay, and the patient was discharged on the fourth postoperative day. On follow-up, the patient did not complain of anything.
This clinical case emphasizes the importance of the high index of diagnostic suspicion in the management and treatment of the rare causes of abdominal pain, often with the possibility of a minimally invasive approach.
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
A Wattiez, R Nasir, I Argay
Surgical intervention
2 years ago
5226 views
311 likes
0 comments
42:42
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
A rare cause of abdominal pain (liposarcoma) treated by a minimally invasive approach
A 53-year-old woman is referred to the emergency department with complaints of an insidious pain in the left lower abdominal quadrant, with no associated fever, neither changes in her bowel habits, nor other complaints. She had a cardiac arrhythmia, medicated with atenolol, and no previous surgeries. Laboratory results showed no significant changes. Abdominal ultrasound demonstrated an inflammatory mass adjacent to the left colon. The abdominal and pelvic CT-scan showed a bulky and capsulated mass at the left iliac fossa extending along the left flank until the lower pole of the left kidney, measuring 9x12x20cm, probably corresponding to a peritoneal lipoma, with no signs of aggressiveness towards adjacent organs. The patient was admitted to hospital for clinical vigilance and complementary exams. Upper and lower endoscopic studies were performed and revealed no significant changes. The patient was then proposed for elective surgery – laparoscopic excision of the intra-abdominal mass, which was independent of the intra-abdominal visceral content. In the postoperative period, the patient had no complications with clinical discharge four days after surgery. The pathology report revealed a well-differentiated lipomatous neoplasia, a lipoma-like liposarcoma. In a multidisciplinary meeting, it was decided not to perform any adjuvant treatment. The patient remains with neither clinical nor imaging signs of the disease after 10 months of follow-up.
A Tojal, J Marques, S Coelho, M Fernandes, N Carrilho, H Oliveira, C Casimiro
Surgical intervention
1 year ago
1037 views
63 likes
0 comments
07:41
A rare cause of abdominal pain (liposarcoma) treated by a minimally invasive approach
A 53-year-old woman is referred to the emergency department with complaints of an insidious pain in the left lower abdominal quadrant, with no associated fever, neither changes in her bowel habits, nor other complaints. She had a cardiac arrhythmia, medicated with atenolol, and no previous surgeries. Laboratory results showed no significant changes. Abdominal ultrasound demonstrated an inflammatory mass adjacent to the left colon. The abdominal and pelvic CT-scan showed a bulky and capsulated mass at the left iliac fossa extending along the left flank until the lower pole of the left kidney, measuring 9x12x20cm, probably corresponding to a peritoneal lipoma, with no signs of aggressiveness towards adjacent organs. The patient was admitted to hospital for clinical vigilance and complementary exams. Upper and lower endoscopic studies were performed and revealed no significant changes. The patient was then proposed for elective surgery – laparoscopic excision of the intra-abdominal mass, which was independent of the intra-abdominal visceral content. In the postoperative period, the patient had no complications with clinical discharge four days after surgery. The pathology report revealed a well-differentiated lipomatous neoplasia, a lipoma-like liposarcoma. In a multidisciplinary meeting, it was decided not to perform any adjuvant treatment. The patient remains with neither clinical nor imaging signs of the disease after 10 months of follow-up.
Laparoscopic total gastrectomy
A multimodality approach remains the only potential treatment for advanced gastric cancer. Oncological outcomes seem to be equivalent either in open surgery or in minimally invasive surgery. Therefore, laparoscopic gastric resection is expanding in expert centers.
The authors present a clinical case of a 70-year-old woman with no relevant clinical past. She presented with a 1-month complaint of epigastric pain and melena. She underwent an upper endoscopy, which showed an ulcerated gastric lesion at the lesser curvature. Biopsy revealed a poorly cohesive gastric carcinoma with signet ring cells. Thoraco-abdominal-pelvic CT-scan revealed a thickening of the gastric wall associated with multiple perigastric and celiac trunk lymph nodes. She was proposed for perioperative chemotherapy. On the restaging CT-scan, there was no evidence of disease progression and therefore she underwent a laparoscopic radical total gastrectomy.
The benefits of minimally invasive surgery, combined with the increasing evidence of oncological results overlapping with open surgery, have contributed to the progressive implementation of laparoscopic surgery in the treatment of malignant gastric pathology.
J Magalhães, C Osorio, L Frutuoso, AM Pereira, A Trovão, R Ferreira de Almeida, M Nora
Surgical intervention
6 months ago
3610 views
15 likes
0 comments
09:44
Laparoscopic total gastrectomy
A multimodality approach remains the only potential treatment for advanced gastric cancer. Oncological outcomes seem to be equivalent either in open surgery or in minimally invasive surgery. Therefore, laparoscopic gastric resection is expanding in expert centers.
The authors present a clinical case of a 70-year-old woman with no relevant clinical past. She presented with a 1-month complaint of epigastric pain and melena. She underwent an upper endoscopy, which showed an ulcerated gastric lesion at the lesser curvature. Biopsy revealed a poorly cohesive gastric carcinoma with signet ring cells. Thoraco-abdominal-pelvic CT-scan revealed a thickening of the gastric wall associated with multiple perigastric and celiac trunk lymph nodes. She was proposed for perioperative chemotherapy. On the restaging CT-scan, there was no evidence of disease progression and therefore she underwent a laparoscopic radical total gastrectomy.
The benefits of minimally invasive surgery, combined with the increasing evidence of oncological results overlapping with open surgery, have contributed to the progressive implementation of laparoscopic surgery in the treatment of malignant gastric pathology.
Laparoscopic salpingotomy for tubal ectopic pregnancy
About 1 to 2% of all pregnancies are ectopic. Most ectopic pregnancies are located in the uterine tube, and surgery is often used as a treatment modality. Traditionally, salpingectomy has been the standard procedure, but salpingotomy provides a conservative option in women who wish to preserve future fertility, especially if the contralateral tube is absent or damaged. Many women do not have access to IVF for financial, geographical, or religious reasons. Having an intrauterine pregnancy after salpingotomy can reach up to 70%. In this video, we demonstrate this procedure in simple steps. The case was that of a 35-year-old lady, P0+1 with a previous right tubal pregnancy, which was treated with a partial salpingectomy through a mini-laparotomy 2 years before. She was admitted to the emergency department as she presented with a 6-week amenorrhea with left iliac fossa pain. Pelvic ultrasound showed left tubal ectopic pregnancy (4 by 3cm in size), with free fluid suggestive of hemoperitoneum. She opted for a conservative laparoscopic surgery as she was keen to have a spontaneous fertility.
B Amro, A Wattiez
Surgical intervention
2 months ago
2113 views
28 likes
2 comments
07:34
Laparoscopic salpingotomy for tubal ectopic pregnancy
About 1 to 2% of all pregnancies are ectopic. Most ectopic pregnancies are located in the uterine tube, and surgery is often used as a treatment modality. Traditionally, salpingectomy has been the standard procedure, but salpingotomy provides a conservative option in women who wish to preserve future fertility, especially if the contralateral tube is absent or damaged. Many women do not have access to IVF for financial, geographical, or religious reasons. Having an intrauterine pregnancy after salpingotomy can reach up to 70%. In this video, we demonstrate this procedure in simple steps. The case was that of a 35-year-old lady, P0+1 with a previous right tubal pregnancy, which was treated with a partial salpingectomy through a mini-laparotomy 2 years before. She was admitted to the emergency department as she presented with a 6-week amenorrhea with left iliac fossa pain. Pelvic ultrasound showed left tubal ectopic pregnancy (4 by 3cm in size), with free fluid suggestive of hemoperitoneum. She opted for a conservative laparoscopic surgery as she was keen to have a spontaneous fertility.
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
JF Noguera, MD, PhD, J Gilabert-Estelles, J Aguirrezabalaga, B López, J Dolz
Surgical intervention
2 years ago
3055 views
302 likes
0 comments
09:55
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
2 years ago
1962 views
178 likes
1 comment
07:49
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Sutures transfixing bladder as a complication of laparoscopic burch colposuspension
Laparoscopic Burch colposuspension may be difficult in cases of stress urinary incontinence (SUI) associated with large lateral cystocele. In these cases, complications may occur. However, they are rare.
This video shows the cystoscopic treatment of intravesical adhesions, secondary to sutures transfixing the bladder during the Burch laparoscopic procedure and lateral suspension, without perioperative use of control cystoscopy. An office cystoscopy was performed after the operation, nine months later, because of gradual onset of entirely isolated pelvic pain at the end of urination. It showed intravesical synechia as bilateral pillars. The different steps of the operation are the following:
1) Diagnostic laparoscopy with a good status of the lateral suspension without mesh migration.
2) Operative laparoscopy with opening of Retzius’s space, dissection, adhesiolysis, and division of the non-absorbable sutures of the past colposuspension in order to mobilize the bladder, followed by reperitonization of Retzius’s space.
3) Diagnostic cystoscopy confirming adhesions as bilateral pillars, laterally to the trigone with normal ejaculation of both ureteral ostia.
4) Operative cystoscopy after catheterization of both ureters: division of the pillars with the monopolar electrode without visualization of the Burch sutures, as they probably migrated upward in the first postoperative months.
In the postoperative period, ureteral catheters are removed 48 hours after surgery. Pain resolves completely during urination. Normal kidneys and ureters are observed at ultrasound.
This video clearly demonstrates the advantages related to the routine use of cystoscopy at the end of the laparoscopic Burch procedure, especially in cases of large lateral cystocele.
JB Dubuisson, J Dubuisson, JM Wenger, A Caviezel
Surgical intervention
2 years ago
2331 views
95 likes
0 comments
07:41
Sutures transfixing bladder as a complication of laparoscopic burch colposuspension
Laparoscopic Burch colposuspension may be difficult in cases of stress urinary incontinence (SUI) associated with large lateral cystocele. In these cases, complications may occur. However, they are rare.
This video shows the cystoscopic treatment of intravesical adhesions, secondary to sutures transfixing the bladder during the Burch laparoscopic procedure and lateral suspension, without perioperative use of control cystoscopy. An office cystoscopy was performed after the operation, nine months later, because of gradual onset of entirely isolated pelvic pain at the end of urination. It showed intravesical synechia as bilateral pillars. The different steps of the operation are the following:
1) Diagnostic laparoscopy with a good status of the lateral suspension without mesh migration.
2) Operative laparoscopy with opening of Retzius’s space, dissection, adhesiolysis, and division of the non-absorbable sutures of the past colposuspension in order to mobilize the bladder, followed by reperitonization of Retzius’s space.
3) Diagnostic cystoscopy confirming adhesions as bilateral pillars, laterally to the trigone with normal ejaculation of both ureteral ostia.
4) Operative cystoscopy after catheterization of both ureters: division of the pillars with the monopolar electrode without visualization of the Burch sutures, as they probably migrated upward in the first postoperative months.
In the postoperative period, ureteral catheters are removed 48 hours after surgery. Pain resolves completely during urination. Normal kidneys and ureters are observed at ultrasound.
This video clearly demonstrates the advantages related to the routine use of cystoscopy at the end of the laparoscopic Burch procedure, especially in cases of large lateral cystocele.
Small bowel obstruction and ileal strangulation by adhesions: role of laparoscopy in early diagnosis and treatment
Adhesive small bowel obstruction (ASBO) is a common surgical emergency, most frequently caused by adhesions. In the absence of signs of strangulations or CT-scan evidence (free fluid mesenteric edema, “small bowel faeces” sign, devascularization), a large portion of ASBO can be resolved using non-operative methods even if a significant number of patients will require an emergency surgery.
Laparoscopy in acute care surgery continues to expand even in cases of small bowel obstruction which were conventionally managed by means of laparotomy.
The authors report a case of a 45-year-old woman, completely laparoscopically treated, with a history of previous appendectomy with pelvic abscess, cholecystectomy and removal of right ovarian cysts. She was admitted to the emergency room five hours before surgery with severe acute abdominal pain which appeared 24 hours before.
CT-scan with oral administration of gastrografin showed signs of intestinal obstruction and adhesions were suspected. The exploratory laparoscopy revealed adhesive small bowel obstruction with ileal strangulation. The intestine was viable and resection was unnecessary.
The role of diagnostic imaging modalities is relevant to decrease ASBO-related morbidity and mortality. However, because of the lack of specific radiological signs and laboratory findings of bowel strangulation, the diagnosis requires, when it is not contraindicated, a timely laparoscopic exploration with both diagnostic and therapeutic purposes.
V Guarino, A Cappiello, N Perrotta, A Scotti, F Mastellone, D Loffredo
Surgical intervention
3 years ago
1899 views
87 likes
0 comments
08:20
Small bowel obstruction and ileal strangulation by adhesions: role of laparoscopy in early diagnosis and treatment
Adhesive small bowel obstruction (ASBO) is a common surgical emergency, most frequently caused by adhesions. In the absence of signs of strangulations or CT-scan evidence (free fluid mesenteric edema, “small bowel faeces” sign, devascularization), a large portion of ASBO can be resolved using non-operative methods even if a significant number of patients will require an emergency surgery.
Laparoscopy in acute care surgery continues to expand even in cases of small bowel obstruction which were conventionally managed by means of laparotomy.
The authors report a case of a 45-year-old woman, completely laparoscopically treated, with a history of previous appendectomy with pelvic abscess, cholecystectomy and removal of right ovarian cysts. She was admitted to the emergency room five hours before surgery with severe acute abdominal pain which appeared 24 hours before.
CT-scan with oral administration of gastrografin showed signs of intestinal obstruction and adhesions were suspected. The exploratory laparoscopy revealed adhesive small bowel obstruction with ileal strangulation. The intestine was viable and resection was unnecessary.
The role of diagnostic imaging modalities is relevant to decrease ASBO-related morbidity and mortality. However, because of the lack of specific radiological signs and laboratory findings of bowel strangulation, the diagnosis requires, when it is not contraindicated, a timely laparoscopic exploration with both diagnostic and therapeutic purposes.
Minimally invasive surgical approach to small bowel obstruction
Due to the lack of laparoscopic experience to work in a small space (small bowel distension), small bowel obstruction seems to be a relative contraindication for a minimally invasive approach. In other hands, many patients have co-morbidities, and consequently it is key to work with a low intra-abdominal pressure to prevent any conversion for pneumoperitoneum intolerance. Small bowel obstruction must be resolved by experts in order to prevent any excessive mobilization and iatrogenic perforation.

Critical comments:
This video presents the laparoscopic management of bowel obstruction. It demonstrates the feasibility of the identification and management of mechanical bowel obstruction. Several parts of the video can be discussed:
1. In their comments, the authors report that the whole bowel has to be explored in order to prevent the presence of a secondary band at the origin of the obstruction. This is absolutely mandatory. Usually, the recommendation is to start the exploration at the level of the caecum and to mobilize the whole non-dilated bowel in order to prevent a risk of bowel injury during this manipulation. Exploration of the dilated bowel is much more risky. The authors did not show this extensive and systematic exploration.
2. The authors reported that they used 5 to 10 liters of warm saline for abdominal lavage. Today, there is no evidence of the benefit of this major abdominal lavage including 5 to 10 liters. Selective lavage can be recommended in case of significant bacterial contamination.
3. The authors consider the potential benefit of irrigation of the ischemic bowel with hot water after band division. This indication can be considered as potentially efficient regarding the recommendations in open surgery. However, laparoscopy has a significant advantage to keep the internal temperature of 37°C at a minimum, and certainly hot lavage, which cannot be over 39°C to 40°C, will probably also have limited impact.
Despite these minor remarks, this video has a scientific value in demonstrating a safe approach to a small bowel obstruction related to a single band, which is, in this case, very safely resected.
One can also focus on the value of working with a high quality camera, which gives the surgeon the possibility to clearly evaluate the vitality of the small bowel after an ischemic period, which is well demonstrated in this video.
S Rua, F Silveira, P Mira
Surgical intervention
3 years ago
1314 views
60 likes
0 comments
06:59
Minimally invasive surgical approach to small bowel obstruction
Due to the lack of laparoscopic experience to work in a small space (small bowel distension), small bowel obstruction seems to be a relative contraindication for a minimally invasive approach. In other hands, many patients have co-morbidities, and consequently it is key to work with a low intra-abdominal pressure to prevent any conversion for pneumoperitoneum intolerance. Small bowel obstruction must be resolved by experts in order to prevent any excessive mobilization and iatrogenic perforation.

Critical comments:
This video presents the laparoscopic management of bowel obstruction. It demonstrates the feasibility of the identification and management of mechanical bowel obstruction. Several parts of the video can be discussed:
1. In their comments, the authors report that the whole bowel has to be explored in order to prevent the presence of a secondary band at the origin of the obstruction. This is absolutely mandatory. Usually, the recommendation is to start the exploration at the level of the caecum and to mobilize the whole non-dilated bowel in order to prevent a risk of bowel injury during this manipulation. Exploration of the dilated bowel is much more risky. The authors did not show this extensive and systematic exploration.
2. The authors reported that they used 5 to 10 liters of warm saline for abdominal lavage. Today, there is no evidence of the benefit of this major abdominal lavage including 5 to 10 liters. Selective lavage can be recommended in case of significant bacterial contamination.
3. The authors consider the potential benefit of irrigation of the ischemic bowel with hot water after band division. This indication can be considered as potentially efficient regarding the recommendations in open surgery. However, laparoscopy has a significant advantage to keep the internal temperature of 37°C at a minimum, and certainly hot lavage, which cannot be over 39°C to 40°C, will probably also have limited impact.
Despite these minor remarks, this video has a scientific value in demonstrating a safe approach to a small bowel obstruction related to a single band, which is, in this case, very safely resected.
One can also focus on the value of working with a high quality camera, which gives the surgeon the possibility to clearly evaluate the vitality of the small bowel after an ischemic period, which is well demonstrated in this video.
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
A Wattiez, R Nasir, A Host
Surgical intervention
3 years ago
3924 views
162 likes
0 comments
31:22
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
Laparoscopic treatment of bilateral endometriotic cysts
The different surgical approaches to ovarian endometriosis are the following: ovarian cystectomy, endometrioma fenestration and removal, or a technique combining cystectomy and removal.
In order to perform a cystectomy without damaging the ovary, different steps must be followed, including adhesiolysis between the ovary and the broad ligament, cyst opening at the site of eversion and adhesion. Traction and counter-traction allow to separate the cyst’s wall from the ovarian cortex. As the endometrioma is surrounded by a fibrotic capsule, there is a risk of removing normal ovarian tissue and ovocytes. Blood vessels must be identified and selective coagulation must be performed to prevent destruction of the normal ovarian tissue.
Endometrioma fenestration and removal can be performed with different sources of energy such as bipolar coagulation, carbon dioxide laser and plasma energy. Depending on the size of the endometrioma, the removal technique can be performed in one or three steps. But to avoid 2 laparoscopic procedures, a combined technique of excision and removal of the endometrioma could be offered in cases of large cysts.
Medical treatment is administered preoperatively only in cases of pelvic pain and postoperatively in cases of pelvic pain and if there is no desire for pregnancy.
According to a recent systematic review and meta-analysis, the ovarian reserve, evaluated by the AMH level, is affected by surgery, and even more in cases of bilateral cysts.

To conclude, ovarian endometrioma surgery requires a learning curve to prevent ovarian damage, which can be caused by normal ovarian tissue removal or by a strong coagulation. Repetitive surgery has to be clearly evaluated as it is also responsible for ovarian reserve decrease.
M Nisolle
Lecture
4 years ago
2514 views
94 likes
0 comments
19:00
Laparoscopic treatment of bilateral endometriotic cysts
The different surgical approaches to ovarian endometriosis are the following: ovarian cystectomy, endometrioma fenestration and removal, or a technique combining cystectomy and removal.
In order to perform a cystectomy without damaging the ovary, different steps must be followed, including adhesiolysis between the ovary and the broad ligament, cyst opening at the site of eversion and adhesion. Traction and counter-traction allow to separate the cyst’s wall from the ovarian cortex. As the endometrioma is surrounded by a fibrotic capsule, there is a risk of removing normal ovarian tissue and ovocytes. Blood vessels must be identified and selective coagulation must be performed to prevent destruction of the normal ovarian tissue.
Endometrioma fenestration and removal can be performed with different sources of energy such as bipolar coagulation, carbon dioxide laser and plasma energy. Depending on the size of the endometrioma, the removal technique can be performed in one or three steps. But to avoid 2 laparoscopic procedures, a combined technique of excision and removal of the endometrioma could be offered in cases of large cysts.
Medical treatment is administered preoperatively only in cases of pelvic pain and postoperatively in cases of pelvic pain and if there is no desire for pregnancy.
According to a recent systematic review and meta-analysis, the ovarian reserve, evaluated by the AMH level, is affected by surgery, and even more in cases of bilateral cysts.

To conclude, ovarian endometrioma surgery requires a learning curve to prevent ovarian damage, which can be caused by normal ovarian tissue removal or by a strong coagulation. Repetitive surgery has to be clearly evaluated as it is also responsible for ovarian reserve decrease.
DIE and laparoscopic treatment
Hormone therapy was designed to suppress estrogen synthesis and to reduce the size of ectopic endometrial implants. However, the recurrence of pain after cessation is estimated at 50% and indicates that surgery is required for symptomatic patients.
Conservative surgery is effective in terms of pain reduction if complete excision is obtained, and consequently a preoperative assessment is mandatory to put forward a multidisciplinary approach in specialized centers.
In cases of excision of the nodular lesion by means of mucosal skinning, the resection of uterosacral ligaments and of the posterior vaginal fornix is usually recommended. A comparison between standard and reverse laparoscopic techniques demonstrated a statistically significant lower rate of major postoperative complications by using the reverse technique.
Bowel endometriosis requires bowel resection if the size is estimated to exceed 3cm, to affect 50% of the bowel's diameter or to induce a stenosis. Different techniques could be proposed such as a segmental bowel resection, a discoid resection or a stapled resection.
Concerning the rate of complications, it has been published that mucosal skinning is associated with fewer complications than segmental resection.
Recently, robotic assisted laparoscopy was used for the treatment of advanced stage endometriosis; however, it is associated with an increased operative time and a longer hospital stay.

To conclude, a skilled surgical team is necessary to perform the complete removal of lesions without increasing the risk of complications and to obtain good results in terms of pelvic pain and fertility.
M Nisolle
Lecture
4 years ago
1813 views
78 likes
0 comments
23:49
DIE and laparoscopic treatment
Hormone therapy was designed to suppress estrogen synthesis and to reduce the size of ectopic endometrial implants. However, the recurrence of pain after cessation is estimated at 50% and indicates that surgery is required for symptomatic patients.
Conservative surgery is effective in terms of pain reduction if complete excision is obtained, and consequently a preoperative assessment is mandatory to put forward a multidisciplinary approach in specialized centers.
In cases of excision of the nodular lesion by means of mucosal skinning, the resection of uterosacral ligaments and of the posterior vaginal fornix is usually recommended. A comparison between standard and reverse laparoscopic techniques demonstrated a statistically significant lower rate of major postoperative complications by using the reverse technique.
Bowel endometriosis requires bowel resection if the size is estimated to exceed 3cm, to affect 50% of the bowel's diameter or to induce a stenosis. Different techniques could be proposed such as a segmental bowel resection, a discoid resection or a stapled resection.
Concerning the rate of complications, it has been published that mucosal skinning is associated with fewer complications than segmental resection.
Recently, robotic assisted laparoscopy was used for the treatment of advanced stage endometriosis; however, it is associated with an increased operative time and a longer hospital stay.

To conclude, a skilled surgical team is necessary to perform the complete removal of lesions without increasing the risk of complications and to obtain good results in terms of pelvic pain and fertility.
Laparoscopic management of a type III Mirizzi syndrome: cholecystectomy with flag technique and ideal suture of a cholecystobiliary fistula
In this video, authors demonstrate the laparoscopic management of a Mirizzi syndrome. Due to a cholecystocholedochal fistula and to a difficult dissection of Calot’s triangle, authors decided to modify the dissection technique by performing a primary freeing of the gallblader as described by Jean Mouiel. In order to prevent any further biliary damage, a subtotal cholecystectomy is also achieved by means of an EndoGia™ linear stapler. Cholecystobiliary fistula is repaired using an absorbable running suture protected by an internal choledochal drain placed thanks to preoperative endoscopic catheterization.
HA Mercoli, L Marx, J Leroy, P Pessaux, J Marescaux
Surgical intervention
4 years ago
5908 views
174 likes
0 comments
07:11
Laparoscopic management of a type III Mirizzi syndrome: cholecystectomy with flag technique and ideal suture of a cholecystobiliary fistula
In this video, authors demonstrate the laparoscopic management of a Mirizzi syndrome. Due to a cholecystocholedochal fistula and to a difficult dissection of Calot’s triangle, authors decided to modify the dissection technique by performing a primary freeing of the gallblader as described by Jean Mouiel. In order to prevent any further biliary damage, a subtotal cholecystectomy is also achieved by means of an EndoGia™ linear stapler. Cholecystobiliary fistula is repaired using an absorbable running suture protected by an internal choledochal drain placed thanks to preoperative endoscopic catheterization.
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
A Wattiez, R Fernandes, M Puga, J Alves, C Redondo Guisasola
Surgical intervention
5 years ago
2024 views
35 likes
0 comments
03:00
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
Laparoscopic management of small bowel perforation induced by foreign body
Ingested foreign bodies are a common cause for emergency hospital admission. A precise interview of the patient often allows to establish the diagnosis. In 90% of cases, the foreign body is spontaneously eliminated without inducing any particular symptoms. In less than 10% of cases, it requires non-surgical extraction maneuvers (enemas, endoscopy). Only 1% of cases are treated surgically. Modern imaging frequently allows to establish a precise topographic diagnosis based on aspect, size and density. Coupled with laparoscopic surgery, it allows for an early, targeted and minimally invasive management. In this video, we show the case of a patient presenting with typical signs of peritonitis along with the incidental discovery of an intraluminal foreign body in the small bowel which brought about a micro-perforation.
L Marx, M Raharimanantsoa, J Marescaux
Surgical intervention
6 years ago
1827 views
12 likes
0 comments
10:15
Laparoscopic management of small bowel perforation induced by foreign body
Ingested foreign bodies are a common cause for emergency hospital admission. A precise interview of the patient often allows to establish the diagnosis. In 90% of cases, the foreign body is spontaneously eliminated without inducing any particular symptoms. In less than 10% of cases, it requires non-surgical extraction maneuvers (enemas, endoscopy). Only 1% of cases are treated surgically. Modern imaging frequently allows to establish a precise topographic diagnosis based on aspect, size and density. Coupled with laparoscopic surgery, it allows for an early, targeted and minimally invasive management. In this video, we show the case of a patient presenting with typical signs of peritonitis along with the incidental discovery of an intraluminal foreign body in the small bowel which brought about a micro-perforation.
Laparoscopic rectovaginal resection for endometriosis: transvaginal specimen extraction and anastomosis
The authors demonstrate a rectovaginal resection technique for invasive endometriosis. The original nature of this approach hinges on the mesorectum dissection technique in contact with the rectal wall in order to preserve rectal vascularization and innervation. Additionally, rectal exteriorization through the vagina to prepare for the colorectal anastomosis using a mechanical circular stapling without any abdominal incision is truly original as it contributes to limiting parietal trauma and improving cosmesis. The film truly focuses on the digestive approach just after anterior pelvic dissection has been completed by the team of gynecologic surgeons.
J Leroy, CY Akladios, V Thoma, A Wattiez, J Marescaux
Surgical intervention
6 years ago
1366 views
23 likes
0 comments
21:33
Laparoscopic rectovaginal resection for endometriosis: transvaginal specimen extraction and anastomosis
The authors demonstrate a rectovaginal resection technique for invasive endometriosis. The original nature of this approach hinges on the mesorectum dissection technique in contact with the rectal wall in order to preserve rectal vascularization and innervation. Additionally, rectal exteriorization through the vagina to prepare for the colorectal anastomosis using a mechanical circular stapling without any abdominal incision is truly original as it contributes to limiting parietal trauma and improving cosmesis. The film truly focuses on the digestive approach just after anterior pelvic dissection has been completed by the team of gynecologic surgeons.
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.
A Wattiez, J Albornoz, M Puga, E Faller
Surgical intervention
6 years ago
1785 views
24 likes
0 comments
32:41
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.