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Laparoscopic internal hernia repair after mini gastric bypass
Laparoscopic Roux-en-Y gastric bypass (LGBP) has been shown to be an effective treatment for morbid obesity, both in terms of weight loss and improvement in multiple comorbidities. While the laparoscopic approach offers many advantages to patients in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, some complications of this operation continue to pose difficult clinical problems as the number of procedures performed increases. One such complication is internal hernia through one of the mesenteric defects, which can result in small bowel obstruction (SBO), ischemia, or infarction, and often requires emergency reoperation.
Internal hernias is a significant clinical problem, since it is the most common cause of small bowel obstruction after LGBP. Retrospective reviews have found the incidence of SBO after LGBP to be between 1.8 and 9.7%. The creation of a potential space as a result of weight loss may also be a contributing factor in the etiology of internal hernias, which often present in a delayed fashion. In addition, the particular case of pregnancy (with the mass effect of an enlarging uterus) may predispose to this condition.
An internal hernia can potentially occur through either two or three defects, depending on whether a retrocolic or antecolic technique is used for the Roux limb. Petersen’s defect is defined as the space between the Roux limb and the transverse mesocolon. A defect is also present between the biliopancreatic and Roux limbs at the jejunojejunostomy. If a retrocolic approach is used, a third defect in the transverse mesocolon is created. This is the most common site of internal hernia in most reports, which has prompted many surgeons to adopt an antecolic technique in order to rule out this defect.
G Sojod, L Marx, J Marescaux
Surgical intervention
6 years ago
1599 views
18 likes
0 comments
05:08
Laparoscopic internal hernia repair after mini gastric bypass
Laparoscopic Roux-en-Y gastric bypass (LGBP) has been shown to be an effective treatment for morbid obesity, both in terms of weight loss and improvement in multiple comorbidities. While the laparoscopic approach offers many advantages to patients in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, some complications of this operation continue to pose difficult clinical problems as the number of procedures performed increases. One such complication is internal hernia through one of the mesenteric defects, which can result in small bowel obstruction (SBO), ischemia, or infarction, and often requires emergency reoperation.
Internal hernias is a significant clinical problem, since it is the most common cause of small bowel obstruction after LGBP. Retrospective reviews have found the incidence of SBO after LGBP to be between 1.8 and 9.7%. The creation of a potential space as a result of weight loss may also be a contributing factor in the etiology of internal hernias, which often present in a delayed fashion. In addition, the particular case of pregnancy (with the mass effect of an enlarging uterus) may predispose to this condition.
An internal hernia can potentially occur through either two or three defects, depending on whether a retrocolic or antecolic technique is used for the Roux limb. Petersen’s defect is defined as the space between the Roux limb and the transverse mesocolon. A defect is also present between the biliopancreatic and Roux limbs at the jejunojejunostomy. If a retrocolic approach is used, a third defect in the transverse mesocolon is created. This is the most common site of internal hernia in most reports, which has prompted many surgeons to adopt an antecolic technique in order to rule out this defect.
Laparoscopic simplified gastric bypass
Laparoscopic gastric bypass is currently the gold standard in bariatric surgery. This procedure is complex and yet, it can be perfectly standardized in order to shorten the learning curve. This video presents a well-standardized and easily reproducible technique. All operative steps have been systematized and unroll very naturally. Once the gastric pouch has been divided, the gastrojejunal anastomosis is performed by means of a linear stapler by calibrating a 3cm pouch. The jejunojejunal anastomosis is performed using a 45mm long linear stapler without any division of the alimentary loop. Consequently, it is easy to control the patency of the two anastomoses. Mesenteric defects are closed to avoid internal hernias. Reproducibility is the main advantage of this technique, which has been used by operators to train more than 700 surgeons in South America, Europe, and Asia.
M Galvao Neto, A Cardoso Ramos, M Vix, J Marescaux
Surgical intervention
7 years ago
5277 views
64 likes
0 comments
25:24
Laparoscopic simplified gastric bypass
Laparoscopic gastric bypass is currently the gold standard in bariatric surgery. This procedure is complex and yet, it can be perfectly standardized in order to shorten the learning curve. This video presents a well-standardized and easily reproducible technique. All operative steps have been systematized and unroll very naturally. Once the gastric pouch has been divided, the gastrojejunal anastomosis is performed by means of a linear stapler by calibrating a 3cm pouch. The jejunojejunal anastomosis is performed using a 45mm long linear stapler without any division of the alimentary loop. Consequently, it is easy to control the patency of the two anastomoses. Mesenteric defects are closed to avoid internal hernias. Reproducibility is the main advantage of this technique, which has been used by operators to train more than 700 surgeons in South America, Europe, and Asia.
Management of transpyloric invagination of a gastrointestinal stromal tumor (GIST)
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs are most commonly found in the stomach (40-70%), but can occur in all other parts of the GI tract, with 20 to 40% of GISTs arising in the small intestine and 5 to 15% from the colon and rectum.
They typically grow endophytically, parallel to the bowel lumen, commonly with overlying mucosal necrosis and ulceration. They also vary in size, from a few millimeters to 40cm in diameter. Many GISTs are well defined by a thin pseudo-capsule.
Over 95% of patients present with a solitary primary tumor, and in 10 to 40% of these cases, the tumor directly invades neighboring organs. Gastric GISTs are usually presented with GI bleeding and abdominal pain. However, most patients are symptom-free and the lesions are discovered incidentally during an upper endoscopy performed for other reasons (chronic abdominal pain and intermittent gastric obstruction in this patient).
Surgery remains the mainstay of curative treatment.
Surgical resection of localized gastric GISTs is the preferred treatment modality, as resection of the tumor renders the only chance for cure at this time. Historically, a 1 to 2cm margin was thought to be necessary for an adequate resection. However, more recently, DeMatteo et al. demonstrated that tumor size and not negative microscopic surgical margins determine survival.
It is therefore accepted that the surgical goal should be a complete resection with gross negative margins only.
Given this, wedge resection has been advocated by many investigators for the majority of gastric GISTs.
J D'Agostino, Gf Donatelli, S Perretta, J Marescaux
Surgical intervention
7 years ago
2103 views
18 likes
0 comments
04:15
Management of transpyloric invagination of a gastrointestinal stromal tumor (GIST)
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs are most commonly found in the stomach (40-70%), but can occur in all other parts of the GI tract, with 20 to 40% of GISTs arising in the small intestine and 5 to 15% from the colon and rectum.
They typically grow endophytically, parallel to the bowel lumen, commonly with overlying mucosal necrosis and ulceration. They also vary in size, from a few millimeters to 40cm in diameter. Many GISTs are well defined by a thin pseudo-capsule.
Over 95% of patients present with a solitary primary tumor, and in 10 to 40% of these cases, the tumor directly invades neighboring organs. Gastric GISTs are usually presented with GI bleeding and abdominal pain. However, most patients are symptom-free and the lesions are discovered incidentally during an upper endoscopy performed for other reasons (chronic abdominal pain and intermittent gastric obstruction in this patient).
Surgery remains the mainstay of curative treatment.
Surgical resection of localized gastric GISTs is the preferred treatment modality, as resection of the tumor renders the only chance for cure at this time. Historically, a 1 to 2cm margin was thought to be necessary for an adequate resection. However, more recently, DeMatteo et al. demonstrated that tumor size and not negative microscopic surgical margins determine survival.
It is therefore accepted that the surgical goal should be a complete resection with gross negative margins only.
Given this, wedge resection has been advocated by many investigators for the majority of gastric GISTs.
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
8759 views
131 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.
Treitz laparoscopic resection with intracorporeal anastomosis with a new barbed suture
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract. Life-threatening hemorrhage or intestinal obstruction are the most common presenting symptoms. In the last year, we observed four patients affected by GIST of the small bowel presenting with a massive bleeding. After the endoscopic diagnosis, all the neoplasms were ink marked.
We present a video showing a Treitz’s GIST treated with a laparoscopic resection, followed by a mechanical latero-lateral intracorporeal anastomosis and enterotomy closure using a new kind of self-anchoring barbed suture (V-Loc® advanced wound closure device-Covidien, Mansfield, MA).
M Scatizzi, E Lenzi, M Baraghini, KC Kröning, F Menici, S Cantafio, F Feroci
Surgical intervention
8 years ago
2361 views
16 likes
0 comments
07:26
Treitz laparoscopic resection with intracorporeal anastomosis with a new barbed suture
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract. Life-threatening hemorrhage or intestinal obstruction are the most common presenting symptoms. In the last year, we observed four patients affected by GIST of the small bowel presenting with a massive bleeding. After the endoscopic diagnosis, all the neoplasms were ink marked.
We present a video showing a Treitz’s GIST treated with a laparoscopic resection, followed by a mechanical latero-lateral intracorporeal anastomosis and enterotomy closure using a new kind of self-anchoring barbed suture (V-Loc® advanced wound closure device-Covidien, Mansfield, MA).
Laparoscopic right colectomy for cancer
Laparoscopic colorectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colorectal procedures has been demonstrated. Surgeons performing right hemicolectomy using the laparo-assisted technique consider it more difficult than open colectomy. It is possible to perform a completely laparoscopic right hemicolectomy in advanced laparoscopic centers with many benefits: less postoperative pain, short-term postoperative ileus, earlier return to daily activity. This chapter describes surgical anatomy, indications and techniques of laparoscopic right colon resection for cancer.
J Leroy, J Marescaux
Operative technique
10 years ago
87558 views
776 likes
1 comment
Laparoscopic right colectomy for cancer
Laparoscopic colorectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colorectal procedures has been demonstrated. Surgeons performing right hemicolectomy using the laparo-assisted technique consider it more difficult than open colectomy. It is possible to perform a completely laparoscopic right hemicolectomy in advanced laparoscopic centers with many benefits: less postoperative pain, short-term postoperative ileus, earlier return to daily activity. This chapter describes surgical anatomy, indications and techniques of laparoscopic right colon resection for cancer.
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
1625 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.
Technique: laparoscopic distal gastrectomy
The description of the technique of laparoscopic distal gastrectomy covers all aspects of the surgical procedure used for the management of chronic gastric ulcers.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical procedure, exploration, dissection of greater curvature, resection of the antrum, gastroduodenal anastomosis, Billroth II anastomosis, complications, intraoperative complications, postoperative complications, functional complications.
Consequently, this operating technique is well standardized for the management of this condition.
D Mutter
Operative technique
18 years ago
4058 views
124 likes
0 comments
Technique: laparoscopic distal gastrectomy
The description of the technique of laparoscopic distal gastrectomy covers all aspects of the surgical procedure used for the management of chronic gastric ulcers.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical procedure, exploration, dissection of greater curvature, resection of the antrum, gastroduodenal anastomosis, Billroth II anastomosis, complications, intraoperative complications, postoperative complications, functional complications.
Consequently, this operating technique is well standardized for the management of this condition.
Transabdominal preperitoneal approach (TAPP)
The description of the transabdominal preperitoneal approach (TAPP) covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: hernia types, Nyhus classification, laparoscopic classification, exposure and exploration, incision of peritoneum, preperitoneal dissection, hernia sac dissection, preperitoneal space, the mesh, mesh placement, fixing the mesh, closing the peritoneum.
Consequently, this operating technique is well standardized for the management of this condition.
J Leroy
Operative technique
18 years ago
17546 views
472 likes
0 comments
Transabdominal preperitoneal approach (TAPP)
The description of the transabdominal preperitoneal approach (TAPP) covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: hernia types, Nyhus classification, laparoscopic classification, exposure and exploration, incision of peritoneum, preperitoneal dissection, hernia sac dissection, preperitoneal space, the mesh, mesh placement, fixing the mesh, closing the peritoneum.
Consequently, this operating technique is well standardized for the management of this condition.