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Wilkie's syndrome surgery
Wilkie’s syndrome (or superior mesenteric artery syndrome) was first described by Von Rokitansky in 1861. It consists in an extrinsic pressure over the third duodenal portion originating from an uncertain cause. Wilkie found a decreased angle (25 degrees, or less) between the superior mesenteric artery and the aorta, conditioning a duodenal (3rd portion) obstruction of vascular origin. It is associated with weight loss. The real incidence remains unknown due to the lack of diagnosis. However, the estimated incidence varies between 0.013 to 1% of the population. The male/female ratio is 2:3, ranging age between 10 and 39 years old.
Symptoms include postprandial abdominal pain, nausea and vomiting, weight loss, early gastric fullness and anorexia (acute high gastroduodenal obstruction).
Diagnostic studies include barium esophageal gastroduodenal series, CT-scan, MRI, high endoscopy (peptic esophagitis, ulcer). Endoscopic studies must come together with barium esophageal gastroduodenal X-ray studies.
Surgical treatment is performed when there is no response to medical treatment, consisting in duodenojejunal anastomoses, with Treitz’s ligament division. Gastrojejunal anastomosis is an alternative option. Laparoscopic surgical treatment can be performed.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres
Surgical intervention
9 months ago
1456 views
8 likes
0 comments
13:16
Wilkie's syndrome surgery
Wilkie’s syndrome (or superior mesenteric artery syndrome) was first described by Von Rokitansky in 1861. It consists in an extrinsic pressure over the third duodenal portion originating from an uncertain cause. Wilkie found a decreased angle (25 degrees, or less) between the superior mesenteric artery and the aorta, conditioning a duodenal (3rd portion) obstruction of vascular origin. It is associated with weight loss. The real incidence remains unknown due to the lack of diagnosis. However, the estimated incidence varies between 0.013 to 1% of the population. The male/female ratio is 2:3, ranging age between 10 and 39 years old.
Symptoms include postprandial abdominal pain, nausea and vomiting, weight loss, early gastric fullness and anorexia (acute high gastroduodenal obstruction).
Diagnostic studies include barium esophageal gastroduodenal series, CT-scan, MRI, high endoscopy (peptic esophagitis, ulcer). Endoscopic studies must come together with barium esophageal gastroduodenal X-ray studies.
Surgical treatment is performed when there is no response to medical treatment, consisting in duodenojejunal anastomoses, with Treitz’s ligament division. Gastrojejunal anastomosis is an alternative option. Laparoscopic surgical treatment can be performed.
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
F Signorini, HK Yang
Surgical intervention
3 months ago
1739 views
5 likes
1 comment
10:02
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Morbid obesity has reached epidemic proportions. Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective bariatric surgery procedure for weight loss. This procedure was first described by Scopinaro in 1979. It consisted of a horizontal gastrectomy, a transection of the bowel halfway from the ligament of Treitz and the ileocecal junction, and a Roux-en-Y reconstruction with a 50cm common channel. This was later modified: the duodenal switch was added and the gastrectomy was performed in a vertical sleeve fashion, thereby preserving the pylorus and increasing the common channel to 100cm. This modification greatly reduced the incidence of marginal ulceration, dumping, and nutritional deficiencies. However, this operation is still uncommon due to the perceived technical difficulty and risk of nutritional morbidity. This video demonstrates a standardized technique for this complex procedure.
RC Pullatt
Surgical intervention
3 months ago
3338 views
12 likes
2 comments
13:00
Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Morbid obesity has reached epidemic proportions. Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective bariatric surgery procedure for weight loss. This procedure was first described by Scopinaro in 1979. It consisted of a horizontal gastrectomy, a transection of the bowel halfway from the ligament of Treitz and the ileocecal junction, and a Roux-en-Y reconstruction with a 50cm common channel. This was later modified: the duodenal switch was added and the gastrectomy was performed in a vertical sleeve fashion, thereby preserving the pylorus and increasing the common channel to 100cm. This modification greatly reduced the incidence of marginal ulceration, dumping, and nutritional deficiencies. However, this operation is still uncommon due to the perceived technical difficulty and risk of nutritional morbidity. This video demonstrates a standardized technique for this complex procedure.
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
9 months ago
4627 views
19 likes
1 comment
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.
A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
S Greco, M Giulii Capponi, M Lotti, M Khotcholava
Surgical intervention
3 months ago
1259 views
4 likes
2 comments
14:14
A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
Laparoscopic management of perforated ulcer of the stomach
A 43-year-old woman with a history of chronic use of NSAIDs was admitted to the emergency care unit for acute abdominal epigastric pain. CT-scan showed both free air and fluid in the peritoneal cavity with marked thickening and irregularity at the level of the gastric antrum and the duodenal bulb. The patient underwent emergency laparoscopy. A large amount of purulent fluid was found in the peritoneal cavity and evacuated. The gastric defect was identified at the level of the anterior wall of the gastric antrum. A 2/0 Vicryl suture is used to oversew the perforation. As an additional protection, an omental patch was brought in place and fixed against the sutured lesion. Abundant peritoneal lavage was performed. The patient was discharged on postoperative day 5. One month later, esophagogastroduodenoscopies (EGDs) with biopsies of the ulcer’s margins were performed.
X Untereiner, M Pizzicannella, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
8 months ago
5496 views
16 likes
2 comments
06:55
Laparoscopic management of perforated ulcer of the stomach
A 43-year-old woman with a history of chronic use of NSAIDs was admitted to the emergency care unit for acute abdominal epigastric pain. CT-scan showed both free air and fluid in the peritoneal cavity with marked thickening and irregularity at the level of the gastric antrum and the duodenal bulb. The patient underwent emergency laparoscopy. A large amount of purulent fluid was found in the peritoneal cavity and evacuated. The gastric defect was identified at the level of the anterior wall of the gastric antrum. A 2/0 Vicryl suture is used to oversew the perforation. As an additional protection, an omental patch was brought in place and fixed against the sutured lesion. Abundant peritoneal lavage was performed. The patient was discharged on postoperative day 5. One month later, esophagogastroduodenoscopies (EGDs) with biopsies of the ulcer’s margins were performed.
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
C Viana, M Lozano, D Poletto, T Moreno, C Varela, A Toscano
Surgical intervention
1 year ago
3635 views
10 likes
1 comment
15:27
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
G Baiocchi, S Molfino, B Molteni, L Arru, F Gheza, M Diana
Surgical intervention
10 months ago
4096 views
11 likes
0 comments
12:41
Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass
Introduction: Obesity is a known etiological factor for gastroesophageal reflux disease (GERD) and is also a growing public health concern. Although Nissen fundoplication is a highly effective technique to treat GERD, it may fail in obese patients. Roux-en-Y gastric bypass provides excellent long-term control of GERD symptoms with the additional benefit of weight loss.
Clinical case: A 57-year-old woman underwent a laparoscopic Nissen fundoplication for GERD (BMI 30.0 Kg/m2) with excellent outcomes during the first postoperative year in 2011. Two years later, GERD symptoms recurred, and her weight increased progressively (BMI of 36.0 Kg/m2). The patient was proposed to a laparoscopic conversion of Nissen fundoplication to a Roux-en-Y gastric bypass. The procedure was uneventful, and the patient was discharged on postoperative day 4. One year later, she remained asymptomatic, off antacids medication, and with her weight decreased to 63.5Kg which corresponded to a BMI of 25.4 Kg/m2.
Discussion/conclusion: Roux-en-Y gastric bypass successfully reduces GERD symptoms by diverting bile away from the esophagus, decreasing acid production in the gastric pouch, therefore limiting the amount of acid reflux and by promoting weight loss decreases abdominal pressure over the lower esophageal sphincter and esophageal hiatus. In obese patients (BMI>35) with GERD, Roux-en-Y gastric bypass seems to be the most effective and advantageous treatment since it provides control of GERD symptoms with the additional benefit of weight loss. In patients who have previously undergone anti-reflux surgery, bariatric surgery can be technically demanding. However, if performed by high-volume surgeons in high-volume centers, it is perfectly feasible with low morbidity and excellent results.
J Magalhães, AM Pereira, T Fonseca, R Ferreira de Almeida, M Nora
Surgical intervention
10 months ago
1742 views
4 likes
0 comments
09:34
Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass
Introduction: Obesity is a known etiological factor for gastroesophageal reflux disease (GERD) and is also a growing public health concern. Although Nissen fundoplication is a highly effective technique to treat GERD, it may fail in obese patients. Roux-en-Y gastric bypass provides excellent long-term control of GERD symptoms with the additional benefit of weight loss.
Clinical case: A 57-year-old woman underwent a laparoscopic Nissen fundoplication for GERD (BMI 30.0 Kg/m2) with excellent outcomes during the first postoperative year in 2011. Two years later, GERD symptoms recurred, and her weight increased progressively (BMI of 36.0 Kg/m2). The patient was proposed to a laparoscopic conversion of Nissen fundoplication to a Roux-en-Y gastric bypass. The procedure was uneventful, and the patient was discharged on postoperative day 4. One year later, she remained asymptomatic, off antacids medication, and with her weight decreased to 63.5Kg which corresponded to a BMI of 25.4 Kg/m2.
Discussion/conclusion: Roux-en-Y gastric bypass successfully reduces GERD symptoms by diverting bile away from the esophagus, decreasing acid production in the gastric pouch, therefore limiting the amount of acid reflux and by promoting weight loss decreases abdominal pressure over the lower esophageal sphincter and esophageal hiatus. In obese patients (BMI>35) with GERD, Roux-en-Y gastric bypass seems to be the most effective and advantageous treatment since it provides control of GERD symptoms with the additional benefit of weight loss. In patients who have previously undergone anti-reflux surgery, bariatric surgery can be technically demanding. However, if performed by high-volume surgeons in high-volume centers, it is perfectly feasible with low morbidity and excellent results.
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.
WJ Hyung, S Perretta, B Dallemagne, B Seeliger, D Mutter, J Marescaux
Surgical intervention
10 months ago
2209 views
15 likes
0 comments
04:27
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.
Robotic Nissen fundoplication with the da Vinci Xi robotic surgical system
For a long time, laparoscopic Nissen fundoplication has been used to treat gastroesophageal reflux disease (GERD). The main challenges of laparoscopic Nissen fundoplication involve the 2-dimensional visualization, exposure of complex gastroesophageal anatomy, and suturing of the wrap fundoplication. In 1999, robotic Nissen fundoplication, a completely new technique, was introduced, demonstrating advantages over conventional laparoscopic surgery due to improved manual dexterity, ergonomics, and 3-dimensional visualization. However, time spent on robotic platform docking and arm clashing during the procedure are factors that surgeons often find cumbersome and time-consuming. The newest surgical platform, the da Vinci Xi surgical robotic system, can help to overcome such problems. This video shows a stepwise approach of the da Vinci Xi docking process and surgical technique demonstrating fundoplication according to the Nissen technique.
L Marano, A Spaziani, G Castagnoli
Surgical intervention
10 months ago
1614 views
7 likes
0 comments
07:00
Robotic Nissen fundoplication with the da Vinci Xi robotic surgical system
For a long time, laparoscopic Nissen fundoplication has been used to treat gastroesophageal reflux disease (GERD). The main challenges of laparoscopic Nissen fundoplication involve the 2-dimensional visualization, exposure of complex gastroesophageal anatomy, and suturing of the wrap fundoplication. In 1999, robotic Nissen fundoplication, a completely new technique, was introduced, demonstrating advantages over conventional laparoscopic surgery due to improved manual dexterity, ergonomics, and 3-dimensional visualization. However, time spent on robotic platform docking and arm clashing during the procedure are factors that surgeons often find cumbersome and time-consuming. The newest surgical platform, the da Vinci Xi surgical robotic system, can help to overcome such problems. This video shows a stepwise approach of the da Vinci Xi docking process and surgical technique demonstrating fundoplication according to the Nissen technique.
Fully robotic Roux-en-Y gastric bypass
Roux-en-Y gastric bypass is becoming increasingly popular. The use of the surgical robot is developing rapidly, and this is especially true for digestive surgery. The aim of this video is to show that Roux-en-Y gastric bypass can be performed using a totally robotic approach. When using the robot, one follows the same steps as for a conventional intervention. The 3D vision and the degrees of freedom of the instruments facilitate the dissection, especially around the cardia, and for suturing procedures. The surgeon takes advantage of the console's user friendly set-up which does not put his/her shoulders or back in a vulnerable position, as they sometimes are when using a laparoscopic approach.
M Vix, B Seeliger, D Mutter, J Marescaux
Surgical intervention
10 months ago
1582 views
7 likes
0 comments
12:00
Fully robotic Roux-en-Y gastric bypass
Roux-en-Y gastric bypass is becoming increasingly popular. The use of the surgical robot is developing rapidly, and this is especially true for digestive surgery. The aim of this video is to show that Roux-en-Y gastric bypass can be performed using a totally robotic approach. When using the robot, one follows the same steps as for a conventional intervention. The 3D vision and the degrees of freedom of the instruments facilitate the dissection, especially around the cardia, and for suturing procedures. The surgeon takes advantage of the console's user friendly set-up which does not put his/her shoulders or back in a vulnerable position, as they sometimes are when using a laparoscopic approach.
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
F Signorini, S Reimondez, M España, L Obeide, F Moser
Surgical intervention
1 year ago
10891 views
428 likes
0 comments
06:41
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
D Lipski, D Garcilazo Arismendi, S Targa
Surgical intervention
1 year ago
3607 views
427 likes
0 comments
07:37
Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
B Dallemagne, S Perretta, B Seeliger, D Mutter, J Marescaux
Surgical intervention
1 year ago
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Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.