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PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.
A Anuwong, M Vix, HS Wu
Surgical intervention
2 years ago
4618 views
316 likes
1 comment
25:34
PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.
Totally endoscopic left hemithyroidectomy: axillary approach for papillary carcinoma, including a critical analysis by M Vix, MD, and point by point answer by Dr. Shah
Introduction:
Endoscopic thyroidectomy is a novel approach used to avoid cervical scar, which represents sequelae of conventional thyroidectomies. This technique is feasible providing equal results under expert hands.
Case presentation:
This is the case of a 20 year-old woman with cervical swelling, a 3 by 3cm solitary nodule in the left thyroid lobe, which was evaluated clinically, radiologically, and withfine-needle aspiration cytology (FNAC). She was diagnosed with a low-risk papillary carcinoma.
Discussion:
The patient underwent an endoscopic transaxillary left hemithyroidectomy under general anesthesia. The recurrent laryngeal nerve and the parathyroid gland were preserved. The patient was discharged with a normal tone on postoperative day 1.
Conclusion:
Endoscopic transaxillary thyroidectomy is a feasible good technique with equal results, which can be considered for patients with small thyroid lesions. Conventional laparoscopic instruments are used without the need for extra instrumentation.

This video is commented upon by Dr. M Vix, MD (University Hospital, Strasbourg, France), providing a comprehensive outline of Dr. Shah's original technique.


Point by point answer by Dr. Shah:

1. Carbon dioxide causing surgical emphysema, especially of an incapacitating nature, has not been experienced since intracavitary pressures are generally maintained at a low level by the almost continuous low-grade suction used throughout the surgery.

2. In our experience, adequate visualization of the thyroid pedicles in close proximity to the gland precludes the need for a deeper and more lateral dissection to identify the jugulocarotid vessels. This potentially decreases the risk of a major vascular mishap.

3. As is the norm with open thyroidectomy, division of the superior thyroid pedicle close to the gland usually does not require the identification of the superior laryngeal nerve.

4. In this approach, the recurrent laryngeal nerve is identified very early on in the dissection. Subsequent dissection is performed in a plane anterior to the visualized nerve, hence preventing any injuries. The recurrent laryngeal nerve is visualized in its entire extent up to Berry's ligament.



AR Shah
Surgical intervention
2 years ago
1063 views
115 likes
0 comments
11:09
Totally endoscopic left hemithyroidectomy: axillary approach for papillary carcinoma, including a critical analysis by M Vix, MD, and point by point answer by Dr. Shah
Introduction:
Endoscopic thyroidectomy is a novel approach used to avoid cervical scar, which represents sequelae of conventional thyroidectomies. This technique is feasible providing equal results under expert hands.
Case presentation:
This is the case of a 20 year-old woman with cervical swelling, a 3 by 3cm solitary nodule in the left thyroid lobe, which was evaluated clinically, radiologically, and withfine-needle aspiration cytology (FNAC). She was diagnosed with a low-risk papillary carcinoma.
Discussion:
The patient underwent an endoscopic transaxillary left hemithyroidectomy under general anesthesia. The recurrent laryngeal nerve and the parathyroid gland were preserved. The patient was discharged with a normal tone on postoperative day 1.
Conclusion:
Endoscopic transaxillary thyroidectomy is a feasible good technique with equal results, which can be considered for patients with small thyroid lesions. Conventional laparoscopic instruments are used without the need for extra instrumentation.

This video is commented upon by Dr. M Vix, MD (University Hospital, Strasbourg, France), providing a comprehensive outline of Dr. Shah's original technique.


Point by point answer by Dr. Shah:

1. Carbon dioxide causing surgical emphysema, especially of an incapacitating nature, has not been experienced since intracavitary pressures are generally maintained at a low level by the almost continuous low-grade suction used throughout the surgery.

2. In our experience, adequate visualization of the thyroid pedicles in close proximity to the gland precludes the need for a deeper and more lateral dissection to identify the jugulocarotid vessels. This potentially decreases the risk of a major vascular mishap.

3. As is the norm with open thyroidectomy, division of the superior thyroid pedicle close to the gland usually does not require the identification of the superior laryngeal nerve.

4. In this approach, the recurrent laryngeal nerve is identified very early on in the dissection. Subsequent dissection is performed in a plane anterior to the visualized nerve, hence preventing any injuries. The recurrent laryngeal nerve is visualized in its entire extent up to Berry's ligament.



Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
The presence of a single parathyroid adenoma accurately located using preoperative imaging is the best indication for minimally invasive surgery when dealing with primary hyperparathyroidism. It is certainly possible to search for several glands that may be suspicious of adenoma, but an extensive experience in video-assisted cervical surgery is required to find the anatomical structures allowing to explore the four parathyroid locations.
Patient and methods:
A 75-year-old obese woman is diagnosed with hypercalcemia, hypophosphoremia, and a high level of PTH during a work-up for joint pain.

Preoperative imaging includes a 3D-reconstructed cervico-mediastinal CT-scan —a computer program developed at the IRCAD-Strasbourg, named VrAnat™, Vr planning™, is used for that purpose. This 3D virtual reconstruction demonstrates three suspicious images respectively located at the right superior parathyroid territory, at the right latero-esophageal area, and at the left inferior parathyroid territory. A video-assisted cervical exploration, guided by this reconstruction, is decided upon. The objective is to find the three suspicious images and to explore the four parathyroid glands.

A 3cm median incision is carried out 2cm above the sternal notch. The right thyrotracheal groove is reached through a dissection performed laterally to the strap muscles and medially to the omohyoid muscle. A complete dissection of the lateral aspect of the thyroid lobe is obtained using blunt dissection and small instruments under endoscopic vision, which is provided by a 30-degree, 5mm scope (Storz, Tüttlingen, Germany). The recurrent laryngeal nerve is identified.

Dissection is now carried on above the inferior thyroid artery. It allows to rapidly identify a superior parathyroid adenoma, which will be resected. It exactly matches with one of the suspicious images.

Dissection is pursued anterior to the intersection between the artery and the nerve so as to find the right inferior parathyroid, which is healthy, underneath the capsule. The latero-esophageal image is now searched for. It is nothing but an anthracosic lymph node.

The left side is approached by dissecting the left jugulocarotid gutter. The left recurrent nerve is identified. The left inferior parathyroid is identified and looks healthy. The suspected image is nothing else but a nodule of the apex of the thyrothymic ligament. The left superior parathyroid, which is healthy, can be finally identified in a strictly orthotopic position, although partially hidden behind a Zuckerkandl’s nodule.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

Miccoli P, Materazzi G, Baggiani A, Miccoli M. Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 2011;34:473-80.
M Vix, D Mutter, J Marescaux
Surgical intervention
2 years ago
574 views
71 likes
0 comments
09:39
Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
The presence of a single parathyroid adenoma accurately located using preoperative imaging is the best indication for minimally invasive surgery when dealing with primary hyperparathyroidism. It is certainly possible to search for several glands that may be suspicious of adenoma, but an extensive experience in video-assisted cervical surgery is required to find the anatomical structures allowing to explore the four parathyroid locations.
Patient and methods:
A 75-year-old obese woman is diagnosed with hypercalcemia, hypophosphoremia, and a high level of PTH during a work-up for joint pain.

Preoperative imaging includes a 3D-reconstructed cervico-mediastinal CT-scan —a computer program developed at the IRCAD-Strasbourg, named VrAnat™, Vr planning™, is used for that purpose. This 3D virtual reconstruction demonstrates three suspicious images respectively located at the right superior parathyroid territory, at the right latero-esophageal area, and at the left inferior parathyroid territory. A video-assisted cervical exploration, guided by this reconstruction, is decided upon. The objective is to find the three suspicious images and to explore the four parathyroid glands.

A 3cm median incision is carried out 2cm above the sternal notch. The right thyrotracheal groove is reached through a dissection performed laterally to the strap muscles and medially to the omohyoid muscle. A complete dissection of the lateral aspect of the thyroid lobe is obtained using blunt dissection and small instruments under endoscopic vision, which is provided by a 30-degree, 5mm scope (Storz, Tüttlingen, Germany). The recurrent laryngeal nerve is identified.

Dissection is now carried on above the inferior thyroid artery. It allows to rapidly identify a superior parathyroid adenoma, which will be resected. It exactly matches with one of the suspicious images.

Dissection is pursued anterior to the intersection between the artery and the nerve so as to find the right inferior parathyroid, which is healthy, underneath the capsule. The latero-esophageal image is now searched for. It is nothing but an anthracosic lymph node.

The left side is approached by dissecting the left jugulocarotid gutter. The left recurrent nerve is identified. The left inferior parathyroid is identified and looks healthy. The suspected image is nothing else but a nodule of the apex of the thyrothymic ligament. The left superior parathyroid, which is healthy, can be finally identified in a strictly orthotopic position, although partially hidden behind a Zuckerkandl’s nodule.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

Miccoli P, Materazzi G, Baggiani A, Miccoli M. Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 2011;34:473-80.
Is robotic thyroid surgery a real progress?
In this key lecture, Prof. WY Chung briefly describes his experience and his own technique to perform robotic thyroid surgery. He presents advances in surgical indications and compares the main differences of single incision robotic thyroidectomy and LND with novel techniques, e.g. BABA, facelift thyroidectomy, and transoral periosteal thyroidectomy. He demonstrates the advantages and limitations using research data to describe the future of robotic thyroidectomy as a minimally invasive surgery. He highlights new technologies and newly developed robotic systems with current improvements, which focus on haptic feedback, tactile sensation, and single orifice surgery, which will make AI robotic automation surgery possible in the future.
WY Chung
Lecture
2 years ago
405 views
50 likes
0 comments
13:32
Is robotic thyroid surgery a real progress?
In this key lecture, Prof. WY Chung briefly describes his experience and his own technique to perform robotic thyroid surgery. He presents advances in surgical indications and compares the main differences of single incision robotic thyroidectomy and LND with novel techniques, e.g. BABA, facelift thyroidectomy, and transoral periosteal thyroidectomy. He demonstrates the advantages and limitations using research data to describe the future of robotic thyroidectomy as a minimally invasive surgery. He highlights new technologies and newly developed robotic systems with current improvements, which focus on haptic feedback, tactile sensation, and single orifice surgery, which will make AI robotic automation surgery possible in the future.
Transoral endoscopic thyroidectomy: vestibular approach
In this state-of-the-art lecture, Dr. Anuwong briefly describes the historical developments of thyroidectomy with various approaches, emphasizing natural orifice thyroid surgery with an overview of the first report in animal models, cadaveric models, and human patients in different countries as it happened over time. He describes the key steps, main principles, and complications of TOVANS, ETOA, and TOPOT with their drawbacks. He also introduces his technique of transoral endoscopic thyroidectomy: vestibular approach (TOETVA) with the brief concept of mental nerve injury. He demonstrates his experience in a case report of right lobectomy using TOETVA with postoperative management and impressive results achieved with no infection and no scar. The TOETVA technique proves to be promising as it is safe, feasible, comparable to other approaches, and has excellent cosmetic results.
A Anuwong
Lecture
2 years ago
1763 views
130 likes
0 comments
28:41
Transoral endoscopic thyroidectomy: vestibular approach
In this state-of-the-art lecture, Dr. Anuwong briefly describes the historical developments of thyroidectomy with various approaches, emphasizing natural orifice thyroid surgery with an overview of the first report in animal models, cadaveric models, and human patients in different countries as it happened over time. He describes the key steps, main principles, and complications of TOVANS, ETOA, and TOPOT with their drawbacks. He also introduces his technique of transoral endoscopic thyroidectomy: vestibular approach (TOETVA) with the brief concept of mental nerve injury. He demonstrates his experience in a case report of right lobectomy using TOETVA with postoperative management and impressive results achieved with no infection and no scar. The TOETVA technique proves to be promising as it is safe, feasible, comparable to other approaches, and has excellent cosmetic results.
Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
M Vix, HA Mercoli, S Tzedakis, J Marescaux
Surgical intervention
2 years ago
1097 views
119 likes
1 comment
08:28
Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
Gasless transaxillary robotic thyroidectomy
Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.
WY Chung
Lecture
7 years ago
1751 views
6 likes
0 comments
31:16
Gasless transaxillary robotic thyroidectomy
Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
Parathyroid surgery has largely benefited from advances in preoperative imaging modalities allowing to determine potential adenomas. Conventionally, ultrasonography and scintigraphy with 99mTc-sestamibi (MIBI) provide sufficient information to guide the surgical procedure. Specific software has been developed at the IRCAD to allow for the 3D reconstruction of the entire cervical structures. The handling of such reconstruction helps to perform a precise preoperative assessment. Arterial reconstruction allows to predict the existence of an arteria lusoria and of a non-recurrent recurrent nerve. In this case, the position of a potential adenoma in relation to the inferior thyroid artery allows to anticipate that it is not an adenoma but a thyroid nodule. A second potential target is visualized inferiorly. These two potential locations will be explored during the video-assisted surgical intervention.
M Vix, J D'Agostino, L Soler, J Marescaux
Surgical intervention
6 years ago
4858 views
6 likes
0 comments
05:46
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
Parathyroid surgery has largely benefited from advances in preoperative imaging modalities allowing to determine potential adenomas. Conventionally, ultrasonography and scintigraphy with 99mTc-sestamibi (MIBI) provide sufficient information to guide the surgical procedure. Specific software has been developed at the IRCAD to allow for the 3D reconstruction of the entire cervical structures. The handling of such reconstruction helps to perform a precise preoperative assessment. Arterial reconstruction allows to predict the existence of an arteria lusoria and of a non-recurrent recurrent nerve. In this case, the position of a potential adenoma in relation to the inferior thyroid artery allows to anticipate that it is not an adenoma but a thyroid nodule. A second potential target is visualized inferiorly. These two potential locations will be explored during the video-assisted surgical intervention.
Video-assisted parathyroidectomy using augmented reality
The effectiveness of preoperative imaging to detect parathyroid adenomas allows for a targeted minimally invasive video-assisted approach. In our department, at the IRCAD, special software is used to virtually reconstruct the neck and its structures from mere CT-scan images of the cervicomediastinal region. This virtual reconstruction helps to precisely define the location of the parathyroid adenoma in relation to the superior part of the sternum, to the inferior thyroid artery and to the thyroid gland, hence guiding the surgeon in the proper identification of anatomical landmarks.
The reconstruction also helps to control the absence of "non-recurrent" recurrent nerves showing the presence of a right brachiocephalic arterial trunk.
M Vix, HA Mercoli, L Soler, J Marescaux
Surgical intervention
6 years ago
1317 views
17 likes
0 comments
06:14
Video-assisted parathyroidectomy using augmented reality
The effectiveness of preoperative imaging to detect parathyroid adenomas allows for a targeted minimally invasive video-assisted approach. In our department, at the IRCAD, special software is used to virtually reconstruct the neck and its structures from mere CT-scan images of the cervicomediastinal region. This virtual reconstruction helps to precisely define the location of the parathyroid adenoma in relation to the superior part of the sternum, to the inferior thyroid artery and to the thyroid gland, hence guiding the surgeon in the proper identification of anatomical landmarks.
The reconstruction also helps to control the absence of "non-recurrent" recurrent nerves showing the presence of a right brachiocephalic arterial trunk.
Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism
In recent years, the advances in preoperative localization studies, the availability of intraoperative parathyroid hormone (PTH) assay and the introduction of cervicoscopy revolutionized the surgical treatment of primary hyperparathyroidism (PHPT).
Minimally invasive video-assisted parathyroidectomy (MIVAP) is an efficacious and feasible procedure with the same complication rate as conventional surgery and has significant advantages in terms of cosmetic results, postoperative pain, recovery, and patient satisfaction. MIVAP should be considered a valid and validated option for the treatment of sporadic primary hyperparathyroidism, especially in case of a suspected single adenoma. This video demonstrates a minimally invasive approach for the excision of a right superior parathyroid adenoma in an inter-crico-thyroid position in a 65-year-old female patient.
M Vix, L Soler, J Marescaux
Surgical intervention
10 years ago
1517 views
29 likes
0 comments
04:46
Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism
In recent years, the advances in preoperative localization studies, the availability of intraoperative parathyroid hormone (PTH) assay and the introduction of cervicoscopy revolutionized the surgical treatment of primary hyperparathyroidism (PHPT).
Minimally invasive video-assisted parathyroidectomy (MIVAP) is an efficacious and feasible procedure with the same complication rate as conventional surgery and has significant advantages in terms of cosmetic results, postoperative pain, recovery, and patient satisfaction. MIVAP should be considered a valid and validated option for the treatment of sporadic primary hyperparathyroidism, especially in case of a suspected single adenoma. This video demonstrates a minimally invasive approach for the excision of a right superior parathyroid adenoma in an inter-crico-thyroid position in a 65-year-old female patient.
Laparoscopic endoluminal resection of a Brunner’s gland hamartoma
Brunner glands are located in the proximal submucosal part of the duodenum. They secrete an alkaline mucin, which protects the mucosa from gastric acid. Hyperplasia of the Brunner glands larger than 1cm can evolve to a Brunner’s gland hamartoma. It is a hamartoma because the lesion does not have a capsule, a mix of acini, mucosal cells, adipose tissue, smooth muscle and Paneth cells, but no cell atypia. Such hamartomas are very rare and represent between 5 and 10% of benign duodenal tumors with the highest prevalence in patients aged between 40 and 60. The most common clinical presentation is bleeding or obstructive symptoms. Excision is recommended because of the risk of bleeding. Long-term outcome is good and no recurrence after complete excision has been reported.
This video presents the case of a 40-year-old patient who was admitted to our hospital with anemia (5.1g/dL), dark stools, and a past history of Hodgkin’s lymphoma with dysfunction of the spleen and of thyroid gland. Further examination using upper GI flexible endoscopy revealed a pedunculated mass in the duodenal bulb (D1). This mass migrates through the pylorus to the antrum. Additional imaging (CT-scan, MRI) confirms the localization of the mass. Biopsy is suggestive of a Brunner’s gland hamartoma. It was decided to perform a minimally invasive approach using flexible endoscopy in combination with laparoscopy. A laparoscopic endoluminal mass resection was performed using a stapling device. The finding was confirmed on the final pathological report.
S Heyman, Y Pirenne, D Vervloessem, P Willemsen
Surgical intervention
3 years ago
353 views
8 likes
0 comments
05:12
Laparoscopic endoluminal resection of a Brunner’s gland hamartoma
Brunner glands are located in the proximal submucosal part of the duodenum. They secrete an alkaline mucin, which protects the mucosa from gastric acid. Hyperplasia of the Brunner glands larger than 1cm can evolve to a Brunner’s gland hamartoma. It is a hamartoma because the lesion does not have a capsule, a mix of acini, mucosal cells, adipose tissue, smooth muscle and Paneth cells, but no cell atypia. Such hamartomas are very rare and represent between 5 and 10% of benign duodenal tumors with the highest prevalence in patients aged between 40 and 60. The most common clinical presentation is bleeding or obstructive symptoms. Excision is recommended because of the risk of bleeding. Long-term outcome is good and no recurrence after complete excision has been reported.
This video presents the case of a 40-year-old patient who was admitted to our hospital with anemia (5.1g/dL), dark stools, and a past history of Hodgkin’s lymphoma with dysfunction of the spleen and of thyroid gland. Further examination using upper GI flexible endoscopy revealed a pedunculated mass in the duodenal bulb (D1). This mass migrates through the pylorus to the antrum. Additional imaging (CT-scan, MRI) confirms the localization of the mass. Biopsy is suggestive of a Brunner’s gland hamartoma. It was decided to perform a minimally invasive approach using flexible endoscopy in combination with laparoscopy. A laparoscopic endoluminal mass resection was performed using a stapling device. The finding was confirmed on the final pathological report.
Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique
This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.
F Costantino, M Vix, J Marescaux
Surgical intervention
11 years ago
922 views
20 likes
0 comments
08:20
Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique
This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.