We use cookies to offer you an optimal experience on our website. By browsing our website, you accept the use of cookies.

Hall of Fame

Participate in the Hall of Fame contest of WebSurg.

The last winner - 2019

Harleen GROVER, MD
Jalandhar, India
Dr. Harleen Grover is a consultant gynecologist at the New Ruby Hospital, Jalandhar, India. She completed her MD in obstetrics and gynecology at the prestigious Government Medical College, Amritsar. She also did her fellowship in reproductive medicine. She got one-on-one training in office hysteroscopy from Prof. Stefano Bettocchi. Later on, she gained invaluable experience under the mentorship of Dr. Ameya B. Padmawar and performed diverse surgeries, thereby enhancing her surgical skills in the field of laparoscopy. She has a special inclination towards fertility enhancing surgeries.
Rizwana SYED, MD
Mumbai, India
Dr. Rizwana Syed is a consultant gynecologic endoscopic surgeon at the Carnation Medical and Diagnostic Center with more than 10 years of experience. She has been working with Dr. Ameya B. Padmawar, a renowned laparoscopic surgeon in Mumbai, for the past 7 years.
Ameya PADMAWAR, MD, DGO, DNB
Mumbai, India
Dr. Ameya Padmawar is a consultant gynecologic endoscopic surgeon at the Kanyaka Women’s Clinic, a center of excellence in MAS for gynecology, in Mumbai, India. Dr. Padmawar completed his masters in gynecology at the prestigious Seth GS Medical College and the Nowrosjee Wadia Maternity Hospital in Mumbai. He has performed surgeries with Dr. Neeta R Warty and Dr. Shailesh Puntambekar, and successfully mentored multiple students over the last decade. He went on to expand his skills and expertise in gynecologic endoscopy with Dr. Arnaud Wattiez, IRCAD, and Dr. Georg Keckstein, Austria, in 2013. He has a keen interest in giving back to the gynecologist community by being a faculty at the CEMAST and EISE, Mumbai. Dr. Padmawar has a keen interest in retroperitoneal pelvic anatomy and its applications in MAS for endometriosis and gynecologic surgical oncology.
View more
Filter by
Specialty
View more
Total laparoscopic Hudson’s procedure, pelvic and para-aortic node dissection, omentectomy with primary re-anastomosis and loop ileostomy
This patient previously underwent a right ovarian cystectomy for endometrioma with final histopathology confirming an endometrioid adenocarcinoma in association with endometriosis (at least FIGO 1C1). Preoperative MRI and CT-scan suggested endometriosis/disease in the rectouterine pouch, with no evidence of disease outside the pelvis. Completion surgery with a Hudson’s procedure and comprehensive surgical staging was planned as a laparoscopic intervention. On initial inspection, intravenous indocyanine green (ICG) was used to facilitate the identification of endometriosis disease in the pelvis. Following surgical staging, including ‘en bloc’ dissection of the uterus, tubes, ovaries, and rectosigmoid, the specimen was removed via the vagina with the aid of an Alexis wound retractor. For re-anastomosis, the distal descending colon was delivered through the vagina, the anvil applied, and the anastomosis completed laparoscopically. This anastomosis was then defunctioned via a loop ileostomy. ICG was used to confirm anastomotic perfusion. The ileostomy was successfully reversed after 10 days facilitating postoperative treatment with chemotherapy.
M Graham, E Craig, A Armstrong, C Wilson, I Harley
Surgical intervention
7 days ago
351 views
4 likes
0 comments
25:31
Total laparoscopic Hudson’s procedure, pelvic and para-aortic node dissection, omentectomy with primary re-anastomosis and loop ileostomy
This patient previously underwent a right ovarian cystectomy for endometrioma with final histopathology confirming an endometrioid adenocarcinoma in association with endometriosis (at least FIGO 1C1). Preoperative MRI and CT-scan suggested endometriosis/disease in the rectouterine pouch, with no evidence of disease outside the pelvis. Completion surgery with a Hudson’s procedure and comprehensive surgical staging was planned as a laparoscopic intervention. On initial inspection, intravenous indocyanine green (ICG) was used to facilitate the identification of endometriosis disease in the pelvis. Following surgical staging, including ‘en bloc’ dissection of the uterus, tubes, ovaries, and rectosigmoid, the specimen was removed via the vagina with the aid of an Alexis wound retractor. For re-anastomosis, the distal descending colon was delivered through the vagina, the anvil applied, and the anastomosis completed laparoscopically. This anastomosis was then defunctioned via a loop ileostomy. ICG was used to confirm anastomotic perfusion. The ileostomy was successfully reversed after 10 days facilitating postoperative treatment with chemotherapy.
Right thoracoscopic mediastinal mass resection and bronchial injury repair
The objective is to demonstrate our technique for thoracoscopic mediastinal mass excision with concomitant bronchial injury repair.
A 13-year-old boy presented with one-month of dysphagia and a history of a recent tick bite prophylactically treated. Esophagram showed a mid-esophageal externally compressing mass confirmed by endoscopy. Chest MRI showed a 5cm mediastinal mass. Differential diagnosis included infected esophageal duplication cyst versus histoplasmoma. A thoracoscopic mass resection was scheduled.
Upon accessing the right chest, a mid-thoracic lesion next to the esophagus was noted. The mass was adherent to the esophageal wall during dissection. Intraoperative biopsy revealed a cottage cheese-like substance in the mass. Frozen section suspected a duplication cyst in the esophageal musculature. As a result, we proceeded with the resection. The cavity was then irrigated and some fluid was noted at the endotracheal tube. A 5mm right mainstem bronchus tear was found. Flexible bronchoscopy was used to repair the injury with absorbable sutures. The mass was removed from the esophageal wall and repaired with absorbable sutures. A small pleural flap was created to prevent the sutures from communicating. The patient had a small persistent pneumothorax several days postoperatively. Repeat flexible bronchoscopy showed no leak or narrowing on postoperative day (POD) 7. The patient was discharged home on POD 8. Final pathology showed a mediastinal lymph node with a non-caseating granuloma. He had positive antibodies to Francisella tularensis (tularemia Ab). His final diagnosis was mediastinal tularemia.
This video demonstrates mediastinal mass diagnostic and treatment challenges. It also shows that concomitant bronchial injuries are safe and effective to repair thoracoscopically.
T Huy, AS Munoz Abraham, H Osei, C Cappiello, GA Villalona
Surgical intervention
1 month ago
554 views
7 likes
0 comments
05:17
Right thoracoscopic mediastinal mass resection and bronchial injury repair
The objective is to demonstrate our technique for thoracoscopic mediastinal mass excision with concomitant bronchial injury repair.
A 13-year-old boy presented with one-month of dysphagia and a history of a recent tick bite prophylactically treated. Esophagram showed a mid-esophageal externally compressing mass confirmed by endoscopy. Chest MRI showed a 5cm mediastinal mass. Differential diagnosis included infected esophageal duplication cyst versus histoplasmoma. A thoracoscopic mass resection was scheduled.
Upon accessing the right chest, a mid-thoracic lesion next to the esophagus was noted. The mass was adherent to the esophageal wall during dissection. Intraoperative biopsy revealed a cottage cheese-like substance in the mass. Frozen section suspected a duplication cyst in the esophageal musculature. As a result, we proceeded with the resection. The cavity was then irrigated and some fluid was noted at the endotracheal tube. A 5mm right mainstem bronchus tear was found. Flexible bronchoscopy was used to repair the injury with absorbable sutures. The mass was removed from the esophageal wall and repaired with absorbable sutures. A small pleural flap was created to prevent the sutures from communicating. The patient had a small persistent pneumothorax several days postoperatively. Repeat flexible bronchoscopy showed no leak or narrowing on postoperative day (POD) 7. The patient was discharged home on POD 8. Final pathology showed a mediastinal lymph node with a non-caseating granuloma. He had positive antibodies to Francisella tularensis (tularemia Ab). His final diagnosis was mediastinal tularemia.
This video demonstrates mediastinal mass diagnostic and treatment challenges. It also shows that concomitant bronchial injuries are safe and effective to repair thoracoscopically.
Robotic assisted ovary preserving excision of a benign serous cystadenoma in a prepubertal symptomatic girl
Symptomatic ovarian cysts or larger incidentally diagnosed ovarian cysts require treatment. If features of malignancy can be reasonably ruled out, minimally invasive procedures can be offered to not only excise the lesion but also preserve the ovary at the same time.
A 10-year-old female child was referred to our department with complaints of right lower abdominal pain which lasted for 6 months. She had no history of vomiting. On examination, her abdomen was soft, non-tender, with no palpable mass, and not distended. Abdominal sonography revealed a 5 by 4.5cm simple cyst in the right adnexa with a 1.7mm wall thickness, with no solid component or septation. Her right ovary was not seen separately. Her left ovary and uterus showed no abnormalities. Malignancy work-up revealed nothing suspicious (Beta-HCG: 2.9 IU/L, AFP: 1.3ng/mL, CA125: 10.9, all within normal range). A robotic-assisted complete cyst excision with preservation of the ovary was performed using 3 arms of the Da Vinci Xi™ robotic surgical system. The patient resumed oral food intake the same evening. He was discharged the following day within 24 hours of the procedure on paracetamol only. The patient was healthy and well. The biopsy reported a benign serous cystadenoma. At a 1-year follow-up, the child is asymptomatic and ovarian preservation was confirmed on postoperative ultrasound. While oophorectomy is eminently feasible with a minimally invasive approach, ovary preservation in benign lesions is quite challenging using pure laparoscopy. Robotic assistance, with its 3D binocular high-definition vision, articulating instruments, and availability of simultaneous energy in both arms, provides better precision and a maximum range of movements. It also helps to preserve the ovary while removing the cyst completely. The case report with a stepwise video of the procedure is demonstrated.
S Kumaravel, A Shenoy
Surgical intervention
1 month ago
529 views
8 likes
1 comment
05:24
Robotic assisted ovary preserving excision of a benign serous cystadenoma in a prepubertal symptomatic girl
Symptomatic ovarian cysts or larger incidentally diagnosed ovarian cysts require treatment. If features of malignancy can be reasonably ruled out, minimally invasive procedures can be offered to not only excise the lesion but also preserve the ovary at the same time.
A 10-year-old female child was referred to our department with complaints of right lower abdominal pain which lasted for 6 months. She had no history of vomiting. On examination, her abdomen was soft, non-tender, with no palpable mass, and not distended. Abdominal sonography revealed a 5 by 4.5cm simple cyst in the right adnexa with a 1.7mm wall thickness, with no solid component or septation. Her right ovary was not seen separately. Her left ovary and uterus showed no abnormalities. Malignancy work-up revealed nothing suspicious (Beta-HCG: 2.9 IU/L, AFP: 1.3ng/mL, CA125: 10.9, all within normal range). A robotic-assisted complete cyst excision with preservation of the ovary was performed using 3 arms of the Da Vinci Xi™ robotic surgical system. The patient resumed oral food intake the same evening. He was discharged the following day within 24 hours of the procedure on paracetamol only. The patient was healthy and well. The biopsy reported a benign serous cystadenoma. At a 1-year follow-up, the child is asymptomatic and ovarian preservation was confirmed on postoperative ultrasound. While oophorectomy is eminently feasible with a minimally invasive approach, ovary preservation in benign lesions is quite challenging using pure laparoscopy. Robotic assistance, with its 3D binocular high-definition vision, articulating instruments, and availability of simultaneous energy in both arms, provides better precision and a maximum range of movements. It also helps to preserve the ovary while removing the cyst completely. The case report with a stepwise video of the procedure is demonstrated.
Laparoscopic TEP hernia repair for unilateral inguinal hernia in the canal of Nuck in a 7-year-old female patient
In this video, we present the case of a left-sided unilateral indirect inguinal hernia in the canal of Nuck in a 7-year-old female patient. Treatment was performed using the laparoscopic TEP inguinal hernia repair technique. The hernia sac was promptly identified and dissected without any concern to cord structures since the patient was a female. The herniotomy was performed with an Endoloop®. The only constraints of surgery were limited operating space and ergonomic handling of instruments. The patient was discharged in the evening of surgery and wounds healed within a week. Postoperative follow-up after 6 months revealed excellent cosmesis and a complete absence of hernia on the operated site. Mini laparoscopic instruments can also be used to improve surgical cosmesis and ensure same day discharge without any postoperative sequelae.
KB Kaundinya
Surgical intervention
1 month ago
780 views
4 likes
0 comments
03:35
Laparoscopic TEP hernia repair for unilateral inguinal hernia in the canal of Nuck in a 7-year-old female patient
In this video, we present the case of a left-sided unilateral indirect inguinal hernia in the canal of Nuck in a 7-year-old female patient. Treatment was performed using the laparoscopic TEP inguinal hernia repair technique. The hernia sac was promptly identified and dissected without any concern to cord structures since the patient was a female. The herniotomy was performed with an Endoloop®. The only constraints of surgery were limited operating space and ergonomic handling of instruments. The patient was discharged in the evening of surgery and wounds healed within a week. Postoperative follow-up after 6 months revealed excellent cosmesis and a complete absence of hernia on the operated site. Mini laparoscopic instruments can also be used to improve surgical cosmesis and ensure same day discharge without any postoperative sequelae.
Laparoscopic left hemicolectomy with manual intracorporeal anastomosis
The best surgical approach for splenic flexure tumors is not well defined yet.
The distal third of the transverse colon has an embryological origin in the hindgut, and the splenic flexure classically shows a dual lymphatic drainage, the proximal retropancreatic and the distal to the lymphatic pedicle of both the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV). Nakagoe et al. showed that the majority of positive nodes have distal lymphatic spread to the paracolic archway and up to the origin of the left colic artery. Lymph nodes of the middle colic artery and its left branch are positive in a small percentage (0 and 4.2% respectively).
As a result, a left segmental colectomy is a valid option for splenic flexure and distal transverse colon tumors because it allows vascular ligation at the root of the vessels, dissection along the embryological planes, and adequate bowel margins from the tumor. The preservation of the IMV should reduce impaired venous drainage of the sigmoid colon, which can be associated with anastomotic leakage, without compromising complete mesocolic excision.
An intracorporeal anastomosis for left colonic resection may have the same advantages as for a right hemicolectomy, but can be technically more challenging.
This video shows a laparoscopic left hemicolectomy with manual intracorporeal anastomosis and preservation of the IMV for a tumor of the distal transverse colon.
A Canaveira Manso, M Rosete, R Nemésio, M Fernandes
Surgical intervention
1 month ago
1203 views
10 likes
0 comments
16:43
Laparoscopic left hemicolectomy with manual intracorporeal anastomosis
The best surgical approach for splenic flexure tumors is not well defined yet.
The distal third of the transverse colon has an embryological origin in the hindgut, and the splenic flexure classically shows a dual lymphatic drainage, the proximal retropancreatic and the distal to the lymphatic pedicle of both the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV). Nakagoe et al. showed that the majority of positive nodes have distal lymphatic spread to the paracolic archway and up to the origin of the left colic artery. Lymph nodes of the middle colic artery and its left branch are positive in a small percentage (0 and 4.2% respectively).
As a result, a left segmental colectomy is a valid option for splenic flexure and distal transverse colon tumors because it allows vascular ligation at the root of the vessels, dissection along the embryological planes, and adequate bowel margins from the tumor. The preservation of the IMV should reduce impaired venous drainage of the sigmoid colon, which can be associated with anastomotic leakage, without compromising complete mesocolic excision.
An intracorporeal anastomosis for left colonic resection may have the same advantages as for a right hemicolectomy, but can be technically more challenging.
This video shows a laparoscopic left hemicolectomy with manual intracorporeal anastomosis and preservation of the IMV for a tumor of the distal transverse colon.
Laparoscopic right hemicolectomy with excision of a pancreatic neuroendocrine tumor (pNET)
Pancreatic neuroendocrine tumors (pNETs) are rare neoplasms, which account for less than 5% of all pancreatic tumors, with an incidence of 0.48 cases/100,000. They may be benign or malignant and tend to grow slower than exocrine tumors. They develop from the abnormal growth of endocrine cells in the pancreas and are either functional or nonfunctional, and may or may not cause signs or symptoms. Pancreatic NETs that have not spread outside the pancreas should be completely removed, if possible, because these tumors are more likely to be cured with surgery. This video shows a case of a pNET of the uncinate process, discovered in the study of a right colon cancer. Because of the small size of the pNET and its location, the association of a right laparoscopic hemicolectomy with a pancreatic tumor excision was deemed feasible. The mobilization of the mesenteric root allowed to identify the uncinate process and to prepare for the pNET excision. After the exposure of the duodenum and the retroperitoneal plane, the surgery continued with a right hemicolectomy and a complete mesocolic excision. An intracorporeal anastomosis was constructed and the surgical specimen was retrieved through a suprapubic incision. The pathological report revealed a T2N1 caecal adenocarcinoma and a G2 pNET.
A Canaveira Manso, M Rosete, R Nemésio, R Martins
Surgical intervention
1 month ago
398 views
3 likes
0 comments
17:16
Laparoscopic right hemicolectomy with excision of a pancreatic neuroendocrine tumor (pNET)
Pancreatic neuroendocrine tumors (pNETs) are rare neoplasms, which account for less than 5% of all pancreatic tumors, with an incidence of 0.48 cases/100,000. They may be benign or malignant and tend to grow slower than exocrine tumors. They develop from the abnormal growth of endocrine cells in the pancreas and are either functional or nonfunctional, and may or may not cause signs or symptoms. Pancreatic NETs that have not spread outside the pancreas should be completely removed, if possible, because these tumors are more likely to be cured with surgery. This video shows a case of a pNET of the uncinate process, discovered in the study of a right colon cancer. Because of the small size of the pNET and its location, the association of a right laparoscopic hemicolectomy with a pancreatic tumor excision was deemed feasible. The mobilization of the mesenteric root allowed to identify the uncinate process and to prepare for the pNET excision. After the exposure of the duodenum and the retroperitoneal plane, the surgery continued with a right hemicolectomy and a complete mesocolic excision. An intracorporeal anastomosis was constructed and the surgical specimen was retrieved through a suprapubic incision. The pathological report revealed a T2N1 caecal adenocarcinoma and a G2 pNET.
Robotically assisted right colectomy with fluorescence-guided complete mesocolon excision
In robotic right hemicolectomy for cancer, appropriate lymphadenectomy and anastomotic leak prevention are critical. Visualization of draining lymph nodes, of primary tumor site and blood flow using the near-infrared (NIR) fluorescence da Vinci® imaging system is a recent development.
We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenectomy using Indocyanine Green (ICG) fluorescence.
The day before surgery, a colonoscopy was performed and ICG was injected around the tumor in the submucosa.
Robotic right hemicolectomy was performed with suprapubic trocars layout and bottom to up dissection, with CME, central vessel ligation, and D3 lymphadenectomy.
ICG was intraoperatively administered intravenously to assess bowel perfusion before anastomosis. The identification of the primary tumor site and of bowel stumps perfusion were possible and the accuracy in identifying the D3 lymphatic basin was high, allowing for an image-guided radical lymphadenectomy. Fluorescent technology represents a valuable innovation to improve colon cancer surgery.
W Petz, E Bertani, D Ribero, D Lo Conte, A Mellano, A Piccioli, S Borin, G Spinoglio
Surgical intervention
1 month ago
446 views
2 likes
0 comments
08:43
Robotically assisted right colectomy with fluorescence-guided complete mesocolon excision
In robotic right hemicolectomy for cancer, appropriate lymphadenectomy and anastomotic leak prevention are critical. Visualization of draining lymph nodes, of primary tumor site and blood flow using the near-infrared (NIR) fluorescence da Vinci® imaging system is a recent development.
We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenectomy using Indocyanine Green (ICG) fluorescence.
The day before surgery, a colonoscopy was performed and ICG was injected around the tumor in the submucosa.
Robotic right hemicolectomy was performed with suprapubic trocars layout and bottom to up dissection, with CME, central vessel ligation, and D3 lymphadenectomy.
ICG was intraoperatively administered intravenously to assess bowel perfusion before anastomosis. The identification of the primary tumor site and of bowel stumps perfusion were possible and the accuracy in identifying the D3 lymphatic basin was high, allowing for an image-guided radical lymphadenectomy. Fluorescent technology represents a valuable innovation to improve colon cancer surgery.
Vascular anatomy of left and right colon: standard vs. variations
The vascular anatomy of the colon has some anatomical variations [1]. In this video, starting from the normal surgical anatomy of the colon, authors show many vascular anomalies of surgical interest, which should be known in order to avoid intraoperative complications. In the right colon, the ileocolic artery and the middle colic artery are constantly present in all patients as they arise from the superior mesenteric vessels [2]. Right colic vessels are present only in 80% of cases. The position of ileocolic vessels related to the superior mesenteric vein (SMV) is a key landmark. In this video, starting from the normal surgical anatomy of the right colon, authors show variant ileocolic vessels position defined type A pattern, with ileocolic artery (ICA) which lies in the anterior position in respect to the ileocolic vein (ICV). Authors also show an anomalous origin of the ileocolic vessels, which are more upper in respect to their standard position. Commonly, the ileocolic artery (ICA) lies posterior to the SMV (83%, type B). However, the ICA sometimes lies anteriorly to the SMV (17%, type A) [1]. The vascular system of the left colon has fewer variations in terms of position and origin, contrarily to the right colon. The most frequent variations of the inferior mesenteric artery (IMA) supply involve the division of the sigmoid arteries, as classified by Latarjet in two different types, depending on the anatomical relationship between the left colic and sigmoid arteries [3]. However, in this video authors show a rare case of IMA arising from the superior mesenteric artery [4].
References:
1. Milsom JW, Böhm B, Nakajima K. Laparoscopic Colorectal Surgery 2006, Springer.
2. Wu C, Ye K, Wu Y, Chen Q, Xu J, Lin J, Kang W. Variations in right colic vascular anatomy observed during laparoscopic right colectomy. World J Surg Oncol 2019;17:16.
3. Patroni A, Bonnet S, Bourillon C, Bruzzi M, Zinzindohoue F, Chevallier JM, Douard R, Berger A. Technical difficulties of left colic artery preservation during left colectomy for colon cancer. Surg Radiol Anat 2016;38:477-84.
4. Yoo SJ, Ku MJ, Cho SS, Yoon SP. A case of the inferior mesenteric artery arising from the superior mesenteric artery in a Korean woman. J Korean Med Sci 2011;26:1382-5.
F Corcione, E Pontecorvi, V Silvestri, G Merola, U Bracale
Surgical intervention
1 month ago
1713 views
19 likes
0 comments
21:44
Vascular anatomy of left and right colon: standard vs. variations
The vascular anatomy of the colon has some anatomical variations [1]. In this video, starting from the normal surgical anatomy of the colon, authors show many vascular anomalies of surgical interest, which should be known in order to avoid intraoperative complications. In the right colon, the ileocolic artery and the middle colic artery are constantly present in all patients as they arise from the superior mesenteric vessels [2]. Right colic vessels are present only in 80% of cases. The position of ileocolic vessels related to the superior mesenteric vein (SMV) is a key landmark. In this video, starting from the normal surgical anatomy of the right colon, authors show variant ileocolic vessels position defined type A pattern, with ileocolic artery (ICA) which lies in the anterior position in respect to the ileocolic vein (ICV). Authors also show an anomalous origin of the ileocolic vessels, which are more upper in respect to their standard position. Commonly, the ileocolic artery (ICA) lies posterior to the SMV (83%, type B). However, the ICA sometimes lies anteriorly to the SMV (17%, type A) [1]. The vascular system of the left colon has fewer variations in terms of position and origin, contrarily to the right colon. The most frequent variations of the inferior mesenteric artery (IMA) supply involve the division of the sigmoid arteries, as classified by Latarjet in two different types, depending on the anatomical relationship between the left colic and sigmoid arteries [3]. However, in this video authors show a rare case of IMA arising from the superior mesenteric artery [4].
References:
1. Milsom JW, Böhm B, Nakajima K. Laparoscopic Colorectal Surgery 2006, Springer.
2. Wu C, Ye K, Wu Y, Chen Q, Xu J, Lin J, Kang W. Variations in right colic vascular anatomy observed during laparoscopic right colectomy. World J Surg Oncol 2019;17:16.
3. Patroni A, Bonnet S, Bourillon C, Bruzzi M, Zinzindohoue F, Chevallier JM, Douard R, Berger A. Technical difficulties of left colic artery preservation during left colectomy for colon cancer. Surg Radiol Anat 2016;38:477-84.
4. Yoo SJ, Ku MJ, Cho SS, Yoon SP. A case of the inferior mesenteric artery arising from the superior mesenteric artery in a Korean woman. J Korean Med Sci 2011;26:1382-5.
Laparoscopic gastrectomy for gastric cancer after liver transplantation
It has already been demonstrated that laparoscopic gastrectomy is a safe approach for early gastric cancer. It can provide the same oncological outcomes as open gastrectomy with the benefit of fewer complications and early recovery.
Liver transplantation has a high incidence rate in the Korean population, just like gastric cancer. Additionally, South Korea has the highest incidence of this type of cancer worldwide. Patients who had received a liver transplant might benefit from a better recovery thanks to laparoscopic gastrectomy, and this approach can be performed by experienced surgeons.
Please add in the text narrative how you performed the anastomosis.
F Signorini, DJ Park, HK Yang
Surgical intervention
2 months ago
1216 views
6 likes
0 comments
09:23
Laparoscopic gastrectomy for gastric cancer after liver transplantation
It has already been demonstrated that laparoscopic gastrectomy is a safe approach for early gastric cancer. It can provide the same oncological outcomes as open gastrectomy with the benefit of fewer complications and early recovery.
Liver transplantation has a high incidence rate in the Korean population, just like gastric cancer. Additionally, South Korea has the highest incidence of this type of cancer worldwide. Patients who had received a liver transplant might benefit from a better recovery thanks to laparoscopic gastrectomy, and this approach can be performed by experienced surgeons.
Please add in the text narrative how you performed the anastomosis.
Winslow's hiatal hernia: laparoscopic treatment
Less than 200 cases of internal hernia have been described through the hiatus of Winslow, usually related to congenital or acquired anatomical defects. The most frequent affectation corresponds to the colon, small intestine and, rarely, to the gallbladder. There is usually occlusion with variable grade ischemia, but it can also occur as obstructive jaundice, biliary colic, secondary pancreatitis and non-symptomatic herniation.
The association of Winslow’s hiatus hernia with various anatomical abnormalities (high or subhepatic caecum, mobile ascending colon, large and long colonic mesentery, etc.) may actually correspond to different degrees of intestinal malrotation and, although the diagnosis of “malrotation” is not usually specified, we believe that this could underlie part of Winslow’s hiatus hernia associated with non-acquired anatomical defects.
Hiatal hernia corresponds to 0.2-0.9% of all cases of intestinal obstruction, of which 8% are from Winslow’s hiatus. If pre-surgical diagnosis is difficult, it occurs in less than 10% of cases.
Mortality is around 50% when it has vascular implication. We have not thought of applying the omentum to seal the defect because we did not have adequate surgical anchor sites since we were working millimeters from the vena cava, extrahepatic bile duct, duodenum, and perirenal area. We decided to fix the colon from the hepatic flexure to the right iliac fossa with continuous stitches, from the colonic serosa to Toldt’s fascia, as it is from the embryonic stage.
JL Limon Aguilar, CO Castillo Cabrera
Surgical intervention
2 months ago
1195 views
12 likes
2 comments
09:56
Winslow's hiatal hernia: laparoscopic treatment
Less than 200 cases of internal hernia have been described through the hiatus of Winslow, usually related to congenital or acquired anatomical defects. The most frequent affectation corresponds to the colon, small intestine and, rarely, to the gallbladder. There is usually occlusion with variable grade ischemia, but it can also occur as obstructive jaundice, biliary colic, secondary pancreatitis and non-symptomatic herniation.
The association of Winslow’s hiatus hernia with various anatomical abnormalities (high or subhepatic caecum, mobile ascending colon, large and long colonic mesentery, etc.) may actually correspond to different degrees of intestinal malrotation and, although the diagnosis of “malrotation” is not usually specified, we believe that this could underlie part of Winslow’s hiatus hernia associated with non-acquired anatomical defects.
Hiatal hernia corresponds to 0.2-0.9% of all cases of intestinal obstruction, of which 8% are from Winslow’s hiatus. If pre-surgical diagnosis is difficult, it occurs in less than 10% of cases.
Mortality is around 50% when it has vascular implication. We have not thought of applying the omentum to seal the defect because we did not have adequate surgical anchor sites since we were working millimeters from the vena cava, extrahepatic bile duct, duodenum, and perirenal area. We decided to fix the colon from the hepatic flexure to the right iliac fossa with continuous stitches, from the colonic serosa to Toldt’s fascia, as it is from the embryonic stage.
Proximal gastrectomy with stapled circular esophagogastrostomy: manual purse-string technique
Early tumors of the esophagogastric junction can be managed with a minimally invasive proximal gastrectomy. This operation has recently been reevaluated for early-stage tumors since it offers a good postoperative quality of life with oncological outcomes equivalent to more extended procedures. In this video, we present the case of a 72-year-old man presenting with a 2cm adenocarcinoma of the esophagogastric junction. The clinical stage of the lesion was T1N0. A laparoscopic proximal gastrectomy with stapled circular esophagogastrostomy was decided upon. Five ports were placed. The left trocar incision was enlarged to introduce the circular stapler for the anastomoses and for specimen extraction. The procedure began with a complete abdominal exploration to rule out peritoneal metastases. The gastrocolic and gastrosplenic ligaments were divided with an ultrasonic scalpel. Short splenic vessels were clipped and divided and the greater curvature completely isolated with careful preservation of the gastroepiploic arcade and of the right gastroepiploic artery and vein. Left gastric vessels were divided at their origin with a vascular stapler and the distal esophagus was isolated through the diaphragmatic hiatus. A gastric tube was created with multiple applications of a linear stapler. The anvil of the circular stapler was secured to the esophageal stump with a hand-sewn purse-string suture in order to avoid the overlap of two suture lines. The esophagogastric anastomosis was then achieved with a circular stapler.
C Battiston, D Citterio, L Conti, M Virdis, V Mazzaferro
Surgical intervention
2 months ago
738 views
12 likes
1 comment
11:43
Proximal gastrectomy with stapled circular esophagogastrostomy: manual purse-string technique
Early tumors of the esophagogastric junction can be managed with a minimally invasive proximal gastrectomy. This operation has recently been reevaluated for early-stage tumors since it offers a good postoperative quality of life with oncological outcomes equivalent to more extended procedures. In this video, we present the case of a 72-year-old man presenting with a 2cm adenocarcinoma of the esophagogastric junction. The clinical stage of the lesion was T1N0. A laparoscopic proximal gastrectomy with stapled circular esophagogastrostomy was decided upon. Five ports were placed. The left trocar incision was enlarged to introduce the circular stapler for the anastomoses and for specimen extraction. The procedure began with a complete abdominal exploration to rule out peritoneal metastases. The gastrocolic and gastrosplenic ligaments were divided with an ultrasonic scalpel. Short splenic vessels were clipped and divided and the greater curvature completely isolated with careful preservation of the gastroepiploic arcade and of the right gastroepiploic artery and vein. Left gastric vessels were divided at their origin with a vascular stapler and the distal esophagus was isolated through the diaphragmatic hiatus. A gastric tube was created with multiple applications of a linear stapler. The anvil of the circular stapler was secured to the esophageal stump with a hand-sewn purse-string suture in order to avoid the overlap of two suture lines. The esophagogastric anastomosis was then achieved with a circular stapler.
Leiomyosarcoma paracaval laparoscopic resection
Primary retroperitoneal tumors are rare, usually malignant and of mesenchymal origin. Surgery is the treatment of choice and complete tumor excision is the main factor which determines the prognosis. They represent between 0.3 and 0.8% of all neoplasms.
The most frequent tumors are sarcomas in their different varieties (totaling 83.7%), mainly liposarcomas (6-20%) and leiomyosarcomas (8-10%); 85% of retroperitoneal tumors are malignant and, of these, about 50% are sarcomas.
The involvement of the inferior vena cava in different tumor processes has long represented a criterion of inoperability and unresectability.
Extirpative surgery of the entire lesion is the treatment of choice for retroperitoneal tumors, but it is not always possible due to the infiltrative commitment of vital structures, despite the possibility of large visceral resections (stomach, kidney, spleen, tail of the pancreas, duodenum, colon, abdominal cava, etc.) and in which case we will not talk about recurrence but about residual tumor.
The laparoscopic approach performed by a multidisciplinary team with experience and expertise can help establish a correct diagnosis and achieve a fine dissection of the lesion, even if it is in difficult anatomical regions.
The video shows a laparoscopic resection of a paracaval mass of unknown origin. This is the case of a 39-year-old female patient who presents with abdominal pain in the epigastrium and right hypochondrium with 2 weeks of evolution. She receives analgesic treatment without any improvement accompanied by vomiting of gastrobiliary content, exacerbation of pain (VAS of 9/10). Hematic biometrics and blood chemistry demonstrated normal results. Ultrasound, CT-scan of the abdomen, and magnetic resonance cholangiography showed a pericaval tumor of about 6 or 4cm, not compromising the inferior vena cava with intimate interphase. After an appropriate assessment by the multidisciplinary team, it is decided to perform a laparoscopic resection.
Operating time was 110 minutes with insignificant blood loss. The procedure is performed successfully without any complications. There were no intraoperative complications. Oral feeding was reintroduced on the first postoperative day and the patient was discharged on postoperative day 2, without complications. Histopathological examination revealed a low-grade leiomyosarcoma. 5 years of follow-up without adjacent lesions.
JL Limon Aguilar, CO Castillo Cabrera
Surgical intervention
2 months ago
579 views
8 likes
0 comments
12:31
Leiomyosarcoma paracaval laparoscopic resection
Primary retroperitoneal tumors are rare, usually malignant and of mesenchymal origin. Surgery is the treatment of choice and complete tumor excision is the main factor which determines the prognosis. They represent between 0.3 and 0.8% of all neoplasms.
The most frequent tumors are sarcomas in their different varieties (totaling 83.7%), mainly liposarcomas (6-20%) and leiomyosarcomas (8-10%); 85% of retroperitoneal tumors are malignant and, of these, about 50% are sarcomas.
The involvement of the inferior vena cava in different tumor processes has long represented a criterion of inoperability and unresectability.
Extirpative surgery of the entire lesion is the treatment of choice for retroperitoneal tumors, but it is not always possible due to the infiltrative commitment of vital structures, despite the possibility of large visceral resections (stomach, kidney, spleen, tail of the pancreas, duodenum, colon, abdominal cava, etc.) and in which case we will not talk about recurrence but about residual tumor.
The laparoscopic approach performed by a multidisciplinary team with experience and expertise can help establish a correct diagnosis and achieve a fine dissection of the lesion, even if it is in difficult anatomical regions.
The video shows a laparoscopic resection of a paracaval mass of unknown origin. This is the case of a 39-year-old female patient who presents with abdominal pain in the epigastrium and right hypochondrium with 2 weeks of evolution. She receives analgesic treatment without any improvement accompanied by vomiting of gastrobiliary content, exacerbation of pain (VAS of 9/10). Hematic biometrics and blood chemistry demonstrated normal results. Ultrasound, CT-scan of the abdomen, and magnetic resonance cholangiography showed a pericaval tumor of about 6 or 4cm, not compromising the inferior vena cava with intimate interphase. After an appropriate assessment by the multidisciplinary team, it is decided to perform a laparoscopic resection.
Operating time was 110 minutes with insignificant blood loss. The procedure is performed successfully without any complications. There were no intraoperative complications. Oral feeding was reintroduced on the first postoperative day and the patient was discharged on postoperative day 2, without complications. Histopathological examination revealed a low-grade leiomyosarcoma. 5 years of follow-up without adjacent lesions.
Laparoscopic segment 7 resection with extracorporeal Pringle maneuver on a cirrhotic liver
This is the case of a 73-year-old man presenting with a 33mm hepatocellular carcinoma arising on a Hepatitis C virus-related well-compensated cirrhosis without portal hypertension. A laparoscopic segment 7 atypical resection was decided upon. Five ports are placed. The procedure begins with complete abdominal exploration and intraoperative liver ultrasonography. The right triangular and coronary ligaments are divided in order to mobilize the right lobe and gain access to liver segment 7. The hepatic hilum is encircled with an umbilical tape. The tape is passed percutaneously through a 24 French chest tube used as Rommel’s tourniquet to allow for a safe and fast extracorporeal Pringle maneuver. The transection plane is controlled using ultrasound. The first part of parenchymal transection is performed using Thunderbeat™ while an ultrasonic dissector (CUSA™) is used more deeply. Hemostasis is controlled with irrigated bipolar forceps and clips on major vessels. To allow for a bloodless parenchymal transection and a more precise isolation and clipping of the vessels, the hepatic hilum is clamped for 10 minutes. The chest tube is pushed towards the hilum and clamped extracorporeally. After 10 minutes, the Pringle maneuver is released for 5 minutes and then repeated for another 10 minutes until parenchymal transection is complete. No drains are placed. Operative time took 180 minutes and total blood loss was 50mL. The postoperative course was uneventful and the patient was discharged on postoperative day 3. The pathology confirmed a 3cm hepatocellular carcinoma without microvascular invasion. Resection margins were negative for tumor invasion.
D Citterio, C Battiston, C Sposito, M Altomare, A Benedetti, V Mazzaferro
Surgical intervention
2 months ago
1264 views
10 likes
2 comments
10:10
Laparoscopic segment 7 resection with extracorporeal Pringle maneuver on a cirrhotic liver
This is the case of a 73-year-old man presenting with a 33mm hepatocellular carcinoma arising on a Hepatitis C virus-related well-compensated cirrhosis without portal hypertension. A laparoscopic segment 7 atypical resection was decided upon. Five ports are placed. The procedure begins with complete abdominal exploration and intraoperative liver ultrasonography. The right triangular and coronary ligaments are divided in order to mobilize the right lobe and gain access to liver segment 7. The hepatic hilum is encircled with an umbilical tape. The tape is passed percutaneously through a 24 French chest tube used as Rommel’s tourniquet to allow for a safe and fast extracorporeal Pringle maneuver. The transection plane is controlled using ultrasound. The first part of parenchymal transection is performed using Thunderbeat™ while an ultrasonic dissector (CUSA™) is used more deeply. Hemostasis is controlled with irrigated bipolar forceps and clips on major vessels. To allow for a bloodless parenchymal transection and a more precise isolation and clipping of the vessels, the hepatic hilum is clamped for 10 minutes. The chest tube is pushed towards the hilum and clamped extracorporeally. After 10 minutes, the Pringle maneuver is released for 5 minutes and then repeated for another 10 minutes until parenchymal transection is complete. No drains are placed. Operative time took 180 minutes and total blood loss was 50mL. The postoperative course was uneventful and the patient was discharged on postoperative day 3. The pathology confirmed a 3cm hepatocellular carcinoma without microvascular invasion. Resection margins were negative for tumor invasion.
Laparoscopic pancreaticoduodenectomy with venous reconstruction
Laparoscopic pancreaticoduodenectomy is an alternative to open surgery, which offers equivalent oncological results with a faster recovery associated with the minimally invasive approach. In cases of venous invasion, laparoscopic reconstruction with graft interposition is technically demanding. Nevertheless, good results can be achieved. This is the case of a 79-year-old man who was evaluated for jaundice. CT-scan found a tumor in the head of the pancreas with a 180-degree infiltration of the portal vein. After neoadjuvant chemotherapy with volumetric shrinking, but persistence of venous infiltration, a laparoscopic pancreaticoduodenectomy with venous reconstruction was decided upon.
E Giordano, A Alcaraz, S Reimondez, M Marani, W Salinas, R Pereyra, F Signorini, M Maraschio, L Obeide
Surgical intervention
2 months ago
1598 views
15 likes
1 comment
08:05
Laparoscopic pancreaticoduodenectomy with venous reconstruction
Laparoscopic pancreaticoduodenectomy is an alternative to open surgery, which offers equivalent oncological results with a faster recovery associated with the minimally invasive approach. In cases of venous invasion, laparoscopic reconstruction with graft interposition is technically demanding. Nevertheless, good results can be achieved. This is the case of a 79-year-old man who was evaluated for jaundice. CT-scan found a tumor in the head of the pancreas with a 180-degree infiltration of the portal vein. After neoadjuvant chemotherapy with volumetric shrinking, but persistence of venous infiltration, a laparoscopic pancreaticoduodenectomy with venous reconstruction was decided upon.
Revisional surgery: analysis of technical errors during failed bile duct injury repair
This is the case of a 42-year-old woman who suffered from bile duct injury during an elective cholecystectomy. Immediate repair was performed by means of an open Roux-en-Y hepaticojejunostomy. Five months later, she developed cholangitis. Critical stenosis of the anastomosis was demonstrated with percutaneous transhepatic cholangiography. She was transferred to our unit to address the failed reconstruction. Many clues on why the initial attempt at reconstruction failed were found during our surgery. Discussion of these errors and how to avoid them is the main objective of the video. Secondary learning objectives are to highlight the principles of high quality bilioenteric anastomosis and demonstration of our standard technique for bile duct injury repair.
JM Cabada-Lee
Surgical intervention
2 months ago
787 views
11 likes
1 comment
08:00
Revisional surgery: analysis of technical errors during failed bile duct injury repair
This is the case of a 42-year-old woman who suffered from bile duct injury during an elective cholecystectomy. Immediate repair was performed by means of an open Roux-en-Y hepaticojejunostomy. Five months later, she developed cholangitis. Critical stenosis of the anastomosis was demonstrated with percutaneous transhepatic cholangiography. She was transferred to our unit to address the failed reconstruction. Many clues on why the initial attempt at reconstruction failed were found during our surgery. Discussion of these errors and how to avoid them is the main objective of the video. Secondary learning objectives are to highlight the principles of high quality bilioenteric anastomosis and demonstration of our standard technique for bile duct injury repair.
Spleen-preserving total laparoscopic pancreatoduodenectomy
A 68-year-old woman was referred to us for multiple pancreatic cysts incidentally discovered on a routine ultrasound. An MRI was performed showing multiple cystic tumors throughout the pancreas, the largest of which was 15mm. This led to a suspicion of multifocal, side-branch intraductal papillary mucinous neoplasm (IPMN), with minimal dilatation of the main pancreatic duct. An echo-endoscopy was subsequently performed indicating the presence of a multifocal IPMN. A fine-needle aspiration (FNA) was performed during this procedure, with aspiration of cystic content which was sent for CEA analysis and cytology. Cytology was compatible with a mucinous neoplasm with mild atypia and CEA at 98 IU/mL.
A spleen-preserving total laparoscopic pancreatoduodenectomy was proposed. The procedure was uneventful and the patient was discharged on postoperative day 5. Pathology revealed a 19mm IPMN, with severe dysplasia and 3 foci of micro-invasive ductal adenocarcinoma of 1mm - pT1N0R0.
H Cristino, M Almeida, V Gomes, J Costa Maia
Surgical intervention
2 months ago
752 views
5 likes
2 comments
07:41
Spleen-preserving total laparoscopic pancreatoduodenectomy
A 68-year-old woman was referred to us for multiple pancreatic cysts incidentally discovered on a routine ultrasound. An MRI was performed showing multiple cystic tumors throughout the pancreas, the largest of which was 15mm. This led to a suspicion of multifocal, side-branch intraductal papillary mucinous neoplasm (IPMN), with minimal dilatation of the main pancreatic duct. An echo-endoscopy was subsequently performed indicating the presence of a multifocal IPMN. A fine-needle aspiration (FNA) was performed during this procedure, with aspiration of cystic content which was sent for CEA analysis and cytology. Cytology was compatible with a mucinous neoplasm with mild atypia and CEA at 98 IU/mL.
A spleen-preserving total laparoscopic pancreatoduodenectomy was proposed. The procedure was uneventful and the patient was discharged on postoperative day 5. Pathology revealed a 19mm IPMN, with severe dysplasia and 3 foci of micro-invasive ductal adenocarcinoma of 1mm - pT1N0R0.
Laparoscopic living donor right hepatectomy (LLDH) fully exposing the right hepatic vein (conventional approach)
Introduction:
Laparoscopic living donor hepatectomy (LLDH) has gradually become a widespread technique in high volume transplant centers over the last decade.
Right LLDH is considered as a procedure which requires an expert level in both living donor liver transplantation and laparoscopic liver resection.
In order to fully expose and encircle the right hepatic vein before parenchymal transection implies the full mobilization of the right liver lobe as well as the clipping and cutting of the short hepatic veins in a same way as in a conventional open approach, using the hanging maneuver.
This approach could be more applicable as an initial experience in centers introducing the right LLDH.
Method: Right LLDH was demonstrated in a 31-year-old woman with standard liver anatomy. The procedure was performed using five ports with the patient placed in the French position. The graft was transplanted to a 10-year-old girl with Wilson’s disease (PELD score of 19).
Result: Operating time was 420 min. Blood loss was 120mL. Donor and recipient were discharged on postoperative day 6 and 28 respectively without any complications.
Conclusion: Right LLDH is a feasible procedure. The technique shown is reproducible.
A Monakhov, K Semash, K Khizroev, M Voskanov, SV Gautier
Surgical intervention
2 months ago
1113 views
14 likes
3 comments
10:38
Laparoscopic living donor right hepatectomy (LLDH) fully exposing the right hepatic vein (conventional approach)
Introduction:
Laparoscopic living donor hepatectomy (LLDH) has gradually become a widespread technique in high volume transplant centers over the last decade.
Right LLDH is considered as a procedure which requires an expert level in both living donor liver transplantation and laparoscopic liver resection.
In order to fully expose and encircle the right hepatic vein before parenchymal transection implies the full mobilization of the right liver lobe as well as the clipping and cutting of the short hepatic veins in a same way as in a conventional open approach, using the hanging maneuver.
This approach could be more applicable as an initial experience in centers introducing the right LLDH.
Method: Right LLDH was demonstrated in a 31-year-old woman with standard liver anatomy. The procedure was performed using five ports with the patient placed in the French position. The graft was transplanted to a 10-year-old girl with Wilson’s disease (PELD score of 19).
Result: Operating time was 420 min. Blood loss was 120mL. Donor and recipient were discharged on postoperative day 6 and 28 respectively without any complications.
Conclusion: Right LLDH is a feasible procedure. The technique shown is reproducible.
Radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction: 3D HD video laparoscopy
The author presents the case of a 64-year-old male patient with a high-grade urothelial carcinoma infiltrating the bladders (pT2-G2), with a CT-scan of the abdomen and thorax negative for secondary localizations. The patient was subjected to a radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction, performed entirely in 3D HD videolaparoscopy. After the intervention, the patient is mobilized early. Parenteral feeding is given until restoration of bowel peristalsis. The nasogastric tube is removed with restoration of bowel peristalsis. Continuous antibiotic treatment is administered for 7 days after surgery. Neobladder lavage is performed daily to evacuate mucus. Stents are inspected daily to ensure patency and sterile saline is used if there is any suspicion of obstruction. Deep vein thrombosis prophylaxis is continued. The drain is removed when the draining liquid is less than 50cc per day and when there is no urine leak. A cystogram is performed on postoperative day 14. The stents are removed sequentially at 24 hours of interval. The catheter is extracted from the neobladder 20 days after surgery. The patient is discharged from hospital 21 days after surgery. Two years after the intervention, he presents a negative oncology follow-up. The patient is in a satisfactory general health condition. He has fully recovered and returned to a normal professional life. He urinates regularly and empties his neobladder every 3 to 4 hours, with minimal stress incontinence, particularly in the evening when he is physically tired; he gains erectile activity with the use of medical devices, benefiting from a more effective intracavernous injection therapy and vacuum device, and pharmacotherapy proves less effective.
D Geddo
Surgical intervention
5 months ago
2131 views
16 likes
2 comments
17:33
Radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction: 3D HD video laparoscopy
The author presents the case of a 64-year-old male patient with a high-grade urothelial carcinoma infiltrating the bladders (pT2-G2), with a CT-scan of the abdomen and thorax negative for secondary localizations. The patient was subjected to a radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction, performed entirely in 3D HD videolaparoscopy. After the intervention, the patient is mobilized early. Parenteral feeding is given until restoration of bowel peristalsis. The nasogastric tube is removed with restoration of bowel peristalsis. Continuous antibiotic treatment is administered for 7 days after surgery. Neobladder lavage is performed daily to evacuate mucus. Stents are inspected daily to ensure patency and sterile saline is used if there is any suspicion of obstruction. Deep vein thrombosis prophylaxis is continued. The drain is removed when the draining liquid is less than 50cc per day and when there is no urine leak. A cystogram is performed on postoperative day 14. The stents are removed sequentially at 24 hours of interval. The catheter is extracted from the neobladder 20 days after surgery. The patient is discharged from hospital 21 days after surgery. Two years after the intervention, he presents a negative oncology follow-up. The patient is in a satisfactory general health condition. He has fully recovered and returned to a normal professional life. He urinates regularly and empties his neobladder every 3 to 4 hours, with minimal stress incontinence, particularly in the evening when he is physically tired; he gains erectile activity with the use of medical devices, benefiting from a more effective intracavernous injection therapy and vacuum device, and pharmacotherapy proves less effective.
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, NS Gómez Peña-Alfaro
Surgical intervention
5 months ago
7131 views
29 likes
4 comments
12:40
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
Laparoscopic central hepatectomy for hepatoma using a Glissonian approach
Introduction: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic central hepatectomy remains a challenging and technically demanding procedure because it requires two transection planes. This video illustrates a useful technique for laparoscopic central hepatectomy, which was successfully performed in a cirrhotic patient with hepatoma. Method: We demonstrated a total laparoscopic central hepatectomy which was performed in a 65-year-old woman who had a centrally located hepatoma, and this tumor was in contact with the middle hepatic vein. The operative procedure was performed by using five ports with the patient placed in a low lithotomy position. Results: The technique was successfully performed without any complications. The operative time was 380 min. Intraoperative blood loss was 60mL. The length of hospital stay was 5 days. The pathological report was well-differentiated HCC and free surgical margins. Conclusions: Laparoscopic central hepatectomy for hepatoma by using a Glissonian approach is feasible and safe.
R Chanwat, C Bunchaliew
Surgical intervention
5 months ago
5003 views
35 likes
6 comments
10:01
Laparoscopic central hepatectomy for hepatoma using a Glissonian approach
Introduction: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic central hepatectomy remains a challenging and technically demanding procedure because it requires two transection planes. This video illustrates a useful technique for laparoscopic central hepatectomy, which was successfully performed in a cirrhotic patient with hepatoma. Method: We demonstrated a total laparoscopic central hepatectomy which was performed in a 65-year-old woman who had a centrally located hepatoma, and this tumor was in contact with the middle hepatic vein. The operative procedure was performed by using five ports with the patient placed in a low lithotomy position. Results: The technique was successfully performed without any complications. The operative time was 380 min. Intraoperative blood loss was 60mL. The length of hospital stay was 5 days. The pathological report was well-differentiated HCC and free surgical margins. Conclusions: Laparoscopic central hepatectomy for hepatoma by using a Glissonian approach is feasible and safe.
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
5 months ago
2224 views
6 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.
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
5 months ago
1630 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 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
5 months ago
4154 views
16 likes
4 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.
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
F Corcione, M D'Ambra, U Bracale, S Dilillo, G Luglio
Surgical intervention
5 months ago
2916 views
3 likes
1 comment
23:20
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
P Agami, A Andrianov, M Baychorov, R Izrailov
Surgical intervention
5 months ago
2151 views
14 likes
3 comments
17:23
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.
Y Aawsaj, I Ibrahim, A Mitchell, A Gilliam
Surgical intervention
6 months ago
946 views
15 likes
2 comments
10:08
Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.
Minimally invasive surgery for esophagectomy and tubularized gastric pull-up
The accidental ingestion of caustic agents is a common problem in pediatric emergency units. These agents can cause a series of damage to the upper gastrointestinal tract and can lead to an esophageal stricture. We present the case of a 4-year-old girl who was referred to our hospital for vomiting and hematemesis after ingesting a caustic solution. Physical examination revealed tongue edema and denuded buccal mucosa. Friable mucosa and esophageal ulceration were observed in the endoscopy. The patient was administered omeprazole and a nasogastric tube was placed for a week. Two esophageal strictures were observed after 3 weeks of the ingestion. The patient underwent esophageal dilatation once or twice a month during 21 months depending on the symptoms. Due to the refractory stricture, we decided to perform an esophagectomy and tubularized gastric pull-up by combining thoracoscopy, laparoscopy, and cervicotomy. In addition, we performed a jejunostomy to provide sufficient nutritional support. The patient started feeding on postoperative day 7 and she is currently asymptomatic.
I Cano Novillo, A García Vázquez, F de la Cruz Vigo, B Aneiros Castro
Surgical intervention
6 months ago
1067 views
5 likes
2 comments
12:40
Minimally invasive surgery for esophagectomy and tubularized gastric pull-up
The accidental ingestion of caustic agents is a common problem in pediatric emergency units. These agents can cause a series of damage to the upper gastrointestinal tract and can lead to an esophageal stricture. We present the case of a 4-year-old girl who was referred to our hospital for vomiting and hematemesis after ingesting a caustic solution. Physical examination revealed tongue edema and denuded buccal mucosa. Friable mucosa and esophageal ulceration were observed in the endoscopy. The patient was administered omeprazole and a nasogastric tube was placed for a week. Two esophageal strictures were observed after 3 weeks of the ingestion. The patient underwent esophageal dilatation once or twice a month during 21 months depending on the symptoms. Due to the refractory stricture, we decided to perform an esophagectomy and tubularized gastric pull-up by combining thoracoscopy, laparoscopy, and cervicotomy. In addition, we performed a jejunostomy to provide sufficient nutritional support. The patient started feeding on postoperative day 7 and she is currently asymptomatic.
Surgical technique of tubal reanastomosis
Many women who undergo tubal ligation surgery later decide to have children again. One option available to these women is tubal ligation reversal, or tubal reanastomosis. In this microsurgery, the two separated parts of a uterine tube are surgically reunited. It is ideally performed in younger women under 39 years of age with good ovarian reserve. Depending on the previously used tubal ligation method, it may be necessary to first perform a diagnostic laparoscopy to check the condition of the uterus, the uterine tubes, and the ovaries and to make sure that the tubal length is sufficient for reversal. Following the proper principles of microsurgery, this procedure can yield very good results and offer a more economical option to women desirous of childbearing if the tubal pathology related to tubal sterilization is the only cause of infertility.
H Grover, A Padmawar
Surgical intervention
7 months ago
3036 views
22 likes
0 comments
08:48
Surgical technique of tubal reanastomosis
Many women who undergo tubal ligation surgery later decide to have children again. One option available to these women is tubal ligation reversal, or tubal reanastomosis. In this microsurgery, the two separated parts of a uterine tube are surgically reunited. It is ideally performed in younger women under 39 years of age with good ovarian reserve. Depending on the previously used tubal ligation method, it may be necessary to first perform a diagnostic laparoscopy to check the condition of the uterus, the uterine tubes, and the ovaries and to make sure that the tubal length is sufficient for reversal. Following the proper principles of microsurgery, this procedure can yield very good results and offer a more economical option to women desirous of childbearing if the tubal pathology related to tubal sterilization is the only cause of infertility.
Various approaches to uterine artery ligation at laparoscopy
Isolating the uterine artery can be performed safely and efficiently with a proper knowledge of the anatomy, as pelvic vascular anatomy is relatively constant with a very predictive retroperitoneal course. In this video, authors review the anatomy relevant to the uterine artery and demonstrate various approaches to ligating it laparoscopically. It is essential as it provides hemostasis and reduces the incidence of potential injury to bladder and ureter, particularly in cases where anatomical relationships have been distorted by intra-abdominal adhesions as in cases of previous surgery, severe endometriosis or large fibroids or when access to the cervix is limited due to wide uteri or to a fibrogenic cul-de-sac or when access to the vesicouterine space is obliterated due to previous surgeries. The various approaches to ligating the uterine artery in relation to the broad ligament are lateral, posterior, anterior, and medial. These approaches can be used based on the patient’s pathology and requirements.
H Grover, R Syed, A Padmawar
Surgical intervention
7 months ago
10415 views
91 likes
24 comments
07:04
Various approaches to uterine artery ligation at laparoscopy
Isolating the uterine artery can be performed safely and efficiently with a proper knowledge of the anatomy, as pelvic vascular anatomy is relatively constant with a very predictive retroperitoneal course. In this video, authors review the anatomy relevant to the uterine artery and demonstrate various approaches to ligating it laparoscopically. It is essential as it provides hemostasis and reduces the incidence of potential injury to bladder and ureter, particularly in cases where anatomical relationships have been distorted by intra-abdominal adhesions as in cases of previous surgery, severe endometriosis or large fibroids or when access to the cervix is limited due to wide uteri or to a fibrogenic cul-de-sac or when access to the vesicouterine space is obliterated due to previous surgeries. The various approaches to ligating the uterine artery in relation to the broad ligament are lateral, posterior, anterior, and medial. These approaches can be used based on the patient’s pathology and requirements.
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
L Taglietti, G Baronio, L Lussardi, R Cazzaniga, S Dester, A Zanoletti
Surgical intervention
8 months ago
2695 views
8 likes
1 comment
09:56
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
S Macina, L Baldari, E Cassinotti, M Ballabio, A Spota, M de Francesco, L Boni
Surgical intervention
8 months ago
4609 views
22 likes
1 comment
07:10
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.
E Soricelli, E Facchiano, L Leuratti, G Quartararo, N Console, P Tonelli, M Lucchese
Surgical intervention
8 months ago
3669 views
13 likes
0 comments
09:10
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.