Monthly publications : January 2007 | WebSurg, the online university of IRCAD

Laparoscopic total extraperitoneal approach (TEP) for a left inguinal hernia

This "live" surgery demonstrates the totally extraperitoneal (TEP) approach for a left indirect inguinal hernia repair in a young, muscular male. Some tips are offered regarding surgery in such patients.

GF Bégin

Surgical intervention

Laparoscopic total extraperitoneal approach (TEP) for a left inguinal hernia

This "live" surgery demonstrates the totally extraperitoneal (TEP) approach for a left indirect inguinal hernia repair in a young, muscular male. Some tips are offered regarding surgery in such patients.

Left hepatic pedicle control for laparoscopic left lateral segmentectomy

This video demonstrates in detail the primary vascular approach to left lateral segmentectomy, using a 5-port laparoscopic technique. Once the vascular pedicles are well controlled, liver resection is performed with minimal blood loss. Intestinal staplers are used for vascular division while the liver is divided with the ultrasonic (harmonic) scalpel.

D Mutter

Surgical intervention

Left hepatic pedicle control for laparoscopic left lateral segmentectomy

This video demonstrates in detail the primary vascular approach to left lateral segmentectomy, using a 5-port laparoscopic technique. Once the vascular pedicles are well controlled, liver resection is performed with minimal blood loss. Intestinal staplers are used for vascular division while the liver is divided with the ultrasonic (harmonic) scalpel.

Laparoscopic right hepatectomy: intra-hepatic Glissonian approach

This video demonstrates a totally laparoscopic approach to right hemi-hepatectomy. The right portal pedicle is first divided with an endoscopic stapler. The liver parenchyma is then divided with a combination of ultrasonic scalpel, Cavitron Ultrasound Surgical Aspirator (CUSA), bipolar cautery and clips.

Many surgeons prefer to employ the hand-assisted approach, but in this totally laparoscopic demonstration the author uses the intrahepatic Glissonian approach without the Pringle maneuver. The procedure starts with surgical exploration and laparoscopic evaluation of the liver. The harmonic scalpel divides the hepatic round and falciform ligaments. The author visualizes the suprahepatic inferior vena cava and right hepatic vein, then explores the hepatoduodenal ligament for enlarged lymph nodes. He then mobilizes the right liver as high as possible by transecting the right triangular ligament. Paying attention to the area of the adrenal gland, he dissects the gallbladder hilum, and transects both the cystic artery and duct. He starts the hepatic hilar dissection with an incision of the liver parenchyma, continuing outside the portal pedicle bifurcation toward the right and left sheet. The procedure continues with transection of the right portal pedicle.

B Topal

Surgical intervention

Laparoscopic right hepatectomy: intra-hepatic Glissonian approach

This video demonstrates a totally laparoscopic approach to right hemi-hepatectomy. The right portal pedicle is first divided with an endoscopic stapler. The liver parenchyma is then divided with a combination of ultrasonic scalpel, Cavitron Ultrasound Surgical Aspirator (CUSA), bipolar cautery and clips.

Many surgeons prefer to employ the hand-assisted approach, but in this totally laparoscopic demonstration the author uses the intrahepatic Glissonian approach without the Pringle maneuver. The procedure starts with surgical exploration and laparoscopic evaluation of the liver. The harmonic scalpel divides the hepatic round and falciform ligaments. The author visualizes the suprahepatic inferior vena cava and right hepatic vein, then explores the hepatoduodenal ligament for enlarged lymph nodes. He then mobilizes the right liver as high as possible by transecting the right triangular ligament. Paying attention to the area of the adrenal gland, he dissects the gallbladder hilum, and transects both the cystic artery and duct. He starts the hepatic hilar dissection with an incision of the liver parenchyma, continuing outside the portal pedicle bifurcation toward the right and left sheet. The procedure continues with transection of the right portal pedicle.

Laparoscopic splenectomy by posterior approach

This "live" surgery demonstrates the posterior approach to splenectomy. Dr. Mutter, MD, PhD, describes each step of the procedure as he performs it. There is an interactive discussion with the audience. The tail of the pancreas was adherent to the splenic hilum and the LigaSure device is used to discover this plane.

The authors mark the margin of costal margin and place a 12-mm trocar through an incision at the anterior costal margin. They then place a 5-12 mm trocar 5 cm anterior to the first trocar, and a third 5-cm trocar 3-4 cm below the costal margin.

D Mutter, J Marescaux

Surgical intervention

Laparoscopic splenectomy by posterior approach

This "live" surgery demonstrates the posterior approach to splenectomy. Dr. Mutter, MD, PhD, describes each step of the procedure as he performs it. There is an interactive discussion with the audience. The tail of the pancreas was adherent to the splenic hilum and the LigaSure device is used to discover this plane.

The authors mark the margin of costal margin and place a 12-mm trocar through an incision at the anterior costal margin. They then place a 5-12 mm trocar 5 cm anterior to the first trocar, and a third 5-cm trocar 3-4 cm below the costal margin.

What is your preferred surgical treatment for impalpable testis, and why? How is this choice related to the age of the patient?

Laparoscopic total gastrectomy for adenocarcinoma

This is a video demonstrating laparoscopic total gastrectomy for adenocarcinoma. Mobilization of the greater omentum and stomach are presented in detail, together with vascular and lymph node dissection according to the Japanese gastric cancer classification. Finally, a stapled esophago-jejunostomy is performed for restoration of gastro-intestinal continuity. This is another case where Dr. Dallemagne, MD demonstrates how a complex resection can be undertaken laparoscopically using a stepwise approach.

B Dallemagne

Surgical intervention

Laparoscopic total gastrectomy for adenocarcinoma

This is a video demonstrating laparoscopic total gastrectomy for adenocarcinoma. Mobilization of the greater omentum and stomach are presented in detail, together with vascular and lymph node dissection according to the Japanese gastric cancer classification. Finally, a stapled esophago-jejunostomy is performed for restoration of gastro-intestinal continuity. This is another case where Dr. Dallemagne, MD demonstrates how a complex resection can be undertaken laparoscopically using a stepwise approach.

What are the complications of a laparoscopic approach specific to pediatric surgery?

What is your preferred surgical treatment for GERD, and why? How is this choice related to the age of the patient?

What is the future of robotics in pediatric surgery?

Are you not worried that with the insufflation of carbon dioxide in the bladder, the gas may migrate to the kidneys and cause a gas embolus?

Are there limits to the pressures and insufflation flows in the bladder?

What are the advantages of the retroperitoneal access specific to pediatric surgery?

Can you explain the key steps of this intervention: endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting vesicoureteral reflux in children?

Could you please develop your surgical approach to biliary atresia?

In South America, what is the evolution of pediatric videosurgery?

Is videosurgery widespread in Brazil?

In South America, are there any new treatments in neonatal surgery?

Could you give us the technical details of transvesicoscopic surgery in children?

What are the benefits of retroperitoneoscopy in pediatric surgery?

Total nephrectomy in children by a lateral retroperitoneoscopic approach

This didactic video demonstrates the retroperitoneal approach to nephrectomy in children. A simple technique for creation of the retroperitoneal space and different methods of dissection, vessel division and specimen extraction are presented. These techniques are applicable for use in patients ranging from infants to adolescents.

The tip of the telescope progressively enlarges the working space created in the retroperitoneoscopic approach. This frees retroperitoneal fibrous tissues behind the kidney. The authors place two additional ports under direct vision: one to gently sweep the peritoneum anteriorly and to increase the working space for the placement of a third trocar.

JS Valla

Surgical intervention

Total nephrectomy in children by a lateral retroperitoneoscopic approach

This didactic video demonstrates the retroperitoneal approach to nephrectomy in children. A simple technique for creation of the retroperitoneal space and different methods of dissection, vessel division and specimen extraction are presented. These techniques are applicable for use in patients ranging from infants to adolescents.

The tip of the telescope progressively enlarges the working space created in the retroperitoneoscopic approach. This frees retroperitoneal fibrous tissues behind the kidney. The authors place two additional ports under direct vision: one to gently sweep the peritoneum anteriorly and to increase the working space for the placement of a third trocar.

Ureteral reimplantation under pneumovesicoscopy according to Cohen technique in children

This didactic video describes in detail the technique of ureteral reimplantation in the bladder using a pneumovesicoscopic approach. Dr. Valla, MD shares some of the finer points to be observed during this procedure.

JS Valla

Surgical intervention

Ureteral reimplantation under pneumovesicoscopy according to Cohen technique in children

This didactic video describes in detail the technique of ureteral reimplantation in the bladder using a pneumovesicoscopic approach. Dr. Valla, MD shares some of the finer points to be observed during this procedure.