Monthly publications : July 2009 | WebSurg, the online university of IRCAD

NOTES transgastric cholecystectomy: our technique

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques. There are several benefits of the NOTES approach, decreased abdominal pain, wound infections, and hernia formation. This video demonstrates the technique by which we perform transgastric NOTES cholecystectomy in human patients.

B Dallemagne, S Perretta, Gf Donatelli, J Marescaux

Surgical intervention

NOTES transgastric cholecystectomy: our technique

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques. There are several benefits of the NOTES approach, decreased abdominal pain, wound infections, and hernia formation. This video demonstrates the technique by which we perform transgastric NOTES cholecystectomy in human patients.

Totally robotic low anterior resection (RLAR) with trans-anal specimen extraction and single stapling technique

We present the case of a 76-year-old woman with a low rectal cancer (T3N0 at 7cm) status post-chemoradiation therapy. Using a four-arm DaVinci system, we carry out the dissection in a medial to lateral fashion dividing the inferior mesenteric vessels and mobilizing the splenic flexure. A total mesorectal excision is performed to the level of the pelvic floor. The specimen is delivered through a wound protector covering the anus. The sigmoid colon is divided extracorporeally, an anvil is secured. Using robotic instruments, a purse-string is sutured to the rectal stump and tied around the EEA stapler spike. An end-to-end anastomosis is created under vision. A diverting ileostomy is performed. This novel robotic procedure eliminates the need for an incision for specimen extraction and may facilitate transection of the rectum during RLAR.

JH Baek, C Pastor, J Garcia-Aguilar, S McKenzie, A Pigazzi

Surgical intervention

Totally robotic low anterior resection (RLAR) with trans-anal specimen extraction and single stapling technique

We present the case of a 76-year-old woman with a low rectal cancer (T3N0 at 7cm) status post-chemoradiation therapy. Using a four-arm DaVinci system, we carry out the dissection in a medial to lateral fashion dividing the inferior mesenteric vessels and mobilizing the splenic flexure. A total mesorectal excision is performed to the level of the pelvic floor. The specimen is delivered through a wound protector covering the anus. The sigmoid colon is divided extracorporeally, an anvil is secured. Using robotic instruments, a purse-string is sutured to the rectal stump and tied around the EEA stapler spike. An end-to-end anastomosis is created under vision. A diverting ileostomy is performed. This novel robotic procedure eliminates the need for an incision for specimen extraction and may facilitate transection of the rectum during RLAR.

Transanal Endoscopic Microsurgery (TEM): ancestor of NOTES and still alive

Transanal Endoscopic Microsurgery (TEM) allows local excision of rectal tumors located 4 to 18cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. In this lecture, N. Demartines provides us with a videoclip demonstration, and goes over the current status of TEM and addresses questions with regards to future applications.

Transanal Endoscopic Microsurgery (TEM): ancestor of NOTES and still alive

Transanal Endoscopic Microsurgery (TEM) allows local excision of rectal tumors located 4 to 18cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. In this lecture, N. Demartines provides us with a videoclip demonstration, and goes over the current status of TEM and addresses questions with regards to future applications.

Laparoscopic hysterectomy with adnexectomy

This video demonstrates the technique of a total laparoscopic hysterectomy with adnexectomy. Our patient is a 44-year-old lady with Tamoxifen-induced endometrial hyperplasia, which failed to respond to medical treatment.
Umbilical incision is made on the left internal border to give a more aesthetic scar.
Direct entry is performed. The assistant helps to lift the abdomen while the surgeon directs the trocar perpendicularly towards the rectus sheath first, then directs it towards the pelvis. The midline port is inserted: this should be at a slightly higher level than the lateral ports for better ergonomics. The uterine manipulator has a rotating ceramic valve for opening the vagina and a set of rings to maintain the pneumoperitoneum. The procedure is started by coagulating and cutting the round ligament on the left and opening the broad ligament. The broad ligament is opened parallel to the infundibulopelvic ligament for adnexectomy and a window is made over the grey area. The posterior leaf of the broad ligament is opened towards the left uterosacral ligament. The anterior leaf of the broad ligament is opened towards the vagina by dissecting the space and coagulating and cutting the tissues in between. The dissection is continued until the uterine artery is reached. The left infundibulopelvic ligament is coagulated and cut. The same procedure is done on the other side. Bladder dissection is performed with the help of the assistant holding up the bladder and entering the vesicovaginal space. The bladder is dissected away, beyond the valve of the manipulator. The left uterine artery is coagulated and cut. The left uterosacral ligament is coagulated and cut. The right uterine vessels are coagulated and cut followed by the uterosacral ligament. The vagina is now cut against the valve of the manipulator using a monopolar hook. Bleeding points are coagulated with a bipolar forceps. The vagina is sutured in two layers using extracorporeal knots. The procedure is now complete and hemostasis is confirmed. This patient had a favourable postoperative outcome and was discharged on postoperative day 1.

A Wattiez, E Kovoor, J Nassif, I Miranda-Mendoza

Surgical intervention

Laparoscopic hysterectomy with adnexectomy

This video demonstrates the technique of a total laparoscopic hysterectomy with adnexectomy. Our patient is a 44-year-old lady with Tamoxifen-induced endometrial hyperplasia, which failed to respond to medical treatment.
Umbilical incision is made on the left internal border to give a more aesthetic scar.
Direct entry is performed. The assistant helps to lift the abdomen while the surgeon directs the trocar perpendicularly towards the rectus sheath first, then directs it towards the pelvis. The midline port is inserted: this should be at a slightly higher level than the lateral ports for better ergonomics. The uterine manipulator has a rotating ceramic valve for opening the vagina and a set of rings to maintain the pneumoperitoneum. The procedure is started by coagulating and cutting the round ligament on the left and opening the broad ligament. The broad ligament is opened parallel to the infundibulopelvic ligament for adnexectomy and a window is made over the grey area. The posterior leaf of the broad ligament is opened towards the left uterosacral ligament. The anterior leaf of the broad ligament is opened towards the vagina by dissecting the space and coagulating and cutting the tissues in between. The dissection is continued until the uterine artery is reached. The left infundibulopelvic ligament is coagulated and cut. The same procedure is done on the other side. Bladder dissection is performed with the help of the assistant holding up the bladder and entering the vesicovaginal space. The bladder is dissected away, beyond the valve of the manipulator. The left uterine artery is coagulated and cut. The left uterosacral ligament is coagulated and cut. The right uterine vessels are coagulated and cut followed by the uterosacral ligament. The vagina is now cut against the valve of the manipulator using a monopolar hook. Bleeding points are coagulated with a bipolar forceps. The vagina is sutured in two layers using extracorporeal knots. The procedure is now complete and hemostasis is confirmed. This patient had a favourable postoperative outcome and was discharged on postoperative day 1.

Paraesophageal herniation of the colon: laparoscopic repair

Large paraesophageal hernias (PEHs) occur most commonly in an elderly, debilitated patient population with existing co-morbid conditions. The surgical approach to paraesophageal hernias (PEHs) has changed with the advent of laparoscopic techniques. This video presents the case of a 72-year-old male patient referred to our unit for epigastric pain. In this patient, the endoscopy showed nothing specific concerning this pain. The barium swallow showed no abnormality, but just a lateralization of the esophagus. The CT-scan demonstrated a large hiatal hernia. The laparoscopic repair is presented here.

B Dallemagne, S Perretta, J Marescaux

Surgical intervention

Paraesophageal herniation of the colon: laparoscopic repair

Large paraesophageal hernias (PEHs) occur most commonly in an elderly, debilitated patient population with existing co-morbid conditions. The surgical approach to paraesophageal hernias (PEHs) has changed with the advent of laparoscopic techniques. This video presents the case of a 72-year-old male patient referred to our unit for epigastric pain. In this patient, the endoscopy showed nothing specific concerning this pain. The barium swallow showed no abnormality, but just a lateralization of the esophagus. The CT-scan demonstrated a large hiatal hernia. The laparoscopic repair is presented here.

Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient

Rectal prolapse is an uncommon disease mainly seen in patients of advanced age.
In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.

J Leroy, D Mutter, F Costantino, J Marescaux

Surgical intervention

Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient

Rectal prolapse is an uncommon disease mainly seen in patients of advanced age.
In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.

Totally laparoscopic right hemicolectomy with transvaginal specimen extraction

We present our technique for totally laparoscopic right colectomy for locally advanced colon cancer with transvaginal specimen extraction. The patient was a 73-year-old female who presented with a biopsy proven cecal adenocarcinoma. We performed a right hemicolectomy using a 4 port approach with the patient in modified lithotomy position. Medial to lateral mobilization and early high ligation of the ileocolic pedicle were performed. The resected specimen was placed in a large retrieval bag.
With the patient positioned in modified lithotomy, a posterior culpotomy was made and the specimen removed intact through the vagina. The culpotomy was closed from the vaginal approach. A 60mm stapled side-to-side anastomosis was created intracorporeally to complete the procedure. The specimen was 52cm in length and contained a 3.2cm tumor and 13 lymph nodes. The patient's pathologic stage was T3N1.

S McKenzie, JH Baek, A Pigazzi

Surgical intervention

Totally laparoscopic right hemicolectomy with transvaginal specimen extraction

We present our technique for totally laparoscopic right colectomy for locally advanced colon cancer with transvaginal specimen extraction. The patient was a 73-year-old female who presented with a biopsy proven cecal adenocarcinoma. We performed a right hemicolectomy using a 4 port approach with the patient in modified lithotomy position. Medial to lateral mobilization and early high ligation of the ileocolic pedicle were performed. The resected specimen was placed in a large retrieval bag.
With the patient positioned in modified lithotomy, a posterior culpotomy was made and the specimen removed intact through the vagina. The culpotomy was closed from the vaginal approach. A 60mm stapled side-to-side anastomosis was created intracorporeally to complete the procedure. The specimen was 52cm in length and contained a 3.2cm tumor and 13 lymph nodes. The patient's pathologic stage was T3N1.

Laparoscopic management of gangrenous perforated cholecystitis

The video "Laparoscopic management of gangrenous perforated cholecystitis" authored by J D'Agostino and J Marescaux is analysed by Dr. Benoit Navez, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

B Navez, J D'Agostino, J Marescaux

Surgical intervention

Laparoscopic management of gangrenous perforated cholecystitis

The video "Laparoscopic management of gangrenous perforated cholecystitis" authored by J D'Agostino and J Marescaux is analysed by Dr. Benoit Navez, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Unusual cause of new onset persistent dysphagia after Nissen fundoplication

Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.

B Dallemagne, J Marescaux

Surgical intervention

Unusual cause of new onset persistent dysphagia after Nissen fundoplication

Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.

Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection

Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.

D Mutter, L Soler, J Marescaux

Surgical intervention

Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection

Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.

Combined NOTES sentinel node biopsy and endoscopic submucosal dissection (ESD)

Lymphatic mapping and sentinel node biopsy could perhaps allow accurate nodal staging as complement to endoscopic submucosal resection of early primary neoplasia. Here we demonstrate how this technique could be performed by a NOTES approach as an oncological supplement to the intraluminal resective procedure for both the stomach and colon.

R Cahill, M Asakuma, S Perretta, J Leroy, B Dallemagne, D Coumaros, J Marescaux

Surgical intervention

Combined NOTES sentinel node biopsy and endoscopic submucosal dissection (ESD)

Lymphatic mapping and sentinel node biopsy could perhaps allow accurate nodal staging as complement to endoscopic submucosal resection of early primary neoplasia. Here we demonstrate how this technique could be performed by a NOTES approach as an oncological supplement to the intraluminal resective procedure for both the stomach and colon.

Laparoscopic single port splenectomy

A technique for single port splenectomy in a normal sized spleen and using a single 2cm subcostal incision is demonstrated. This approach was chosen to allow the use of a straight (non-articulated) 5mm Ligasure device. This was used to divide the gastrosplenic ligament and short gastric vessels, to seal in continuity the splenic artery, divide the lienorenal ligament and seal and divide the splenic hilar vessels. The SILS port easily accommodated a 15mm port for passage of large retrieval bag without excessive distraction of the incision.

Z Krukowski, I Ahmed

Surgical intervention

Laparoscopic single port splenectomy

A technique for single port splenectomy in a normal sized spleen and using a single 2cm subcostal incision is demonstrated. This approach was chosen to allow the use of a straight (non-articulated) 5mm Ligasure device. This was used to divide the gastrosplenic ligament and short gastric vessels, to seal in continuity the splenic artery, divide the lienorenal ligament and seal and divide the splenic hilar vessels. The SILS port easily accommodated a 15mm port for passage of large retrieval bag without excessive distraction of the incision.

Extraperitoneal laparoscopic prostatectomy

Extraperitoneal laparoscopic prostatectomy results in a significant decrease in operative time and intraoperative blood loss. This is the case of a 56-year-old man who was found to have prostate cancer because PSA had risen to 4.3. The prostatic biopsy showed a bilateral Gleason 3+4 carcinoma. On clinical exam, he had a small benign prostate. He was a suitable candidate for radical prostatectomy. The surgeon performed this procedure using an extraperitoneal laparoscopic approach and have done this in over 800 cases.

D Dahl

Surgical intervention

Extraperitoneal laparoscopic prostatectomy

Extraperitoneal laparoscopic prostatectomy results in a significant decrease in operative time and intraoperative blood loss. This is the case of a 56-year-old man who was found to have prostate cancer because PSA had risen to 4.3. The prostatic biopsy showed a bilateral Gleason 3+4 carcinoma. On clinical exam, he had a small benign prostate. He was a suitable candidate for radical prostatectomy. The surgeon performed this procedure using an extraperitoneal laparoscopic approach and have done this in over 800 cases.

Laparoscopic partial TME for sessile polyp with intraoperative endoscopic control

Total mesorectal excision (TME) was described 20 years ago and is now recognized as the therapeutic gold standard for middle and lower third rectal cancers.
This is the case of a 70-year-old man with a BMI of 24 presenting with multiple polyps of the sigmoid colon larger than 3cm at 10 to 30cm from the anal verge. He has no past surgical history and colonoscopy revealed 3 sessile polyps at 15, 20, and 30cm from the anal verge as well as a flat polyp at 10cm from the anal verge. The histological examination concluded in one adenomatous, one adenovillous with high-grade dysplasia and one hyperplastic lesion. A laparoscopic partial TME with intraoperative endoscopic control is performed.

M Li

Surgical intervention

Laparoscopic partial TME for sessile polyp with intraoperative endoscopic control

Total mesorectal excision (TME) was described 20 years ago and is now recognized as the therapeutic gold standard for middle and lower third rectal cancers.
This is the case of a 70-year-old man with a BMI of 24 presenting with multiple polyps of the sigmoid colon larger than 3cm at 10 to 30cm from the anal verge. He has no past surgical history and colonoscopy revealed 3 sessile polyps at 15, 20, and 30cm from the anal verge as well as a flat polyp at 10cm from the anal verge. The histological examination concluded in one adenomatous, one adenovillous with high-grade dysplasia and one hyperplastic lesion. A laparoscopic partial TME with intraoperative endoscopic control is performed.

Adenocarcinoma of colorectal junction: laparoscopic anterior rectal resection. Advantage of the Ligasure Advance® device

The purpose of this video is to show an anterior rectal resection technique for an adenocarcinoma of the rectosigmoid junction using the Ligasure Advance® device (Valleylab, Covidien, Boulder, CO).This video shows how this device can optimize efficiency and safety in the operating room and potentially reduce overall operating time.

J Leroy, J Marescaux

Surgical intervention

Adenocarcinoma of colorectal junction: laparoscopic anterior rectal resection. Advantage of the Ligasure Advance® device

The purpose of this video is to show an anterior rectal resection technique for an adenocarcinoma of the rectosigmoid junction using the Ligasure Advance® device (Valleylab, Covidien, Boulder, CO).This video shows how this device can optimize efficiency and safety in the operating room and potentially reduce overall operating time.

Developments in esophageal capsule endoscopy

In this lecture, Dr. E. Coron shows the technical aspects of the Wireless Capsule Endoscopy, its advantages and its limits in conventional endoscopy. He presents also the results of this device in the diagnosis of GERD, esophageal varices and its application in portal hypertension.

E Coron

Developments in esophageal capsule endoscopy

In this lecture, Dr. E. Coron shows the technical aspects of the Wireless Capsule Endoscopy, its advantages and its limits in conventional endoscopy. He presents also the results of this device in the diagnosis of GERD, esophageal varices and its application in portal hypertension.

Capsule endoscopy: indications and results

Colonoscopy is regarded as the gold standard for colorectal cancer (CRC) screening. In this lecture, Prof. J. Deviere presents the PillCam capsule endoscopy as an alternative approach for screening large populations. He reports a pilot evaluation in humans of the safety, feasibility, and performance of colon capsule endoscopy as compared to colonoscopy.

Capsule endoscopy: indications and results

Colonoscopy is regarded as the gold standard for colorectal cancer (CRC) screening. In this lecture, Prof. J. Deviere presents the PillCam capsule endoscopy as an alternative approach for screening large populations. He reports a pilot evaluation in humans of the safety, feasibility, and performance of colon capsule endoscopy as compared to colonoscopy.

Single port left direct inguinal hernia repair

Minimally invasive techniques continue to evolve. This leads to an improvement of less invasive surgery over standard procedures. Single port TAPP inguinal hernia repair is technically feasible. This video shows a left direct inguinal hernia repair using the R port (namely the TriPort manufactured by Advanced surgical concepts).

I Ahmed

Surgical intervention

Single port left direct inguinal hernia repair

Minimally invasive techniques continue to evolve. This leads to an improvement of less invasive surgery over standard procedures. Single port TAPP inguinal hernia repair is technically feasible. This video shows a left direct inguinal hernia repair using the R port (namely the TriPort manufactured by Advanced surgical concepts).

Selective tissue elevation by pressure (STEP) for EMR and ESD in the GI tract

Endoscopic mucosal resection (EMR) and Endoscopic Submucosal Dissection (ESD) are advanced endoscopic techniques for the treatment of flat superficial tumors of the gastrointestinal tract. In this lecture, Prof. G. Kaehler presents the technique of selective fluid accumulation in the submucosa by pressure injection, the selective tissue elevation by pressure injection (STEP). All technical details are carefully described.

Selective tissue elevation by pressure (STEP) for EMR and ESD in the GI tract

Endoscopic mucosal resection (EMR) and Endoscopic Submucosal Dissection (ESD) are advanced endoscopic techniques for the treatment of flat superficial tumors of the gastrointestinal tract. In this lecture, Prof. G. Kaehler presents the technique of selective fluid accumulation in the submucosa by pressure injection, the selective tissue elevation by pressure injection (STEP). All technical details are carefully described.

Laparoscopic fenestration of a symptomatic primary splenic cyst using a single port access approach

Non-neoplastic cysts of the spleen are rare and their management has evolved from total open splenectomy to laparoscopic cyst decapsulation.
The aim of this video is to present a lesser invasive laparoscopic splenic cyst fenestration using a transumbilical single port device.

EM Targarona Soler

Surgical intervention

Laparoscopic fenestration of a symptomatic primary splenic cyst using a single port access approach

Non-neoplastic cysts of the spleen are rare and their management has evolved from total open splenectomy to laparoscopic cyst decapsulation.
The aim of this video is to present a lesser invasive laparoscopic splenic cyst fenestration using a transumbilical single port device.

Transanal Endoscopic Operation (TEO) for rectal polyp: first step for NOTES colorectal procedure?

Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique for the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision, which would otherwise necessitate major surgery. The objective of this film is to demonstrate the transanal resection of an endorectal polyp using the TEO, a Karl Storz system, according to the TEM principles as was first described by Gerhard Buess in 1983 (and published in the literature in 1984).

J Leroy, J Marescaux

Surgical intervention

Transanal Endoscopic Operation (TEO) for rectal polyp: first step for NOTES colorectal procedure?

Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique for the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision, which would otherwise necessitate major surgery. The objective of this film is to demonstrate the transanal resection of an endorectal polyp using the TEO, a Karl Storz system, according to the TEM principles as was first described by Gerhard Buess in 1983 (and published in the literature in 1984).

Postoperative hemoperitoneum and inefficient suction drain

After any major procedure, bleeding into the abdominal cavity or from the abdominal wound is possible. This complication is unusual because of the precautions that are taken, but when important bleeding happens, it may be necessary to return to the operating room. Drainage tubes are often used for monitoring after an operation to allow secretions or blood to come away. It is very important to select the appropriate type of drain for each procedure. This video is presented in order to demonstrate the poor benefit of a suction drain in case of postoperative abdominal complications.

D Mutter, J Marescaux

Surgical intervention

Postoperative hemoperitoneum and inefficient suction drain

After any major procedure, bleeding into the abdominal cavity or from the abdominal wound is possible. This complication is unusual because of the precautions that are taken, but when important bleeding happens, it may be necessary to return to the operating room. Drainage tubes are often used for monitoring after an operation to allow secretions or blood to come away. It is very important to select the appropriate type of drain for each procedure. This video is presented in order to demonstrate the poor benefit of a suction drain in case of postoperative abdominal complications.

Laparoscopic treatment of gastrogastric fistulas after gastric bypass

Gastrogastric fistula (GGF) is a rare complication that occurs after a divided Roux-en-Y gastric bypass (RYGBP). The incidence can be as high as 49% in patients who undergo non-divided or partially divided RYGBP. This is the case of a 33-year-old female patient who benefited of a gastric bypass 4 months earlier. After the procedure, the patient suffered from dysphagia. During preoperative work-up, a gastrogastric fistula was discovered. This video shows the laparoscopic treatment of the gastrogastric fistula.

M Vix, D Mutter, J Marescaux

Surgical intervention

Laparoscopic treatment of gastrogastric fistulas after gastric bypass

Gastrogastric fistula (GGF) is a rare complication that occurs after a divided Roux-en-Y gastric bypass (RYGBP). The incidence can be as high as 49% in patients who undergo non-divided or partially divided RYGBP. This is the case of a 33-year-old female patient who benefited of a gastric bypass 4 months earlier. After the procedure, the patient suffered from dysphagia. During preoperative work-up, a gastrogastric fistula was discovered. This video shows the laparoscopic treatment of the gastrogastric fistula.

Laparoscopic low anterior resection, technical tips: how to prevent anastomotic leakage?

Despite improved surgical techniques, anastomotic leakage is still a severe complication in colorectal surgery, with increased morbidity and mortality. The leakage reported rate varies from 3% to 19%, and is usually higher than 10%. In this lecture, Prof. Junji Okuda reports his experience, with video demonstration, in performing low anterior resection and provides his recommendations to prevent anastomotic leakage.

J Okuda, N Tanigawa

Laparoscopic low anterior resection, technical tips: how to prevent anastomotic leakage?

Despite improved surgical techniques, anastomotic leakage is still a severe complication in colorectal surgery, with increased morbidity and mortality. The leakage reported rate varies from 3% to 19%, and is usually higher than 10%. In this lecture, Prof. Junji Okuda reports his experience, with video demonstration, in performing low anterior resection and provides his recommendations to prevent anastomotic leakage.

Laparoscopic coloproctectomy for Inflammatory Bowel Disease (IBD)

Laparoscopic surgery for inflammatory bowel disease (IBD) is technically demanding.
Fistulous disease is common, but can be managed safely and with acceptable morbidity in experienced hands. In this lecture, Dr. B. Salky presents his experience in performing laparoscopic coloproctectomy for IBD.

B Salky

Laparoscopic coloproctectomy for Inflammatory Bowel Disease (IBD)

Laparoscopic surgery for inflammatory bowel disease (IBD) is technically demanding.
Fistulous disease is common, but can be managed safely and with acceptable morbidity in experienced hands. In this lecture, Dr. B. Salky presents his experience in performing laparoscopic coloproctectomy for IBD.

Laparoscopic one trocar cholecystectomy: Gelport® technique

Single port access cholecystectomy is a new laparoscopic procedure using only one transumbilically placed port. This video shows a procedure performed using a Gelport® through a 2.5cm incision. This Gelport® is usually used to perform hand-assisted surgery. In this case, the incision used to introduce the hand was closed by a single suture and 3 ports are inserted in the gel. These 3 ports allow to insert a 5mm 30 degree optic and straight or angulated instruments into the abdomen.

D Mutter, J Marescaux

Surgical intervention

Laparoscopic one trocar cholecystectomy: Gelport® technique

Single port access cholecystectomy is a new laparoscopic procedure using only one transumbilically placed port. This video shows a procedure performed using a Gelport® through a 2.5cm incision. This Gelport® is usually used to perform hand-assisted surgery. In this case, the incision used to introduce the hand was closed by a single suture and 3 ports are inserted in the gel. These 3 ports allow to insert a 5mm 30 degree optic and straight or angulated instruments into the abdomen.

Laparoscopic Collis gastroplasty and partial fundoplication for valve slippage

Re-operative antireflux surgery represents a challenging and complex clinical undertaking requiring careful patient selection as well as a high level of technical expertise. The procedures themselves are associated with a high rate of morbidity.
This video shows a laparoscopic Collis gastroplasty and partial fundoplication for the treatment of valve slippage.

B Dallemagne, S Perretta, J Marescaux

Surgical intervention

Laparoscopic Collis gastroplasty and partial fundoplication for valve slippage

Re-operative antireflux surgery represents a challenging and complex clinical undertaking requiring careful patient selection as well as a high level of technical expertise. The procedures themselves are associated with a high rate of morbidity.
This video shows a laparoscopic Collis gastroplasty and partial fundoplication for the treatment of valve slippage.

Laparoscopic right colectomy with Ligasure Advance® for ileocaecal mass in a young male patient

Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk of perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. The purpose of this film is to demonstrate our right colectomy technique, which respects oncological principles. The case is performed in a male patient with a BMI of 22 and presenting with a voluminous caecal mass with a lipoma found on biopsy. Because of its volume, a right colectomy has been decided upon.

J Leroy, J Marescaux

Surgical intervention

Laparoscopic right colectomy with Ligasure Advance® for ileocaecal mass in a young male patient

Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk of perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. The purpose of this film is to demonstrate our right colectomy technique, which respects oncological principles. The case is performed in a male patient with a BMI of 22 and presenting with a voluminous caecal mass with a lipoma found on biopsy. Because of its volume, a right colectomy has been decided upon.

Laparoscopic right colectomy for voluminous polyp of the ascending colon

Laparoscopic resection of colorectal polyps is a safe and minimally invasive technique for the management of colorectal tumors. Thus, the laparoscopic approach to endoscopically not resectable polyps with suspicion of malignancy enriches the therapeutic spectrum.
The purpose of the video is to show the right colectomy technique for a caecal polyp with a possible degenerative disease. An oncological resection is therefore offered. The positioning of the trocars is no different than usual.

J Leroy, J Marescaux

Surgical intervention

Laparoscopic right colectomy for voluminous polyp of the ascending colon

Laparoscopic resection of colorectal polyps is a safe and minimally invasive technique for the management of colorectal tumors. Thus, the laparoscopic approach to endoscopically not resectable polyps with suspicion of malignancy enriches the therapeutic spectrum.
The purpose of the video is to show the right colectomy technique for a caecal polyp with a possible degenerative disease. An oncological resection is therefore offered. The positioning of the trocars is no different than usual.

Laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is an emerging bariatric procedure. Its acceptance as an alternative surgical treatment for morbid obesity in the last years is due to the fact that is a rapid and less traumatic operation and thus far is showing good resolution of co-morbidities and good weight loss. We present the stepwise approach for the construction of sleeve gastrectomy in an obese patient with the aid of five abdominal trocars.

M Vix, J Marescaux

Surgical intervention

Laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is an emerging bariatric procedure. Its acceptance as an alternative surgical treatment for morbid obesity in the last years is due to the fact that is a rapid and less traumatic operation and thus far is showing good resolution of co-morbidities and good weight loss. We present the stepwise approach for the construction of sleeve gastrectomy in an obese patient with the aid of five abdominal trocars.

Laparoscopic right colectomy with LigaSure Advance® for ileocaecal mass in a young male patient

The video "Laparoscopic right colectomy with LigaSure Advance® for ileocaecal mass in a young male patient" authored by J Leroy and J Marescaux is analysed by Dr. Barry Salky, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

B Salky, J Leroy, J Marescaux

Surgical intervention

Laparoscopic right colectomy with LigaSure Advance® for ileocaecal mass in a young male patient

The video "Laparoscopic right colectomy with LigaSure Advance® for ileocaecal mass in a young male patient" authored by J Leroy and J Marescaux is analysed by Dr. Barry Salky, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.