Monthly publications : May 2013 | WebSurg, the online university of IRCAD

Full endoscopic robot-assisted trisegmentectomy of the pulmonary left upper lobe for diagnosis and treatment

Objective:
When small pulmonary lesions are discovered on CT-scan during cancer surveillance, the differentiation between primary cancer metastasis and another metachronous carcinoma is impossible on frozen section. In this context, segmentectomy as sparing-lung resection is probably a valuable option to treat both lesions. However, segmentectomy is a complex procedure when using video thoracoscopy. Robotic segmentectomy, as described by Ninan (1) and Melfi (2), could be a more accurate and easier approach. Our objective is to show this reproducible technique.

Bibliographic references:
1. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2.
2. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
Materials and methods:
In 2006, a 78-year-old man was found with a medical history of asbestos exposure and colonic adenocarcinoma with lymph node metastasis treated by hemi-colectomy and adjuvant chemotherapy. During colon cancer surveillance, a centrimetric pulmonary mass of the left upper lobe was found on CT-scan in September 2012. In this context, the lesion was suggestive of metastasis, but primary lung cancer could not be ruled out (due to the patient’s history of smoking). As a result, trisegmentectomy of the left upper lobe was decided upon instead of wedge resection, for diagnosis and treatment of the lesion.
Results: The postoperative course was uneventful, with a medical discharge on the fourth day following trisegmentectomy. Pathological findings concluded to a primary lung carcinoma without lymph node invasion.
Conclusion: Complete and precise segmentectomy can be performed safely by means of the da Vinci™ robotic system, without using a utility thoracotomy. This diagnostic and therapeutic option must be considered in case of small pulmonary lesions occurring during cancer surveillance.

JM Baste, M Renaux-Petel, C Peillon

Surgical intervention

Full endoscopic robot-assisted trisegmentectomy of the pulmonary left upper lobe for diagnosis and treatment

Objective:
When small pulmonary lesions are discovered on CT-scan during cancer surveillance, the differentiation between primary cancer metastasis and another metachronous carcinoma is impossible on frozen section. In this context, segmentectomy as sparing-lung resection is probably a valuable option to treat both lesions. However, segmentectomy is a complex procedure when using video thoracoscopy. Robotic segmentectomy, as described by Ninan (1) and Melfi (2), could be a more accurate and easier approach. Our objective is to show this reproducible technique.

Bibliographic references:
1. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2.
2. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
Materials and methods:
In 2006, a 78-year-old man was found with a medical history of asbestos exposure and colonic adenocarcinoma with lymph node metastasis treated by hemi-colectomy and adjuvant chemotherapy. During colon cancer surveillance, a centrimetric pulmonary mass of the left upper lobe was found on CT-scan in September 2012. In this context, the lesion was suggestive of metastasis, but primary lung cancer could not be ruled out (due to the patient’s history of smoking). As a result, trisegmentectomy of the left upper lobe was decided upon instead of wedge resection, for diagnosis and treatment of the lesion.
Results: The postoperative course was uneventful, with a medical discharge on the fourth day following trisegmentectomy. Pathological findings concluded to a primary lung carcinoma without lymph node invasion.
Conclusion: Complete and precise segmentectomy can be performed safely by means of the da Vinci™ robotic system, without using a utility thoracotomy. This diagnostic and therapeutic option must be considered in case of small pulmonary lesions occurring during cancer surveillance.

EMR/ESD and beyond, CLEAN-NET

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are commonly accepted methods for the resection of early neoplastic lesions in the upper and lower gastrointestinal tract. In this lecture, Dr. Inoue presents a new combined endoscopic and laparoscopic approach for gastric lesions, the CLEAN-NET.

H Inoue

EMR/ESD and beyond, CLEAN-NET

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are commonly accepted methods for the resection of early neoplastic lesions in the upper and lower gastrointestinal tract. In this lecture, Dr. Inoue presents a new combined endoscopic and laparoscopic approach for gastric lesions, the CLEAN-NET.

SET submucosal endoscopic tumor resection

Endoscopic submucosal dissection (ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus. In this key lecture, Dr. Inoue presents the therapeutic strategy for leiomyomas of the esophagus and cardia.

H Inoue

SET submucosal endoscopic tumor resection

Endoscopic submucosal dissection (ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus. In this key lecture, Dr. Inoue presents the therapeutic strategy for leiomyomas of the esophagus and cardia.

Robot-assisted revision of stenotic gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass

This video presents the case of a 37-year-old woman who benefited from a laparoscopic Roux-en-Y gastric bypass with circular gastrojejunal anastomosis one year ago. An anastomotic stenosis rapidly occurred. It was managed conventionally by several endoscopic balloon dilatations without any stable results. It was found legitimate to offer the patient a revision of the gastrojejunostomy. Prior to performing the reintervention, a nasojejunal tube was placed in order to improve the patient’s enteral nutrition. Surgery consisted in the resection of the existing gastrojejunostomy and in the tailoring of a new manual anastomosis using the da Vinci™ robotic Surgical System. The postoperative outcome was uneventful. The patient no longer reports any dysphagia 3 months postoperatively.

M Vix, J Marescaux

Surgical intervention

Robot-assisted revision of stenotic gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass

This video presents the case of a 37-year-old woman who benefited from a laparoscopic Roux-en-Y gastric bypass with circular gastrojejunal anastomosis one year ago. An anastomotic stenosis rapidly occurred. It was managed conventionally by several endoscopic balloon dilatations without any stable results. It was found legitimate to offer the patient a revision of the gastrojejunostomy. Prior to performing the reintervention, a nasojejunal tube was placed in order to improve the patient’s enteral nutrition. Surgery consisted in the resection of the existing gastrojejunostomy and in the tailoring of a new manual anastomosis using the da Vinci™ robotic Surgical System. The postoperative outcome was uneventful. The patient no longer reports any dysphagia 3 months postoperatively.

Ablative and resective therapies of Barrett's esophagus

Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma (EAC). Patients with BE have a 40-fold higher risk of EAC as compared with the general population. In this lecture, Dr. Oliver Pech presents the management strategies for this condition.

O Pech

Ablative and resective therapies of Barrett's esophagus

Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma (EAC). Patients with BE have a 40-fold higher risk of EAC as compared with the general population. In this lecture, Dr. Oliver Pech presents the management strategies for this condition.

Laparoscopic Roux-en-Y gastric bypass with linear gastrojejunostomy: occurrence of postsurgical complications

Roux-en-Y gastric bypass is a common procedure in bariatric surgery. It can be perfectly standardized in order to make it technically easier to perform and to reduce risks of postoperative complications. This video shows a conventional gastric bypass procedure with linear gastrojejunostomy. The intervention ran smoothly. Twenty-four hours postoperatively, the patient complained of abdominal pain. Serum chemistries demonstrated severe inflammatory signs. An emergency CT-scan demonstrated a gastrojejunal fistula. It was decided to perform an emergency laparoscopic reintervention. An anastomotic dehiscence was identified and sutured. The postoperative outcome was finally uneventful.

M Vix, G Sojod, J Marescaux

Surgical intervention

Laparoscopic Roux-en-Y gastric bypass with linear gastrojejunostomy: occurrence of postsurgical complications

Roux-en-Y gastric bypass is a common procedure in bariatric surgery. It can be perfectly standardized in order to make it technically easier to perform and to reduce risks of postoperative complications. This video shows a conventional gastric bypass procedure with linear gastrojejunostomy. The intervention ran smoothly. Twenty-four hours postoperatively, the patient complained of abdominal pain. Serum chemistries demonstrated severe inflammatory signs. An emergency CT-scan demonstrated a gastrojejunal fistula. It was decided to perform an emergency laparoscopic reintervention. An anastomotic dehiscence was identified and sutured. The postoperative outcome was finally uneventful.

New instrumentation for flexible surgery

Incisionless surgical approaches hold the promise of fewer complications, reduced pain, faster recovery, and improved cosmesis as compared with traditional open or laparoscopic approaches but some problems persist regarding the available tools. In this key lecture, Dr. Perretta presents the emerging new tools for endoscopic and hybrid procedures.

New instrumentation for flexible surgery

Incisionless surgical approaches hold the promise of fewer complications, reduced pain, faster recovery, and improved cosmesis as compared with traditional open or laparoscopic approaches but some problems persist regarding the available tools. In this key lecture, Dr. Perretta presents the emerging new tools for endoscopic and hybrid procedures.

Laparoscopic hand-sewn re-gastrojejunostomy for complicated Roux-en-Y gastric bypass

Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a popular bariatric procedure associated with potential risk of late complications such as anastomotic stricture, marginal ulceration, fistula formation, weight gain, and nutritional deficiencies. A 48-year-old woman submitted to LRYGB 1.5 year before, presented a marginal ulcer of the gastrojejunostomy, non-responsive to medical therapy, associated with total dysphagia and cachexia. At the time of LRYGB, a linear stapled side-to-side gastrojejunostomy has been performed.

Video: The revision was completed using 4 abdominal trocars and consisted in these successive steps: adhesiolysis between the left liver lobe, gastrojejunostomy and gastric pouch; identification of right crus and lower esophagus; mobilization of the stoma and gastric pouch from both crura, transverse colon and gastric remnant; division of the gastric pouch above the stoma with preservation of the left gastric vessels; division of the proximal alimentary limb under the stoma; new double-layer hand-sewn gastrojejunostomy (PDS 1 externally, PDS 2/0 internally); hiatoplasty; leak test; specimen’s removal through trocar enlargement.

Results: No perioperative complications or additional trocars were registered. Operative time was 157 minutes and estimated blood loss 20 cc. The postoperative course was uneventful and patient was discharged on postoperative day 3. After 1 year, the patient is well and tolerates a regular diet.

Conclusions: Postoperative complications after LRYGB, such as marginal ulcer, can be safely treated by laparoscopy. New hand-sewn anastomosis permits to control the stoma openings and to calibrate the anastomosis size, especially in case of small gastric pouch.

G Dapri

Surgical intervention

Laparoscopic hand-sewn re-gastrojejunostomy for complicated Roux-en-Y gastric bypass

Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a popular bariatric procedure associated with potential risk of late complications such as anastomotic stricture, marginal ulceration, fistula formation, weight gain, and nutritional deficiencies. A 48-year-old woman submitted to LRYGB 1.5 year before, presented a marginal ulcer of the gastrojejunostomy, non-responsive to medical therapy, associated with total dysphagia and cachexia. At the time of LRYGB, a linear stapled side-to-side gastrojejunostomy has been performed.

Video: The revision was completed using 4 abdominal trocars and consisted in these successive steps: adhesiolysis between the left liver lobe, gastrojejunostomy and gastric pouch; identification of right crus and lower esophagus; mobilization of the stoma and gastric pouch from both crura, transverse colon and gastric remnant; division of the gastric pouch above the stoma with preservation of the left gastric vessels; division of the proximal alimentary limb under the stoma; new double-layer hand-sewn gastrojejunostomy (PDS 1 externally, PDS 2/0 internally); hiatoplasty; leak test; specimen’s removal through trocar enlargement.

Results: No perioperative complications or additional trocars were registered. Operative time was 157 minutes and estimated blood loss 20 cc. The postoperative course was uneventful and patient was discharged on postoperative day 3. After 1 year, the patient is well and tolerates a regular diet.

Conclusions: Postoperative complications after LRYGB, such as marginal ulcer, can be safely treated by laparoscopy. New hand-sewn anastomosis permits to control the stoma openings and to calibrate the anastomosis size, especially in case of small gastric pouch.

Update on endoscopic Rx of GERD

Many procedures exist for GERD therapy. In this key lecture, Dr. Soper outlines the different endoscopic options as well as the new LINX® system.

N Soper

Update on endoscopic Rx of GERD

Many procedures exist for GERD therapy. In this key lecture, Dr. Soper outlines the different endoscopic options as well as the new LINX® system.

Robot-assisted Roux-en-Y gastric bypass using Sonicision™ cordless ultrasonic dissection device

The video entitled "Robot-assisted Roux-en-Y gastric bypass, Sonicision™ cordless ultrasonic dissection device", authored by M Vix, KH Liu, and J Marescaux is analyzed by John Morton, MD, MPH, FACS (Stanford Hospital and Clinics, Stanford, CA, USA), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

J Morton

Surgical intervention

Robot-assisted Roux-en-Y gastric bypass using Sonicision™ cordless ultrasonic dissection device

The video entitled "Robot-assisted Roux-en-Y gastric bypass, Sonicision™ cordless ultrasonic dissection device", authored by M Vix, KH Liu, and J Marescaux is analyzed by John Morton, MD, MPH, FACS (Stanford Hospital and Clinics, Stanford, CA, USA), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Interventional flexible endoscopy for surgeons: hybrid laparo-endoscopic procedures

In this key lecture, Dr. Swanström stresses the importance of endoscopic experience for general surgeons and presents the future developments in hybrid endoscopic and laparoscopic approaches.

Interventional flexible endoscopy for surgeons: hybrid laparo-endoscopic procedures

In this key lecture, Dr. Swanström stresses the importance of endoscopic experience for general surgeons and presents the future developments in hybrid endoscopic and laparoscopic approaches.

Petrous bone tumors imaging

In this key lecture, Dr. Veillon presents petrous bone tumors imaging.

Petrous bone tumors imaging

In this key lecture, Dr. Veillon presents petrous bone tumors imaging.

Technique and portals

In this key lecture, Dr. Samson presents fundamentals regarding technique and portals.

Technique and portals

In this key lecture, Dr. Samson presents fundamentals regarding technique and portals.

Advanced endoscopic procedures, techniques and indications: clivus surgery for chordomas

In this key lecture, Dr. Herman outlines advanced endoscopic procedures, techniques and indications related to clivus surgery for chordomas.

Advanced endoscopic procedures, techniques and indications: clivus surgery for chordomas

In this key lecture, Dr. Herman outlines advanced endoscopic procedures, techniques and indications related to clivus surgery for chordomas.

Petrous apex approach

In this key lecture, Dr. Herman outlines the petrous apex approach.

Petrous apex approach

In this key lecture, Dr. Herman outlines the petrous apex approach.

Sagittal plane modules

In this key lecture, Dr. Herman outlines sagittal plane modules.

Sagittal plane modules

In this key lecture, Dr. Herman outlines sagittal plane modules.

Long-term results: bariatric surgery

In this circumstantial lecture, Professor Buchwald reviews the results of bariatric procedures.

Long-term results: bariatric surgery

In this circumstantial lecture, Professor Buchwald reviews the results of bariatric procedures.

Operative approach to one-stage duodenal switch

In this key lecture, Professor Buchwald details the duodenal switch procedure for severe morbid obesity. He analyzes and compares the results with other bariatric procedures.

Operative approach to one-stage duodenal switch

In this key lecture, Professor Buchwald details the duodenal switch procedure for severe morbid obesity. He analyzes and compares the results with other bariatric procedures.

Do volumes influence outcomes?

In this key lecture, Dr. Herron looks into the influence of volumes of patients on clinical outcome.

Do volumes influence outcomes?

In this key lecture, Dr. Herron looks into the influence of volumes of patients on clinical outcome.

How to take the needle holder?

The first step for successful suturing is to respect adequate ergonomics rules. In this video, the appropriate way of taking the needle holder is shown, in order to ensure precision in the movements required to perform a perfect stitch.

A Wattiez, C Redondo Guisasola, M Puga, Al Ussia

Surgical intervention

How to take the needle holder?

The first step for successful suturing is to respect adequate ergonomics rules. In this video, the appropriate way of taking the needle holder is shown, in order to ensure precision in the movements required to perform a perfect stitch.

Deep endometriosis: technique and strategy

Deep infiltrating endometriosis (DIE) surgery is one of the most challenging procedures that gynecologic surgeons can be faced with. In order to achieve the highest efficacy with a lesser risk of complications, one should be aware of technical and strategic principles in order to handle the procedure. In this authoritative lecture, Dr. Marco Puga outlines the main facts one must bear in mind.

M Puga

Deep endometriosis: technique and strategy

Deep infiltrating endometriosis (DIE) surgery is one of the most challenging procedures that gynecologic surgeons can be faced with. In order to achieve the highest efficacy with a lesser risk of complications, one should be aware of technical and strategic principles in order to handle the procedure. In this authoritative lecture, Dr. Marco Puga outlines the main facts one must bear in mind.

Tenodermodesis for Mallet finger

Rupture of the distal insertion of the extensor tendon in long digits is common when extension is thwarted. Orthopedic repair is the rule, but in case of failure, an original technique of secondary tenodermodesis allows for a good repair. This video was captured using the VITOM system from KARL STORZ.

C Mathoulin

Surgical intervention

Tenodermodesis for Mallet finger

Rupture of the distal insertion of the extensor tendon in long digits is common when extension is thwarted. Orthopedic repair is the rule, but in case of failure, an original technique of secondary tenodermodesis allows for a good repair. This video was captured using the VITOM system from KARL STORZ.

Management of Roux-en-Y gastric bypass (RYGB) complications: laparoscopic gastric bypass case, abrupt onset abdominal pain

In this key lecture, Dr. Herron outlines the surgical management of RYGB complications.

Management of Roux-en-Y gastric bypass (RYGB) complications: laparoscopic gastric bypass case, abrupt onset abdominal pain

In this key lecture, Dr. Herron outlines the surgical management of RYGB complications.

Right iliac fossa mass

This video shows the case of a 40-year-old woman complaining of pain in the right iliac fossa. Clinical history and complementary exams were suggestive of an appendicitis alleviated by an antibiotic treatment. However, they did not contribute to rule out the presence of a mucoid tumor of the appendix or of any gynecologic origin. The laparoscopic approach makes it possible to define the etiology of the lesion and to treat it. A centripetal strategy is used to safely perform the resection of this appendicular phlegmon.

M Vix, M Raharimanantsoa, J Marescaux

Surgical intervention

Right iliac fossa mass

This video shows the case of a 40-year-old woman complaining of pain in the right iliac fossa. Clinical history and complementary exams were suggestive of an appendicitis alleviated by an antibiotic treatment. However, they did not contribute to rule out the presence of a mucoid tumor of the appendix or of any gynecologic origin. The laparoscopic approach makes it possible to define the etiology of the lesion and to treat it. A centripetal strategy is used to safely perform the resection of this appendicular phlegmon.

Laparoscopic hysterectomy

Laparoscopic hysterectomy is a common procedure in the gynecological sphere. In order to perform a safe, easy and reproducible surgery, surgeons require adequate training as well as theoretical knowledge. In this key lecture, a perfect approach to the main steps required for a perfect laparoscopic hysterectomy is demonstrated.

Laparoscopic hysterectomy

Laparoscopic hysterectomy is a common procedure in the gynecological sphere. In order to perform a safe, easy and reproducible surgery, surgeons require adequate training as well as theoretical knowledge. In this key lecture, a perfect approach to the main steps required for a perfect laparoscopic hysterectomy is demonstrated.

Is sleeve gastrectomy a metabolic operation?

Sleeve gastrectomy is a valuable emerging bariatric procedure. In this authoritative lecture, Dr. Herron presents the results of this procedure on metabolic aspects.

Is sleeve gastrectomy a metabolic operation?

Sleeve gastrectomy is a valuable emerging bariatric procedure. In this authoritative lecture, Dr. Herron presents the results of this procedure on metabolic aspects.

Laparoscopic management of small bowel perforation induced by foreign body

Ingested foreign bodies are a common cause for emergency hospital admission. A precise interview of the patient often allows to establish the diagnosis. In 90% of cases, the foreign body is spontaneously eliminated without inducing any particular symptoms. In less than 10% of cases, it requires non-surgical extraction maneuvers (enemas, endoscopy). Only 1% of cases are treated surgically. Modern imaging frequently allows to establish a precise topographic diagnosis based on aspect, size and density. Coupled with laparoscopic surgery, it allows for an early, targeted and minimally invasive management. In this video, we show the case of a patient presenting with typical signs of peritonitis along with the incidental discovery of an intraluminal foreign body in the small bowel which brought about a micro-perforation.

L Marx, M Raharimanantsoa, J Marescaux

Surgical intervention

Laparoscopic management of small bowel perforation induced by foreign body

Ingested foreign bodies are a common cause for emergency hospital admission. A precise interview of the patient often allows to establish the diagnosis. In 90% of cases, the foreign body is spontaneously eliminated without inducing any particular symptoms. In less than 10% of cases, it requires non-surgical extraction maneuvers (enemas, endoscopy). Only 1% of cases are treated surgically. Modern imaging frequently allows to establish a precise topographic diagnosis based on aspect, size and density. Coupled with laparoscopic surgery, it allows for an early, targeted and minimally invasive management. In this video, we show the case of a patient presenting with typical signs of peritonitis along with the incidental discovery of an intraluminal foreign body in the small bowel which brought about a micro-perforation.

Laparoscopic colposacropexy for the treatment of an apical defect in a patient with previous total hysterectomy

We present the case of a 69-year-old patient who suffered from an elytrocele. Previously, she had undergone a total hysterectomy with anterior and posterior colpoperineoplasty due to the presence of a grade 2 cystocele, without urinary incontinence. The management of genital prolapse requires a thorough knowledge of the anatomy and physiology of the female pelvic floor. This video outlines the main steps to follow for the repair of an apical defect with no true rectocele or cystocele. It also offers a very good insight of the specific issues to be considered when performing dissection and mesh fixation in specific situations, such as distortion of the normal anatomy due to the scarring process from a previous surgery and obesity. This surgery was performed and streamed live.

A Wattiez, C Redondo Guisasola, M Puga, F Asencio

Surgical intervention

Laparoscopic colposacropexy for the treatment of an apical defect in a patient with previous total hysterectomy

We present the case of a 69-year-old patient who suffered from an elytrocele. Previously, she had undergone a total hysterectomy with anterior and posterior colpoperineoplasty due to the presence of a grade 2 cystocele, without urinary incontinence. The management of genital prolapse requires a thorough knowledge of the anatomy and physiology of the female pelvic floor. This video outlines the main steps to follow for the repair of an apical defect with no true rectocele or cystocele. It also offers a very good insight of the specific issues to be considered when performing dissection and mesh fixation in specific situations, such as distortion of the normal anatomy due to the scarring process from a previous surgery and obesity. This surgery was performed and streamed live.

In your opinion, should hysterectomy be performed in all prolapse surgeries?

JB Dubuisson, R Milani, A Setúbal

Cerebral revascularization in the 21st century

In this key lecture, Dr. Zuccarello presents cerebral revascularization in the 21st century.

Cerebral revascularization in the 21st century

In this key lecture, Dr. Zuccarello presents cerebral revascularization in the 21st century.

A difficult case of ureteral and bowel endometriosis: conservative vs. radical treatment

Deep infiltrating endometriosis is a challenging surgical procedure. Even if preoperative work-up is of major importance, several decisions can only be made after surgical re-evaluation of the lesion. Both ureteral and bowel endometriosis are good instances of this philosophy. The conservative approach must be considered first whenever possible. However, in some cases, the success of the procedure combined with patient prognosis is unsatisfactory.

A Wattiez, M Puga, C Redondo Guisasola, F Ruhlmann, J Leroy

Surgical intervention

A difficult case of ureteral and bowel endometriosis: conservative vs. radical treatment

Deep infiltrating endometriosis is a challenging surgical procedure. Even if preoperative work-up is of major importance, several decisions can only be made after surgical re-evaluation of the lesion. Both ureteral and bowel endometriosis are good instances of this philosophy. The conservative approach must be considered first whenever possible. However, in some cases, the success of the procedure combined with patient prognosis is unsatisfactory.

Full laparoscopic pancreaticoduodenectomy for malignant ampulloma

In the first description of Laparoscopic PancreaticoDuodenectomy (LPD) by Gagner and Pomp in 1994, the authors reported the technical feasibility of the procedure, but questioned its advantages as compared with the open approach. Recent reports on large series of LPD demonstrated that the procedure might not only be feasible, but that it might have advantages as compared with open pancreaticoduodenectomy. Blood loss, ICU length of stay and overall hospital length of stay were shorter in the LPD group at the cost of significantly higher operative times. This video demonstrates a full LPD performed for a malignant ampulloma. All major steps of the procedure are extensively and clearly demonstrated.

A Talvane Torres de Oliveira, C Lacerda, PA Bertulucci

Surgical intervention

Full laparoscopic pancreaticoduodenectomy for malignant ampulloma

In the first description of Laparoscopic PancreaticoDuodenectomy (LPD) by Gagner and Pomp in 1994, the authors reported the technical feasibility of the procedure, but questioned its advantages as compared with the open approach. Recent reports on large series of LPD demonstrated that the procedure might not only be feasible, but that it might have advantages as compared with open pancreaticoduodenectomy. Blood loss, ICU length of stay and overall hospital length of stay were shorter in the LPD group at the cost of significantly higher operative times. This video demonstrates a full LPD performed for a malignant ampulloma. All major steps of the procedure are extensively and clearly demonstrated.

Laparoscopic anatomy

Proper knowledge of the pelvic anatomy is fundamental to perform laparoscopic surgery. In this key lecture, Dr. Ferreira provides an overview of all anatomical structures along with their anatomical relationships. The knowledge required to perform a successful and safe procedure is provided.

H Ferreira Carvalho

Laparoscopic anatomy

Proper knowledge of the pelvic anatomy is fundamental to perform laparoscopic surgery. In this key lecture, Dr. Ferreira provides an overview of all anatomical structures along with their anatomical relationships. The knowledge required to perform a successful and safe procedure is provided.

Laparoscopic suturing

In order to acquire the necessary skills for suturing, it is essential to perfectly know the different principles and techniques. In this key lecture, one can find a medley of the basic rules to bear in mind when suturing, as well as ergonomic tenets and different types of knots.

C Redondo Guisasola

Laparoscopic suturing

In order to acquire the necessary skills for suturing, it is essential to perfectly know the different principles and techniques. In this key lecture, one can find a medley of the basic rules to bear in mind when suturing, as well as ergonomic tenets and different types of knots.

Wrist arthroscopy: indications, complications

In this key lecture, Dr. Rizzo presents wrist arthroscopy indications and complications.

C Rizzo

Wrist arthroscopy: indications, complications

In this key lecture, Dr. Rizzo presents wrist arthroscopy indications and complications.