Monthly publications : May 2014 | WebSurg, the online university of IRCAD

Reoperation for symptomatic intrathoracic migration of a fundoplication: valve repositioning and reinforced crural repair

Intrathoracic migration of the fundoplication is one of the most common causes of failure after antireflux surgery. When the patient develops symptoms related to the volume of intramediastinal hernia, the only option is to reoperate. Such redos are complex and necessitate a thorough and painstaking approach to the potential underlying mechanisms causing intrathoracic migration, namely the length of the esophagus and cruroplasty.

B Dallemagne, S Perretta, LL Swanström, J Marescaux

Surgical intervention

Reoperation for symptomatic intrathoracic migration of a fundoplication: valve repositioning and reinforced crural repair

Intrathoracic migration of the fundoplication is one of the most common causes of failure after antireflux surgery. When the patient develops symptoms related to the volume of intramediastinal hernia, the only option is to reoperate. Such redos are complex and necessitate a thorough and painstaking approach to the potential underlying mechanisms causing intrathoracic migration, namely the length of the esophagus and cruroplasty.

Laparoscopic Roux-en-Y gastric bypass: second redo

Bariatric surgery has undergone a rapid evolution over the last few years. Nowadays, laparoscopic sleeve gastrectomy represents a valuable alternative to laparoscopic Roux-en-Y gastric bypass, especially in patients with a very high BMI and in whom a gastric bypass procedure may be difficult. A thorough preoperative evaluation should always be performed in order to rule out any contraindication (e.g., hiatal hernia, gastroesophageal reflux). Here, we present a case of a female patient suffering from severe gastroesophageal reflux after sleeve gastrectomy associated with a major weight regain further to two bariatric surgeries.

L Marx, M Nedelcu, M Vix, J Marescaux

Surgical intervention

Laparoscopic Roux-en-Y gastric bypass: second redo

Bariatric surgery has undergone a rapid evolution over the last few years. Nowadays, laparoscopic sleeve gastrectomy represents a valuable alternative to laparoscopic Roux-en-Y gastric bypass, especially in patients with a very high BMI and in whom a gastric bypass procedure may be difficult. A thorough preoperative evaluation should always be performed in order to rule out any contraindication (e.g., hiatal hernia, gastroesophageal reflux). Here, we present a case of a female patient suffering from severe gastroesophageal reflux after sleeve gastrectomy associated with a major weight regain further to two bariatric surgeries.

A new tool to access the extraperitoneal space in bilateral hernia TEP repair

Access to the extraperitoneal space is a key step in the totally extraperitoneal approach for the management of inguinal hernia. Different techniques have been described. However, the safest technique remains a standardized approach to the muscular sheath of rectus abdominis muscles. In this film, we demonstrate the benefit of using a port equipped with a dilatation sheath. The entire procedure is also shown.

B Dallemagne, A D'Urso, J Marescaux

Surgical intervention

A new tool to access the extraperitoneal space in bilateral hernia TEP repair

Access to the extraperitoneal space is a key step in the totally extraperitoneal approach for the management of inguinal hernia. Different techniques have been described. However, the safest technique remains a standardized approach to the muscular sheath of rectus abdominis muscles. In this film, we demonstrate the benefit of using a port equipped with a dilatation sheath. The entire procedure is also shown.

Laparoscopic right ureterovesical reimplantation according to Lich-Gregoir

The video entitled "Laparoscopic right ureterovesical reimplantation according to Lich-Gregoir", authored by F Becmeur is analyzed by Abraham Cherian, MBBS, MS, DNB, FRCS (Great Ormond Street Hospital, London, United Kingdom), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

A Cherian

Surgical intervention

Laparoscopic right ureterovesical reimplantation according to Lich-Gregoir

The video entitled "Laparoscopic right ureterovesical reimplantation according to Lich-Gregoir", authored by F Becmeur is analyzed by Abraham Cherian, MBBS, MS, DNB, FRCS (Great Ormond Street Hospital, London, United Kingdom), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Rectovaginal nodule and discoid resection for endometriosis

This case shows a rectovaginal endometriotic nodule with transmural involvement of the vagina and a tight attachment of the sigmoid colon to the posterior aspect of the uterus. Nodule resection required a vaginal opening and a sigmoid anterior discoid resection. A flap was then performed to protect the stapling line on the bowel and prevent the risk of rectovaginal fistula.

A Wattiez, R Murtada, K Afors, J Castellano, G Centini, R Fernandes, C Meza Paul

Surgical intervention

Rectovaginal nodule and discoid resection for endometriosis

This case shows a rectovaginal endometriotic nodule with transmural involvement of the vagina and a tight attachment of the sigmoid colon to the posterior aspect of the uterus. Nodule resection required a vaginal opening and a sigmoid anterior discoid resection. A flap was then performed to protect the stapling line on the bowel and prevent the risk of rectovaginal fistula.

Stepwise radical vaginal trachelectomy: Dargent’s operation

Up to 40% of early cervical cancers are diagnosed in young women who might desire fertility preservation. More than 1,000 cases of Radical Vaginal Trachelectomy (RVT) have been published so far, with over 450 pregnancies achieved. Oncological outcomes of this treatment are totally comparable with the ones obtained with radical hysterectomies for similar size lesions. Additionally, these results are similar or superior when compared to the other routes of trachelectomy.
The procedure is always combined with a laparoscopic pelvic lymphadenectomy to rule out the possibility of lymph node metastases.
This video demonstrates the technique of RVT. Interesting parts of the vaginal steps are shown along with their contemporary laparoscopic views for didactic purposes.

E Leblanc, F Narducci, L Bresson, M Puga

Surgical intervention

Stepwise radical vaginal trachelectomy: Dargent’s operation

Up to 40% of early cervical cancers are diagnosed in young women who might desire fertility preservation. More than 1,000 cases of Radical Vaginal Trachelectomy (RVT) have been published so far, with over 450 pregnancies achieved. Oncological outcomes of this treatment are totally comparable with the ones obtained with radical hysterectomies for similar size lesions. Additionally, these results are similar or superior when compared to the other routes of trachelectomy.
The procedure is always combined with a laparoscopic pelvic lymphadenectomy to rule out the possibility of lymph node metastases.
This video demonstrates the technique of RVT. Interesting parts of the vaginal steps are shown along with their contemporary laparoscopic views for didactic purposes.

Voluminous pararectal and presacral paraganglioma: laparoscopic resection

In this video, authors demonstrate the feasibility of performing the laparoscopic resection of a voluminous benign right pararectal tumor encapsulated in the pelvic floor.

J Leroy, D Ntourakis, J Marescaux

Surgical intervention

Voluminous pararectal and presacral paraganglioma: laparoscopic resection

In this video, authors demonstrate the feasibility of performing the laparoscopic resection of a voluminous benign right pararectal tumor encapsulated in the pelvic floor.

In your opinion, what is the optimal way of teaching anatomy to trainees?

P Bonnet, M Ceccaroni, V Delmas

Bariatric/metabolic surgery: take home message

Morbid obesity is a medical and social problem worldwide. In this lecture, Dr. Pomp demonstrates the current status and indications for morbid obesity.

A Pomp

Bariatric/metabolic surgery: take home message

Morbid obesity is a medical and social problem worldwide. In this lecture, Dr. Pomp demonstrates the current status and indications for morbid obesity.

Scopinaro's technique in bariatric surgery

Professor Nicola Scopinaro performed the first biliopancreatic diversion in 1976. Today, his procedure is performed in about 150 centers in the United States. In this lecture, he details his procedure and presents his 30 years’ experience.

Scopinaro's technique in bariatric surgery

Professor Nicola Scopinaro performed the first biliopancreatic diversion in 1976. Today, his procedure is performed in about 150 centers in the United States. In this lecture, he details his procedure and presents his 30 years’ experience.

Surgical treatment of type 2 diabetes in non-obese patients

Type 2 diabetes and morbid obesity are major health problems that have reached epidemic proportions and are growing at alarming rates around the world. In this lecture, Professor Scopinaro outlines the current management of type 2 diabetes in obese patients.

Surgical treatment of type 2 diabetes in non-obese patients

Type 2 diabetes and morbid obesity are major health problems that have reached epidemic proportions and are growing at alarming rates around the world. In this lecture, Professor Scopinaro outlines the current management of type 2 diabetes in obese patients.

Robotic bariatric surgery

In this lecture, Dr. Katz presents the evolution of robotic surgery and its application in morbidly obese patients. Dr. Katz’s technique is also outlined.

L Katz

Robotic bariatric surgery

In this lecture, Dr. Katz presents the evolution of robotic surgery and its application in morbidly obese patients. Dr. Katz’s technique is also outlined.

Left upper lobectomy: how I do it?

Dr. Thomas presents his technique of video-assisted left upper lobectomy for lung cancer.

Left upper lobectomy: how I do it?

Dr. Thomas presents his technique of video-assisted left upper lobectomy for lung cancer.

Middle lobectomy: how I do it?

Dr. Thomas presents his technique of video-assisted middle lobectomy for lung cancer.

Middle lobectomy: how I do it?

Dr. Thomas presents his technique of video-assisted middle lobectomy for lung cancer.

VATS thymectomy: left approach

Dr. Thomas presents the advantages of a single left approach for VATS thymectomy.

VATS thymectomy: left approach

Dr. Thomas presents the advantages of a single left approach for VATS thymectomy.

Minimizing entry-related complications in laparoscopy in women

Entry is a key step in laparoscopic surgery. It must be mastered in order to prevent potential major complications. This key lecture will help you understand the principles of the Endotip entry technique, also providing an overview of other techniques.

Minimizing entry-related complications in laparoscopy in women

Entry is a key step in laparoscopic surgery. It must be mastered in order to prevent potential major complications. This key lecture will help you understand the principles of the Endotip entry technique, also providing an overview of other techniques.

Deep infiltrating endometriosis (DIE), technique and strategy

In this authoritative lecture, Professor Arnaud Wattiez provides the perfect introduction to deep infiltrating endometriosis surgery. He teaches you how to tailor your surgery according to patient symptoms and objectives. The therapeutic strategy will allow you to approach the disease balancing radicality with organ function preservation.

Deep infiltrating endometriosis (DIE), technique and strategy

In this authoritative lecture, Professor Arnaud Wattiez provides the perfect introduction to deep infiltrating endometriosis surgery. He teaches you how to tailor your surgery according to patient symptoms and objectives. The therapeutic strategy will allow you to approach the disease balancing radicality with organ function preservation.

Sleeve gastrectomy and hiatal hernia/reflux disease

A Pomp

Dural repair/closure/protection

In this key lecture, Dr. Herman outlines dural repair/closure/protection issues.

Dural repair/closure/protection

In this key lecture, Dr. Herman outlines dural repair/closure/protection issues.

The transmaxillary window – route to the pterygoids and beyond, the lateral skull base

In this key lecture, Dr. Herman outlines the transmaxillary window, route to the pterygoids and beyond, the lateral skull base.

The transmaxillary window – route to the pterygoids and beyond, the lateral skull base

In this key lecture, Dr. Herman outlines the transmaxillary window, route to the pterygoids and beyond, the lateral skull base.

Robotic thoracoscopy, intercostal nerves harvesting

In this key lecture, Dr. Liverneaux outlines the use of robotic thoracoscopy with regards to intercostal nerves harvesting.

Robotic thoracoscopy, intercostal nerves harvesting

In this key lecture, Dr. Liverneaux outlines the use of robotic thoracoscopy with regards to intercostal nerves harvesting.

Endoscopic endonasal vs. keyhole approaches for anterior skull base lesion

In this key lecture, Dr. Hopf outlines endoscopic endonasal vs. keyhole approaches for anterior skull base lesion.

Endoscopic endonasal vs. keyhole approaches for anterior skull base lesion

In this key lecture, Dr. Hopf outlines endoscopic endonasal vs. keyhole approaches for anterior skull base lesion.

Bony TFCC refixation

In this key lecture, Dr. Schmelzer-Schmied outlines bony TFCC refixation.

N Schmelzer-Schmied

Bony TFCC refixation

In this key lecture, Dr. Schmelzer-Schmied outlines bony TFCC refixation.

da Vinci® Si™ Surgical System: current and future technologies

Since the first robotic case in 1999 with the da Vinci® system, Intuitive Surgical has created three different surgical platforms: the da Vinci Standard, the S and the Si. This presentation first reviews the latest da Vinci® system and instrumentation: the simulator, firefly, suction-irrigation, and the vessel-sealer. It then moves on to show upcoming instruments (the linear stapler) and introduces the possible future application of medical imaging agents (non-specific to the robot). As this presentation was made within the context of the RAMSES congress, a few slides show ongoing work specific to “shallow procedures” as well as ongoing research in that field.

da Vinci® Si™ Surgical System: current and future technologies

Since the first robotic case in 1999 with the da Vinci® system, Intuitive Surgical has created three different surgical platforms: the da Vinci Standard, the S and the Si. This presentation first reviews the latest da Vinci® system and instrumentation: the simulator, firefly, suction-irrigation, and the vessel-sealer. It then moves on to show upcoming instruments (the linear stapler) and introduces the possible future application of medical imaging agents (non-specific to the robot). As this presentation was made within the context of the RAMSES congress, a few slides show ongoing work specific to “shallow procedures” as well as ongoing research in that field.

Robotic-assisted latissimus dorsi in delayed immediate breast reconstruction

Background: For two-stage delayed-immediate reconstruction of the radiated breast, robotic-assisted latissimus dorsi harvest (RALDH) is a secondary option for patients who wish to avoid a donor site incision. The purpose of this study was to compare outcomes of RALDH versus a traditional open technique (TOT) for patients undergoing delayed-immediate breast reconstruction following radiation therapy.
Methods: A retrospective analysis of a prospective database of all consecutive patients undergoing latissimus dorsi harvest for radiated breast reconstruction between 2009 and 2013 was performed. Indications, surgical technique, complications and outcomes were assessed.
Results: 146 pedicled latissimus dorsi muscle flaps were performed for breast reconstruction and 17 were performed with robotic assistance during the study period (average follow-up 14.6 ±7.3 months). Latissimus dorsi breast reconstruction following radiation was performed in 64 TOT patients and 12 RALDH patients. Surgical complication rates were 37.5% TOT versus 16.7% RALDH (p=0.31), which included seroma (8.9% vs. 8.3%), infection (14.1 vs. 8.3%), wound healing (7.8% vs. 0), and capsular contracture (4.7% vs. 0).
Conclusion: RALDH is associated with a low complication rate and reliable results for reconstruction of the irradiated breast while obviating the need for a donor site incision.

Robotic-assisted latissimus dorsi in delayed immediate breast reconstruction

Background: For two-stage delayed-immediate reconstruction of the radiated breast, robotic-assisted latissimus dorsi harvest (RALDH) is a secondary option for patients who wish to avoid a donor site incision. The purpose of this study was to compare outcomes of RALDH versus a traditional open technique (TOT) for patients undergoing delayed-immediate breast reconstruction following radiation therapy.
Methods: A retrospective analysis of a prospective database of all consecutive patients undergoing latissimus dorsi harvest for radiated breast reconstruction between 2009 and 2013 was performed. Indications, surgical technique, complications and outcomes were assessed.
Results: 146 pedicled latissimus dorsi muscle flaps were performed for breast reconstruction and 17 were performed with robotic assistance during the study period (average follow-up 14.6 ±7.3 months). Latissimus dorsi breast reconstruction following radiation was performed in 64 TOT patients and 12 RALDH patients. Surgical complication rates were 37.5% TOT versus 16.7% RALDH (p=0.31), which included seroma (8.9% vs. 8.3%), infection (14.1 vs. 8.3%), wound healing (7.8% vs. 0), and capsular contracture (4.7% vs. 0).
Conclusion: RALDH is associated with a low complication rate and reliable results for reconstruction of the irradiated breast while obviating the need for a donor site incision.

Robotics in shoulder and elbow

When a patient presents ulnar nerve entrapment with clear surgical indication, there are many surgical techniques which can be used for nerve release.
Endoscopic techniques have recently been developed in order to access the ulnar nerve by using a minimally invasive approach. However, these techniques are considered difficult and often dangerous, and should only be used by experienced elbow arthroscopic surgeons.
A new endoscopic approach can make this surgery safer and easier by using robotic technology.
In this note, the authors report the technique they use to endoscopically access the ulnar nerve and its entrapment sites, assisted by the da Vinci® robot.

Robotics in shoulder and elbow

When a patient presents ulnar nerve entrapment with clear surgical indication, there are many surgical techniques which can be used for nerve release.
Endoscopic techniques have recently been developed in order to access the ulnar nerve by using a minimally invasive approach. However, these techniques are considered difficult and often dangerous, and should only be used by experienced elbow arthroscopic surgeons.
A new endoscopic approach can make this surgery safer and easier by using robotic technology.
In this note, the authors report the technique they use to endoscopically access the ulnar nerve and its entrapment sites, assisted by the da Vinci® robot.

Intercostal nerves harvesting through thoracoscopy without da Vinci™ robot

Intercostal nerve transfer is useful in brachial plexus surgery, especially for the restoration of elbow flexion. Freeing of intercostal nerves for nerve transfer, however, requires a long skin incision and can result in damage to the muscles and ribs. Video-assisted thoracoscopic surgery (VATS) has been developed recently as a diagnostic and therapeutic technique for intrathoracic organ diseases. Intercostal nerve transfer to the musculocutaneous nerve (MCN) using the VATS system has been performed in eight patients with brachial plexus injuries.

Eight patients (seven males, one female, 17-32 y.o.) underwent intercostal nerve transfer to the MCN using the VATS system between 2005 and 2012. Two patients were converted from thoracoscopic surgery to open surgery. Power of the biceps was recovered to M3 or more in five out of seven patients, who were followed for more than two years postoperatively. No respiratory complications occurred.
Although this technique is challenging, the da Vinci® system will make the procedure easier and improve its accuracy and safety.

Intercostal nerves harvesting through thoracoscopy without da Vinci™ robot

Intercostal nerve transfer is useful in brachial plexus surgery, especially for the restoration of elbow flexion. Freeing of intercostal nerves for nerve transfer, however, requires a long skin incision and can result in damage to the muscles and ribs. Video-assisted thoracoscopic surgery (VATS) has been developed recently as a diagnostic and therapeutic technique for intrathoracic organ diseases. Intercostal nerve transfer to the musculocutaneous nerve (MCN) using the VATS system has been performed in eight patients with brachial plexus injuries.

Eight patients (seven males, one female, 17-32 y.o.) underwent intercostal nerve transfer to the MCN using the VATS system between 2005 and 2012. Two patients were converted from thoracoscopic surgery to open surgery. Power of the biceps was recovered to M3 or more in five out of seven patients, who were followed for more than two years postoperatively. No respiratory complications occurred.
Although this technique is challenging, the da Vinci® system will make the procedure easier and improve its accuracy and safety.

Robotic subinguinal varicocelectomy

Purpose: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy.
Material and Methods: Ten patients with an average age of 28.4 years underwent 11 microscopic subinguinal varicocelectomies. Ten patients with an average age of 23.1 years underwent 11 robot-assisted varicocelectomies.
Results: The average operative time for microscopic inguinal varicocelectomy was 69.2 minutes, whereas the robot-assisted technique took 70.3 minutes. There were no difficulties in identifying and isolating vessels and the vas deferens with robotic-assisted subinguinal varicocelectomy. Hand tremor was eliminated with the robotic procedure. Robotic patients were able to resume daily activities on the day of surgery and full activities within two weeks. There were no complications or recurrences of varicocele.
Conclusions: From our experience, we believe that robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic surgery, with the added benefit of reducing hand tremor.

T Shu

Robotic subinguinal varicocelectomy

Purpose: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy.
Material and Methods: Ten patients with an average age of 28.4 years underwent 11 microscopic subinguinal varicocelectomies. Ten patients with an average age of 23.1 years underwent 11 robot-assisted varicocelectomies.
Results: The average operative time for microscopic inguinal varicocelectomy was 69.2 minutes, whereas the robot-assisted technique took 70.3 minutes. There were no difficulties in identifying and isolating vessels and the vas deferens with robotic-assisted subinguinal varicocelectomy. Hand tremor was eliminated with the robotic procedure. Robotic patients were able to resume daily activities on the day of surgery and full activities within two weeks. There were no complications or recurrences of varicocele.
Conclusions: From our experience, we believe that robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic surgery, with the added benefit of reducing hand tremor.

Thymoma: VATS or not?

Based on an analysis of the recent literature, Dr. Thomas discusses the pros and cons of the VATS approach for some thymomas.

Thymoma: VATS or not?

Based on an analysis of the recent literature, Dr. Thomas discusses the pros and cons of the VATS approach for some thymomas.