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Complex cases in laparoscopic recurrent and incisional hernia repair: multi-recurrence, infections, fistulas, difficult abdomen
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
1 month ago
1681 views
1 like
0 comments
03:00
Complex cases in laparoscopic recurrent and incisional hernia repair: multi-recurrence, infections, fistulas, difficult abdomen
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
Recurrent and incisional hernia repair: complex cases
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
A D'Urso, D Mutter, J Marescaux
State of the art
1 month ago
606 views
3 likes
0 comments
00:00
Recurrent and incisional hernia repair: complex cases
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
L Taglietti, G Baronio, L Lussardi, R Cazzaniga, S Dester, A Zanoletti
Surgical intervention
2 months ago
1209 views
2 likes
1 comment
09:56
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
S Macina, L Baldari, E Cassinotti, M Ballabio, A Spota, M de Francesco, L Boni
Surgical intervention
2 months ago
2142 views
14 likes
0 comments
07:10
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.
E Soricelli, E Facchiano, L Leuratti, G Quartararo, N Console, P Tonelli, M Lucchese
Surgical intervention
2 months ago
1742 views
3 likes
0 comments
09:10
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.
Endoscopic full-thickness colonic resection for malignant polyp excision
This is the case of an 83-year-old woman who presented with per rectal bleeding. She had flexible sigmoidoscopy, which showed a 1.5 to 2cm flat polyp with central depression and non-lifting sign. CT-scan of the chest, abdomen, and pelvis was performed and showed no metastasis. The case was discussed with the multidisciplinary team and decision was made to perform an endoscopic full-thickness colonic resection. The case was performed using the colonic FTRD® set (OVESCO™). The procedure was completed successfully and the patient was discharged on postoperative day 1. During the postoperative follow-up, the resection margin was clear. This is the first case performed in the North-East of England to our knowledge. Since this case, we have performed another case.
Y Aawsaj, K Khan, M Hayat
Surgical intervention
2 months ago
504 views
2 likes
1 comment
05:30
Endoscopic full-thickness colonic resection for malignant polyp excision
This is the case of an 83-year-old woman who presented with per rectal bleeding. She had flexible sigmoidoscopy, which showed a 1.5 to 2cm flat polyp with central depression and non-lifting sign. CT-scan of the chest, abdomen, and pelvis was performed and showed no metastasis. The case was discussed with the multidisciplinary team and decision was made to perform an endoscopic full-thickness colonic resection. The case was performed using the colonic FTRD® set (OVESCO™). The procedure was completed successfully and the patient was discharged on postoperative day 1. During the postoperative follow-up, the resection margin was clear. This is the first case performed in the North-East of England to our knowledge. Since this case, we have performed another case.
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
WTL Chen, J Verde
Surgical intervention
2 months ago
1076 views
1 like
0 comments
47:24
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
Laparoscopic cholecystectomy - Basic rules - Bile duct injury
There is twice as much risk of incidental biliary injuries in laparoscopic cholecystectomy than in open cholecystectomy.
About half of surgeons will cause a bile duct injury during their careers. In this lecture, Dr. Dallemagne provides key national data of bile duct injury and explains that the lack of surgical experience or visual misperception leads to an increase in the rate of incidental injuries, mentioning his own cases. Dr. Dallemagne also outlines the fundamental techniques to prevent injuries and use bailout procedures (partial and subtotal cholecystectomy) in laparoscopic cholecystectomy, according to the latest version of the Tokyo guidelines.
B Dallemagne
Lecture
3 months ago
2790 views
25 likes
0 comments
22:02
Laparoscopic cholecystectomy - Basic rules - Bile duct injury
There is twice as much risk of incidental biliary injuries in laparoscopic cholecystectomy than in open cholecystectomy.
About half of surgeons will cause a bile duct injury during their careers. In this lecture, Dr. Dallemagne provides key national data of bile duct injury and explains that the lack of surgical experience or visual misperception leads to an increase in the rate of incidental injuries, mentioning his own cases. Dr. Dallemagne also outlines the fundamental techniques to prevent injuries and use bailout procedures (partial and subtotal cholecystectomy) in laparoscopic cholecystectomy, according to the latest version of the Tokyo guidelines.
Bile duct injury: what to do?
In this key lecture, Dr. Soubrane outlines the various types of bile duct injuries and demonstrates how to manage them, classifying them into bile duct injuries during or after index surgery. When injuries are detected during index surgery, surgeons either have to add stitches combined with drainage in case of minor injuries or create an anastomosis in case of complete common bile duct division. When injuries are detected after index surgery, surgeons may either solve them with endoscopic stenting in case of minor injuries or have to wait at least 2 months in case of complete common bile duct division. As an example of major liver resection for severe bile duct injuries, Dr. Soubrane also shows a case of right liver resection for severe bile duct injury with concomitant arterial interruption and massive portal vein thrombosis after laparoscopic cholecystectomy.
O Soubrane
Lecture
3 months ago
1385 views
11 likes
0 comments
31:48
Bile duct injury: what to do?
In this key lecture, Dr. Soubrane outlines the various types of bile duct injuries and demonstrates how to manage them, classifying them into bile duct injuries during or after index surgery. When injuries are detected during index surgery, surgeons either have to add stitches combined with drainage in case of minor injuries or create an anastomosis in case of complete common bile duct division. When injuries are detected after index surgery, surgeons may either solve them with endoscopic stenting in case of minor injuries or have to wait at least 2 months in case of complete common bile duct division. As an example of major liver resection for severe bile duct injuries, Dr. Soubrane also shows a case of right liver resection for severe bile duct injury with concomitant arterial interruption and massive portal vein thrombosis after laparoscopic cholecystectomy.
Minimal access surgery approach to benign biliary disease
The laparoscopic biliary approach for benign diseases has been discussed for a quarter of a century. However, there were few articles in the literature about laparoscopic bilioenteric anastomoses, such as choledochoduodenostomy and hepatico/choledochojejunostomy which require advanced laparoscopic skills and experience. In this key lecture, Dr. Asbun demonstrates his own laparoscopic techniques for bilioenteric anastomoses. For choledochal cysts representative of benign biliary diseases, cyst excision is required. The difficulty lies in the fact that the cyst extends towards the intrapancreatic portion. Dr. Asbun demonstrates the techniques for complete exposure of the intrapancreatic bile duct portion in such cases. Finally, Dr. Asbun shows bile duct injury cases managed using a hepaticojejunostomy.
HJ Asbun
Lecture
3 months ago
562 views
5 likes
2 comments
24:34
Minimal access surgery approach to benign biliary disease
The laparoscopic biliary approach for benign diseases has been discussed for a quarter of a century. However, there were few articles in the literature about laparoscopic bilioenteric anastomoses, such as choledochoduodenostomy and hepatico/choledochojejunostomy which require advanced laparoscopic skills and experience. In this key lecture, Dr. Asbun demonstrates his own laparoscopic techniques for bilioenteric anastomoses. For choledochal cysts representative of benign biliary diseases, cyst excision is required. The difficulty lies in the fact that the cyst extends towards the intrapancreatic portion. Dr. Asbun demonstrates the techniques for complete exposure of the intrapancreatic bile duct portion in such cases. Finally, Dr. Asbun shows bile duct injury cases managed using a hepaticojejunostomy.
Laparoscopic Frey's procedure with management of intraoperative complication
This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.
After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards.
The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing.
Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure.
P Agami, A Andrianov, V Shchadrova, M Baychorov, R Izrailov
Surgical intervention
3 months ago
4416 views
15 likes
3 comments
12:28
Laparoscopic Frey's procedure with management of intraoperative complication
This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.
After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards.
The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing.
Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure.
Laparoscopic distal pancreatectomy for intraductal papillary mucinous neoplasm (IPMN)
This is the case of a 76-year-old female patient who was referred to our hospital because of intraductal papillary mucinous neoplasm (IPMN). The patient has a medical history of renal insufficiency, sleep apnea syndrome, type 2 diabetes mellitus (T2DM), and hypertension. She has also a history of previous total hysterectomy.
MRI findings showed that the patient’s IPMN affected secondary pancreatic ducts entirely.
The main pancreatic duct is dilated, especially in the distal part at 6mm, but there are no remarkable findings of cystic wall thickening or intracystic nodules. A laparoscopic distal pancreatectomy was planned.
The postoperative course was uneventful and the patient was discharged on postoperative day 8.
Pathological findings showed that the intraductal papillary mucinous neoplasm was without any malignant component.
P Pessaux, E Felli, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
3 months ago
2081 views
5 likes
0 comments
13:26
Laparoscopic distal pancreatectomy for intraductal papillary mucinous neoplasm (IPMN)
This is the case of a 76-year-old female patient who was referred to our hospital because of intraductal papillary mucinous neoplasm (IPMN). The patient has a medical history of renal insufficiency, sleep apnea syndrome, type 2 diabetes mellitus (T2DM), and hypertension. She has also a history of previous total hysterectomy.
MRI findings showed that the patient’s IPMN affected secondary pancreatic ducts entirely.
The main pancreatic duct is dilated, especially in the distal part at 6mm, but there are no remarkable findings of cystic wall thickening or intracystic nodules. A laparoscopic distal pancreatectomy was planned.
The postoperative course was uneventful and the patient was discharged on postoperative day 8.
Pathological findings showed that the intraductal papillary mucinous neoplasm was without any malignant component.
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
P Pessaux, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
3 months ago
1413 views
2 likes
0 comments
05:51
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
Laparoscopic left lateral sectionectomy for hepatocarcinoma in a cirrhotic patient
This video demonstrates a laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC) in a cirrhotic liver with hemochromatosis. This is the case of a 77-year-old patient who presented with a 40mm HCC located in Couinaud’s liver segment II and III. After left liver mobilization, parenchymal transection was initiated along the left side of the falciform ligament, mainly using the cavitron ultrasonic surgical aspirator (CUSA®). Tissue Select mode was used during the exposure of the vascular structure. The Glissonian pedicles of segments III and II were encircled and transected, and finally the suprahepatic vein was divided using an Endo GIA™ linear stapler. The specimen was extracted with a short suprapubic incision. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of a well-differentiated HCC.
P Pessaux, T Urade, T Wakabayashi, E Felli, A Mazzotta, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
3 months ago
1770 views
8 likes
0 comments
07:22
Laparoscopic left lateral sectionectomy for hepatocarcinoma in a cirrhotic patient
This video demonstrates a laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC) in a cirrhotic liver with hemochromatosis. This is the case of a 77-year-old patient who presented with a 40mm HCC located in Couinaud’s liver segment II and III. After left liver mobilization, parenchymal transection was initiated along the left side of the falciform ligament, mainly using the cavitron ultrasonic surgical aspirator (CUSA®). Tissue Select mode was used during the exposure of the vascular structure. The Glissonian pedicles of segments III and II were encircled and transected, and finally the suprahepatic vein was divided using an Endo GIA™ linear stapler. The specimen was extracted with a short suprapubic incision. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of a well-differentiated HCC.
Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor
In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter, at the pancreatic isthmus. Scintigraphy does not evidence any intense uptake.
The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall.
A postoperative pancreatic fistula grade B was reported. It was successfully managed. The presence of a well-differentiated neuroendocrine tumor was confirmed. The patient was discharged on postoperative day 22.
P Pessaux, E Felli, T Wakabayashi, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
3 months ago
2232 views
4 likes
3 comments
07:01
Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor
In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter, at the pancreatic isthmus. Scintigraphy does not evidence any intense uptake.
The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall.
A postoperative pancreatic fistula grade B was reported. It was successfully managed. The presence of a well-differentiated neuroendocrine tumor was confirmed. The patient was discharged on postoperative day 22.
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
This is the case of a 69-year-old male patient presenting to the emergency department for abdominal pain and fever. After CT-scan and liver MRI, a biliary cystadenoma was suspected. CEA and CA 19-9 were normal. Hydatid cyst serology was negative. Considering the localization and the size of the tumor, a left laparoscopic hepatectomy was indicated. The patient’s surgical history included laparoscopic sigmoidectomy, intestinal occlusion for internal hernia, appendectomy, and bilateral inguinal hernia repair. Dissection of adhesions and cholecystectomy were performed first. After transection of the left hepatic artery and the left portal vein, parenchymal transection was performed by exposing the middle hepatic vein under intermittent clamping using blood flow occlusion. During parenchymal transection, the left hepatic duct and the left hepatic vein were divided. The specimen was extracted through a suprapubic incision. The postoperative outcome was uneventful. Pathological findings showed the presence of a biliary cyst communicating with the biliary system, without any malignant characteristics.
O Soubrane, P Pessaux, E Felli, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
3 months ago
1634 views
2 likes
0 comments
34:11
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
This is the case of a 69-year-old male patient presenting to the emergency department for abdominal pain and fever. After CT-scan and liver MRI, a biliary cystadenoma was suspected. CEA and CA 19-9 were normal. Hydatid cyst serology was negative. Considering the localization and the size of the tumor, a left laparoscopic hepatectomy was indicated. The patient’s surgical history included laparoscopic sigmoidectomy, intestinal occlusion for internal hernia, appendectomy, and bilateral inguinal hernia repair. Dissection of adhesions and cholecystectomy were performed first. After transection of the left hepatic artery and the left portal vein, parenchymal transection was performed by exposing the middle hepatic vein under intermittent clamping using blood flow occlusion. During parenchymal transection, the left hepatic duct and the left hepatic vein were divided. The specimen was extracted through a suprapubic incision. The postoperative outcome was uneventful. Pathological findings showed the presence of a biliary cyst communicating with the biliary system, without any malignant characteristics.
Laparoscopic en bloc splenopancreatectomy with left adrenalectomy and para-aortic lymphadenectomy
The objective of this video is to present a surgical approach to a left adrenal mass caused by the invasion of a pancreatic lesion. A pulmonary lesion was also found. However, a preoperative biopsy of that lesion was impossible to perform. In order to distinguish the primary origin of this lung lesion, a laparoscopic ‘en bloc’ splenopancreatectomy combined with a left adrenalectomy and a para-aortic lymphadenectomy were planned.
Retrograde distal pancreatectomy with splenectomy is the standard procedure for cancers of the body and tail of the pancreas. In the literature, fewer studies describe the feasibility and the oncological safety of the laparoscopic approach.
This video aims to show the different operative steps of the procedure beginning with laparoscopic adrenalectomy followed by distal pancreatectomy and para-aortic lympadenectomy.
R Romito, L Portigliotti, G Bondonno, M Zacchero, A Volpe
Surgical intervention
3 months ago
998 views
9 likes
0 comments
13:28
Laparoscopic en bloc splenopancreatectomy with left adrenalectomy and para-aortic lymphadenectomy
The objective of this video is to present a surgical approach to a left adrenal mass caused by the invasion of a pancreatic lesion. A pulmonary lesion was also found. However, a preoperative biopsy of that lesion was impossible to perform. In order to distinguish the primary origin of this lung lesion, a laparoscopic ‘en bloc’ splenopancreatectomy combined with a left adrenalectomy and a para-aortic lymphadenectomy were planned.
Retrograde distal pancreatectomy with splenectomy is the standard procedure for cancers of the body and tail of the pancreas. In the literature, fewer studies describe the feasibility and the oncological safety of the laparoscopic approach.
This video aims to show the different operative steps of the procedure beginning with laparoscopic adrenalectomy followed by distal pancreatectomy and para-aortic lympadenectomy.
Laparoscopic central hepatectomy using a Glissonian approach for hepatocellular adenoma
A 32-year-old asymptomatic female patient presented an incidental finding of a liver mass during pregnancy. The mass grew during pregnancy, and a biopsy confirmed the diagnosis of hepatocellular adenoma. On MRI, a hypodense 7 by 6.1cm mass with adipose infiltration was identified. Previously, it was a 5.8 by 5.1cm mass, located in liver segments IV, V, and VIII inferiorly.
The cystic duct and its artery were ligated. However, the gallbladder was kept in place for traction. After dissection of the anterior pedicle, a linear stapler was applied. The right lobe was mobilized and the right transection line was made according to the ischemia line of the anterior sector.
During the liver transection of segment IVB, the pedicle was identified, and linear stapling helped to control it. The parenchymal transection was performed with an ultrasonic scalpel and bipolar cautery. The liver surface of the anterior sector was demarcated and transected. Both the left and the right plane of transection were inferiorly joined. The middle and right hepatic vein branches were stapled.
The specimen was mobilized. Argon beam and bipolar forceps provided the hemostasis. The specimen was removed via a Pfannenstiel’s incision and a drain was placed. The duration of the procedure was 345 minutes. The estimated blood loss was 1200mL.
The patient was discharged from the intensive care unit on postoperative day 1 and from hospital on postoperative day 4. No complication was noted in 90 days. Pathological findings showed a mass of 10.7 by 8.4 by 4.8cm. The lesion represented a hepatocellular adenoma with negative margins.
R Araujo, D Burgardt, V Vazquez, F Felippe, MA Sanctis, D Wohnrath
Surgical intervention
3 months ago
642 views
3 likes
0 comments
09:00
Laparoscopic central hepatectomy using a Glissonian approach for hepatocellular adenoma
A 32-year-old asymptomatic female patient presented an incidental finding of a liver mass during pregnancy. The mass grew during pregnancy, and a biopsy confirmed the diagnosis of hepatocellular adenoma. On MRI, a hypodense 7 by 6.1cm mass with adipose infiltration was identified. Previously, it was a 5.8 by 5.1cm mass, located in liver segments IV, V, and VIII inferiorly.
The cystic duct and its artery were ligated. However, the gallbladder was kept in place for traction. After dissection of the anterior pedicle, a linear stapler was applied. The right lobe was mobilized and the right transection line was made according to the ischemia line of the anterior sector.
During the liver transection of segment IVB, the pedicle was identified, and linear stapling helped to control it. The parenchymal transection was performed with an ultrasonic scalpel and bipolar cautery. The liver surface of the anterior sector was demarcated and transected. Both the left and the right plane of transection were inferiorly joined. The middle and right hepatic vein branches were stapled.
The specimen was mobilized. Argon beam and bipolar forceps provided the hemostasis. The specimen was removed via a Pfannenstiel’s incision and a drain was placed. The duration of the procedure was 345 minutes. The estimated blood loss was 1200mL.
The patient was discharged from the intensive care unit on postoperative day 1 and from hospital on postoperative day 4. No complication was noted in 90 days. Pathological findings showed a mass of 10.7 by 8.4 by 4.8cm. The lesion represented a hepatocellular adenoma with negative margins.
Robotic distal pancreatectomy with splenectomy
This is the case of a 73-year-old asymptomatic female patient who presented with an incidental pancreatic lesion on CT-scan. Her previous medical history was relevant for systemic lupus erythematosus. On the CT-scan, a single hypervascular lesion in the arterial phase was identified in the distal pancreas. The lesion size was 3.1 by 3.3 by 4.3cm. Neither suspicious nodes nor distant metastases were found. The patient was considered to be ASA2 and ECOG0.
The patient was placed in a reverse Trendelenburg position. A 12mm port was placed in the umbilicus for the camera, and three 8mm ports were inserted to accommodate the robotic arms, and another 12mm auxiliary port was used.
The greater curvature of the stomach was released from the transverse colon to expose the supramesocolic area. The neck of the pancreas was dissected close to the splenic-mesenteric confluence. The inferior mesenteric vein opening to the splenic vein was identified, clipped and cut. The splenic artery was dissected, clipped and cut close to the celiac trunk. A stapler was placed in the neck of the pancreas and it was safely stapled. The splenic vein was dissected close to the confluence, and then clipped and cut. The distal pancreas and splenic ligaments were cut and . detached. The specimen was removed using a Pfannenstiel’s incision.
The duration of the procedure was 255 minutes. The estimated blood loss was 100mL. The patient was discharged on postoperative day 5 and no complication was observed over a period of 90 days. Pathology confirmed the presence of a neuroendocrine tumor (grade 2) as a 4cm single lesion and negative margins. One positive node was detected among 10 nodes harvested.
R Araujo, MA Sanctis, F Felippe, D Burgardt, D Wohnrath
Surgical intervention
3 months ago
793 views
2 likes
0 comments
08:04
Robotic distal pancreatectomy with splenectomy
This is the case of a 73-year-old asymptomatic female patient who presented with an incidental pancreatic lesion on CT-scan. Her previous medical history was relevant for systemic lupus erythematosus. On the CT-scan, a single hypervascular lesion in the arterial phase was identified in the distal pancreas. The lesion size was 3.1 by 3.3 by 4.3cm. Neither suspicious nodes nor distant metastases were found. The patient was considered to be ASA2 and ECOG0.
The patient was placed in a reverse Trendelenburg position. A 12mm port was placed in the umbilicus for the camera, and three 8mm ports were inserted to accommodate the robotic arms, and another 12mm auxiliary port was used.
The greater curvature of the stomach was released from the transverse colon to expose the supramesocolic area. The neck of the pancreas was dissected close to the splenic-mesenteric confluence. The inferior mesenteric vein opening to the splenic vein was identified, clipped and cut. The splenic artery was dissected, clipped and cut close to the celiac trunk. A stapler was placed in the neck of the pancreas and it was safely stapled. The splenic vein was dissected close to the confluence, and then clipped and cut. The distal pancreas and splenic ligaments were cut and . detached. The specimen was removed using a Pfannenstiel’s incision.
The duration of the procedure was 255 minutes. The estimated blood loss was 100mL. The patient was discharged on postoperative day 5 and no complication was observed over a period of 90 days. Pathology confirmed the presence of a neuroendocrine tumor (grade 2) as a 4cm single lesion and negative margins. One positive node was detected among 10 nodes harvested.
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
S Morales-Conde, T Urade, D Mutter, J Marescaux
Surgical intervention
4 months ago
4154 views
16 likes
2 comments
42:53
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
D Mutter, T Urade, J Marescaux
Surgical intervention
4 months ago
6410 views
44 likes
0 comments
46:18
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.
B Dallemagne, T Urade, D Mutter, J Marescaux
Surgical intervention
4 months ago
1549 views
16 likes
1 comment
39:46
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.