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Online university

The largest online video library in minimally invasive surgery.

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WebSurg is a virtual university created by surgeons for surgeons. It is an extensive source of knowledge in minimally invasive surgery. It is free and accessible to all. WebSurg promotes technological advances in the field of minimally invasive surgery, in all surgical fields, i.e. general and digestive surgery, urology, gynecology, pediatric surgery, endoscopic surgery, skull base surgery, arthroscopy and upper limb surgery. Define your educational objectives and watch the videos which correspond to your specialty.

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WeBsurg allows you to improve your surgical skills but also to share your knowledge with the largest community of surgeons worldwide. Submit the video of your surgical procedure on our website and become part of our international Faculty.

Surgical intervention
08:13
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
L Marano, A Spaziani, G Castagnoli
265 views
2 months ago
Surgical intervention
11:27
Robotic abdominoperineal resection (APR) with intraperitoneal puborectalis incision
The da Vinci™ surgical robotic system with its increased instrument stability, tridimensional view, and dexterity with 7 degrees of wristed motion offers a distinct surgical advantage over traditional laparoscopic instruments. This advantage is mainly in the deep pelvis where the limited working space and visibility makes distal rectal dissection extremely challenging. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.

An abdominoperineal resection (APR) involves the excision of the rectum with a total mesorectal excision (TME), and excision of the anus with an adequate circumferential resection margin (CRM). In a conventional open or laparoscopic approach, the rectal dissection is performed down to the level of the pelvic floor, after which the perineal approach is used to excise the anus and to cut the pelvic floor muscles circumferentially to allow for ‘en bloc’ tumor removal. However, as the pelvic floor is frequently very deep from the skin surface, dissection is technically challenging due to poor visualization, often leading to blind dissection. As a result, many APR specimens suffer from the problem of “waisting” and a positive CRM at the level of the levator ani muscle. In order to solve this problem, some units practice extralevator APR – however, in those cases, the patient ends up with a large perineal defect which frequently needs to be closed with either mesh or flap reconstruction.
With the da Vinci™ robotic system, this problem can potentially be minimized. The robotic system can be used to access deep into the pelvic cavity and make an incision in the puborectalis sling down to the ischiorectal fat. This incision, once completed, allows for easy access from the perineal approach to enter the pelvic cavity and complete the dissection, preventing any blind dissection and facilitating a CRM-clear specimen to be excised.
This video features a totally robotic approach to an abdominoperineal resection for a poorly differentiated anorectal adenocarcinoma, with intraperitoneal incision of the puborectalis sling to facilitate subsequent perineal dissection and specimen extraction.

Clinical case
A 79-year-old female patient presented with a perianal lump and discomfort. Colonoscopy revealed a 2cm mobile adenomatous polypoid lesion at the anorectal junction. Excision biopsy showed a poorly differentiated adenocarcinoma.

CT-scan of the thorax, abdomen and pelvis did not show any distant metastases, and MRI of the rectum did not show any significant locoregional disease. A robotic abdominoperineal resection was performed.

Patient set-up
The da Vinci™ Si™ robotic system was used, and a dual docking approach was chosen.
The patient was placed in a Lloyd-Davies position. Robotic ports (8mm) were placed in the epigastrium, left flank, suprapubic region, and in the right iliac fossa respectively. A 12mm trocar is inserted into the right flank for assistance and stapling.
Robotic abdominoperineal resection (APR) with intraperitoneal puborectalis incision
SAE Yeo
90 views
2 months ago
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