We use cookies to offer you an optimal experience on our website. By browsing our website, you accept the use of cookies.

Hall of Fame

Participate in the Hall of Fame contest of WebSurg.

The last winner - 2018

Surgical intervention
05:37
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
JL Ng, SAE Yeo
11721 views
1 year ago
Jia Lin NG, MD
Singapore, Singapore
Dr. Ng Jia Lin is an Associate Consultant at the Department of Colorectal Surgery in Singapore General Hospital, Singapore. Having completed her general surgical residency training and colorectal surgery fellowship training in Singapore, she is currently pursuing a fellowship program in advanced laparoscopic and open pelvic surgery in Bangkok, Thailand.
Shen-Ann Eugene YEO, MBBS, MMed (Surg), FRCS (Ed)
Singapore, Singapore
Dr. Eugene Yeo is currently a Consultant Colorectal Surgeon in the Department of Colorectal Surgery, Singapore General Hospital. He completed his basic medical degree and his surgical training in Singapore and spent one year in Seoul, South Korea attending a fellowship in robotics and advanced laparoscopic surgical procedures. Dr. Yeo has a special interest in minimally invasive colorectal surgery, particularly in laparoscopic and robotic approaches, including transanal work. He has also interest in advanced endoscopic procedures such as colonic stenting and resection of advanced colonic polyps.
View more
Filter by
Clear filter Specialty
View more

Clear filter Media type
View more
Pancreatic duplication associated with a gastric duplication cyst: laparoscopic approach
This video shows the case of a 48-year-old male patient with a history of epigastric pain for 20 days, with the presence of nausea and vomiting but no self-reported fever. The patient was presented at the ER for examination. Computerized tomography (CT) scanning revealed a very rare case of pancreatic duplication associated with a gastric duplication cyst. He was referred to our service and then treated by laparoscopic route with partial gastrectomy and pancreatic resection (pancreas horn). On the 2nd postoperative day, the patient was discharged and allowed for free oral feeding. This is the second study in the literature reporting a case of laparoscopic resection of a gastric duplication cyst together with pancreatic resection. Of note, this is the first study in which the accessory pancreas communicates with the pancreatic head.
F Freire Lisboa Junior, R de Lima França, A de Araujo Lima Liguori, AC de Medeiros Junior, M HSMP Tavares, F Medeiros de Azevedo, D Myller Barros Lima
Surgical intervention
15 hours ago
22 views
0 likes
0 comments
14:36
Pancreatic duplication associated with a gastric duplication cyst: laparoscopic approach
This video shows the case of a 48-year-old male patient with a history of epigastric pain for 20 days, with the presence of nausea and vomiting but no self-reported fever. The patient was presented at the ER for examination. Computerized tomography (CT) scanning revealed a very rare case of pancreatic duplication associated with a gastric duplication cyst. He was referred to our service and then treated by laparoscopic route with partial gastrectomy and pancreatic resection (pancreas horn). On the 2nd postoperative day, the patient was discharged and allowed for free oral feeding. This is the second study in the literature reporting a case of laparoscopic resection of a gastric duplication cyst together with pancreatic resection. Of note, this is the first study in which the accessory pancreas communicates with the pancreatic head.
Laparoscopic treatment of primary omental infarction
A 53-year-old man was admitted to the emergency department for right hypochondrium pain, fever, and weight loss, with clinical evidence of an abdominal mass in his right lumbar region.
His white blood cell (WBC) count was 11.9x109/L and his C-reactive protein value was 11.7mg/dL.
His abdominal CT-scan and MRI showed a 12.5cm omental mass, suggestive of omental infarction with a hemorrhagic component. His gastroscopy and colonoscopy were negative, and the needle biopsy of the mass was not suggestive of malignancy. Exploratory laparoscopy with biopsy or resection of the omental lesion was indicated. The total duration of the operation was 1 hour, and the omental mass was resected. The patient completely recovered from his symptoms, and was discharged after two days. Final histology of his lesion demonstrated an omental infarction with thrombosis, hemorrhage, and fat cell necrosis.
M Lotti, M Marini, M Giulii Capponi
Surgical intervention
15 hours ago
40 views
0 likes
0 comments
14:43
Laparoscopic treatment of primary omental infarction
A 53-year-old man was admitted to the emergency department for right hypochondrium pain, fever, and weight loss, with clinical evidence of an abdominal mass in his right lumbar region.
His white blood cell (WBC) count was 11.9x109/L and his C-reactive protein value was 11.7mg/dL.
His abdominal CT-scan and MRI showed a 12.5cm omental mass, suggestive of omental infarction with a hemorrhagic component. His gastroscopy and colonoscopy were negative, and the needle biopsy of the mass was not suggestive of malignancy. Exploratory laparoscopy with biopsy or resection of the omental lesion was indicated. The total duration of the operation was 1 hour, and the omental mass was resected. The patient completely recovered from his symptoms, and was discharged after two days. Final histology of his lesion demonstrated an omental infarction with thrombosis, hemorrhage, and fat cell necrosis.
Laparoscopic excision of urachal cyst - a minimally invasive approach of a rare cause of abdominal pain in adults
Congenital abnormalities of the urachus are rare, with an incidence of 2:300000 children and 1:5000 adults. The urachus is a fibrous remnant of the allantois, usually occluded in the 4-5th gestational months, with the descent of the bladder towards the pelvis. It lies in the space of Retzius, between the transverse fascia anteriorly and the peritoneum posteriorly. The absence of its obliteration can result in an urachal cyst in 36% of cases. The main complication of the cyst is focal infection with associated risks of rupture and intestinal involvement. Diagnosis relies on clinical history, abdominopelvic ultrasonography and CT-scan. The treatment consists in complete excision of abnormal tissue and a small portion of adjacent bladder wall, therefore reducing the risk of malignant degeneration of the entire remnant.
A twenty-year-old healthy woman was referred to the emergency department with localized discomfort and a foul smelling purulent discharge from the umbilicus with three days of evolution. The patient was afebrile with periumbilical inflammatory signs, without signs of peritoneal irritation on physical exam. Blood tests were all normal, apart from a raised C-reactive protein (2.52mg/dL). Abdominal ultrasound was suggestive of an infected urachal cyst with umbilical fistulization. Empirical treatment with antibiotics was started and an abdominopelvic CT-scan, made as outpatient surgery, showed a probable 26mm urachal cyst, posterior and adjacent to the umbilicus, without bladder attachment.
The patient was treated surgically with a laparoscopic excision of the remainder of the urachus, without intraoperative complications. A good clinical evolution was observed during the hospital stay, and the patient was discharged on the fourth postoperative day. On follow-up, the patient did not complain of anything.
This clinical case emphasizes the importance of the high index of diagnostic suspicion in the management and treatment of the rare causes of abdominal pain, often with the possibility of a minimally invasive approach.
A Tojal, AR Loureiro, B Prata, R Patrão, N Carrilho, C Casimiro
Surgical intervention
1 day ago
23 views
0 likes
0 comments
10:34
Laparoscopic excision of urachal cyst - a minimally invasive approach of a rare cause of abdominal pain in adults
Congenital abnormalities of the urachus are rare, with an incidence of 2:300000 children and 1:5000 adults. The urachus is a fibrous remnant of the allantois, usually occluded in the 4-5th gestational months, with the descent of the bladder towards the pelvis. It lies in the space of Retzius, between the transverse fascia anteriorly and the peritoneum posteriorly. The absence of its obliteration can result in an urachal cyst in 36% of cases. The main complication of the cyst is focal infection with associated risks of rupture and intestinal involvement. Diagnosis relies on clinical history, abdominopelvic ultrasonography and CT-scan. The treatment consists in complete excision of abnormal tissue and a small portion of adjacent bladder wall, therefore reducing the risk of malignant degeneration of the entire remnant.
A twenty-year-old healthy woman was referred to the emergency department with localized discomfort and a foul smelling purulent discharge from the umbilicus with three days of evolution. The patient was afebrile with periumbilical inflammatory signs, without signs of peritoneal irritation on physical exam. Blood tests were all normal, apart from a raised C-reactive protein (2.52mg/dL). Abdominal ultrasound was suggestive of an infected urachal cyst with umbilical fistulization. Empirical treatment with antibiotics was started and an abdominopelvic CT-scan, made as outpatient surgery, showed a probable 26mm urachal cyst, posterior and adjacent to the umbilicus, without bladder attachment.
The patient was treated surgically with a laparoscopic excision of the remainder of the urachus, without intraoperative complications. A good clinical evolution was observed during the hospital stay, and the patient was discharged on the fourth postoperative day. On follow-up, the patient did not complain of anything.
This clinical case emphasizes the importance of the high index of diagnostic suspicion in the management and treatment of the rare causes of abdominal pain, often with the possibility of a minimally invasive approach.
Endoscopic mucosal resection (EMR) of laterally spreading tumor in rectum and resolution of late bleeding
The objectives of this video are manifold, namely to present the totally endoscopic treatment of a laterally spreading tumor in the upper rectum with a piecemeal technique, and how to act against one of its most frequent complications, post-polypectomy bleeding.
Methods: The procedure was performed in an advanced flexible endoscopy unit, with the patient lying supine, with anesthesia (Propofol), and insufflation of carbon dioxide. A videocolonoscope was used, the lesion was identified and elevated with hydroxyethyl starch (Voluven). It was dried with a hot snare in parts ("piecemeal" technique), thereby achieving complete resection. The defect was closed with metal clips. The specimen was recovered for histopathological study.
Results: During screening colonoscopy, a 56-year-old patient was found with a 30mm granular laterally spreading tumor of the rectum (LST-G or nodular mixed type), located 15cm from the anal verge. Complete endoscopic resection of the lesion with a curative intent was performed. On postoperative day 5, proctorrhagia presented without hemodynamic alteration. Emergency endoscopy was decided upon. Upon entering with the colonoscope, we identified a clot attached to the surgical site. Once the bleeding had been confirmed, a saline solution with 1/20,000 adrenaline was injected. And then, with a hot snare, electrocoagulation was performed in the same area, combining an injection method with a thermal one and achieving a satisfying hemostasis. The patient was discharged on the same day without any other complications. The pathology report showed a villous adenoma with low-grade dysplasia, including patches of high-grade dysplasia, and injury-free resection margins.
Conclusions: EMR of laterally spreading tumors is safe, although it is not devoid of complications such as bleeding, which is present in up to 9.8 of every 100,000 polypectomies in some series (Reumkens et al., AJG 2016). It is essential to suspect and know how to solve it efficiently with the tools available at that time of emergency.
J Isaguirre, A Insausti
Surgical intervention
2 days ago
15 views
0 likes
0 comments
05:38
Endoscopic mucosal resection (EMR) of laterally spreading tumor in rectum and resolution of late bleeding
The objectives of this video are manifold, namely to present the totally endoscopic treatment of a laterally spreading tumor in the upper rectum with a piecemeal technique, and how to act against one of its most frequent complications, post-polypectomy bleeding.
Methods: The procedure was performed in an advanced flexible endoscopy unit, with the patient lying supine, with anesthesia (Propofol), and insufflation of carbon dioxide. A videocolonoscope was used, the lesion was identified and elevated with hydroxyethyl starch (Voluven). It was dried with a hot snare in parts ("piecemeal" technique), thereby achieving complete resection. The defect was closed with metal clips. The specimen was recovered for histopathological study.
Results: During screening colonoscopy, a 56-year-old patient was found with a 30mm granular laterally spreading tumor of the rectum (LST-G or nodular mixed type), located 15cm from the anal verge. Complete endoscopic resection of the lesion with a curative intent was performed. On postoperative day 5, proctorrhagia presented without hemodynamic alteration. Emergency endoscopy was decided upon. Upon entering with the colonoscope, we identified a clot attached to the surgical site. Once the bleeding had been confirmed, a saline solution with 1/20,000 adrenaline was injected. And then, with a hot snare, electrocoagulation was performed in the same area, combining an injection method with a thermal one and achieving a satisfying hemostasis. The patient was discharged on the same day without any other complications. The pathology report showed a villous adenoma with low-grade dysplasia, including patches of high-grade dysplasia, and injury-free resection margins.
Conclusions: EMR of laterally spreading tumors is safe, although it is not devoid of complications such as bleeding, which is present in up to 9.8 of every 100,000 polypectomies in some series (Reumkens et al., AJG 2016). It is essential to suspect and know how to solve it efficiently with the tools available at that time of emergency.
Laparoscopic treatment of a hydatid cyst of the liver in children
Introduction:
Hydatid cyst is a parasitic disease caused by the Echinococcus granulosus tapeworm. Laparoscopic treatment of a hydatid cyst of the liver remains controversial and few series have been published. The aim of this work is to present a case of liver hydatid cyst in an 8-year-old girl treated laparoscopically.
Case presentation:
An 8-year-old child was admitted to our department for the management of a voluminous liver hydatid cyst. The patient underwent a thoraco-abdominal CT-scan, which concluded to a left lobe liver hydatid cyst. The laparoscopic open access is achieved at the umbilicus using a 10mm port. Carbon dioxide pneumoperitoneum pressure is maintained at 10mmHg. Two other 5mm ports are introduced in the right and left hypochondrium. A 0-degree laparoscope is then used. The cyst is protected by means of pads filled with a 10% hypertonic saline solution. After we proceed to a puncture aspiration of the cyst, sterilization is achieved via injection of a hypertonic saline solution during 15 minutes, then reaspiration is performed with a Veress needle. The cyst is opened with a coagulating hook and the proligerous membrane is removed and put in a bag. The last step is the resection of the dome and the search for biliary fistula. We drained the residual cavity. The pads are removed. The Redon drain was removed on day 2 and the patient was discharged from hospital on postoperative day 3. Postoperatively, the patient was put on albendazole (10mg/kg) for one month.
Conclusion:
Laparoscopy stands for an excellent approach to the treatment of a hydatid cyst of the liver in children by respecting appropriate indications.
R Adjerid, F Sebaa, N Otsmane, A Khelifaoui
Surgical intervention
2 days ago
13 views
1 like
0 comments
05:13
Laparoscopic treatment of a hydatid cyst of the liver in children
Introduction:
Hydatid cyst is a parasitic disease caused by the Echinococcus granulosus tapeworm. Laparoscopic treatment of a hydatid cyst of the liver remains controversial and few series have been published. The aim of this work is to present a case of liver hydatid cyst in an 8-year-old girl treated laparoscopically.
Case presentation:
An 8-year-old child was admitted to our department for the management of a voluminous liver hydatid cyst. The patient underwent a thoraco-abdominal CT-scan, which concluded to a left lobe liver hydatid cyst. The laparoscopic open access is achieved at the umbilicus using a 10mm port. Carbon dioxide pneumoperitoneum pressure is maintained at 10mmHg. Two other 5mm ports are introduced in the right and left hypochondrium. A 0-degree laparoscope is then used. The cyst is protected by means of pads filled with a 10% hypertonic saline solution. After we proceed to a puncture aspiration of the cyst, sterilization is achieved via injection of a hypertonic saline solution during 15 minutes, then reaspiration is performed with a Veress needle. The cyst is opened with a coagulating hook and the proligerous membrane is removed and put in a bag. The last step is the resection of the dome and the search for biliary fistula. We drained the residual cavity. The pads are removed. The Redon drain was removed on day 2 and the patient was discharged from hospital on postoperative day 3. Postoperatively, the patient was put on albendazole (10mg/kg) for one month.
Conclusion:
Laparoscopy stands for an excellent approach to the treatment of a hydatid cyst of the liver in children by respecting appropriate indications.
Laparoscopic ligation of middle sacral artery and dissection of sacrococcygeal teratoma to decrease intraoperative hemorrhagic risk
Sacrococcygeal teratomas are the most common teratomas presenting at birth. Life-threatening bleeding is a major complication during tumor excision in children. In this video, we demonstrate our technique for the laparoscopic division of the middle sacral artery during dissection of sacrococcygeal teratomas in two pediatric patients.
Two female infants diagnosed with type IV and type III sacrococcygeal teratomas underwent preoperative evaluation in the postnatal period. The first patient was an 18-month-old female patient who presented with a metastatic type IV teratoma resected after neoadjuvant therapy. The second patient was a 6-day-old female infant with a prenatal diagnosis of cystic type III teratoma. Using laparoscopy in both patients, the presacral space was reached by opening the peritoneal reflection with blunt dissection and the middle sacral artery was identified. It was then carefully isolated and divided with a 5mm LigaSure™ vessel-sealing device. The pelvic components of the tumors were partially dissected using laparoscopy. The first patient’s tumor resection was completed using a posterior sagittal approach and the second patient required a standard Chevron incision.
Both patients underwent a successful laparoscopic division of the middle sacral artery and resection of the sacrococcygeal teratomas without complications. As a result, laparoscopic middle sacral artery division before sacrococcygeal teratoma excision offers a safe approach which can reduce the risk of hemorrhage during surgery.
T Huy, H Osei, AS Munoz Abraham, R Damle, GA Villalona
Surgical intervention
2 days ago
10 views
1 like
0 comments
05:33
Laparoscopic ligation of middle sacral artery and dissection of sacrococcygeal teratoma to decrease intraoperative hemorrhagic risk
Sacrococcygeal teratomas are the most common teratomas presenting at birth. Life-threatening bleeding is a major complication during tumor excision in children. In this video, we demonstrate our technique for the laparoscopic division of the middle sacral artery during dissection of sacrococcygeal teratomas in two pediatric patients.
Two female infants diagnosed with type IV and type III sacrococcygeal teratomas underwent preoperative evaluation in the postnatal period. The first patient was an 18-month-old female patient who presented with a metastatic type IV teratoma resected after neoadjuvant therapy. The second patient was a 6-day-old female infant with a prenatal diagnosis of cystic type III teratoma. Using laparoscopy in both patients, the presacral space was reached by opening the peritoneal reflection with blunt dissection and the middle sacral artery was identified. It was then carefully isolated and divided with a 5mm LigaSure™ vessel-sealing device. The pelvic components of the tumors were partially dissected using laparoscopy. The first patient’s tumor resection was completed using a posterior sagittal approach and the second patient required a standard Chevron incision.
Both patients underwent a successful laparoscopic division of the middle sacral artery and resection of the sacrococcygeal teratomas without complications. As a result, laparoscopic middle sacral artery division before sacrococcygeal teratoma excision offers a safe approach which can reduce the risk of hemorrhage during surgery.
Laparoscopic total gastrectomy
A multimodality approach remains the only potential treatment for advanced gastric cancer. Oncological outcomes seem to be equivalent either in open surgery or in minimally invasive surgery. Therefore, laparoscopic gastric resection is expanding in expert centers.
The authors present a clinical case of a 70-year-old woman with no relevant clinical past. She presented with a 1-month complaint of epigastric pain and melena. She underwent an upper endoscopy, which showed an ulcerated gastric lesion at the lesser curvature. Biopsy revealed a poorly cohesive gastric carcinoma with signet ring cells. Thoraco-abdominal-pelvic CT-scan revealed a thickening of the gastric wall associated with multiple perigastric and celiac trunk lymph nodes. She was proposed for perioperative chemotherapy. On the restaging CT-scan, there was no evidence of disease progression and therefore she underwent a laparoscopic radical total gastrectomy.
The benefits of minimally invasive surgery, combined with the increasing evidence of oncological results overlapping with open surgery, have contributed to the progressive implementation of laparoscopic surgery in the treatment of malignant gastric pathology.
J Magalhães, C Osorio, L Frutuoso, AM Pereira, A Trovão, R Ferreira de Almeida, M Nora
Surgical intervention
2 days ago
38 views
1 like
0 comments
09:44
Laparoscopic total gastrectomy
A multimodality approach remains the only potential treatment for advanced gastric cancer. Oncological outcomes seem to be equivalent either in open surgery or in minimally invasive surgery. Therefore, laparoscopic gastric resection is expanding in expert centers.
The authors present a clinical case of a 70-year-old woman with no relevant clinical past. She presented with a 1-month complaint of epigastric pain and melena. She underwent an upper endoscopy, which showed an ulcerated gastric lesion at the lesser curvature. Biopsy revealed a poorly cohesive gastric carcinoma with signet ring cells. Thoraco-abdominal-pelvic CT-scan revealed a thickening of the gastric wall associated with multiple perigastric and celiac trunk lymph nodes. She was proposed for perioperative chemotherapy. On the restaging CT-scan, there was no evidence of disease progression and therefore she underwent a laparoscopic radical total gastrectomy.
The benefits of minimally invasive surgery, combined with the increasing evidence of oncological results overlapping with open surgery, have contributed to the progressive implementation of laparoscopic surgery in the treatment of malignant gastric pathology.
Wilkie's syndrome surgery
Wilkie’s syndrome (or superior mesenteric artery syndrome) was first described by Von Rokitansky in 1861. It consists in an extrinsic pressure over the third duodenal portion originating from an uncertain cause. Wilkie found a decreased angle (25 degrees, or less) between the superior mesenteric artery and the aorta, conditioning a duodenal (3rd portion) obstruction of vascular origin. It is associated with weight loss. The real incidence remains unknown due to the lack of diagnosis. However, the estimated incidence varies between 0.013 to 1% of the population. The male/female ratio is 2:3, ranging age between 10 and 39 years old.
Symptoms include postprandial abdominal pain, nausea and vomiting, weight loss, early gastric fullness and anorexia (acute high gastroduodenal obstruction).
Diagnostic studies include barium esophageal gastroduodenal series, CT-scan, MRI, high endoscopy (peptic esophagitis, ulcer). Endoscopic studies must come together with barium esophageal gastroduodenal X-ray studies.
Surgical treatment is performed when there is no response to medical treatment, consisting in duodenojejunal anastomoses, with Treitz’s ligament division. Gastrojejunal anastomosis is an alternative option. Laparoscopic surgical treatment can be performed.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, J López Gutiérrez
Surgical intervention
2 days ago
20 views
0 likes
0 comments
13:16
Wilkie's syndrome surgery
Wilkie’s syndrome (or superior mesenteric artery syndrome) was first described by Von Rokitansky in 1861. It consists in an extrinsic pressure over the third duodenal portion originating from an uncertain cause. Wilkie found a decreased angle (25 degrees, or less) between the superior mesenteric artery and the aorta, conditioning a duodenal (3rd portion) obstruction of vascular origin. It is associated with weight loss. The real incidence remains unknown due to the lack of diagnosis. However, the estimated incidence varies between 0.013 to 1% of the population. The male/female ratio is 2:3, ranging age between 10 and 39 years old.
Symptoms include postprandial abdominal pain, nausea and vomiting, weight loss, early gastric fullness and anorexia (acute high gastroduodenal obstruction).
Diagnostic studies include barium esophageal gastroduodenal series, CT-scan, MRI, high endoscopy (peptic esophagitis, ulcer). Endoscopic studies must come together with barium esophageal gastroduodenal X-ray studies.
Surgical treatment is performed when there is no response to medical treatment, consisting in duodenojejunal anastomoses, with Treitz’s ligament division. Gastrojejunal anastomosis is an alternative option. Laparoscopic surgical treatment can be performed.
Laparoscopic distal splenopancreatectomy for pancreatic cystadenoma: clockwise technique assisted with T’Lift device
Serous cystic neoplasm is a cystic neoplasm of the pancreas, which is increasingly detected at an asymptomatic stage. Serous cystadenomas are benign cystic tumors which occur more often in women than in men, and particularly in the seventh decade of life. Despite this, in the literature, three patients were reported to have malignant serous cystadenomas, with sizes greater than 7cm. The serous cystic neoplasm was confirmed by an imaging characteristic appearance, with multiple small or different-sized cysts, but when the diagnosis is doubtful, which often leads to surgery.
The clinical case is the one of a 79-year-old woman with a cystadenoma of the pancreas. She had a history of partial cystectomy for bladder neoplasia and recently (in 2017), she was submitted to laparoscopic focal cryotherapy for the treatment of a left unilateral renal tumor. At that time, she underwent a CT-can, which found a cystic neoplasm of the tail of the pancreas. A heterogeneous 5cm lesion appeared in the left hypochondrium, near the lower pole of the spleen, with no evidence of adenopathies highly suggestive of a serous cystadenoma of the pancreas.
In October 2018, in a follow-up CT-scan, there was an increase in size of the lesion (6.6cm) and a surgical resection was planned. A distal splenopancreatectomy using a clockwise technique was performed using the Signia™ stapling system with no complications. Histological examination confirmed a serous cystadenoma of the pancreas.
M Rui Martins, J Correia, D Jordão, S Martins, H Ferrão
Surgical intervention
2 days ago
21 views
0 likes
0 comments
20:59
Laparoscopic distal splenopancreatectomy for pancreatic cystadenoma: clockwise technique assisted with T’Lift device
Serous cystic neoplasm is a cystic neoplasm of the pancreas, which is increasingly detected at an asymptomatic stage. Serous cystadenomas are benign cystic tumors which occur more often in women than in men, and particularly in the seventh decade of life. Despite this, in the literature, three patients were reported to have malignant serous cystadenomas, with sizes greater than 7cm. The serous cystic neoplasm was confirmed by an imaging characteristic appearance, with multiple small or different-sized cysts, but when the diagnosis is doubtful, which often leads to surgery.
The clinical case is the one of a 79-year-old woman with a cystadenoma of the pancreas. She had a history of partial cystectomy for bladder neoplasia and recently (in 2017), she was submitted to laparoscopic focal cryotherapy for the treatment of a left unilateral renal tumor. At that time, she underwent a CT-can, which found a cystic neoplasm of the tail of the pancreas. A heterogeneous 5cm lesion appeared in the left hypochondrium, near the lower pole of the spleen, with no evidence of adenopathies highly suggestive of a serous cystadenoma of the pancreas.
In October 2018, in a follow-up CT-scan, there was an increase in size of the lesion (6.6cm) and a surgical resection was planned. A distal splenopancreatectomy using a clockwise technique was performed using the Signia™ stapling system with no complications. Histological examination confirmed a serous cystadenoma of the pancreas.
Robotic Nissen fundoplication with the da Vinci Xi robotic surgical system
For a long time, laparoscopic Nissen fundoplication has been used to treat gastroesophageal reflux disease (GERD). The main challenges of laparoscopic Nissen fundoplication involve the 2-dimensional visualization, exposure of complex gastroesophageal anatomy, and suturing of the wrap fundoplication. In 1999, robotic Nissen fundoplication, a completely new technique, was introduced, demonstrating advantages over conventional laparoscopic surgery due to improved manual dexterity, ergonomics, and 3-dimensional visualization. However, time spent on robotic platform docking and arm clashing during the procedure are factors that surgeons often find cumbersome and time-consuming. The newest surgical platform, the da Vinci Xi surgical robotic system, can help to overcome such problems. This video shows a stepwise approach of the da Vinci Xi docking process and surgical technique demonstrating fundoplication according to the Nissen technique.
L Marano, A Spaziani, G Castagnoli
Surgical intervention
1 month ago
560 views
1 like
2 comments
07:00
Robotic Nissen fundoplication with the da Vinci Xi robotic surgical system
For a long time, laparoscopic Nissen fundoplication has been used to treat gastroesophageal reflux disease (GERD). The main challenges of laparoscopic Nissen fundoplication involve the 2-dimensional visualization, exposure of complex gastroesophageal anatomy, and suturing of the wrap fundoplication. In 1999, robotic Nissen fundoplication, a completely new technique, was introduced, demonstrating advantages over conventional laparoscopic surgery due to improved manual dexterity, ergonomics, and 3-dimensional visualization. However, time spent on robotic platform docking and arm clashing during the procedure are factors that surgeons often find cumbersome and time-consuming. The newest surgical platform, the da Vinci Xi surgical robotic system, can help to overcome such problems. This video shows a stepwise approach of the da Vinci Xi docking process and surgical technique demonstrating fundoplication according to the Nissen technique.
Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
G Baiocchi, S Molfino, B Molteni, L Arru, F Gheza, M Diana
Surgical intervention
1 month ago
1094 views
4 likes
0 comments
12:41
Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass
Introduction: Obesity is a known etiological factor for gastroesophageal reflux disease (GERD) and is also a growing public health concern. Although Nissen fundoplication is a highly effective technique to treat GERD, it may fail in obese patients. Roux-en-Y gastric bypass provides excellent long-term control of GERD symptoms with the additional benefit of weight loss.
Clinical case: A 57-year-old woman underwent a laparoscopic Nissen fundoplication for GERD (BMI 30.0 Kg/m2) with excellent outcomes during the first postoperative year in 2011. Two years later, GERD symptoms recurred, and her weight increased progressively (BMI of 36.0 Kg/m2). The patient was proposed to a laparoscopic conversion of Nissen fundoplication to a Roux-en-Y gastric bypass. The procedure was uneventful, and the patient was discharged on postoperative day 4. One year later, she remained asymptomatic, off antacids medication, and with her weight decreased to 63.5Kg which corresponded to a BMI of 25.4 Kg/m2.
Discussion/conclusion: Roux-en-Y gastric bypass successfully reduces GERD symptoms by diverting bile away from the esophagus, decreasing acid production in the gastric pouch, therefore limiting the amount of acid reflux and by promoting weight loss decreases abdominal pressure over the lower esophageal sphincter and esophageal hiatus. In obese patients (BMI>35) with GERD, Roux-en-Y gastric bypass seems to be the most effective and advantageous treatment since it provides control of GERD symptoms with the additional benefit of weight loss. In patients who have previously undergone anti-reflux surgery, bariatric surgery can be technically demanding. However, if performed by high-volume surgeons in high-volume centers, it is perfectly feasible with low morbidity and excellent results.
J Magalhães, AM Pereira, T Fonseca, R Ferreira de Almeida, M Nora
Surgical intervention
1 month ago
571 views
2 likes
1 comment
09:34
Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass
Introduction: Obesity is a known etiological factor for gastroesophageal reflux disease (GERD) and is also a growing public health concern. Although Nissen fundoplication is a highly effective technique to treat GERD, it may fail in obese patients. Roux-en-Y gastric bypass provides excellent long-term control of GERD symptoms with the additional benefit of weight loss.
Clinical case: A 57-year-old woman underwent a laparoscopic Nissen fundoplication for GERD (BMI 30.0 Kg/m2) with excellent outcomes during the first postoperative year in 2011. Two years later, GERD symptoms recurred, and her weight increased progressively (BMI of 36.0 Kg/m2). The patient was proposed to a laparoscopic conversion of Nissen fundoplication to a Roux-en-Y gastric bypass. The procedure was uneventful, and the patient was discharged on postoperative day 4. One year later, she remained asymptomatic, off antacids medication, and with her weight decreased to 63.5Kg which corresponded to a BMI of 25.4 Kg/m2.
Discussion/conclusion: Roux-en-Y gastric bypass successfully reduces GERD symptoms by diverting bile away from the esophagus, decreasing acid production in the gastric pouch, therefore limiting the amount of acid reflux and by promoting weight loss decreases abdominal pressure over the lower esophageal sphincter and esophageal hiatus. In obese patients (BMI>35) with GERD, Roux-en-Y gastric bypass seems to be the most effective and advantageous treatment since it provides control of GERD symptoms with the additional benefit of weight loss. In patients who have previously undergone anti-reflux surgery, bariatric surgery can be technically demanding. However, if performed by high-volume surgeons in high-volume centers, it is perfectly feasible with low morbidity and excellent results.
Totally laparoscopic splenic flexure resection for cancer
The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.
G Basili, D Pietrasanta, N Romano, AF Costa
Surgical intervention
2 months ago
1927 views
7 likes
0 comments
10:12
Totally laparoscopic splenic flexure resection for cancer
The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
J Magalhães, L Matos, J Costa, J Costa Pereira, G Gonçalves, M Nora
Surgical intervention
2 months ago
1209 views
8 likes
3 comments
10:31
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
Laparoscopic rectal resection with ICG-guided nodal navigation
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of a 66-year-old woman with a sigmoid-rectal junction early stage cancer submitted to laparoscopic resection. Before surgery, the patient was submitted to endoscopy with the objective to mark the distal margin of the neoplasia, and 2mL of ICG were injected into the mucosa of the rectum, 2cm distal to the inferior border of the tumor.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588 camera system), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
It was possible to verify the good perfusion of the proximal stump of the anastomosis before the Knight-Griffen anastomosis was performed, thanks to an intravenous injection of ICG.
This technique could allow for a more precise and radical nodal dissection, a safer work respecting vascular and nerve structures, and could be related with a lower risk of anastomotic fistula, controlling the adequate perfusion of the stump.
G Baiocchi, S Molfino, B Molteni, A Titi, G Gaverini
Surgical intervention
3 months ago
2469 views
5 likes
1 comment
11:48
Laparoscopic rectal resection with ICG-guided nodal navigation
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of a 66-year-old woman with a sigmoid-rectal junction early stage cancer submitted to laparoscopic resection. Before surgery, the patient was submitted to endoscopy with the objective to mark the distal margin of the neoplasia, and 2mL of ICG were injected into the mucosa of the rectum, 2cm distal to the inferior border of the tumor.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588 camera system), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
It was possible to verify the good perfusion of the proximal stump of the anastomosis before the Knight-Griffen anastomosis was performed, thanks to an intravenous injection of ICG.
This technique could allow for a more precise and radical nodal dissection, a safer work respecting vascular and nerve structures, and could be related with a lower risk of anastomotic fistula, controlling the adequate perfusion of the stump.
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
S Qian, P Tejedor, M Leon, M Ortega, C Pastor
Surgical intervention
3 months ago
2923 views
3 likes
2 comments
06:45
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
Laparoscopic distal pancreatectomy with splenectomy for a recurrent GIST
GISTs are tumors of the gastrointestinal stroma which, although rare, are the most common mesenchymal neoplasms of the digestive tract. They are most common in the stomach and small intestine, in patients aged between 50 and 70 years. The definitive diagnosis is established with immunohistochemistry (CD117), and the risk of postoperative recurrence should be estimated. Studies relate small intestine’s lesions with greater aggressiveness; however, more recent studies emphasize mitotic index and lesion size.
The clinical case is that of a 53-year-old woman with a stage TNM IIIb, AFIP 6b gastric GIST. In 2013, she underwent a sleeve gastrectomy followed by the daily administration of Imatinib (400mg). After 3 years of adjuvant therapy, she stopped treatment. In May 2017, in a follow-up CT-scan, a solid, heterogeneous 6.7cm lesion appeared in the left hypochondrium, separated from the metal suture, invading the lower pole of the spleen, with no evidence of adenopathies or free liquid.
Surgical resection was planned. A splenectomy with distal pancreatectomy, documented in the video, was performed with no complications. The histological examination confirmed a 5.8cm tumor implant, located in the splenic cord, compatible with GIST recurrence (>50 mitoses/50 fields, free margins, prognostic group 6b).
JP Pinto, T Moreno, D Poletto, A Toscano, M Lozano
Surgical intervention
4 months ago
1646 views
2 likes
0 comments
14:02
Laparoscopic distal pancreatectomy with splenectomy for a recurrent GIST
GISTs are tumors of the gastrointestinal stroma which, although rare, are the most common mesenchymal neoplasms of the digestive tract. They are most common in the stomach and small intestine, in patients aged between 50 and 70 years. The definitive diagnosis is established with immunohistochemistry (CD117), and the risk of postoperative recurrence should be estimated. Studies relate small intestine’s lesions with greater aggressiveness; however, more recent studies emphasize mitotic index and lesion size.
The clinical case is that of a 53-year-old woman with a stage TNM IIIb, AFIP 6b gastric GIST. In 2013, she underwent a sleeve gastrectomy followed by the daily administration of Imatinib (400mg). After 3 years of adjuvant therapy, she stopped treatment. In May 2017, in a follow-up CT-scan, a solid, heterogeneous 6.7cm lesion appeared in the left hypochondrium, separated from the metal suture, invading the lower pole of the spleen, with no evidence of adenopathies or free liquid.
Surgical resection was planned. A splenectomy with distal pancreatectomy, documented in the video, was performed with no complications. The histological examination confirmed a 5.8cm tumor implant, located in the splenic cord, compatible with GIST recurrence (>50 mitoses/50 fields, free margins, prognostic group 6b).
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
SAE Yeo
Surgical intervention
4 months ago
1316 views
5 likes
0 comments
15:36
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence
Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.
S Rua
Surgical intervention
4 months ago
2498 views
9 likes
0 comments
13:14
Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence
Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
C Viana, M Lozano, D Poletto, T Moreno, C Varela, A Toscano
Surgical intervention
4 months ago
2306 views
6 likes
0 comments
15:27
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
C Sposito, D Citterio, C Battiston, V Mazzaferro
Surgical intervention
4 months ago
1889 views
6 likes
0 comments
10:57
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
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.
L Marano, A Spaziani, G Castagnoli
Surgical intervention
7 months ago
872 views
4 likes
0 comments
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 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.
SAE Yeo
Surgical intervention
7 months ago
340 views
1 like
0 comments
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.
Right laparoscopic ureteroureteroplasty
Lower ureteral strictures are commonly managed with ureteral reimplant surgeries. However, some patients still have a good distal ureteral stump, which can be used in the repair of these pathologies. In those cases, reimplant ureteral surgeries and their surgical maneuvers, e.g. psoas hitch, Boari flap, are not the best management options.
This video shows a ureteroureteroplasty in a 37-year-old female patient with ureteral stricture at the level of the crossing iliac vessels due to several previous endoscopic manipulations for the treatment of ureteral/kidney stones.
The ureteroureteroplasty technique was chosen since the proximal and distal parts of the ureter near the stenosed area were healthy.
At the end of the video, preoperative MRI and 1-year follow-up CT urogram 3D reconstructions are placed side by side, demonstrating the resolution of hydronephrosis.
B Lopes-Cançado Machado, V Chamum Costa
Surgical intervention
7 months ago
1353 views
2 likes
0 comments
08:39
Right laparoscopic ureteroureteroplasty
Lower ureteral strictures are commonly managed with ureteral reimplant surgeries. However, some patients still have a good distal ureteral stump, which can be used in the repair of these pathologies. In those cases, reimplant ureteral surgeries and their surgical maneuvers, e.g. psoas hitch, Boari flap, are not the best management options.
This video shows a ureteroureteroplasty in a 37-year-old female patient with ureteral stricture at the level of the crossing iliac vessels due to several previous endoscopic manipulations for the treatment of ureteral/kidney stones.
The ureteroureteroplasty technique was chosen since the proximal and distal parts of the ureter near the stenosed area were healthy.
At the end of the video, preoperative MRI and 1-year follow-up CT urogram 3D reconstructions are placed side by side, demonstrating the resolution of hydronephrosis.
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
Background: Minimally invasive surgery (MIS) was shown to offer advantages in general and oncologic surgery (1). Over the last decade, reduced port laparoscopy (RPL) has been introduced to reduce the risks related to ports and abdominal wall trauma, with enhanced cosmetic outcomes (2). In this video, the authors report the case of a 59-year-old man with a small bowel neuroendocrine tumor, and who underwent a three-trocar right ileocolectomy.
Video: Preoperative work-up, including endoscopic ultrasound, octreoscan, PET-scan, and FDG PET-CT, showed a 15mm small bowel tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the third portion of the duodenum. The biopsy revealed a low-grade well-differentiated neuroendocrine tumor. The procedure was performed using three abdominal trocars: a 12mm one in the umbilicus, a 5mm one in the right flank, and a 5mm port in the left flank (Figure 1). Abdominal cavity exploration demonstrated the presence of a tumor located in the mesentery of the last small bowel loop, with consequent bowel retraction, dislocation of the caecum and appendix, located under the right lobe of the liver, and tumoral extension into the proximal transverse mesocolon. After mobilization of the right colon from laterally to medially, the second and third duodenal segments were exposed, showing tumor extension towards the anterior duodenal wall of these segments. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape (Figure 2), an endoscopic linear stapler was inserted through the umbilical trocar under the visual guidance of a 5mm scope in the left flank (Figure 3a), and it was fired (Figure 3b). The specimen was removed through a suprapubic access. Perioperative frozen section biopsy showed a free duodenal margin, and the procedure was subsequently completed with an ileocolic anastomosis, performed in a side-to-side handsewn intracorporeal fashion. At the end, the mesocolic defect was closed.

Results: Operative time was 4 hours. No added trocars were necessary. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Pathological findings showed a grade I well-differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration (1/20 metastatic nodes, free margins, stage: pT3N1 (8 UICC edition). A follow-up under somatostatin therapy was put forward.

Conclusions: RPL is a feasible option when performing advanced oncological surgery. Patients benefit from all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
G Dapri
Surgical intervention
8 months ago
4682 views
93 likes
3 comments
11:10
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
Background: Minimally invasive surgery (MIS) was shown to offer advantages in general and oncologic surgery (1). Over the last decade, reduced port laparoscopy (RPL) has been introduced to reduce the risks related to ports and abdominal wall trauma, with enhanced cosmetic outcomes (2). In this video, the authors report the case of a 59-year-old man with a small bowel neuroendocrine tumor, and who underwent a three-trocar right ileocolectomy.
Video: Preoperative work-up, including endoscopic ultrasound, octreoscan, PET-scan, and FDG PET-CT, showed a 15mm small bowel tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the third portion of the duodenum. The biopsy revealed a low-grade well-differentiated neuroendocrine tumor. The procedure was performed using three abdominal trocars: a 12mm one in the umbilicus, a 5mm one in the right flank, and a 5mm port in the left flank (Figure 1). Abdominal cavity exploration demonstrated the presence of a tumor located in the mesentery of the last small bowel loop, with consequent bowel retraction, dislocation of the caecum and appendix, located under the right lobe of the liver, and tumoral extension into the proximal transverse mesocolon. After mobilization of the right colon from laterally to medially, the second and third duodenal segments were exposed, showing tumor extension towards the anterior duodenal wall of these segments. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape (Figure 2), an endoscopic linear stapler was inserted through the umbilical trocar under the visual guidance of a 5mm scope in the left flank (Figure 3a), and it was fired (Figure 3b). The specimen was removed through a suprapubic access. Perioperative frozen section biopsy showed a free duodenal margin, and the procedure was subsequently completed with an ileocolic anastomosis, performed in a side-to-side handsewn intracorporeal fashion. At the end, the mesocolic defect was closed.

Results: Operative time was 4 hours. No added trocars were necessary. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Pathological findings showed a grade I well-differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration (1/20 metastatic nodes, free margins, stage: pT3N1 (8 UICC edition). A follow-up under somatostatin therapy was put forward.

Conclusions: RPL is a feasible option when performing advanced oncological surgery. Patients benefit from all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent
This video demonstrates a case of EUS-guided choledochoduodenostomy, emblematic of the latest cutting-edge technology.
A 86-year-old woman with recent abdominal pain and jaundice underwent a CT-scan, which showed an enlarged tumor of the second portion of the duodenum with biliary tree dilatation. Gastroscopy with biopsy confirmed the diagnosis of duodenal adenocarcinoma of the 2nd duodenum.
First, endoscopic retrograde cholangiopancreatography (ERCP) failed to achieve biliary drainage because of an inability to cannulate the papilla due to tumor infiltration. EUS-guided hepatogastrostomy (EUS-HGS) was not attempted because the left intra-hepatic bile ducts were minimally dilated (3mm). However, the common bile duct (CBD) was largely dilated (20 mm). A Hot AXIOS™ Stent and Electrocautery Enhanced Delivery System (stent of 8 by 6mm) was advanced through the bulb. Pure cut electrocautery current was then applied, allowing the device to reach the CBD. Next, the distal flange was opened and retracted towards the EUS transducer, and once a biliary and bulbar tissue apposition had been noted, the proximal flange was released. Good drainage of purulent bile was observed and no complications occurred during the procedure and one month afterwards.
A Sportes, G Airinei, R Kamel, R Benamouzig
Surgical intervention
8 months ago
230 views
6 likes
0 comments
03:09
Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent
This video demonstrates a case of EUS-guided choledochoduodenostomy, emblematic of the latest cutting-edge technology.
A 86-year-old woman with recent abdominal pain and jaundice underwent a CT-scan, which showed an enlarged tumor of the second portion of the duodenum with biliary tree dilatation. Gastroscopy with biopsy confirmed the diagnosis of duodenal adenocarcinoma of the 2nd duodenum.
First, endoscopic retrograde cholangiopancreatography (ERCP) failed to achieve biliary drainage because of an inability to cannulate the papilla due to tumor infiltration. EUS-guided hepatogastrostomy (EUS-HGS) was not attempted because the left intra-hepatic bile ducts were minimally dilated (3mm). However, the common bile duct (CBD) was largely dilated (20 mm). A Hot AXIOS™ Stent and Electrocautery Enhanced Delivery System (stent of 8 by 6mm) was advanced through the bulb. Pure cut electrocautery current was then applied, allowing the device to reach the CBD. Next, the distal flange was opened and retracted towards the EUS transducer, and once a biliary and bulbar tissue apposition had been noted, the proximal flange was released. Good drainage of purulent bile was observed and no complications occurred during the procedure and one month afterwards.
Laparoscopic resection of inguinal recurrence of myxoid liposarcoma
This is the case of a laparoscopic resection of inguinal recurrence of myxoid liposarcoma (MLS). In 2003, a 29-year-old man presented with a 23cm right thigh mass, compatible with soft tissue sarcoma. He underwent radical surgery and the final pathological examination confirmed a grade 1 myxoid liposarcoma. He received adjuvant radiotherapy (70 Gy). Follow-up demonstrated that the patient was disease-free until 2015. In September 2017, he presented to the emergency room with a lower right extremity edema. Radiological examination demonstrated the presence of an 8cm inguinal mass compatible with a late inguinal recurrence of known sarcoma. Neoadjuvant chemotherapy was indicated and elective surgery was performed in January 2018. CT-scan revealed a mass in the preperitoneal space, displacing the urinary bladder medially, involving right external iliac vessels and getting into the femoral canal distally. A laparoscopic approach was decided upon.
C Rodríguez-Otero Luppi, M Rodríguez Blanco, E Ballester Vázquez, V Artigas Raventós
Surgical intervention
8 months ago
950 views
37 likes
2 comments
09:00
Laparoscopic resection of inguinal recurrence of myxoid liposarcoma
This is the case of a laparoscopic resection of inguinal recurrence of myxoid liposarcoma (MLS). In 2003, a 29-year-old man presented with a 23cm right thigh mass, compatible with soft tissue sarcoma. He underwent radical surgery and the final pathological examination confirmed a grade 1 myxoid liposarcoma. He received adjuvant radiotherapy (70 Gy). Follow-up demonstrated that the patient was disease-free until 2015. In September 2017, he presented to the emergency room with a lower right extremity edema. Radiological examination demonstrated the presence of an 8cm inguinal mass compatible with a late inguinal recurrence of known sarcoma. Neoadjuvant chemotherapy was indicated and elective surgery was performed in January 2018. CT-scan revealed a mass in the preperitoneal space, displacing the urinary bladder medially, involving right external iliac vessels and getting into the femoral canal distally. A laparoscopic approach was decided upon.
Transanal minimally invasive full-thickness middle rectum polyp resection with the patient in a prone position
Background: Nowadays, rectal preservation has gained popularity when it comes to the management of degenerated rectal polyps or early rectal cancer (1, 2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment via transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report the case of a 60-year-old woman who underwent a TAMIS procedure for a large polyp located anteriorly in the middle rectum, which was 7cm away from the pectineal line and staged as uTisN0M0 preoperatively.
Video: The patient was placed in a prone position with a split-leg kneeling position. A reusable transanal D-Port (Karl Storz Endoskope, Tuttlingen, Germany) was introduced into the anus together with DAPRI monocurved instruments (Figure 1). The polyp was put in evidence (Figure 2) and resection margins were defined circumferentially using the monocurved coagulating hook. A full-thickness resection was performed with a complete removal of the rectal serosa and exposure of the peritoneal cavity, due to the anatomical polyp positioning (Figure 3). The rectal opening was subsequently closed using two converging full-thickness running sutures using 3/0 V-loc™ sutures (Figure 4a). The two sutures were started laterally and joined together medially (Figure 4b).
Results: Total operative time was 60 minutes whereas suturing time was 35 minutes. There was no perioperative bleeding. The postoperative course was uneventful, and the patient was discharged after 2 days. The pathological report showed a tubular adenoma with high-grade dysplasia and clear margins.
Conclusions: In the presence of degenerated rectal polyps, full-thickness TAMIS is oncologically safe and feasible. The final rectal flap can be safely closed by means of laparoscopic endoluminal sutures.
G Dapri, L Qin Yi, A Wong, P Tan Enjiu, S Hsien Lin, D Lee, T Kok Yang, S Mantoo
Surgical intervention
9 months ago
750 views
196 likes
0 comments
05:53
Transanal minimally invasive full-thickness middle rectum polyp resection with the patient in a prone position
Background: Nowadays, rectal preservation has gained popularity when it comes to the management of degenerated rectal polyps or early rectal cancer (1, 2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment via transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report the case of a 60-year-old woman who underwent a TAMIS procedure for a large polyp located anteriorly in the middle rectum, which was 7cm away from the pectineal line and staged as uTisN0M0 preoperatively.
Video: The patient was placed in a prone position with a split-leg kneeling position. A reusable transanal D-Port (Karl Storz Endoskope, Tuttlingen, Germany) was introduced into the anus together with DAPRI monocurved instruments (Figure 1). The polyp was put in evidence (Figure 2) and resection margins were defined circumferentially using the monocurved coagulating hook. A full-thickness resection was performed with a complete removal of the rectal serosa and exposure of the peritoneal cavity, due to the anatomical polyp positioning (Figure 3). The rectal opening was subsequently closed using two converging full-thickness running sutures using 3/0 V-loc™ sutures (Figure 4a). The two sutures were started laterally and joined together medially (Figure 4b).
Results: Total operative time was 60 minutes whereas suturing time was 35 minutes. There was no perioperative bleeding. The postoperative course was uneventful, and the patient was discharged after 2 days. The pathological report showed a tubular adenoma with high-grade dysplasia and clear margins.
Conclusions: In the presence of degenerated rectal polyps, full-thickness TAMIS is oncologically safe and feasible. The final rectal flap can be safely closed by means of laparoscopic endoluminal sutures.
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
F Signorini, S Reimondez, M España, L Obeide, F Moser
Surgical intervention
9 months ago
6490 views
417 likes
5 comments
06:41
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
Laparoscopic repair of giant left Bochdalek hernia in adults: resolution of 2 cases
A Bochdalek hernia is a congenital diaphragmatic defect which results from the improper fusion of the septum transversum and of the pleuroperitoneal folds. It rarely persists asymptomatically until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases, using open surgery or laparoscopy/thoracoscopy.
We present two cases of fully laparoscopic repair of a giant Bochdalek hernia in adults. In both cases, we used a GORE® DUALMESH® biomaterial and we had no complications and no recurrence. It is worth mentioning that the hernia sac was not found in any of the cases. This has been described as a distinct characteristic, which confirms the diagnosis.
Bochdalek hernia in adults is a rare entity, which requires surgical treatment to prevent any complications.
F Signorini, S Reimondez, P Maldonado, V Gorodner, L Obeide, F Moser, N Bollati
Surgical intervention
9 months ago
1913 views
176 likes
0 comments
10:10
Laparoscopic repair of giant left Bochdalek hernia in adults: resolution of 2 cases
A Bochdalek hernia is a congenital diaphragmatic defect which results from the improper fusion of the septum transversum and of the pleuroperitoneal folds. It rarely persists asymptomatically until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases, using open surgery or laparoscopy/thoracoscopy.
We present two cases of fully laparoscopic repair of a giant Bochdalek hernia in adults. In both cases, we used a GORE® DUALMESH® biomaterial and we had no complications and no recurrence. It is worth mentioning that the hernia sac was not found in any of the cases. This has been described as a distinct characteristic, which confirms the diagnosis.
Bochdalek hernia in adults is a rare entity, which requires surgical treatment to prevent any complications.