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#March 2011
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TEP repair of a recurrent right inguinal hernia following failed TAPP repair: world’s first report
A 10mm paraumbilical balloon-tipped port was inserted into the preperitoneal space under direct vision and CO2 was insufflated.
Blunt dissection of the preperitoneal space to the pubis inferiorly and towards the left hernial orifices was performed using the 10mm laparoscope.
A further 10mm port was introduced into the pre-peritoneal space midway between the pubic symphysis and umbilicus. An atraumatic grasper was used to aid with further pre-peritoneal dissection. An indirect sac was identified on the left, freed from the adherent cord and then reduced. After excluding a direct hernia on the ipsilateral side and ensuring adequate clearance for mesh placement, a third 5mm port was introduced. This was inserted 1cm above and medial to the left anterior superior iliac spine
Dissection of the right pre-peritoneal space was performed using a combination of atraumatic graspers, scissors and diathermy. The mesh from the previous repair was identified and noted to be very adherent to the anterior abdominal wall. Careful and patient mobilisation revealed that this mesh had curled up and formed part of the contents of a direct inguinal hernia on the right. After meticulous dissection, the mesh was entirely freed from the anterior abdominal wall and direct space and reduced inferiorly remaining adherent to the underlying peritoneum. The inferior epigastric vessels were then identified. Preperitoneal dissection had resulted in distortion of their position such that they had been pulled down away from the anterior abdominal wall. Care was required not to injure these vessels as they were mobilised and lifted up to their normal anatomical position. The cord on this side was examined and after confirming the absence of an indirect sac, further preperitoneal dissection was performed to ensure adequate space for mesh placement.
Bilateral Bard™ 3D meshes were inserted ensuring adequate cover of all hernial orifices with overlapping of meshes in the midline. The left indirect sac and right direct hernia contents, consisting mainly of old mesh, were well clear of the new meshes. No tackers were used. CO2 insufflation was stopped and the preperitoneal space was allowed to close under vision ensuring no mesh displacement. Ports were closed via a standard technique.
MH Mobasheri, A Wan, G Vasilikostas , KM Reddy
Surgical intervention
7 years ago
5343 views
42 likes
0 comments
10:26
TEP repair of a recurrent right inguinal hernia following failed TAPP repair: world’s first report
A 10mm paraumbilical balloon-tipped port was inserted into the preperitoneal space under direct vision and CO2 was insufflated.
Blunt dissection of the preperitoneal space to the pubis inferiorly and towards the left hernial orifices was performed using the 10mm laparoscope.
A further 10mm port was introduced into the pre-peritoneal space midway between the pubic symphysis and umbilicus. An atraumatic grasper was used to aid with further pre-peritoneal dissection. An indirect sac was identified on the left, freed from the adherent cord and then reduced. After excluding a direct hernia on the ipsilateral side and ensuring adequate clearance for mesh placement, a third 5mm port was introduced. This was inserted 1cm above and medial to the left anterior superior iliac spine
Dissection of the right pre-peritoneal space was performed using a combination of atraumatic graspers, scissors and diathermy. The mesh from the previous repair was identified and noted to be very adherent to the anterior abdominal wall. Careful and patient mobilisation revealed that this mesh had curled up and formed part of the contents of a direct inguinal hernia on the right. After meticulous dissection, the mesh was entirely freed from the anterior abdominal wall and direct space and reduced inferiorly remaining adherent to the underlying peritoneum. The inferior epigastric vessels were then identified. Preperitoneal dissection had resulted in distortion of their position such that they had been pulled down away from the anterior abdominal wall. Care was required not to injure these vessels as they were mobilised and lifted up to their normal anatomical position. The cord on this side was examined and after confirming the absence of an indirect sac, further preperitoneal dissection was performed to ensure adequate space for mesh placement.
Bilateral Bard™ 3D meshes were inserted ensuring adequate cover of all hernial orifices with overlapping of meshes in the midline. The left indirect sac and right direct hernia contents, consisting mainly of old mesh, were well clear of the new meshes. No tackers were used. CO2 insufflation was stopped and the preperitoneal space was allowed to close under vision ensuring no mesh displacement. Ports were closed via a standard technique.
Laparoscopic closed cystopericystectomy in liver hydatidosis
A 54-year-old woman presented to our Department with epigastric pain. Abdominal ultrasound and MRI showed a cystic lesion of 30 x 36 x 37mm located in segment III of the liver. The left portal trunk, which divides into branches, can be found close to the lesion. Serological test of hydatidosis was positive (1/2560). The surgical intervention was decided upon. In our opinion, radical surgery (total cystectomy or liver resection) should be the technique of choice in liver hydatidosis, since better results are obtained, especially in terms of morbidity, relapse and hospital stay. Totally laparoscopic closed cystopericystectomy, when feasible, could be done, but it is more technically demanding than conservative techniques.
JM Ramia, JE Quiñones, R de la Plaza, J García-Parreño
Surgical intervention
7 years ago
2702 views
87 likes
0 comments
10:03
Laparoscopic closed cystopericystectomy in liver hydatidosis
A 54-year-old woman presented to our Department with epigastric pain. Abdominal ultrasound and MRI showed a cystic lesion of 30 x 36 x 37mm located in segment III of the liver. The left portal trunk, which divides into branches, can be found close to the lesion. Serological test of hydatidosis was positive (1/2560). The surgical intervention was decided upon. In our opinion, radical surgery (total cystectomy or liver resection) should be the technique of choice in liver hydatidosis, since better results are obtained, especially in terms of morbidity, relapse and hospital stay. Totally laparoscopic closed cystopericystectomy, when feasible, could be done, but it is more technically demanding than conservative techniques.
Video-assisted thoracoscopic (VATS) lobectomy: right lower lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via postero-lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air-leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for adenocarcinoma of the right lower lobe in a 78-year-old patient (the video emphasizes the steps of lobe resection - mediastinal lymph node dissection was effected but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Girard RN, and Mélodie Leclerc RN for their continued support.

*The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
G Rakovich, D Ouellette, G Beauchamp
Surgical intervention
7 years ago
851 views
39 likes
1 comment
09:56
Video-assisted thoracoscopic (VATS) lobectomy: right lower lobe
Standard treatment of early-stage non-small cell lung cancer involves anatomic pulmonary lobectomy and mediastinal lymph node dissection. Traditionally, this procedure has been carried out via postero-lateral thoracotomy, requiring division of chest wall muscles and rib spreading. This is frequently associated with chronic postoperative pain, which may become incapacitating in 5% of patients.
One of the major potential advantages of video-assisted thoracoscopic (VATS) lobectomy is decreasing the incidence of chronic post-thoracotomy pain.
Key aspects of the procedure include:
- proper patient positioning;
- access to the pleural cavity and appropriate positioning of operating incisions*;
- careful dissection of pulmonary arterial branches, using a “fissure-sparing” technique whenever possible to decrease the incidence of prolonged postoperative air-leaks;
- division of lung parenchyma, blood vessels, and bronchus using endoscopic staplers.
The VATS approach can be carried out with similar morbidity and similar oncologic outcome to traditional open surgery. We present VATS lobectomy for adenocarcinoma of the right lower lobe in a 78-year-old patient (the video emphasizes the steps of lobe resection - mediastinal lymph node dissection was effected but is not shown).
Acknowledgment: we would like to thank Nathalie Leroux RN, Francine Girard RN, and Mélodie Leclerc RN for their continued support.

*The figure used to illustrate the positioning of operating incisions was adapted with permission from: «Handbook of perioperative care in general thoracic surgery», Deslauriers J, Mehran R, eds. Positioning and incisions, pages 206-227, fig 5-19, Copyright Elsevier, 2005.
Laparoscopic sacrocolpopexy with subtotal hysterectomy: the six points technique
Standardization means: implementing guidelines or measurements in order to obtain solutions to a disorganized system. Laparoscopic sacrocolpopexy is a long and complete surgical procedure that requires good knowledge of the anatomy and of the surgical technique, as well as advanced suturing skills. Laparoscopic sacrocolpopexy is also the gold standard procedure for POP repair, and its standardization is justified by its difficulty.
This video demonstrates the standard technique for laparoscopic sacrocolpopexy with sub-total hysterectomy. It is called “the six-point technique” due to the six stitches used to fix the meshes.
A Wattiez, E Baulon, J Nassif, S Maia, P Trompoukis, J Alcocer, A Vázquez Rodriguez
Surgical intervention
7 years ago
7953 views
95 likes
0 comments
28:50
Laparoscopic sacrocolpopexy with subtotal hysterectomy: the six points technique
Standardization means: implementing guidelines or measurements in order to obtain solutions to a disorganized system. Laparoscopic sacrocolpopexy is a long and complete surgical procedure that requires good knowledge of the anatomy and of the surgical technique, as well as advanced suturing skills. Laparoscopic sacrocolpopexy is also the gold standard procedure for POP repair, and its standardization is justified by its difficulty.
This video demonstrates the standard technique for laparoscopic sacrocolpopexy with sub-total hysterectomy. It is called “the six-point technique” due to the six stitches used to fix the meshes.
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
S Perretta, M Diana, B Dallemagne, R Cahill, J Marescaux
Surgical intervention
7 years ago
122 views
3 likes
0 comments
02:28
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.