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Monthly publications

#September 2011
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Posterior approach to laparoscopic left adrenalectomy including virtual reality simulation
Since M. Gagner published the first case of a transperitoneal laparoscopic adrenalectomy in 1992, the laparoscopic adrenalectomy has gradually become the standard operation for removing adrenal tumors. Compared to a traditional adrenalectomy, a laparoscopic adrenalectomy has a number of advantages, including less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. There are many ways to approach the adrenal gland laparoscopically, such as by a lateral transperitoneal approach, anterior transperitoneal approach, lateral retroperitoneal approach, and posterior retroperitoneal approach. This video shows a posterior left adrenalectomy using virtual reality simulation.
M Walz, L Soler, J Marescaux
Surgical intervention
7 years ago
1849 views
30 likes
1 comment
25:24
Posterior approach to laparoscopic left adrenalectomy including virtual reality simulation
Since M. Gagner published the first case of a transperitoneal laparoscopic adrenalectomy in 1992, the laparoscopic adrenalectomy has gradually become the standard operation for removing adrenal tumors. Compared to a traditional adrenalectomy, a laparoscopic adrenalectomy has a number of advantages, including less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. There are many ways to approach the adrenal gland laparoscopically, such as by a lateral transperitoneal approach, anterior transperitoneal approach, lateral retroperitoneal approach, and posterior retroperitoneal approach. This video shows a posterior left adrenalectomy using virtual reality simulation.
Laparoscopic repair of post-traumatic diaphragmatic hernia with mesh insertion
Traumatic injuries of the diaphragm are rare (0.8%-5.8% of all blunt trauma). Early diagnosis is difficult, and many reports have described delayed presentation of diaphragmatic hernia with subsequent significant morbidity and mortality.

We report a case of an acute diaphragmatic hernia in a 47-year-old male presenting 4 years after the traumatic episode (significant fall from a ladder). The patient was admitted to the emergency department with severe vomiting and dehydration. Once the patient was stabilised with fluid resuscitation and nasogastric tube aspiration, an urgent CT-scan was performed. This demonstrated a large defect within the left hemi-diaphragm, associated with herniation of both the antrum and body of the stomach, into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with herniation and rotation of the stomach was confirmed. The hernia was reduced laparoscopically, and the defect repaired with interrupted, non-absorbable polyester sutures (Ethibond 2/0, Ethicon) and a composite mesh (Proceed™, Ethicon). The patient made an uneventful recovery.
Emergency repair of the diaphragm is usually performed via a thoracotomy or/and laparotomy. In our experience, if the patient is haemodynamically stable and major organ injuries have been excluded, a laparoscopic approach can be considered safe and effective.
A Rotundo, T Knowles, S Kadirkamanathan, M Harvey
Surgical intervention
7 years ago
4477 views
46 likes
1 comment
10:21
Laparoscopic repair of post-traumatic diaphragmatic hernia with mesh insertion
Traumatic injuries of the diaphragm are rare (0.8%-5.8% of all blunt trauma). Early diagnosis is difficult, and many reports have described delayed presentation of diaphragmatic hernia with subsequent significant morbidity and mortality.

We report a case of an acute diaphragmatic hernia in a 47-year-old male presenting 4 years after the traumatic episode (significant fall from a ladder). The patient was admitted to the emergency department with severe vomiting and dehydration. Once the patient was stabilised with fluid resuscitation and nasogastric tube aspiration, an urgent CT-scan was performed. This demonstrated a large defect within the left hemi-diaphragm, associated with herniation of both the antrum and body of the stomach, into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with herniation and rotation of the stomach was confirmed. The hernia was reduced laparoscopically, and the defect repaired with interrupted, non-absorbable polyester sutures (Ethibond 2/0, Ethicon) and a composite mesh (Proceed™, Ethicon). The patient made an uneventful recovery.
Emergency repair of the diaphragm is usually performed via a thoracotomy or/and laparotomy. In our experience, if the patient is haemodynamically stable and major organ injuries have been excluded, a laparoscopic approach can be considered safe and effective.
Laparoscopic management of sealed gallbladder perforation
This video features a 62-year-old diabetic male patient who is not undergoing any treatment. He has sufferont from vague upper abdominal pain for one month. He has a past history of acute upper abdominal pain which was managed conservatively.
Abdominal ultrasonography demonstrates cholelithiasis with signs of chronic cholecystitis. Blood examination reveals hyperglycemia with normal liver function tests.
After controlling the hyperglycemic status, the patient is subjected to a laparoscopic cholecystectomy. There is evidence of gallbladder perforation, as the gallbladder is sealed off by the omentum. The gallbladder presents a large amount of calculi which are visible through the thin wall of the gallbladder, and some calculi almost protruding out through the wall.
The laparoscopic cholecystectomy is performed successfully with caution not to soil the peritoneum.
E Khiangte, I Newme, P Phukan
Surgical intervention
7 years ago
3922 views
52 likes
1 comment
06:39
Laparoscopic management of sealed gallbladder perforation
This video features a 62-year-old diabetic male patient who is not undergoing any treatment. He has sufferont from vague upper abdominal pain for one month. He has a past history of acute upper abdominal pain which was managed conservatively.
Abdominal ultrasonography demonstrates cholelithiasis with signs of chronic cholecystitis. Blood examination reveals hyperglycemia with normal liver function tests.
After controlling the hyperglycemic status, the patient is subjected to a laparoscopic cholecystectomy. There is evidence of gallbladder perforation, as the gallbladder is sealed off by the omentum. The gallbladder presents a large amount of calculi which are visible through the thin wall of the gallbladder, and some calculi almost protruding out through the wall.
The laparoscopic cholecystectomy is performed successfully with caution not to soil the peritoneum.
Laparoscopic transperitoneal nephrectomy for nephroblastoma
Laparoscopy may be suggested to manage total nephrectomy in specific cases of Wilms’ tumor in children.
Minimal access surgery in pediatric oncology should remain extremely prudent. Some tumors can readily be treated laparoscopically since there is no risk of seeding. On the contrary, in case of seeding, the prognosis would be endangered during surgery for Wilms’ tumor.
Consequently, the decision as to whether or not choose laparoscopy should absolutely be discussed.
Indications for laparoscopic nephrectomy involve tumors treated according to the SIOP treatment guidelines, including primary chemotherapy.
Laparoscopy is mostly decided upon in the presence of a stage I tumor, more rarely in the presence of a stage II tumor without distant metastasis and without tumor thrombus of the renal vein and/or of the vena cava.
Patients with a bilateral tumor are excluded from such therapeutic strategy. Therefore, they will be offered an open nephron-sparing surgery.
Contraindications to laparoscopy include massive post-chemotherapy residual tumor sizes and tumors located proximal to the hilum, since the risk of injuring the tumor during the primary vascular dissection is high.
F Becmeur, F Varlet
Surgical intervention
7 years ago
2564 views
34 likes
1 comment
09:22
Laparoscopic transperitoneal nephrectomy for nephroblastoma
Laparoscopy may be suggested to manage total nephrectomy in specific cases of Wilms’ tumor in children.
Minimal access surgery in pediatric oncology should remain extremely prudent. Some tumors can readily be treated laparoscopically since there is no risk of seeding. On the contrary, in case of seeding, the prognosis would be endangered during surgery for Wilms’ tumor.
Consequently, the decision as to whether or not choose laparoscopy should absolutely be discussed.
Indications for laparoscopic nephrectomy involve tumors treated according to the SIOP treatment guidelines, including primary chemotherapy.
Laparoscopy is mostly decided upon in the presence of a stage I tumor, more rarely in the presence of a stage II tumor without distant metastasis and without tumor thrombus of the renal vein and/or of the vena cava.
Patients with a bilateral tumor are excluded from such therapeutic strategy. Therefore, they will be offered an open nephron-sparing surgery.
Contraindications to laparoscopy include massive post-chemotherapy residual tumor sizes and tumors located proximal to the hilum, since the risk of injuring the tumor during the primary vascular dissection is high.
Arthroscopic Wafer procedure: abrasion of the distal ulnar head in ulnocarpal conflicts
The ulnocarpal conflict is not a rare condition and should be taken into account in the event of ulnocarpal pain. The conflict is created by too narrow a space of the ulnar head and the ulnar edge of the lunate and the triquetrum. During loading and ulnar deviation of the wrist, a direct contact between these bones is produced. This leads to degenerative changes on the cartilage and produces pain. The origin may be a congenital positive ulnar situation, or a trauma impairing the natural leveling of the forearm bones. We distinguish a fresh traumatic condition (ulnar impaction syndrome) from a chronic condition (ulnar impingement syndrome). The midcarpal bones may also suffer from a similar condition, which is the hamate tip syndrome.
Diagnosis is made by clinical examination including the ulnocarpal stress test, standard X-rays, MRI enhanced with endovenous contrast and subsequent wrist arthroscopy.

Therapeutic options include the ulnar shortening osteotomy and the resection of the distal head of the ulna. Decision can be made depending on the state of the TFCC, the age of the patient and the collateral changes in the wrist. If the lesion occurs in young patients without any concomitant lesion, a shortening osteotomy is more often chosen.

In all other conditions, the less invasive choice for the minimal resection of the distal ulnar head is made by arthroscopic and open surgery. The camera is introduced through the 3-4 portal and the burr through the 6R portal. At the beginning, a 3.5 burr —in more trained hands a 4.2 burr— is used to resect about 2-3 mm of the distal ulnar head during supination and pronation movements. Care is taken not to resect the foveal area or the DRUJ.

After the operation, a comfort splint can be adapted for 3-4 days, and immediate physiotherapy is initiated.
M Haerle
Surgical intervention
7 years ago
679 views
8 likes
0 comments
08:57
Arthroscopic Wafer procedure: abrasion of the distal ulnar head in ulnocarpal conflicts
The ulnocarpal conflict is not a rare condition and should be taken into account in the event of ulnocarpal pain. The conflict is created by too narrow a space of the ulnar head and the ulnar edge of the lunate and the triquetrum. During loading and ulnar deviation of the wrist, a direct contact between these bones is produced. This leads to degenerative changes on the cartilage and produces pain. The origin may be a congenital positive ulnar situation, or a trauma impairing the natural leveling of the forearm bones. We distinguish a fresh traumatic condition (ulnar impaction syndrome) from a chronic condition (ulnar impingement syndrome). The midcarpal bones may also suffer from a similar condition, which is the hamate tip syndrome.
Diagnosis is made by clinical examination including the ulnocarpal stress test, standard X-rays, MRI enhanced with endovenous contrast and subsequent wrist arthroscopy.

Therapeutic options include the ulnar shortening osteotomy and the resection of the distal head of the ulna. Decision can be made depending on the state of the TFCC, the age of the patient and the collateral changes in the wrist. If the lesion occurs in young patients without any concomitant lesion, a shortening osteotomy is more often chosen.

In all other conditions, the less invasive choice for the minimal resection of the distal ulnar head is made by arthroscopic and open surgery. The camera is introduced through the 3-4 portal and the burr through the 6R portal. At the beginning, a 3.5 burr —in more trained hands a 4.2 burr— is used to resect about 2-3 mm of the distal ulnar head during supination and pronation movements. Care is taken not to resect the foveal area or the DRUJ.

After the operation, a comfort splint can be adapted for 3-4 days, and immediate physiotherapy is initiated.
Arthroscopic-assisted scapholunate ligament reconstruction for chronic SL instability
Both the dorsal and the volar portion of the scapholunate interosseous ligaments are the major stabilizers of the scapholunate joint. Most conventional methods to restore scapholunate stability do not address the volar constraints and frequently fail to reduce the SL gapping. Wrist arthroscopy allows for a complete evaluation of the SL interval, accompanying ligament status and associated SLAC wrist changes. It enables simultaneous reconstruction of the dorsal and palmar scapholunate ligaments anatomically with the use of the palmaris longus tendon as a tendon graft in a box-like structure.

With the assistance of arthroscopy, a combined limited dorsal and volar incision can expose the dorsal and palmar scapholunate interval, where bone tunnels can be made by a cannulated drill under image control on the proximal scaphoid and lunate. The palmaris longus tendon graft is then used to reduce and connect the two bones in a box-like fashion. Once joint diastasis has been reduced and DISI malrotation has been corrected, the tendon graft can be knotted under maximal tension on the dorsal surface of the scapholunate joint in a shoe-lacing manner. Correction and control of the DISI deformity can be achieved by placing drill holes at different levels, more proximally over the lunate and distally over the scaphoid to counter-rotate the deformity. Either the scapholunate or the scaphocapitate joint is then transfixed using K-wires for temporary protection of the reconstruction.

From October 2002 to June 2009, the treatment method was applied in 8 patients suffering from chronic SL instability with an average duration of 7.4 months (3-9 months). There were 6 male and 2 female patients. The average age for this group was 45.4 years (34-60 years). Six of the injured wrists were right wrist injuries. There were two Geissler grade 3 and six grade 4 instability cases. The average pre-operative SL interval was 4.7mm (3-9mm). Concomitant procedures were performed in 4 patients. The average follow-up was 34.9 months (10-66 months).

Symptoms in all patients —except in one— either improved or completely disappeared. The functional wrist score improved from 23.1 to 34.4 on a 40-point scale. Pain score decreased from 12 to 4.4 on a 20-point scale. There was no pain in 5 patients and exertion pain in 3. The injured/uninjured grip power ratio improved from 73.9% to 89%. The average SL interval at final follow-up was 3.6mm (2-7mm). An ischemic change of the proximal scaphoid was noted in one case without symptoms or progression. There were no major complications. All patients —except one— were satisfied with the procedure and the treatment outcome.
PC Ho
Lecture
7 years ago
408 views
7 likes
0 comments
17:25
Arthroscopic-assisted scapholunate ligament reconstruction for chronic SL instability
Both the dorsal and the volar portion of the scapholunate interosseous ligaments are the major stabilizers of the scapholunate joint. Most conventional methods to restore scapholunate stability do not address the volar constraints and frequently fail to reduce the SL gapping. Wrist arthroscopy allows for a complete evaluation of the SL interval, accompanying ligament status and associated SLAC wrist changes. It enables simultaneous reconstruction of the dorsal and palmar scapholunate ligaments anatomically with the use of the palmaris longus tendon as a tendon graft in a box-like structure.

With the assistance of arthroscopy, a combined limited dorsal and volar incision can expose the dorsal and palmar scapholunate interval, where bone tunnels can be made by a cannulated drill under image control on the proximal scaphoid and lunate. The palmaris longus tendon graft is then used to reduce and connect the two bones in a box-like fashion. Once joint diastasis has been reduced and DISI malrotation has been corrected, the tendon graft can be knotted under maximal tension on the dorsal surface of the scapholunate joint in a shoe-lacing manner. Correction and control of the DISI deformity can be achieved by placing drill holes at different levels, more proximally over the lunate and distally over the scaphoid to counter-rotate the deformity. Either the scapholunate or the scaphocapitate joint is then transfixed using K-wires for temporary protection of the reconstruction.

From October 2002 to June 2009, the treatment method was applied in 8 patients suffering from chronic SL instability with an average duration of 7.4 months (3-9 months). There were 6 male and 2 female patients. The average age for this group was 45.4 years (34-60 years). Six of the injured wrists were right wrist injuries. There were two Geissler grade 3 and six grade 4 instability cases. The average pre-operative SL interval was 4.7mm (3-9mm). Concomitant procedures were performed in 4 patients. The average follow-up was 34.9 months (10-66 months).

Symptoms in all patients —except in one— either improved or completely disappeared. The functional wrist score improved from 23.1 to 34.4 on a 40-point scale. Pain score decreased from 12 to 4.4 on a 20-point scale. There was no pain in 5 patients and exertion pain in 3. The injured/uninjured grip power ratio improved from 73.9% to 89%. The average SL interval at final follow-up was 3.6mm (2-7mm). An ischemic change of the proximal scaphoid was noted in one case without symptoms or progression. There were no major complications. All patients —except one— were satisfied with the procedure and the treatment outcome.
Surgical treatment of scaphoid fractures with arthroscopic control
The objective of this presentation is not to perform an exhaustive review of the surgical treatment of scaphoid fractures but to try to justify our choice to systematically associate an arthroscopic control in with a percutaneous fixation using a cannulated screw in all non- or minimally displaced scaphoid fractures. Scaphoid fractures are frequent but present unique challenges because of the particular geometry of the bone and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures may lead to non-unions that can progress to carpal collapse and degenerative arthritis of the wrist.
Improvements in diagnosis, surgical treatment and implant materials have encouraged a trend towards early internal fixation even for non-displaced scaphoid fractures that could potentially be treated non-operatively. In our experience, wrist arthroscopy is a useful tool in the management of these fractures not only to assess the quality of reduction but also not to overlook severe carpal ligament injuries, which would be untreated and may lead to chronic and symptomatic carpal instability.
X Martinache
Lecture
7 years ago
182 views
5 likes
0 comments
10:12
Surgical treatment of scaphoid fractures with arthroscopic control
The objective of this presentation is not to perform an exhaustive review of the surgical treatment of scaphoid fractures but to try to justify our choice to systematically associate an arthroscopic control in with a percutaneous fixation using a cannulated screw in all non- or minimally displaced scaphoid fractures. Scaphoid fractures are frequent but present unique challenges because of the particular geometry of the bone and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures may lead to non-unions that can progress to carpal collapse and degenerative arthritis of the wrist.
Improvements in diagnosis, surgical treatment and implant materials have encouraged a trend towards early internal fixation even for non-displaced scaphoid fractures that could potentially be treated non-operatively. In our experience, wrist arthroscopy is a useful tool in the management of these fractures not only to assess the quality of reduction but also not to overlook severe carpal ligament injuries, which would be untreated and may lead to chronic and symptomatic carpal instability.
Arthroscopic reduction of intra-articular distal radius fractures: practical explanations, tips and tricks
The interest of wrist arthroscopy for the treatment of intra-articular fractures of the distal radius has been demonstrated in the literature for several years. This surgical technique requires specific instrumentation,
like a tower traction, small size optics and small tools. Once the stabilization of the wrist has been performed (using K-wires or plates), an arthroscopic control allows to appreciate the reduction of the fracture, and to diagnose and treat ligamentous injuries. Reduction of the fracture is
sometimes not sufficient and can be carried out under arthroscopic control using K-wires as a joystick. This surgical technique needs a learning curve to be able to treat difficult articular fractures of the distal radius. Using arthroscopy, the follow-up of operated articular fractures of the distal radius is easier for the surgeon and the patient.
JM Cognet
Lecture
7 years ago
198 views
1 like
0 comments
13:30
Arthroscopic reduction of intra-articular distal radius fractures: practical explanations, tips and tricks
The interest of wrist arthroscopy for the treatment of intra-articular fractures of the distal radius has been demonstrated in the literature for several years. This surgical technique requires specific instrumentation,
like a tower traction, small size optics and small tools. Once the stabilization of the wrist has been performed (using K-wires or plates), an arthroscopic control allows to appreciate the reduction of the fracture, and to diagnose and treat ligamentous injuries. Reduction of the fracture is
sometimes not sufficient and can be carried out under arthroscopic control using K-wires as a joystick. This surgical technique needs a learning curve to be able to treat difficult articular fractures of the distal radius. Using arthroscopy, the follow-up of operated articular fractures of the distal radius is easier for the surgeon and the patient.