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Monthly publications

#November 2011
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En bloc laparoscopic right hemicolectomy associated to atypical hepatectomy for advanced cancer of the hepatic flexure
Background: An adenocarcinoma of the hepatic colic flexure associated to liver invasion was diagnosed in a 55 year-old woman, who consulted for weight loss and anemia. The patient was submitted to neoadjuvant chemotherapy and, after 4 cycles, an en bloc laparoscopic right hemicolectomy and atypical hepatectomy of segment VI was proposed.
Video: The surgeon stood between the patient’s legs, and the cameraman to the patient’s left. Four trocars were placed in the abdomen. The right mesocolon was opened at the root of the ileocaecal vessels, which were meticulously dissected and clipped. The arterial and venous branch of the middle colic vessels were sectioned as well. The right mesocolon was freed from the duodenum respecting Toldt’s fascia. The proximal transverse colon and the distal ileum were divided by firing of a linear stapler (purple and white loads). Peroperative ultrasonography permitted exclusion of other hepatic lesions and the delimitation of the en bloc resection of segment VI. The hepatic parenchyma was transected using the coagulating hook. A laparoscopic manual side-to-side ileocolic anastomosis by 2 runnings sutures was performed. The mesocolic defect was closed, and the specimen was retrieved through a protected suprapubic incision.
Results: Operative time was 180 minutes and estimated blood loss 150 mL. The patient was discharged on the 5th postoperative day. Pathology evidenced a pT4N1 colic adenocarcinoma. She underwent additional adjuvant chemotherapy, and was doing well at the time of the last office visit.
Conclusion: Advanced colic cancer associated to hepatic invasion can be safely treated by laparoscopy.
G Dapri, J Himpens, GB Cadière
Surgical intervention
6 years ago
6996 views
40 likes
18 comments
10:17
En bloc laparoscopic right hemicolectomy associated to atypical hepatectomy for advanced cancer of the hepatic flexure
Background: An adenocarcinoma of the hepatic colic flexure associated to liver invasion was diagnosed in a 55 year-old woman, who consulted for weight loss and anemia. The patient was submitted to neoadjuvant chemotherapy and, after 4 cycles, an en bloc laparoscopic right hemicolectomy and atypical hepatectomy of segment VI was proposed.
Video: The surgeon stood between the patient’s legs, and the cameraman to the patient’s left. Four trocars were placed in the abdomen. The right mesocolon was opened at the root of the ileocaecal vessels, which were meticulously dissected and clipped. The arterial and venous branch of the middle colic vessels were sectioned as well. The right mesocolon was freed from the duodenum respecting Toldt’s fascia. The proximal transverse colon and the distal ileum were divided by firing of a linear stapler (purple and white loads). Peroperative ultrasonography permitted exclusion of other hepatic lesions and the delimitation of the en bloc resection of segment VI. The hepatic parenchyma was transected using the coagulating hook. A laparoscopic manual side-to-side ileocolic anastomosis by 2 runnings sutures was performed. The mesocolic defect was closed, and the specimen was retrieved through a protected suprapubic incision.
Results: Operative time was 180 minutes and estimated blood loss 150 mL. The patient was discharged on the 5th postoperative day. Pathology evidenced a pT4N1 colic adenocarcinoma. She underwent additional adjuvant chemotherapy, and was doing well at the time of the last office visit.
Conclusion: Advanced colic cancer associated to hepatic invasion can be safely treated by laparoscopy.
The glove TEM port: the poor man's TEM
Objective: Single port laparoscopic tools and principles are transferable to transanal work. Initial experiences and small series have recently been reported with the use of commercially available singe port systems. In an effort to improve the ergonomic constraints as well as to reduce the costs associated with these commercially available ports, we have further evolved our personal experience with the glove port towards an access modality equivalent to Transanal Endoscopic Microsurgery (TEM) for the intraluminal management of rectal disease. Here we describe this new and cost-effective technique for transanal work in a short video.
Materials and Methods: The glove TEM port is constructed on table by using a circular anal dilator (CAD), a wound retractor-protector (ALEXIS®, Applied Medical) and a standard sterile surgical glove. The wound retractor-protector is inserted through the CAD and anchors itself at the anorectal junction. Sealing the outer ring of the wound retractor with the cuff of the surgical glove creates a workspace and airtight seal. Through the fingers of the glove, standard laparoscopic trocar sleeves are inserted (along with a gas insufflation channel) through which a conventional 30-degree videoscope along with straight rigid laparoscopic instruments are inserted. Excellent views can be obtained with the regular laparoscopic optics after the creation of a stable pneumorectum of 10-15mmHg. The same principles apply for the dissection and resection as with a conventional TEM. The flexibility of the glove provides enhanced instrument maneuverability in each of the horizontal, vertical and rotational planes as well as improved tip abduction and adduction especially useful for suturing.
Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument maneuverability and range of movement. Thereafter, all patients eligible for TEM have been offered the option to participate in our pilot study. With this new access modality, ten consecutive patients between October 2010 and January 2011 underwent resection of benign (n=6) or malignant (n=4) rectal tumors. Only one case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. The case we present here is a full-thickness excision of an early rectal cancer in an 87-year-old female patient who was unfit for the conventional radical rectal resection.
Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon-friendly, economically attractive, and universally applicable.
R Hompes, F Ris, C Cunningham, N Mortensen, R Cahill
Surgical intervention
6 years ago
2538 views
30 likes
1 comment
08:10
The glove TEM port: the poor man's TEM
Objective: Single port laparoscopic tools and principles are transferable to transanal work. Initial experiences and small series have recently been reported with the use of commercially available singe port systems. In an effort to improve the ergonomic constraints as well as to reduce the costs associated with these commercially available ports, we have further evolved our personal experience with the glove port towards an access modality equivalent to Transanal Endoscopic Microsurgery (TEM) for the intraluminal management of rectal disease. Here we describe this new and cost-effective technique for transanal work in a short video.
Materials and Methods: The glove TEM port is constructed on table by using a circular anal dilator (CAD), a wound retractor-protector (ALEXIS®, Applied Medical) and a standard sterile surgical glove. The wound retractor-protector is inserted through the CAD and anchors itself at the anorectal junction. Sealing the outer ring of the wound retractor with the cuff of the surgical glove creates a workspace and airtight seal. Through the fingers of the glove, standard laparoscopic trocar sleeves are inserted (along with a gas insufflation channel) through which a conventional 30-degree videoscope along with straight rigid laparoscopic instruments are inserted. Excellent views can be obtained with the regular laparoscopic optics after the creation of a stable pneumorectum of 10-15mmHg. The same principles apply for the dissection and resection as with a conventional TEM. The flexibility of the glove provides enhanced instrument maneuverability in each of the horizontal, vertical and rotational planes as well as improved tip abduction and adduction especially useful for suturing.
Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument maneuverability and range of movement. Thereafter, all patients eligible for TEM have been offered the option to participate in our pilot study. With this new access modality, ten consecutive patients between October 2010 and January 2011 underwent resection of benign (n=6) or malignant (n=4) rectal tumors. Only one case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. The case we present here is a full-thickness excision of an early rectal cancer in an 87-year-old female patient who was unfit for the conventional radical rectal resection.
Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon-friendly, economically attractive, and universally applicable.
Laparoscopic management of intra-abdominal fish bone mimicking acute cholecystitis
This video shows a female patient of 62 years, presenting with acute upper abdominal pain with fever and vomiting for five days. Clinically, she presented with features of acute cholecystitis.
Blood examination revealed leukocytosis with normal liver function tests. Abdominal ultrasonography showed edema of the gallbladder wall with pericholecystic collection, cholelithiasis and signs of acute cholecystitis.
Under antibiotic cover, the patient was subjected for single-port laparoscopic cholecystectomy using the EK glove port. Due to dense and stubborn adhesions, the procedure was converted to conventional 3-port surgery.
The duodenum was found adherent to the infundibulum of the gallbladder with a fish bone and pus within it. A 3.3cm long fish bone perforated the duodenum, produced abscess and mimicked acute cholecystitis.
The fish bone was extracted, perforation was repaired and cholecystectomy was performed.
E Khiangte, I Newme, P Phukan
Surgical intervention
6 years ago
2797 views
24 likes
1 comment
07:27
Laparoscopic management of intra-abdominal fish bone mimicking acute cholecystitis
This video shows a female patient of 62 years, presenting with acute upper abdominal pain with fever and vomiting for five days. Clinically, she presented with features of acute cholecystitis.
Blood examination revealed leukocytosis with normal liver function tests. Abdominal ultrasonography showed edema of the gallbladder wall with pericholecystic collection, cholelithiasis and signs of acute cholecystitis.
Under antibiotic cover, the patient was subjected for single-port laparoscopic cholecystectomy using the EK glove port. Due to dense and stubborn adhesions, the procedure was converted to conventional 3-port surgery.
The duodenum was found adherent to the infundibulum of the gallbladder with a fish bone and pus within it. A 3.3cm long fish bone perforated the duodenum, produced abscess and mimicked acute cholecystitis.
The fish bone was extracted, perforation was repaired and cholecystectomy was performed.
Redo transanal pull-through for Hirschsprung's disease
We present a case of a 3-year-old boy with a history of Hirschsprung’s Disease. He had been diagnosed at the age of two, and at that time underwent a laparoscopic-assisted Soave pull-through. He initially did well, but after a few months, had recurrent severe constipation with fecal impaction as well as an episode of enterocolitis. A contrast enema showed a dilated distal pull-through segment with normal-caliber sigmoid colon proximally, and an EUA found a preserved dentate line circumferentially with a stricture at the previous anastomosis. A biopsy was performed two centimeters proximal to the anastomosis and pathology was consistent with transition zone bowel with hypertrophic nerves and only occasional ganglion cells. We decided to do a redo transanal pull-through to remove the aganglionated and dilated segment of colon.
A Peña, M Levitt, A Bischoff, B Dickie
Surgical intervention
6 years ago
3455 views
48 likes
1 comment
05:14
Redo transanal pull-through for Hirschsprung's disease
We present a case of a 3-year-old boy with a history of Hirschsprung’s Disease. He had been diagnosed at the age of two, and at that time underwent a laparoscopic-assisted Soave pull-through. He initially did well, but after a few months, had recurrent severe constipation with fecal impaction as well as an episode of enterocolitis. A contrast enema showed a dilated distal pull-through segment with normal-caliber sigmoid colon proximally, and an EUA found a preserved dentate line circumferentially with a stricture at the previous anastomosis. A biopsy was performed two centimeters proximal to the anastomosis and pathology was consistent with transition zone bowel with hypertrophic nerves and only occasional ganglion cells. We decided to do a redo transanal pull-through to remove the aganglionated and dilated segment of colon.