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Monthly publications

#June 2012
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Video-assisted thoracic surgery (VATS): right lower lobectomy with complete node clearance using an anterior approach
This video presents the management of a suspicious peripheral pulmonary tumor located in the right lower lobe (RLL), classified cT3N0M0 after preoperative staging (positive PET-scan with positive pathology). This case has been presented in a thoracic oncology multidisciplinary meeting, which validated a first-line surgical treatment by lobectomy and radical mediastinal lymph node resection.
The video demonstrates the videothoracoscopic anterior approach, initially described by McKenna and modified by Hansen. This anterior approach seems easier to reproduce and generally simpler than a videothoracoscopic posterior approach for many reasons: no dissection of the fissure, which is an unpredictable technique depending on the patient, use of a 5cm pleurotomy allowing for an easy access for curved instruments, and a very quick conversion, should it be needed; this last safety measure is fundamental.
Videothoracoscopic surgery is poorly developed in France although it is becoming a standard procedure in some major reference centers in thoracic surgery. This procedure offers many advantages: early rehabilitation linked to lesser postoperative pain, a rapid return to regular daily activities, an earlier onset for any potential adjuvant therapy.
It is important to be familiar with the anterior approach because it presents very different anatomical features as compared with the conventional posterior approach by thoracotomy. The emergence of reference centers should make training for this complex surgery possible, and it will probably become a therapeutic standard for cancer treatment, along with other specialities.
This video shows many tips to deal with fissure and pulmonary artery.
JM Baste, C Peillon
Surgical intervention
6 years ago
3686 views
27 likes
0 comments
10:24
Video-assisted thoracic surgery (VATS): right lower lobectomy with complete node clearance using an anterior approach
This video presents the management of a suspicious peripheral pulmonary tumor located in the right lower lobe (RLL), classified cT3N0M0 after preoperative staging (positive PET-scan with positive pathology). This case has been presented in a thoracic oncology multidisciplinary meeting, which validated a first-line surgical treatment by lobectomy and radical mediastinal lymph node resection.
The video demonstrates the videothoracoscopic anterior approach, initially described by McKenna and modified by Hansen. This anterior approach seems easier to reproduce and generally simpler than a videothoracoscopic posterior approach for many reasons: no dissection of the fissure, which is an unpredictable technique depending on the patient, use of a 5cm pleurotomy allowing for an easy access for curved instruments, and a very quick conversion, should it be needed; this last safety measure is fundamental.
Videothoracoscopic surgery is poorly developed in France although it is becoming a standard procedure in some major reference centers in thoracic surgery. This procedure offers many advantages: early rehabilitation linked to lesser postoperative pain, a rapid return to regular daily activities, an earlier onset for any potential adjuvant therapy.
It is important to be familiar with the anterior approach because it presents very different anatomical features as compared with the conventional posterior approach by thoracotomy. The emergence of reference centers should make training for this complex surgery possible, and it will probably become a therapeutic standard for cancer treatment, along with other specialities.
This video shows many tips to deal with fissure and pulmonary artery.
Myomectomy: variations and difficult cases
The aim of this presentation is to demonstrate the rules to avoid difficult situations in laparoscopic myomectomy. Myomectomy is one of the most challenging laparoscopic procedures, and can be time-consuming. Prior to performing a laparoscopic approach, it is always necessary to consider myoma-related factors such as number, location, and size. Regarding the surgeon’s experience, the most frequent problems are related to hemostasis achievement, traction maneuvers to enucleate myoma, and closure of uterine wall defect. Strategy and experience are truly essential to face difficult cases, and alternatives to facilitate the procedure include trocar placement, uterine artery clipping to reduce blood loss, but the most important issue remains appropriate patient selection.
E Zupi
Lecture
6 years ago
2826 views
68 likes
0 comments
15:08
Myomectomy: variations and difficult cases
The aim of this presentation is to demonstrate the rules to avoid difficult situations in laparoscopic myomectomy. Myomectomy is one of the most challenging laparoscopic procedures, and can be time-consuming. Prior to performing a laparoscopic approach, it is always necessary to consider myoma-related factors such as number, location, and size. Regarding the surgeon’s experience, the most frequent problems are related to hemostasis achievement, traction maneuvers to enucleate myoma, and closure of uterine wall defect. Strategy and experience are truly essential to face difficult cases, and alternatives to facilitate the procedure include trocar placement, uterine artery clipping to reduce blood loss, but the most important issue remains appropriate patient selection.
Fertility enhancing surgery
Reproductive surgery does not solely include tubal surgery, but also uterine surgery (surgery for malformations and myomas) and treatment for endometriosis. In tubal surgery, distal lesions can either be classified as phimosis (partial obstruction) or hydrosalpinx (complete obstruction). Phimosis requires fimbrioplasty; hydrosalpinx needs a neosalpingostomy. Proximal lesions may be functional (spasm, mucosal plugs) or organic (tubal clips, SIN, PID) which need resection and anastomosis. Tubal surgery does not rival with IVF but it is a complementary tool that may be used in selected cases.

To achieve adequate selection of cases suitable for tubal surgery, it is mandatory to accurately evaluate the uterine cavity, the tubal patency, the tubo-peritoneal environment (adhesions) as well as the tubal mucosa.
Non-invasive tests (hysterosalpingography, hysterosonography) do not permit to give a precise analysis of the lesions. Endoscopy is the only way to solve this problem. Fertiloscopy allows an exploration of the pelvis and salpingoscopy allows for an adequate and simple evaluation of the mucosal tube (easier than laparoscopy).

In case of normal salpingoscopy with abnormal fertiloscopy, surgery is recommended. In other cases, the recommended treatments are intrauterine insemination (IUI) or in vitro fertilization (IVF). In case of surgery, it is necessary to apply microsurgical principles: proper magnification, sufficient light, respect of tube (no touch technique), meticulous hemostasis (bipolar), avoidance of peritoneal desiccation, acute ovaro-salpingolysis, use of microsurgical instrumentation and microsuture, prevention of adhesions. When all of these criteria are respected, good results are obtained in terms of pregnancy rate.
A Watrelot
Lecture
6 years ago
1324 views
23 likes
0 comments
22:49
Fertility enhancing surgery
Reproductive surgery does not solely include tubal surgery, but also uterine surgery (surgery for malformations and myomas) and treatment for endometriosis. In tubal surgery, distal lesions can either be classified as phimosis (partial obstruction) or hydrosalpinx (complete obstruction). Phimosis requires fimbrioplasty; hydrosalpinx needs a neosalpingostomy. Proximal lesions may be functional (spasm, mucosal plugs) or organic (tubal clips, SIN, PID) which need resection and anastomosis. Tubal surgery does not rival with IVF but it is a complementary tool that may be used in selected cases.

To achieve adequate selection of cases suitable for tubal surgery, it is mandatory to accurately evaluate the uterine cavity, the tubal patency, the tubo-peritoneal environment (adhesions) as well as the tubal mucosa.
Non-invasive tests (hysterosalpingography, hysterosonography) do not permit to give a precise analysis of the lesions. Endoscopy is the only way to solve this problem. Fertiloscopy allows an exploration of the pelvis and salpingoscopy allows for an adequate and simple evaluation of the mucosal tube (easier than laparoscopy).

In case of normal salpingoscopy with abnormal fertiloscopy, surgery is recommended. In other cases, the recommended treatments are intrauterine insemination (IUI) or in vitro fertilization (IVF). In case of surgery, it is necessary to apply microsurgical principles: proper magnification, sufficient light, respect of tube (no touch technique), meticulous hemostasis (bipolar), avoidance of peritoneal desiccation, acute ovaro-salpingolysis, use of microsurgical instrumentation and microsuture, prevention of adhesions. When all of these criteria are respected, good results are obtained in terms of pregnancy rate.
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
B Dallemagne, S Perretta, T Piardi, J Marescaux
Surgical intervention
6 years ago
1785 views
23 likes
0 comments
18:17
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
Laparoscopic transcystic clearance of the common bile duct (CBD) during three-trocar cholecystectomy
Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma, namely the choice between laparoscopic common bile duct (CBD) exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. Laparoscopic CBD exploration can be performed through the cystic duct or through a choledochotomy, the choice being mainly guided by the size of the CBD stone and the size of the cystic duct and common bile duct. In this patient with a large cystic duct, small stone and normal CBD size, we have opted for the transcystic extraction, using the Dormia basket under fluoroscopic guidance. The procedure was performed using a three-trocar approach and a new internal retraction device that suspends the gallbladder.
B Dallemagne, T Piardi, J Marescaux
Surgical intervention
6 years ago
3903 views
19 likes
0 comments
12:26
Laparoscopic transcystic clearance of the common bile duct (CBD) during three-trocar cholecystectomy
Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma, namely the choice between laparoscopic common bile duct (CBD) exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. Laparoscopic CBD exploration can be performed through the cystic duct or through a choledochotomy, the choice being mainly guided by the size of the CBD stone and the size of the cystic duct and common bile duct. In this patient with a large cystic duct, small stone and normal CBD size, we have opted for the transcystic extraction, using the Dormia basket under fluoroscopic guidance. The procedure was performed using a three-trocar approach and a new internal retraction device that suspends the gallbladder.
Laparoscopic right hemihepatectomy for polyadenomatosis
Hepatic adenomatosis was first described in 1985 by Flejou et al. as multiple adenomas (arbitrarily more than 10), in an otherwise normal liver parenchyma. Several authors have suggested that it is a distinct entity from hepatic adenoma, which is predominantly seen in young women taking oral contraceptives. Although considered a benign disease, it can be associated with potentially fatal complications such as malignant transformation and intraperitoneal hemorrhage due to rupture. Currently, there is no consensus on patient management. However, surgical removal of large lesions may significantly improve symptoms and reduce the risk of complications. Genetic counselling may now play an important role in case management.
We report the case of a 33-year-old woman who underwent a laparoscopic right liver resection for multiple liver adenomatosis. This patient had already had a right liver-appended adenoma resected as well as a cholecystectomy. Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. Hepatic inflow is taken extraparenchymally before the transection of the hepatic parenchyma in an anterior to posterior fashion.
P Pessaux, A Sa Cunha, E Marzano, T Piardi, J Marescaux
Surgical intervention
6 years ago
2692 views
15 likes
0 comments
20:21
Laparoscopic right hemihepatectomy for polyadenomatosis
Hepatic adenomatosis was first described in 1985 by Flejou et al. as multiple adenomas (arbitrarily more than 10), in an otherwise normal liver parenchyma. Several authors have suggested that it is a distinct entity from hepatic adenoma, which is predominantly seen in young women taking oral contraceptives. Although considered a benign disease, it can be associated with potentially fatal complications such as malignant transformation and intraperitoneal hemorrhage due to rupture. Currently, there is no consensus on patient management. However, surgical removal of large lesions may significantly improve symptoms and reduce the risk of complications. Genetic counselling may now play an important role in case management.
We report the case of a 33-year-old woman who underwent a laparoscopic right liver resection for multiple liver adenomatosis. This patient had already had a right liver-appended adenoma resected as well as a cholecystectomy. Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. Hepatic inflow is taken extraparenchymally before the transection of the hepatic parenchyma in an anterior to posterior fashion.
Strategy for laparoscopic total hysterectomy with a big adnexal mass
Hysterectomy when managing a big adnexal mass has always been a challenging situation for laparoscopic surgeons. Complete preoperative assessment, surgical experience and strategy are fundamental to address adnexal pathology laparoscopicallly, both for benign and malignant conditions. Adequate trocar placement, full inspection of the abdominal cavity, comprehensive evaluation of the tumor’s surface, cytology and definition of the nature of the adnexal mass are truly essential. In addition, proper identification of standard anatomical landmarks is fundamental to perform hysterectomy with adnexectomy, which helps to prevent damage to surrounding structures. Final assessment of the vaginal cuff may lead to the diagnosis of pelvic floor disorders that should be repaired during vaginal cuff closure. In this video, we present a case of hysterectomy and adnexectomy by laparoscopy in a 46-year-old patient complaining of abdominal pain secondary to the presence of a 13cm simple adnexal cyst with normal CA 125 values.
A Wattiez, C Zacharopoulou, J Albornoz, M Puga, E Faller
Surgical intervention
6 years ago
4563 views
136 likes
0 comments
28:57
Strategy for laparoscopic total hysterectomy with a big adnexal mass
Hysterectomy when managing a big adnexal mass has always been a challenging situation for laparoscopic surgeons. Complete preoperative assessment, surgical experience and strategy are fundamental to address adnexal pathology laparoscopicallly, both for benign and malignant conditions. Adequate trocar placement, full inspection of the abdominal cavity, comprehensive evaluation of the tumor’s surface, cytology and definition of the nature of the adnexal mass are truly essential. In addition, proper identification of standard anatomical landmarks is fundamental to perform hysterectomy with adnexectomy, which helps to prevent damage to surrounding structures. Final assessment of the vaginal cuff may lead to the diagnosis of pelvic floor disorders that should be repaired during vaginal cuff closure. In this video, we present a case of hysterectomy and adnexectomy by laparoscopy in a 46-year-old patient complaining of abdominal pain secondary to the presence of a 13cm simple adnexal cyst with normal CA 125 values.
Laparoscopic three-trocar sigmoidectomy with transanal extraction and new Sonicision™ cordless ultrasonic dissection device
Introduction
We present the case of a 32-year-old female patient with recurrent episodes of diverticulitis. She underwent an elective sigmoidectomy using the new Sonicision™ cordless ultrasonic dissection device.

Methods
Our set-up consisted of a standard three-port technique with one umbilical optical 10mm port with 1x5mm and 1x12mm right iliac fossa (RIF) ports. After initial peritoneoscopy, the sigmoid mesocolon was divided close to the bowel using the new Sonicision™ cordless ultrasonic dissection device. The mesocolic window was continued distally to the rectosigmoid junction and proximally to the descending colon. The lateral attachments were then mobilized. After rectal washout, the rectum was divided and the sigmoid colon extracted transanally. A colotomy was then made above the inflamed area, the anvil of a circular stapler introduced into the colonic lumen and then advanced up to the proximal bowel (with the aid of a bowel grasper sheathed in a flexible plastic tubing). The proximal sigmoid colon was then divided with a linear stapling device, the specimen removed transanally and the rectum closed. The spike of the anvil was then delivered through the proximal colon using the fishing technique. The colorectal anastomosis was then fashioned in the usual technique with a circular stapler. A leak test was performed thereafter.

Results
The procedure was successfully completed. The Sonicision™ cordless ultrasonic dissection device performed similarly to other power sources but without the impedance of additional wires. It allows for ease of use and quick changing of instruments and ports without the potential of snagging the wire.

Conclusion
The Sonicision™ cordless ultrasonic dissection device performed excellently for laparoscopic colorectal surgery. Cordless dissectors and vessel-sealing devices will be an excellent adjunct to minimally invasive surgery of the future.
J Leroy, B Barry, J Marescaux
Surgical intervention
6 years ago
1680 views
5 likes
2 comments
21:52
Laparoscopic three-trocar sigmoidectomy with transanal extraction and new Sonicision™ cordless ultrasonic dissection device
Introduction
We present the case of a 32-year-old female patient with recurrent episodes of diverticulitis. She underwent an elective sigmoidectomy using the new Sonicision™ cordless ultrasonic dissection device.

Methods
Our set-up consisted of a standard three-port technique with one umbilical optical 10mm port with 1x5mm and 1x12mm right iliac fossa (RIF) ports. After initial peritoneoscopy, the sigmoid mesocolon was divided close to the bowel using the new Sonicision™ cordless ultrasonic dissection device. The mesocolic window was continued distally to the rectosigmoid junction and proximally to the descending colon. The lateral attachments were then mobilized. After rectal washout, the rectum was divided and the sigmoid colon extracted transanally. A colotomy was then made above the inflamed area, the anvil of a circular stapler introduced into the colonic lumen and then advanced up to the proximal bowel (with the aid of a bowel grasper sheathed in a flexible plastic tubing). The proximal sigmoid colon was then divided with a linear stapling device, the specimen removed transanally and the rectum closed. The spike of the anvil was then delivered through the proximal colon using the fishing technique. The colorectal anastomosis was then fashioned in the usual technique with a circular stapler. A leak test was performed thereafter.

Results
The procedure was successfully completed. The Sonicision™ cordless ultrasonic dissection device performed similarly to other power sources but without the impedance of additional wires. It allows for ease of use and quick changing of instruments and ports without the potential of snagging the wire.

Conclusion
The Sonicision™ cordless ultrasonic dissection device performed excellently for laparoscopic colorectal surgery. Cordless dissectors and vessel-sealing devices will be an excellent adjunct to minimally invasive surgery of the future.
Laparoscopic treatment of biliary peritonitis following complete division of posterior right lateral duct
Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. This video shows the laparoscopic management of biliary peritonitis after complete division of a posterior right lateral branch.

Discussion:
The incidence of accessory hepatic ducts is reported to range from 1.4% to 27% and has been found to range from 15% to 28% in autopsy series (1,2,3).
Injury of the extra-hepatic bile ducts (BDI) is the most serious complication when performing cholecystectomy, leading to biliary leakage and peritonitis. Treatment and prevention of this complication are essential in the management of gallstone diseases. The incidence of this complication depends on local inflammation at the hepatoduodenal ligament, on the type of approach used, and on the experience of the surgeon (4,5).
Injuries of tiny posterior aberrant ducts, which enter the main duct proximal to or within the cystic duct, may accidentally occur during surgery, causing partial or total segmental duct obstruction or bile leakage. Bile duct injuries can be split into five groups according to the mechanism of etiology or to the severity of the lesion.
The most commonly used classification of acute bile duct injuries (BDI) is the one proposed by Strasberg et al. (6):
Type A: bile leak from a minor duct still in contact with the common bile duct;
Type B: occlusion of part of the biliary tree;
Type C: bile leak from the duct not in contact with the common bile duct;
Type D: lateral injury to extra-hepatic bile duct;
Type E: circumferential injury of major bile ducts.
Here, the clinical case presents a type C lesion successfully managed through a conservative surgical approach.
References:
1. Seibert D, Matulis SR, Griswold F. A rare right hepatic duct anatomical variant discovered after laparoscopic bile duct transection. Surg Laparosc Endosc 1996;6:61-4.
2. Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. AJR Am J Roentgenol 1999;172:955-9.
3. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K. Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol 2000;175:713-20.
4. Hugh TB. New strategies to prevent laparoscopic bile duct injury--surgeons can learn from pilots. Surgery 2002;132:826-35.
5. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy: the United States experience. Surg Endosc 1998;12:315-21.
6. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.
A D'Urso, D Mutter, J Leroy, J Marescaux
Surgical intervention
6 years ago
5185 views
40 likes
2 comments
07:42
Laparoscopic treatment of biliary peritonitis following complete division of posterior right lateral duct
Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. This video shows the laparoscopic management of biliary peritonitis after complete division of a posterior right lateral branch.

Discussion:
The incidence of accessory hepatic ducts is reported to range from 1.4% to 27% and has been found to range from 15% to 28% in autopsy series (1,2,3).
Injury of the extra-hepatic bile ducts (BDI) is the most serious complication when performing cholecystectomy, leading to biliary leakage and peritonitis. Treatment and prevention of this complication are essential in the management of gallstone diseases. The incidence of this complication depends on local inflammation at the hepatoduodenal ligament, on the type of approach used, and on the experience of the surgeon (4,5).
Injuries of tiny posterior aberrant ducts, which enter the main duct proximal to or within the cystic duct, may accidentally occur during surgery, causing partial or total segmental duct obstruction or bile leakage. Bile duct injuries can be split into five groups according to the mechanism of etiology or to the severity of the lesion.
The most commonly used classification of acute bile duct injuries (BDI) is the one proposed by Strasberg et al. (6):
Type A: bile leak from a minor duct still in contact with the common bile duct;
Type B: occlusion of part of the biliary tree;
Type C: bile leak from the duct not in contact with the common bile duct;
Type D: lateral injury to extra-hepatic bile duct;
Type E: circumferential injury of major bile ducts.
Here, the clinical case presents a type C lesion successfully managed through a conservative surgical approach.
References:
1. Seibert D, Matulis SR, Griswold F. A rare right hepatic duct anatomical variant discovered after laparoscopic bile duct transection. Surg Laparosc Endosc 1996;6:61-4.
2. Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. AJR Am J Roentgenol 1999;172:955-9.
3. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K. Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol 2000;175:713-20.
4. Hugh TB. New strategies to prevent laparoscopic bile duct injury--surgeons can learn from pilots. Surgery 2002;132:826-35.
5. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy: the United States experience. Surg Endosc 1998;12:315-21.
6. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.