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

Monthly publications

#September 2012
Filter by
Clear filter Specialty
View more

Clear filter Media type
View more
Clear filter Category
View more
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
B Dallemagne, S Perretta, J D'Agostino, J Marescaux
Surgical intervention
6 years ago
1391 views
15 likes
0 comments
29:04
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
Laparoscopic partial gastrectomy with D1 beta lymphadenectomy for early gastric cancer
This is the case of a 75-year-old man, symptom-free, with a cT2N0M0 early cancer of the stomach. The lesion is located between the body and the antrum of the stomach.
The laparoscopic approach allows to carry out a partial gastrectomy with D1 beta lymphadenectomy (lymph nodes number: 1-3-4-5-6-7-8-9) with intraoperative gastroscopy.
A Roux-en-Y gastrojejunal anastomosis is performed (intracorporeal gastrojejunal anastomosis and extracorporeal jejunojejunal anastomosis).
Total surgery time was 5 hours and length of hospital stay was 6 days.
Histology shows pT2N0M0 with 25 lymph nodes.
D1 beta lymphadenectomy is an efficient and less aggressive alternative to treat cases of early gastric cancer.
S Rua, A Pinto, P Moura, C Sousa
Surgical intervention
6 years ago
3249 views
19 likes
0 comments
13:20
Laparoscopic partial gastrectomy with D1 beta lymphadenectomy for early gastric cancer
This is the case of a 75-year-old man, symptom-free, with a cT2N0M0 early cancer of the stomach. The lesion is located between the body and the antrum of the stomach.
The laparoscopic approach allows to carry out a partial gastrectomy with D1 beta lymphadenectomy (lymph nodes number: 1-3-4-5-6-7-8-9) with intraoperative gastroscopy.
A Roux-en-Y gastrojejunal anastomosis is performed (intracorporeal gastrojejunal anastomosis and extracorporeal jejunojejunal anastomosis).
Total surgery time was 5 hours and length of hospital stay was 6 days.
Histology shows pT2N0M0 with 25 lymph nodes.
D1 beta lymphadenectomy is an efficient and less aggressive alternative to treat cases of early gastric cancer.
Laparoscopic diagnosis in disorders of sex development: ovotesticular DSD
Background: A normal sex development and appropriate sex assignment take place when sex chromosomes, gonadal histology and genital phenotype are concordant.
A disorder of sex development (DSD) is defined whenever a discordance between two of the aforementioned features is found.
DSDs can be caused by an alteration in the chromosomal complement, or by an abnormal development of the gonads, by a defect in one of the enzymatic pathways for the synthesis of sex hormones or by the absence (or altered structure) of hormone receptors.
In the majority of cases, DSD is heralded by ambiguity of the external genitalia that generally speaking is the result either of a hypervirilization of a 46, XX individual or of a hypovirilization of a 46, XY individual. However, there are cases of DSD in which the genital phenotype is not ambiguous. Those cases are the most difficult to diagnose and are sometimes identified at puberty when unexpected development of secondary sexual characters or primary amenorrhea are observed.
When an obvious ambiguity of the external genitalia is not found, the presence of a DSD should be suspected whenever a newborn with apparent male phenotype shows one of the following features (bilateral impalpable gonads, unilateral undescended testis associated with hypospadias, isolated perineal hypospadias, bifid scrotum) or when an apparent female newborn shows a gonad palpable in a hernia sac, hypertrophied clitoris or fused small labia: such findings should prompt investigation in order to rule out a possible DSD.
Karyotype is key in the diagnosis of suspected DSD. Next step is defining the presence/absence of Müllerian remnants with ultrasound or MRI. At this point, most of the DSD due to an enzymatic defect can be identified by means of hormonal tests (either basal levels or stimulation tests). In the remaining cases in which hormonal tests are not diagnostic, a gonadal biopsy is mandatory to identify a gonadal dysgenesis, an ovotesticular DSD (former hermaphroditism), or a sex reversal.
In cases in which gonads are not palpable, laparoscopy is the gold standard to define their presence, site and macroscopic appearance. It is also very easy to perform a laparoscopic gonadal biopsy and gonadal removal in cases of streak gonads. Finally, laparoscopy is an invaluable tool for the examination of the internal genitalia: it adds useful information to the data obtained by imaging studies and consequently allowing for planning of the definitive treatment.
The video shows a DSD patient in whom laparoscopic gonadal biopsies and left gonadectomy were performed.

Video: A 9-month-old baby with ambiguous genitalia was referred to our centre for evaluation. A female sex assignment was given at birth. At clinical examination, clitoral hypertrophy was evidenced, with a single perineal orifice; the left gonad was palpable in the groin and the right one was non-palpable. No inguinal hernias were detected. Testosterone levels at birth were high (95.8ng/mL) and this finding persisted throughout infancy. The chromosomal complement was 46 XY. Analysis of the AR gene was negative. MRI examination showed the presence of uterus (35 x 10mm); both gonads were visualized in the inguinal region. Laparoscopic gonadal biopsy was decided upon. A 5mm port was placed at the umbilicus through an open access. Pneumoperitoneum was established: carbon dioxide was insufflated at 1L/min and intra-abdominal pressure was set at 8mmHg. Two 3mm operating ports were placed in the right and left iliac fossa.
The presence of a normally developed uterus was confirmed; the right gonad resembled a normal ovary; on the left side, a patent processus vaginalis and an atypical round gonad with a regular surface were observed. Both gonads were biopsied and frozen sections examinations revealed a normal ovary on the right and an ovotestis on the left. Left gonadectomy ensued after monopolar division of the gonadal vessels. The specimen was extracted through the umbilicus.

Results: No conversion to open surgery nor additional trocars were necessary. Total operative time was 120 minutes (including histological examination); biopsy time was 5 minutes for each side; gonadectomy took 15 minutes. No drainage was required. The postoperative course was uneventful and the patient was discharged on day 2.

Conclusion: Laparoscopy in DSD cases is a valuable diagnostic tool in selected patients. It allows gonadal visualization and biopsy together with complete examination of Müllerian derivatives.
L Nanni, G Marrocco, VD Catania
Surgical intervention
6 years ago
1552 views
25 likes
0 comments
05:03
Laparoscopic diagnosis in disorders of sex development: ovotesticular DSD
Background: A normal sex development and appropriate sex assignment take place when sex chromosomes, gonadal histology and genital phenotype are concordant.
A disorder of sex development (DSD) is defined whenever a discordance between two of the aforementioned features is found.
DSDs can be caused by an alteration in the chromosomal complement, or by an abnormal development of the gonads, by a defect in one of the enzymatic pathways for the synthesis of sex hormones or by the absence (or altered structure) of hormone receptors.
In the majority of cases, DSD is heralded by ambiguity of the external genitalia that generally speaking is the result either of a hypervirilization of a 46, XX individual or of a hypovirilization of a 46, XY individual. However, there are cases of DSD in which the genital phenotype is not ambiguous. Those cases are the most difficult to diagnose and are sometimes identified at puberty when unexpected development of secondary sexual characters or primary amenorrhea are observed.
When an obvious ambiguity of the external genitalia is not found, the presence of a DSD should be suspected whenever a newborn with apparent male phenotype shows one of the following features (bilateral impalpable gonads, unilateral undescended testis associated with hypospadias, isolated perineal hypospadias, bifid scrotum) or when an apparent female newborn shows a gonad palpable in a hernia sac, hypertrophied clitoris or fused small labia: such findings should prompt investigation in order to rule out a possible DSD.
Karyotype is key in the diagnosis of suspected DSD. Next step is defining the presence/absence of Müllerian remnants with ultrasound or MRI. At this point, most of the DSD due to an enzymatic defect can be identified by means of hormonal tests (either basal levels or stimulation tests). In the remaining cases in which hormonal tests are not diagnostic, a gonadal biopsy is mandatory to identify a gonadal dysgenesis, an ovotesticular DSD (former hermaphroditism), or a sex reversal.
In cases in which gonads are not palpable, laparoscopy is the gold standard to define their presence, site and macroscopic appearance. It is also very easy to perform a laparoscopic gonadal biopsy and gonadal removal in cases of streak gonads. Finally, laparoscopy is an invaluable tool for the examination of the internal genitalia: it adds useful information to the data obtained by imaging studies and consequently allowing for planning of the definitive treatment.
The video shows a DSD patient in whom laparoscopic gonadal biopsies and left gonadectomy were performed.

Video: A 9-month-old baby with ambiguous genitalia was referred to our centre for evaluation. A female sex assignment was given at birth. At clinical examination, clitoral hypertrophy was evidenced, with a single perineal orifice; the left gonad was palpable in the groin and the right one was non-palpable. No inguinal hernias were detected. Testosterone levels at birth were high (95.8ng/mL) and this finding persisted throughout infancy. The chromosomal complement was 46 XY. Analysis of the AR gene was negative. MRI examination showed the presence of uterus (35 x 10mm); both gonads were visualized in the inguinal region. Laparoscopic gonadal biopsy was decided upon. A 5mm port was placed at the umbilicus through an open access. Pneumoperitoneum was established: carbon dioxide was insufflated at 1L/min and intra-abdominal pressure was set at 8mmHg. Two 3mm operating ports were placed in the right and left iliac fossa.
The presence of a normally developed uterus was confirmed; the right gonad resembled a normal ovary; on the left side, a patent processus vaginalis and an atypical round gonad with a regular surface were observed. Both gonads were biopsied and frozen sections examinations revealed a normal ovary on the right and an ovotestis on the left. Left gonadectomy ensued after monopolar division of the gonadal vessels. The specimen was extracted through the umbilicus.

Results: No conversion to open surgery nor additional trocars were necessary. Total operative time was 120 minutes (including histological examination); biopsy time was 5 minutes for each side; gonadectomy took 15 minutes. No drainage was required. The postoperative course was uneventful and the patient was discharged on day 2.

Conclusion: Laparoscopy in DSD cases is a valuable diagnostic tool in selected patients. It allows gonadal visualization and biopsy together with complete examination of Müllerian derivatives.
Video-assisted thoracoscopic (VATS) lobectomy: left upper 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 a posterior 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 an adenocarcinoma of the left upper lobe in a 66-year-old patient (the video emphasizes the steps of lobe resection – complete mediastinal lymph node dissection was effected but is not shown).

Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
G Rakovich
Surgical intervention
6 years ago
3343 views
20 likes
0 comments
10:02
Video-assisted thoracoscopic (VATS) lobectomy: left upper 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 a posterior 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 an adenocarcinoma of the left upper lobe in a 66-year-old patient (the video emphasizes the steps of lobe resection – complete mediastinal lymph node dissection was effected but is not shown).

Acknowledgment: we would like to thank Nathalie Leroux RN and Suzanne Desbiens RN for their continued support.
Robotic-assisted bladder neck reconstruction using the Goebell-Stoeckel technique and Mitrofanoff appendicovesicostomy
This video reports our experience with robotic bladder neck reconstruction using the Goebell Stoeckel technique and Mitrofanoff appendicovesicostomy.
It is the case of a 62-year-old woman who initially had her urinary stress incontinence treated with a suburethral sling that resulted in the migration of the prosthetic material in the urethra. After prosthesis removal, two attempts of suburethral slings and an attempt at balloon implantation also resulted in erosions and migration of the prosthetic material.
We recommend a continent derivation according to Mitrofanoff principles along with a suburethral autologous sling using Goebell Stoeckel technique.
The video demonstrates that this procedure is feasible and safe with encouraging results.
D Rey, R Mazloum, VE Corona Montes, T Piéchaud
Surgical intervention
6 years ago
1783 views
21 likes
1 comment
14:36
Robotic-assisted bladder neck reconstruction using the Goebell-Stoeckel technique and Mitrofanoff appendicovesicostomy
This video reports our experience with robotic bladder neck reconstruction using the Goebell Stoeckel technique and Mitrofanoff appendicovesicostomy.
It is the case of a 62-year-old woman who initially had her urinary stress incontinence treated with a suburethral sling that resulted in the migration of the prosthetic material in the urethra. After prosthesis removal, two attempts of suburethral slings and an attempt at balloon implantation also resulted in erosions and migration of the prosthetic material.
We recommend a continent derivation according to Mitrofanoff principles along with a suburethral autologous sling using Goebell Stoeckel technique.
The video demonstrates that this procedure is feasible and safe with encouraging results.
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
Parathyroid surgery has largely benefited from advances in preoperative imaging modalities allowing to determine potential adenomas. Conventionally, ultrasonography and scintigraphy with 99mTc-sestamibi (MIBI) provide sufficient information to guide the surgical procedure. Specific software has been developed at the IRCAD to allow for the 3D reconstruction of the entire cervical structures. The handling of such reconstruction helps to perform a precise preoperative assessment. Arterial reconstruction allows to predict the existence of an arteria lusoria and of a non-recurrent recurrent nerve. In this case, the position of a potential adenoma in relation to the inferior thyroid artery allows to anticipate that it is not an adenoma but a thyroid nodule. A second potential target is visualized inferiorly. These two potential locations will be explored during the video-assisted surgical intervention.
M Vix, J D'Agostino, L Soler, J Marescaux
Surgical intervention
6 years ago
4822 views
6 likes
0 comments
05:46
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
Parathyroid surgery has largely benefited from advances in preoperative imaging modalities allowing to determine potential adenomas. Conventionally, ultrasonography and scintigraphy with 99mTc-sestamibi (MIBI) provide sufficient information to guide the surgical procedure. Specific software has been developed at the IRCAD to allow for the 3D reconstruction of the entire cervical structures. The handling of such reconstruction helps to perform a precise preoperative assessment. Arterial reconstruction allows to predict the existence of an arteria lusoria and of a non-recurrent recurrent nerve. In this case, the position of a potential adenoma in relation to the inferior thyroid artery allows to anticipate that it is not an adenoma but a thyroid nodule. A second potential target is visualized inferiorly. These two potential locations will be explored during the video-assisted surgical intervention.
Laparoscopic coloproctectomy with ileoanal pouch anastomosis for familial adenomatous polyposis (FAP)
Coloproctectomy is a challenging surgical procedure, whether open or laparoscopic, particularly when an ileoanal anastomosis with pouch is performed. The objective of this film is to provide some tricks to perform this surgical procedure laparoscopically.
The main trick is probably the preservation of the right and ileocolic vessels and of the right Drummond marginal vascular arcade that later allows for a division of the superior mesenteric vessels, if necessary to gain a length of 2 to 3cm in the pelvis.
The use of new sealing devices such as the Ligasure™ blunt tip facilitated the standardization of the procedure.
J Leroy, J Marescaux
Surgical intervention
6 years ago
2734 views
75 likes
0 comments
14:18
Laparoscopic coloproctectomy with ileoanal pouch anastomosis for familial adenomatous polyposis (FAP)
Coloproctectomy is a challenging surgical procedure, whether open or laparoscopic, particularly when an ileoanal anastomosis with pouch is performed. The objective of this film is to provide some tricks to perform this surgical procedure laparoscopically.
The main trick is probably the preservation of the right and ileocolic vessels and of the right Drummond marginal vascular arcade that later allows for a division of the superior mesenteric vessels, if necessary to gain a length of 2 to 3cm in the pelvis.
The use of new sealing devices such as the Ligasure™ blunt tip facilitated the standardization of the procedure.
Robot-assisted Roux-en-Y gastric bypass using Sonicision™ cordless ultrasonic dissection device
Gastric bypass is considered to be the gold standard in morbid obesity surgery.
If technical principles are well-established, there are several alternatives to apply them. Consequently, gastrojejunostomy can be performed in three different fashions: manual, linear, and circular. Manual anastomosis can be performed with the help of the robotic Da Vinci™ Surgical System. This robot is particularly suited for manual anastomosis thanks to the instruments’ articulated extremities. Operative steps that do not benefit from robotics are performed by means of conventional laparoscopy, and especially gastric pouch division. This video also demonstrates the combined use of ultrasonic wireless scissors developed by Covidien (i.e., the Sonicision™ cordless ultrasonic dissection device).
M Vix, KH Liu, J Marescaux
Surgical intervention
6 years ago
4775 views
4 likes
0 comments
17:20
Robot-assisted Roux-en-Y gastric bypass using Sonicision™ cordless ultrasonic dissection device
Gastric bypass is considered to be the gold standard in morbid obesity surgery.
If technical principles are well-established, there are several alternatives to apply them. Consequently, gastrojejunostomy can be performed in three different fashions: manual, linear, and circular. Manual anastomosis can be performed with the help of the robotic Da Vinci™ Surgical System. This robot is particularly suited for manual anastomosis thanks to the instruments’ articulated extremities. Operative steps that do not benefit from robotics are performed by means of conventional laparoscopy, and especially gastric pouch division. This video also demonstrates the combined use of ultrasonic wireless scissors developed by Covidien (i.e., the Sonicision™ cordless ultrasonic dissection device).
Redo management of Crohn's disease after ileocaecal resection 20 years ago: new ileocolic laparoscopic resection
Crohn’s disease is an evolutive inflammatory bowel disease. Surgery may be performed several times during the patient’s life. Using a laparoscopic approach limits the risk of adhesions and the possibilities of re-operations in those patients.
In this film, the surgeon comes across difficulties due to postoperative adhesions and the interest of using new energy devices such as the LigaSure™ blunt tip device and the Sonicision™ cordless ultrasonic dissection device to free the small bowel and divide the mesos with an easy and secure hemostasis.
Concerning the anastomosis between the small bowel and the colon, the use of the new generation of staples manufactured by Covidien is extremely worthy of interest because of the ergonomics of the new handle and the perfect closure and hemostasis of the stapling line of the Tri-staple™ cartridge technology.
J Leroy, J Marescaux
Surgical intervention
6 years ago
1334 views
9 likes
0 comments
16:40
Redo management of Crohn's disease after ileocaecal resection 20 years ago: new ileocolic laparoscopic resection
Crohn’s disease is an evolutive inflammatory bowel disease. Surgery may be performed several times during the patient’s life. Using a laparoscopic approach limits the risk of adhesions and the possibilities of re-operations in those patients.
In this film, the surgeon comes across difficulties due to postoperative adhesions and the interest of using new energy devices such as the LigaSure™ blunt tip device and the Sonicision™ cordless ultrasonic dissection device to free the small bowel and divide the mesos with an easy and secure hemostasis.
Concerning the anastomosis between the small bowel and the colon, the use of the new generation of staples manufactured by Covidien is extremely worthy of interest because of the ergonomics of the new handle and the perfect closure and hemostasis of the stapling line of the Tri-staple™ cartridge technology.
Total Laparoscopic Hysterectomy (TLH)
Total Laparoscopic Hysterectomy (TLH) is a safe and reproducible technique. However, its use has been limited so far. The most quoted criticisms to this surgery are technical difficulties and concerns about urinary complications.
In the different publications that have demonstrated the feasibility and safety of the procedure, a step by step technique has always been remarked.
It is a very complete lecture that addresses all aspects to achieve good results when performing TLH. Not only Dr. Osorio outlines the 10 key steps of this surgery, but she also presents the preoperative set-up, the instruments required, and the specific considerations related to the ureter and to the management of difficult cases.
F Osorio
Lecture
6 years ago
5297 views
68 likes
0 comments
18:13
Total Laparoscopic Hysterectomy (TLH)
Total Laparoscopic Hysterectomy (TLH) is a safe and reproducible technique. However, its use has been limited so far. The most quoted criticisms to this surgery are technical difficulties and concerns about urinary complications.
In the different publications that have demonstrated the feasibility and safety of the procedure, a step by step technique has always been remarked.
It is a very complete lecture that addresses all aspects to achieve good results when performing TLH. Not only Dr. Osorio outlines the 10 key steps of this surgery, but she also presents the preoperative set-up, the instruments required, and the specific considerations related to the ureter and to the management of difficult cases.