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Monthly publications

#October 2012
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Gastric band removal for weight regain
Patients with a gastric band frequently request for its removal when it becomes inefficient in order to envisage another bariatric procedure. The intervention consists in the dissection of several adhesions between the liver and the stomach, the freeing of the gastric wrap, and the band removal. This procedure may be made uneasy because of the abundance and tightness of adhesions. In a few cases, our team has performed another procedure at the same time but usually we delay the second procedure in order to reduce complication risks, and more particularly anastomotic risks linked to this new intervention. The second interventions should be performed at least 2 months apart in order to allow for proper scarring of the gastric wall which harboured the band.
M Vix, J Marescaux
Surgical intervention
6 years ago
2332 views
18 likes
0 comments
05:25
Gastric band removal for weight regain
Patients with a gastric band frequently request for its removal when it becomes inefficient in order to envisage another bariatric procedure. The intervention consists in the dissection of several adhesions between the liver and the stomach, the freeing of the gastric wrap, and the band removal. This procedure may be made uneasy because of the abundance and tightness of adhesions. In a few cases, our team has performed another procedure at the same time but usually we delay the second procedure in order to reduce complication risks, and more particularly anastomotic risks linked to this new intervention. The second interventions should be performed at least 2 months apart in order to allow for proper scarring of the gastric wall which harboured the band.
Laparoscopic left lymphadenectomy (L-LND) for non-seminomatous testis tumors
This video demonstrates a laparoscopic technique for the treatment of clinical stage I non-seminomatous testicular germ cell tumors (NSGCT). Dissection could be reproduced laparoscopically at our urology center. The laparoscopic approach is a tool used for pathologic lymph node staging and laparoscopy has provided well-known and proven benefits (mean of hospital stay and bleeding), including minor intraoperative and postoperative complications. Currently, there are several options for clinical stage I NSGCT: surveillance, primary chemotherapy, open retroperitoneal lymph node dissection (RPLND) and laparoscopic retroperitoneal lymph node dissection (L-RPLND), and treatment will depend on some parameters such as histology, tumor markers, lymphovascular invasion, and in case surgery is decided upon, the patient’s preference goes to the procedure.

References
1. Valero Fuentealba G. [Antegrade ejaculation alter modified lumboaortic laparoscopic lymphadenectomy]. Arch Esp Urol 2008;61:517-20.

2. Castillo OA, Sánchez-Salas R, Secin FP, Campero JM, Foneron A, Vidal-Mora I. Linfadenectomía retroperitoneal laparoscópica primaria para el tumor testicular de células germinales no seminomatoso en estadio clínico I. Actas Urol Esp 2011;35:22-8.
3. Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Primary retroperitoneal lymph node dissection in clinical stage A non-seminomatous germ cell testis cancer. Review of the Indiana University experience 1965-1989. Br J Urol 1993;71:326-35.
4. Yoon GH, Stein JP, Skinner DG. Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle: an update. Urol Oncol 2005;23:168-77.

5. Carver BS, Sheinfeld J. The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors. Nat Clin Pract Urol 2005;2:330-5.

6. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

7. Nelson JB, Chen RN, Bishoff JT, Oh WK, Kantoff PW, Donehower RC, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors. Urology 1999;54:1064-7.

8. Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003;62:324-7.

9. Donohue JP, Zachary JM, Maynard BR. Distribution of nodal metastases in nonseminomatous testis cancer. J Urol 1982;128:315-20.

10. Weissbach L, Boedefeld EA. Localization of solitary and multiple metastases in stage II nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I. J Urol 1987;138:77-82.

11. Höltl L, Peschel R, Knapp R, Janetschek G, Steiner H, Hittmair A, Rogatsch H, Bartsch G, Hobisch A. Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels. Urology 2002;59:114-8.

12. Chang SS, Mohseni HF, Leon A, Sheinfeld J. Paracolic recurrence: the importance of wide excision of the spermatic cord at retroperitoneal lymph node dissection. J Urol 2002;167:94-6.

13. Beck SD, Cheng L, Bihrle R, Donohue JP, Foster RS. Does the presence of extranodal extension in pathological stage B1 nonseminomatous germ cell tumor necessitate adjuvant chemotherapy? J Urol 2007;177:944-6.

14. Richie JP. Clinical stage I testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol 1990;144:1160-3.

14. Janetschek G, Peschel R, Hobisch A, Bartsch G. Laparoscopic retroperitoneal lymph node dissection. J Endourol 2001;15:449-53.

15. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

16. Poulakis V, Skriapas K, de Vries R, Dillenburg W, Ferakis N, Witzsch U, Becht E. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006;68:154-60.

17. Abdel-Aziz KF, Anderson JK, Svatek R, Margulis V, Sagalowsky AI, Cadeddu JA. Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors. J Endourol 2006;20:627-31.

18. Bhayani SB, Allaf ME, Kavoussi LR. Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status. Urol Oncol 2004;22:145-8.

19. Eggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfeld J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol 2007;177:937-42.

20. Nielsen ME, Lima G, Schaeffer EM, Porter J, Cadeddu JA, Tuerk I, Kavoussi LR. Oncologic efficacy of laparoscopic RPLND in treatment of clinical stage I nonseminomatous germ cell testicular cancer. Urology 2007;70:1168-72.

21. Valdevenito Sepulveda JP, Merhe Nieva E, Valdevenito Sepulveda R, Cuevas Toro M, Gómez Gallo A, Bermúdez Luna H, Contreras Meléndez L, Gallegos Méndez I, Gallardo Escobar J. Palma Ceppi C. [Reduced retroperitoneal lymphadenectomy for clinical stage I non seminomatous germ cell testicular cancer]. Arch Esp Urol 2007;60:245-54.

22. Neyer M, Peschel R, Akkad T, Springer-Stöhr B, Berger A, Bartsch G, Steiner H. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180-3.
JL Hoepffner, JB Roche, VE Corona Montes, T Piéchaud
Surgical intervention
6 years ago
3195 views
51 likes
0 comments
10:37
Laparoscopic left lymphadenectomy (L-LND) for non-seminomatous testis tumors
This video demonstrates a laparoscopic technique for the treatment of clinical stage I non-seminomatous testicular germ cell tumors (NSGCT). Dissection could be reproduced laparoscopically at our urology center. The laparoscopic approach is a tool used for pathologic lymph node staging and laparoscopy has provided well-known and proven benefits (mean of hospital stay and bleeding), including minor intraoperative and postoperative complications. Currently, there are several options for clinical stage I NSGCT: surveillance, primary chemotherapy, open retroperitoneal lymph node dissection (RPLND) and laparoscopic retroperitoneal lymph node dissection (L-RPLND), and treatment will depend on some parameters such as histology, tumor markers, lymphovascular invasion, and in case surgery is decided upon, the patient’s preference goes to the procedure.

References
1. Valero Fuentealba G. [Antegrade ejaculation alter modified lumboaortic laparoscopic lymphadenectomy]. Arch Esp Urol 2008;61:517-20.

2. Castillo OA, Sánchez-Salas R, Secin FP, Campero JM, Foneron A, Vidal-Mora I. Linfadenectomía retroperitoneal laparoscópica primaria para el tumor testicular de células germinales no seminomatoso en estadio clínico I. Actas Urol Esp 2011;35:22-8.
3. Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Primary retroperitoneal lymph node dissection in clinical stage A non-seminomatous germ cell testis cancer. Review of the Indiana University experience 1965-1989. Br J Urol 1993;71:326-35.
4. Yoon GH, Stein JP, Skinner DG. Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle: an update. Urol Oncol 2005;23:168-77.

5. Carver BS, Sheinfeld J. The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors. Nat Clin Pract Urol 2005;2:330-5.

6. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

7. Nelson JB, Chen RN, Bishoff JT, Oh WK, Kantoff PW, Donehower RC, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors. Urology 1999;54:1064-7.

8. Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003;62:324-7.

9. Donohue JP, Zachary JM, Maynard BR. Distribution of nodal metastases in nonseminomatous testis cancer. J Urol 1982;128:315-20.

10. Weissbach L, Boedefeld EA. Localization of solitary and multiple metastases in stage II nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I. J Urol 1987;138:77-82.

11. Höltl L, Peschel R, Knapp R, Janetschek G, Steiner H, Hittmair A, Rogatsch H, Bartsch G, Hobisch A. Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels. Urology 2002;59:114-8.

12. Chang SS, Mohseni HF, Leon A, Sheinfeld J. Paracolic recurrence: the importance of wide excision of the spermatic cord at retroperitoneal lymph node dissection. J Urol 2002;167:94-6.

13. Beck SD, Cheng L, Bihrle R, Donohue JP, Foster RS. Does the presence of extranodal extension in pathological stage B1 nonseminomatous germ cell tumor necessitate adjuvant chemotherapy? J Urol 2007;177:944-6.

14. Richie JP. Clinical stage I testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol 1990;144:1160-3.

14. Janetschek G, Peschel R, Hobisch A, Bartsch G. Laparoscopic retroperitoneal lymph node dissection. J Endourol 2001;15:449-53.

15. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

16. Poulakis V, Skriapas K, de Vries R, Dillenburg W, Ferakis N, Witzsch U, Becht E. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006;68:154-60.

17. Abdel-Aziz KF, Anderson JK, Svatek R, Margulis V, Sagalowsky AI, Cadeddu JA. Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors. J Endourol 2006;20:627-31.

18. Bhayani SB, Allaf ME, Kavoussi LR. Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status. Urol Oncol 2004;22:145-8.

19. Eggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfeld J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol 2007;177:937-42.

20. Nielsen ME, Lima G, Schaeffer EM, Porter J, Cadeddu JA, Tuerk I, Kavoussi LR. Oncologic efficacy of laparoscopic RPLND in treatment of clinical stage I nonseminomatous germ cell testicular cancer. Urology 2007;70:1168-72.

21. Valdevenito Sepulveda JP, Merhe Nieva E, Valdevenito Sepulveda R, Cuevas Toro M, Gómez Gallo A, Bermúdez Luna H, Contreras Meléndez L, Gallegos Méndez I, Gallardo Escobar J. Palma Ceppi C. [Reduced retroperitoneal lymphadenectomy for clinical stage I non seminomatous germ cell testicular cancer]. Arch Esp Urol 2007;60:245-54.

22. Neyer M, Peschel R, Akkad T, Springer-Stöhr B, Berger A, Bartsch G, Steiner H. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180-3.
Gastric bypass after band removal: robotic-assisted gastrojejunostomy and linear-stapled jejunojejunostomy
Laparoscopic gastric bypass performed after gastric band removal requires the same surgical steps as a conventional gastric bypass. The presence of adhesions between the liver and the stomach makes the dissection of the superior gastric pouch more difficult. It is essential to correctly visualize the left crus during the dissection.
When the gastric pouch has been created, the other steps of the intervention remain conventional. Our team is currently evaluating the interest of using the Da Vinci™ surgical robot in morbid obesity surgery. As a result, we regularly perform a hand-assisted gastrojejunal anastomosis using the robot. The anastomosis is therefore easier to perform as the robot offers specific degrees of freedom. Consequently, the surgeon benefits from a more ergonomic position. In order to substantially increase surgical time, we opted for a conventional jejunojejunal anastomosis without the assistance of the surgical robot.
M Vix, J Marescaux
Surgical intervention
6 years ago
1192 views
4 likes
0 comments
20:14
Gastric bypass after band removal: robotic-assisted gastrojejunostomy and linear-stapled jejunojejunostomy
Laparoscopic gastric bypass performed after gastric band removal requires the same surgical steps as a conventional gastric bypass. The presence of adhesions between the liver and the stomach makes the dissection of the superior gastric pouch more difficult. It is essential to correctly visualize the left crus during the dissection.
When the gastric pouch has been created, the other steps of the intervention remain conventional. Our team is currently evaluating the interest of using the Da Vinci™ surgical robot in morbid obesity surgery. As a result, we regularly perform a hand-assisted gastrojejunal anastomosis using the robot. The anastomosis is therefore easier to perform as the robot offers specific degrees of freedom. Consequently, the surgeon benefits from a more ergonomic position. In order to substantially increase surgical time, we opted for a conventional jejunojejunal anastomosis without the assistance of the surgical robot.
Total laparoscopic right hepatectomy for large hepatoma using the Glissonian pedicle control with anterior approach
Background: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic right hepatectomy remains a challenging procedure, especially in patients with large tumor. This video illustrates a useful technique for total laparoscopic right hepatectomy which was successfully performed in patient with large hepatoma.

Methods: We demonstrate the case of a patient with a large tumor located in the right liver who underwent a total laparoscopic right hepatectomy. An anterior approach technique combined with Glissonian approach were used. The main steps of this technique are extraparenchymal control of right Glissonian pedicle en masse without liver dissection, parenchymal transection along the demarcation line, transection of right Glissonian pedicle, separation of whole right liver parenchyma, control and division of right hepatic vein and mobilization of the right liver from surrounding ligaments. No Pringle's maneuver was used.

Results: The technique was successfully performed without complication. Operative time was 560 min. Intraoperative blood loss was 1.100mL. The length of hospital stay was 6 days. The pathological report was well-differentiated HCC and free surgical margin.

Conclusion: Total laparoscopic right hepatectomy for large hepatoma by using the Glissonian pedicle control with anterior approach is feasible and safe.
R Chanwat, C Bunchaliew, T Khuhaprema
Surgical intervention
6 years ago
6129 views
39 likes
4 comments
09:19
Total laparoscopic right hepatectomy for large hepatoma using the Glissonian pedicle control with anterior approach
Background: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic right hepatectomy remains a challenging procedure, especially in patients with large tumor. This video illustrates a useful technique for total laparoscopic right hepatectomy which was successfully performed in patient with large hepatoma.

Methods: We demonstrate the case of a patient with a large tumor located in the right liver who underwent a total laparoscopic right hepatectomy. An anterior approach technique combined with Glissonian approach were used. The main steps of this technique are extraparenchymal control of right Glissonian pedicle en masse without liver dissection, parenchymal transection along the demarcation line, transection of right Glissonian pedicle, separation of whole right liver parenchyma, control and division of right hepatic vein and mobilization of the right liver from surrounding ligaments. No Pringle's maneuver was used.

Results: The technique was successfully performed without complication. Operative time was 560 min. Intraoperative blood loss was 1.100mL. The length of hospital stay was 6 days. The pathological report was well-differentiated HCC and free surgical margin.

Conclusion: Total laparoscopic right hepatectomy for large hepatoma by using the Glissonian pedicle control with anterior approach is feasible and safe.
Laparoscopic resection of giant hepatic cystadenoma
This is the case of a 22-month-old female infant. The pathology started two weeks before with a gradual increase of abdominal circumference and intermittent hypo-colic stools. A CT-scan of the abdomen showed a large cystic tumor with interior partitions measuring 16.5 in width by 10.6 in length by 12.1cm in depth, originating in segments V and VI of the liver, displacing the remaining liver to the left and compressing the right kidney, bowel, celiac artery, gallbladder, and pancreas. A laparoscopic approach for tumor resection was decided on due to the scarce tumor vascularization and entirely cystic consistency. The procedure required 4 ports, three of 5mm and one of 3mm, emptying the cystic content of approximately 2 liters of citrine fluid. Dissection was performed using the Ligasure™ vessel-sealing device and monopolar cautery, preserving adjacent vital structures and preventing bleeding. The surgical specimen was removed through the umbilical scar. No transfusion was required and surgery lasted four hours. There were no postoperative complications. As a result, laparoscopic surgery is considered a safe procedure for the excision of large tumors in children provided they are cystic and benign, as emptying the cyst gives broader visualization of the area and permits better tissue handling.
A Parilli, W Garcia, I Galdon, G Contreras
Surgical intervention
6 years ago
1108 views
9 likes
0 comments
08:03
Laparoscopic resection of giant hepatic cystadenoma
This is the case of a 22-month-old female infant. The pathology started two weeks before with a gradual increase of abdominal circumference and intermittent hypo-colic stools. A CT-scan of the abdomen showed a large cystic tumor with interior partitions measuring 16.5 in width by 10.6 in length by 12.1cm in depth, originating in segments V and VI of the liver, displacing the remaining liver to the left and compressing the right kidney, bowel, celiac artery, gallbladder, and pancreas. A laparoscopic approach for tumor resection was decided on due to the scarce tumor vascularization and entirely cystic consistency. The procedure required 4 ports, three of 5mm and one of 3mm, emptying the cystic content of approximately 2 liters of citrine fluid. Dissection was performed using the Ligasure™ vessel-sealing device and monopolar cautery, preserving adjacent vital structures and preventing bleeding. The surgical specimen was removed through the umbilical scar. No transfusion was required and surgery lasted four hours. There were no postoperative complications. As a result, laparoscopic surgery is considered a safe procedure for the excision of large tumors in children provided they are cystic and benign, as emptying the cyst gives broader visualization of the area and permits better tissue handling.
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.
A Wattiez, J Albornoz, M Puga, E Faller
Surgical intervention
6 years ago
1695 views
24 likes
0 comments
32:41
Laparoscopic partial cystectomy for big bladder endometriosis nodule
Bladder endometriosis is the most common presentation of urinary tract endometriosis and is frequently associated with specific symptoms such as dysuria, hematuria and recurrent urinary tract infections. Although it may be associated with ureteral endometriosis in severe cases, in most cases, it presents as an isolated disease.
The laparoscopic approach for bladder endometriosis nodule excision requires careful dissection of the paravesical spaces and identification of both ureters entering each ureteral tunnel. The shaving technique until healthy tissue is reached should be attempted, but if mucosal invasion is found, complete wall excision should be performed. In some occasions, when the nodule invades the bladder trigone, a double-J catheter may be inserted and left in place for 6 to 8 weeks.
In this video, we present the case of a 23-year-old woman complaining with significant dysuria associated with hematuria, dysmenorrhea, dyspareunia, and chronic pelvic pain. Magnetic resonance imaging described a 5cm nodule located in the bladder dome, and cystoscopy confirmed the diagnosis. The patient was referred to our Endometriosis Centre after diagnostic laparoscopy.
SILS single port splenectomy in a woman diagnosed with idiopathic thrombocytopenia
Laparoscopic splenectomy (LS) has become the technique of choice for surgical removal of the spleen since its first description in 1991. Indications for LS have rapidly increased and LS is now considered the standard approach for the treatment of benign and malignant hematologic disorders, especially by young patients who find small scars cosmetically preferable.
Single incision laparoscopic surgery (SILS) is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery. In this video, we present an original technique of SILS splenectomy in a woman diagnosed with idiopathic thrombocytopenia. A 2.2cm left subcostal incision lateral to the rectus muscles was used for the placement of the single port device with conventional laparoscopic instruments, using a Veress needle covered by a small sponge to lift the spleen that was removed through the same incision.
F Corcione, F Pirozzi, F Galante
Surgical intervention
6 years ago
2475 views
38 likes
0 comments
05:51
SILS single port splenectomy in a woman diagnosed with idiopathic thrombocytopenia
Laparoscopic splenectomy (LS) has become the technique of choice for surgical removal of the spleen since its first description in 1991. Indications for LS have rapidly increased and LS is now considered the standard approach for the treatment of benign and malignant hematologic disorders, especially by young patients who find small scars cosmetically preferable.
Single incision laparoscopic surgery (SILS) is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery. In this video, we present an original technique of SILS splenectomy in a woman diagnosed with idiopathic thrombocytopenia. A 2.2cm left subcostal incision lateral to the rectus muscles was used for the placement of the single port device with conventional laparoscopic instruments, using a Veress needle covered by a small sponge to lift the spleen that was removed through the same incision.