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Monthly publications

#October 2013
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Laparoscopic extended middle duodenal-preserving pancreatectomy: laparoscopic Beger procedure
This is the case of a 45-year-old woman (BMI of 19) who underwent a totally laparoscopic middle pancreatectomy for pancreatic incidentaloma. Preoperative work-up included abdominal ultrasound examination, CT-scan, MRI, and OctreoScan which demonstrated a hyperdense lesion in the pancreatic neck. Endoscopic ultrasound (EUS) allowed to perform a fine-needle aspiration biopsy (FNAB) of the lesion. Histopathological evaluation of the specimen showed a moderately differentiated Non-functioning Pancreatic Neuroendocrine Neoplasms (NF-PanNENs). Laparoscopic US indicated the necessity to perform pancreatic resection. During the intervention, a Roux-en-Y jejunal loop has been interposed using the Longmire-Mouchet reconstruction method.
E Falco, S Berti, E Francone, C Eretta, P Bonfante
Surgical intervention
5 years ago
1912 views
17 likes
1 comment
15:42
Laparoscopic extended middle duodenal-preserving pancreatectomy: laparoscopic Beger procedure
This is the case of a 45-year-old woman (BMI of 19) who underwent a totally laparoscopic middle pancreatectomy for pancreatic incidentaloma. Preoperative work-up included abdominal ultrasound examination, CT-scan, MRI, and OctreoScan which demonstrated a hyperdense lesion in the pancreatic neck. Endoscopic ultrasound (EUS) allowed to perform a fine-needle aspiration biopsy (FNAB) of the lesion. Histopathological evaluation of the specimen showed a moderately differentiated Non-functioning Pancreatic Neuroendocrine Neoplasms (NF-PanNENs). Laparoscopic US indicated the necessity to perform pancreatic resection. During the intervention, a Roux-en-Y jejunal loop has been interposed using the Longmire-Mouchet reconstruction method.
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
G Dapri, L Gerard, V Zulian, M Bortes, J Bruyns, GB Cadière
Surgical intervention
5 years ago
4012 views
74 likes
1 comment
07:50
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
Laparoscopic splenectomy in a patient with cirrhosis and splenomegaly
Introduction
The first laparoscopic splenectomy was initially described more than 20 years ago. Hypersplenism associated with thrombocytopenia in cirrhotic patients could compromise quality of life and also limit therapeutic options such as interferon treatment.
Material and methods
We present the case of a 48-year-old woman with a history of parenteral drug abuse, HCV/HIV co-infection, cirrhosis (Child-Pugh B). Treatment with interferon and antiretrovirals must be discontinued for severe thrombocytopenia. As a result, laparoscopic splenectomy stands out as a therapeutic measure.
Results
In this video, we present a laparoscopic splenectomy approach in a cirrhotic patient with splenomegaly and hypersplenism in order to initiate interferon and antiretroviral treatment. It is possible to note the presence of collateral circulation, cirrhotic liver, and moderate splenomegaly (final spleen weight of 735 grams).
Conclusions
Laparoscopic access proves safe and effective in cirrhotic patients in order to extend the therapeutic managements of their underlying diseases. It can also improve the Child-Pugh score.
C Rodríguez-Otero Luppi, EM Targarona Soler, C Balagué Ponz, JL Pallarés Segura, M Trías Folch
Surgical intervention
5 years ago
6846 views
129 likes
0 comments
08:01
Laparoscopic splenectomy in a patient with cirrhosis and splenomegaly
Introduction
The first laparoscopic splenectomy was initially described more than 20 years ago. Hypersplenism associated with thrombocytopenia in cirrhotic patients could compromise quality of life and also limit therapeutic options such as interferon treatment.
Material and methods
We present the case of a 48-year-old woman with a history of parenteral drug abuse, HCV/HIV co-infection, cirrhosis (Child-Pugh B). Treatment with interferon and antiretrovirals must be discontinued for severe thrombocytopenia. As a result, laparoscopic splenectomy stands out as a therapeutic measure.
Results
In this video, we present a laparoscopic splenectomy approach in a cirrhotic patient with splenomegaly and hypersplenism in order to initiate interferon and antiretroviral treatment. It is possible to note the presence of collateral circulation, cirrhotic liver, and moderate splenomegaly (final spleen weight of 735 grams).
Conclusions
Laparoscopic access proves safe and effective in cirrhotic patients in order to extend the therapeutic managements of their underlying diseases. It can also improve the Child-Pugh score.
Tips 'n tricks: cholecystectomy: antegrade approach for difficult dissection
Today, laparoscopic cholecystectomy is a routinely performed surgical intervention. In certain cases, the identification of Calot’s triangle may be difficult due to adhesions or inflammatory infiltrations of adjacent structures. Hydrodissection can allow for an atraumatic dissection but in more complex cases, an antegrade freeing of the gallbladder should be envisaged.
Here we present the case of a man benefiting from a difficult laparoscopic cholecystectomy for a pancreatitis with common bile duct stone migration. The flag technique, with an antegrade freeing, must be applied in order to complete the procedure laparoscopically.
L Marx, C Hild, J Leroy, J Marescaux
Surgical intervention
5 years ago
4639 views
75 likes
8 comments
06:50
Tips 'n tricks: cholecystectomy: antegrade approach for difficult dissection
Today, laparoscopic cholecystectomy is a routinely performed surgical intervention. In certain cases, the identification of Calot’s triangle may be difficult due to adhesions or inflammatory infiltrations of adjacent structures. Hydrodissection can allow for an atraumatic dissection but in more complex cases, an antegrade freeing of the gallbladder should be envisaged.
Here we present the case of a man benefiting from a difficult laparoscopic cholecystectomy for a pancreatitis with common bile duct stone migration. The flag technique, with an antegrade freeing, must be applied in order to complete the procedure laparoscopically.
Laparoscopic management of a left diaphragmatic hernia in a newborn
Laparoscopic treatment of delayed diaphragmatic hernias in children has been described in 1995 by Klaas Bax and David Van der Zee. Since 2001, we managed to convince the community of pediatric surgeons that it was probably easier to choose a thoracoscopic approach. In some particular conditions, newborns with a congenital diaphragmatic hernia could be treated by thoracoscopy. Until now, more than 400 newborns have been operated on by thoracoscopy to treat a diaphragmatic hernia. Guidelines to specify the appropriate group of newborns for this approach remain discussed in the literature.
Reference:
Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates. Gomes Ferreira C, Kuhn P, Lacreuse I, Kasleas C, Philippe P, Podevin G, Bonnard A, Lopez M, De Lagausie P, Petit T, Lardy H, Becmeur F. J Pediatr Surg 2013;48:488-95.
F Becmeur, C Gomes Ferreira
Surgical intervention
5 years ago
1930 views
50 likes
0 comments
03:45
Laparoscopic management of a left diaphragmatic hernia in a newborn
Laparoscopic treatment of delayed diaphragmatic hernias in children has been described in 1995 by Klaas Bax and David Van der Zee. Since 2001, we managed to convince the community of pediatric surgeons that it was probably easier to choose a thoracoscopic approach. In some particular conditions, newborns with a congenital diaphragmatic hernia could be treated by thoracoscopy. Until now, more than 400 newborns have been operated on by thoracoscopy to treat a diaphragmatic hernia. Guidelines to specify the appropriate group of newborns for this approach remain discussed in the literature.
Reference:
Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates. Gomes Ferreira C, Kuhn P, Lacreuse I, Kasleas C, Philippe P, Podevin G, Bonnard A, Lopez M, De Lagausie P, Petit T, Lardy H, Becmeur F. J Pediatr Surg 2013;48:488-95.
Video-assisted thoracic surgery (VATS): middle lower bilobectomy with lymph nodes dissection for carcinoid tumor
Objective
Carcinoid tumors represent less than 5% of the bronchopulmonary cancers [1], but often concern young people. A lung-sparing anatomical resection is often preferred if possible [2]. However, an uneasy intrabronchial localization mandates a major resection such as bilobectomy and/or sometimes pneumonectomy for complete resection as it is the aim of carcinoid tumor treatment. This can be achieved using a minimally invasive approach [3, 4].
Case presentation
This is the case of a 34-year-old woman suffering from recurrent right pneumopathy, without any other medical history. A mass in the middle lobe bronchus with partial obstruction of the intermedius bronchus was found on CT-scan. Bronchoscopy found the extension of a strawberry-like tumor until segment 6 bronchus. Histopathology confirmed the presence of a carcinoid tumor. A radical excision with middle lower bilobectomy by VATS was decided upon rather than middle lobe sleeve lobectomy in order to ensure complete resection.
Results
There was no postoperative complication and the patient was discharged on postoperative day 5. The operative specimen contained the tumor. Vascular and bronchial resections were free. Histopathology confirmed a typical pT1N0 carcinoid tumor.
Conclusion
Complete middle lower bilobectomy can be performed using a VATS approach. This therapeutic option seems worthwhile in young people because of low postoperative morbidity and fast recovery for active people.

Bibliographic references
1. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, Kramer MR. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest 2001;119:1647-51.
2. Schrevens L, Vansteenkiste J, Deneffe G, De Leyn P, Verbeken E, Vandenberghe T, Demedts M. Clinical-radiological presentation and outcome of surgically treated pulmonary carcinoid tumours: a long-term single institution experience. Lung Cancer 2004;43:39-45.
3. Hansen HJ, Petersen RH, Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Lung Cancer 2011;71,25(4):1263-9.
4. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothoracic Surg 2003;23:397-402.
JM Baste, P Rinieri, A Sebestyen
Surgical intervention
5 years ago
1174 views
18 likes
0 comments
07:26
Video-assisted thoracic surgery (VATS): middle lower bilobectomy with lymph nodes dissection for carcinoid tumor
Objective
Carcinoid tumors represent less than 5% of the bronchopulmonary cancers [1], but often concern young people. A lung-sparing anatomical resection is often preferred if possible [2]. However, an uneasy intrabronchial localization mandates a major resection such as bilobectomy and/or sometimes pneumonectomy for complete resection as it is the aim of carcinoid tumor treatment. This can be achieved using a minimally invasive approach [3, 4].
Case presentation
This is the case of a 34-year-old woman suffering from recurrent right pneumopathy, without any other medical history. A mass in the middle lobe bronchus with partial obstruction of the intermedius bronchus was found on CT-scan. Bronchoscopy found the extension of a strawberry-like tumor until segment 6 bronchus. Histopathology confirmed the presence of a carcinoid tumor. A radical excision with middle lower bilobectomy by VATS was decided upon rather than middle lobe sleeve lobectomy in order to ensure complete resection.
Results
There was no postoperative complication and the patient was discharged on postoperative day 5. The operative specimen contained the tumor. Vascular and bronchial resections were free. Histopathology confirmed a typical pT1N0 carcinoid tumor.
Conclusion
Complete middle lower bilobectomy can be performed using a VATS approach. This therapeutic option seems worthwhile in young people because of low postoperative morbidity and fast recovery for active people.

Bibliographic references
1. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, Kramer MR. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest 2001;119:1647-51.
2. Schrevens L, Vansteenkiste J, Deneffe G, De Leyn P, Verbeken E, Vandenberghe T, Demedts M. Clinical-radiological presentation and outcome of surgically treated pulmonary carcinoid tumours: a long-term single institution experience. Lung Cancer 2004;43:39-45.
3. Hansen HJ, Petersen RH, Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Lung Cancer 2011;71,25(4):1263-9.
4. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothoracic Surg 2003;23:397-402.
Thoracoscopic management of empyema
From the mid-1990s, thoracoscopic treatment of empyemas has gained a wide acceptance. Potential advantages of video-assisted thoracoscopic surgery (VATS) include improved visualization, less surgical trauma and improved quality of life. VATS was initially used in early stage empyema to debride purulent collections and resect fibrin septae that failed to resolve with antibiotics and chest tube drainage (with or without fibrinolytic therapy).
The goals of the thoracoscopic treatment of empyema are as follows: 1) the debridement of purulent collections and fibrin, 2) the evacuation of necrotic material, 3) the breakdown of loculations, 4) to obtain adequate lung re-expansion, and 5) optimal chest tube placement for drainage.
Several reports have demonstrated that VATS debridement is a valid treatment option for stage II empyema, which allows an appropriate control of infection and a complete restoration of pulmonary function in early stage empyemas. Formal exclusion criteria for a primary VATS approach are suspicion of lung abscess, bronchopleural fistula, tumor at initial work-up or the need of muscle flaps with or without thoracoplasty. Presumed stage III empyema with pleural thickening and signs of restriction on CT-scan no longer are formal contraindications, but the conversion rate to decortications via thoracotomy is higher.
M Gonzalez, JY Perentes, T Krueger
Surgical intervention
5 years ago
2927 views
104 likes
1 comment
07:09
Thoracoscopic management of empyema
From the mid-1990s, thoracoscopic treatment of empyemas has gained a wide acceptance. Potential advantages of video-assisted thoracoscopic surgery (VATS) include improved visualization, less surgical trauma and improved quality of life. VATS was initially used in early stage empyema to debride purulent collections and resect fibrin septae that failed to resolve with antibiotics and chest tube drainage (with or without fibrinolytic therapy).
The goals of the thoracoscopic treatment of empyema are as follows: 1) the debridement of purulent collections and fibrin, 2) the evacuation of necrotic material, 3) the breakdown of loculations, 4) to obtain adequate lung re-expansion, and 5) optimal chest tube placement for drainage.
Several reports have demonstrated that VATS debridement is a valid treatment option for stage II empyema, which allows an appropriate control of infection and a complete restoration of pulmonary function in early stage empyemas. Formal exclusion criteria for a primary VATS approach are suspicion of lung abscess, bronchopleural fistula, tumor at initial work-up or the need of muscle flaps with or without thoracoplasty. Presumed stage III empyema with pleural thickening and signs of restriction on CT-scan no longer are formal contraindications, but the conversion rate to decortications via thoracotomy is higher.
Gynecological cancer and laparoscopic approach: state-of-the-art
In this key lecture, Professor Wattiez introduces the history of laparoscopy applied to oncology. The feasibility, accuracy, radicality, and benefits of laparoscopy applied to cancer are addressed. The lack of expansion of laparoscopy used in oncology is explained. Adverse effects and controversies such as port-site metastases as well as their prevention are exposed. Recent data are presented and complications between laparoscopy and laparotomy are outlined, showing no complications related to laparoscopy. Exposure and dissection, which are important steps in order to prevent complications, are explained. To conclude, a take home message emphasizing the importance of training is given.
A Wattiez
Lecture
5 years ago
1402 views
16 likes
0 comments
45:15
Gynecological cancer and laparoscopic approach: state-of-the-art
In this key lecture, Professor Wattiez introduces the history of laparoscopy applied to oncology. The feasibility, accuracy, radicality, and benefits of laparoscopy applied to cancer are addressed. The lack of expansion of laparoscopy used in oncology is explained. Adverse effects and controversies such as port-site metastases as well as their prevention are exposed. Recent data are presented and complications between laparoscopy and laparotomy are outlined, showing no complications related to laparoscopy. Exposure and dissection, which are important steps in order to prevent complications, are explained. To conclude, a take home message emphasizing the importance of training is given.
Endoscopic subcutaneous approach for component separation
This video describes the endoscopic subcutaneous approach for component separation. The patient is a 64-year-old woman with a history of progressive bulging of the abdominal wall and moderate pain. Physical examination revealed two central ventral hernias, measuring approximately 6 and 7cm in diameter. She had previously undergone laparotomy via a midline incision. The video shows in detail the steps of how to perform the endoscopic subcutaneous approach for component separation. We describe preoperative skin marking of the semilunar line under ultrasonic guidance, creation of the subcutaneous space, placement of the working port, division of the external oblique aponeurosis lateral to the semilunar line extending from the inguinal ligament to 4cm above the costal margin, mobilization of the external oblique from the internal oblique muscle, and finally measurement of the extension of the component separation.
J Daes
Surgical intervention
5 years ago
1078 views
32 likes
0 comments
07:15
Endoscopic subcutaneous approach for component separation
This video describes the endoscopic subcutaneous approach for component separation. The patient is a 64-year-old woman with a history of progressive bulging of the abdominal wall and moderate pain. Physical examination revealed two central ventral hernias, measuring approximately 6 and 7cm in diameter. She had previously undergone laparotomy via a midline incision. The video shows in detail the steps of how to perform the endoscopic subcutaneous approach for component separation. We describe preoperative skin marking of the semilunar line under ultrasonic guidance, creation of the subcutaneous space, placement of the working port, division of the external oblique aponeurosis lateral to the semilunar line extending from the inguinal ligament to 4cm above the costal margin, mobilization of the external oblique from the internal oblique muscle, and finally measurement of the extension of the component separation.