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Monthly publications

#February 2014
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Robot-assisted left video thoracoscopic partial thymectomy for mediastinal ectopic parathyroid adenoma
This film presents the case of an 85-year-old man who suffered from primary hyperparathyroidism diagnosed on a pathological cervical fracture and elevated laboratory values for parathyroid hormone and calcium. Preoperative localizing studies showed no anomalies on the parathyroid gland. However, a left anterior mediastinal ectopic parathyroid adenoma was found on 99m Tc-MIBI scintigraphy.
Mediastinal parathyroid adenomas can be resected in a minimally invasive fashion via a conventional transcervical approach, or using a video-assisted thoracoscopic resection, allowing for an access to the lower cervical area without the use of a cervicotomy. Robotic-assisted thoracic surgery (RATS) also allows for a better visualization and less instrument crowding, with no difference in clinical results.
Considering the good efficacy and the better chances not to leave tumor tissue missed out during surgery, and the impossibility to install the patient with cervical hyperextension, we decided to perform a robot-assisted thoracoscopy through a left-sided approach, instead of the conventional transcervical approach.
During the intraoperative period, the adenoma was identified, and we did not feel the need to perform PTH assay. There were no complications in the postoperative period. PTH levels reached a normal range after adenoma removal, and the patient was discharged on postoperative day 3. He remains asymptomatic at 3 months after the intervention.
The robotic resection of an intrathymic parathyroid adenoma is a safe and effective alternative to the conventional transcervical approach.
JM Baste, M Dazza, C Peillon
Surgical intervention
4 years ago
1026 views
29 likes
0 comments
06:54
Robot-assisted left video thoracoscopic partial thymectomy for mediastinal ectopic parathyroid adenoma
This film presents the case of an 85-year-old man who suffered from primary hyperparathyroidism diagnosed on a pathological cervical fracture and elevated laboratory values for parathyroid hormone and calcium. Preoperative localizing studies showed no anomalies on the parathyroid gland. However, a left anterior mediastinal ectopic parathyroid adenoma was found on 99m Tc-MIBI scintigraphy.
Mediastinal parathyroid adenomas can be resected in a minimally invasive fashion via a conventional transcervical approach, or using a video-assisted thoracoscopic resection, allowing for an access to the lower cervical area without the use of a cervicotomy. Robotic-assisted thoracic surgery (RATS) also allows for a better visualization and less instrument crowding, with no difference in clinical results.
Considering the good efficacy and the better chances not to leave tumor tissue missed out during surgery, and the impossibility to install the patient with cervical hyperextension, we decided to perform a robot-assisted thoracoscopy through a left-sided approach, instead of the conventional transcervical approach.
During the intraoperative period, the adenoma was identified, and we did not feel the need to perform PTH assay. There were no complications in the postoperative period. PTH levels reached a normal range after adenoma removal, and the patient was discharged on postoperative day 3. He remains asymptomatic at 3 months after the intervention.
The robotic resection of an intrathymic parathyroid adenoma is a safe and effective alternative to the conventional transcervical approach.
Laparoscopic and endoscopic treatment of a complicated candy cane syndrome after Roux-en-Y gastric bypass
A “Candy Cane” Roux syndrome represents an excessive length of non-functional Roux limb proximal to the gastrojejunostomy, which can cause abnormal upper gastrointestinal symptoms of postprandial epigastric discomfort that is relieved by vomiting. Symptoms of reflux, loss of satiety, and nausea are also common. The length of the blind loop is the essential factor to explain these symptoms, but the orientation of the gastrojejunal anastomosis is equally important to facilitate the emptying of the gastric pouch.
Scarce data can be found in the literature --a case report (1) and a case series (2) with a number of limitations. It is not possible to determine a critical excess length of Roux limb at which symptoms would become evident, nor were we able to determine whether all patients, or just a small minority, would develop symptoms, even with a seemingly excessive Roux limb.
Patients who underwent a gastric bypass technique with a gastrojejunal anastomosis using a circular stapler seem to be more likely to develop this anomaly. All 3 patients described by Cottam et al. (2) have their primary procedure performed by means of a circular stapler.
A long, non-functional Roux limb tip may cause persistent nausea, postprandial epigastric pain, and even a lack of satiety. Surgeons should attempt to minimize redundancy in the Roux limb during the primary procedure. Limiting the length and orientating the Roux limb to aid in gravity and drainage during the initial operation may prevent this syndrome.
References:
1. Dallal RM, Cottam D. "Candy cane" Roux syndrome--a possible complication after gastric bypass surgery. Surg Obes Relat Dis 2007;3:408-10.
2. Romero-Mejía C, Camacho-Aguilera JF, Paipilla-Monroy O. "Candy cane" Roux syndrome in laparoscopic gastric by-pass. Cir Cir 2010;78:347-51.
L Marx, M Nedelcu, M Vix, J Marescaux
Surgical intervention
4 years ago
1483 views
10 likes
0 comments
05:57
Laparoscopic and endoscopic treatment of a complicated candy cane syndrome after Roux-en-Y gastric bypass
A “Candy Cane” Roux syndrome represents an excessive length of non-functional Roux limb proximal to the gastrojejunostomy, which can cause abnormal upper gastrointestinal symptoms of postprandial epigastric discomfort that is relieved by vomiting. Symptoms of reflux, loss of satiety, and nausea are also common. The length of the blind loop is the essential factor to explain these symptoms, but the orientation of the gastrojejunal anastomosis is equally important to facilitate the emptying of the gastric pouch.
Scarce data can be found in the literature --a case report (1) and a case series (2) with a number of limitations. It is not possible to determine a critical excess length of Roux limb at which symptoms would become evident, nor were we able to determine whether all patients, or just a small minority, would develop symptoms, even with a seemingly excessive Roux limb.
Patients who underwent a gastric bypass technique with a gastrojejunal anastomosis using a circular stapler seem to be more likely to develop this anomaly. All 3 patients described by Cottam et al. (2) have their primary procedure performed by means of a circular stapler.
A long, non-functional Roux limb tip may cause persistent nausea, postprandial epigastric pain, and even a lack of satiety. Surgeons should attempt to minimize redundancy in the Roux limb during the primary procedure. Limiting the length and orientating the Roux limb to aid in gravity and drainage during the initial operation may prevent this syndrome.
References:
1. Dallal RM, Cottam D. "Candy cane" Roux syndrome--a possible complication after gastric bypass surgery. Surg Obes Relat Dis 2007;3:408-10.
2. Romero-Mejía C, Camacho-Aguilera JF, Paipilla-Monroy O. "Candy cane" Roux syndrome in laparoscopic gastric by-pass. Cir Cir 2010;78:347-51.
Robot-assisted gastric band removal: any limitations?
Nowadays, indications for gastric band removal are well-standardized. In case of esophageal or gastric dilatation, migration or any injury related to the LAP-BAND® access port or tubing, the band and its access port should be removed. In rare specific cases, part of the LAP-BAND® system (either access port or band) may be preserved.
Before proceeding to the surgical band removal, a complete preoperative radiological and endoscopic work-up should be performed.
Here, we present the case of a 62-year-old woman who benefited from gastric band placement 10 years earlier. The band proved effective. However, for several weeks, she has been suffering from abdominal pain associated with vomiting and hematemesis.
After a work-up which included CT-scanning, water-soluble contrast swallow and gastroscopy, it was decided to remove the band.
L Marx, M Vix, A D'Urso, J Marescaux
Surgical intervention
4 years ago
743 views
10 likes
0 comments
08:36
Robot-assisted gastric band removal: any limitations?
Nowadays, indications for gastric band removal are well-standardized. In case of esophageal or gastric dilatation, migration or any injury related to the LAP-BAND® access port or tubing, the band and its access port should be removed. In rare specific cases, part of the LAP-BAND® system (either access port or band) may be preserved.
Before proceeding to the surgical band removal, a complete preoperative radiological and endoscopic work-up should be performed.
Here, we present the case of a 62-year-old woman who benefited from gastric band placement 10 years earlier. The band proved effective. However, for several weeks, she has been suffering from abdominal pain associated with vomiting and hematemesis.
After a work-up which included CT-scanning, water-soluble contrast swallow and gastroscopy, it was decided to remove the band.
Thoracoscopic enucleation of a middle esophagus leiomyoma
Leiomyoma is the most frequent esophageal benign tumor. It represents 70% of these tumors and 1 to 8% of all esophageal tumors. The most frequent location is the distal esophagus. The majority of cases are asymptomatic and are discovered by chance in endoscopic or radiologic examinations. An endoscopic or surgical treatment can be applied in symptomatic cases (mainly dysphagia), basically depending on its size.
We present a thoracoscopic enucleation of a milddle esophagus leiomyoma in a 41-year-old woman. The operation was performed using a thoracoscopic approach. The patient was placed in a prone decubitus position. The tumor was enucleated by myotomy with subsequent suturing of the muscular gap through three trocars. There were no complications. After 48 hours postoperatively, a water-soluble contrast gastroduodenal study revealed normal passage through the esophageal lumen. The pathologist's diagnosis was esophageal leiomyoma.
F Ochando Cerdan, JM Fernandez Cebrian, L Vega Lopez
Surgical intervention
4 years ago
1246 views
15 likes
0 comments
16:15
Thoracoscopic enucleation of a middle esophagus leiomyoma
Leiomyoma is the most frequent esophageal benign tumor. It represents 70% of these tumors and 1 to 8% of all esophageal tumors. The most frequent location is the distal esophagus. The majority of cases are asymptomatic and are discovered by chance in endoscopic or radiologic examinations. An endoscopic or surgical treatment can be applied in symptomatic cases (mainly dysphagia), basically depending on its size.
We present a thoracoscopic enucleation of a milddle esophagus leiomyoma in a 41-year-old woman. The operation was performed using a thoracoscopic approach. The patient was placed in a prone decubitus position. The tumor was enucleated by myotomy with subsequent suturing of the muscular gap through three trocars. There were no complications. After 48 hours postoperatively, a water-soluble contrast gastroduodenal study revealed normal passage through the esophageal lumen. The pathologist's diagnosis was esophageal leiomyoma.
Laparoscopic transgastric sphincterotomy for common bile duct stones
We report the case of a transgastric sphincterotomy. This is the case of a 67-year-old woman presenting with cholangitis with a past history of an esophageal peptic stenosis. After dilatation, the duodenoscopy does not make it possible to cross this stenosis. A transgastric laparoscopy is decided upon in order to introduce the duodenoscope through a 15mm port. The duodenoscope is then introduced through the port into the anterior gastric wall allowing for a successful sphincterotomy and stone extraction. The duodenoscope is withdrawn and the gastrotomy is closed. A laparoscopic cholecystectomy is performed. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6.
P Pessaux, J Huppertz, D Ntourakis, A Sportes, E Wedi, D Mutter, J Marescaux
Surgical intervention
4 years ago
2801 views
37 likes
0 comments
09:04
Laparoscopic transgastric sphincterotomy for common bile duct stones
We report the case of a transgastric sphincterotomy. This is the case of a 67-year-old woman presenting with cholangitis with a past history of an esophageal peptic stenosis. After dilatation, the duodenoscopy does not make it possible to cross this stenosis. A transgastric laparoscopy is decided upon in order to introduce the duodenoscope through a 15mm port. The duodenoscope is then introduced through the port into the anterior gastric wall allowing for a successful sphincterotomy and stone extraction. The duodenoscope is withdrawn and the gastrotomy is closed. A laparoscopic cholecystectomy is performed. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6.
Bowel obstruction: a late complication after laparoscopic colposacropexy
This video illustrates the case of a patient with bowel adherent to an exposed portion of mesh used for treatment of a previous apical prolapse. The patient presents with abdominal symptoms following a laparoscopic sacrocolpopexy.
In this video, Professor Wattiez performs an extensive pelvic adhesiolysis, detaching the bowel from the mesh, and identifying adequate correction of vaginal prolapse, without any sign of infection. Reperitonization of the vaginal vault and the long arm (sacrum arm) of the mesh was also performed.
This unique case highlights the importance of peritonization when using mesh. Complications such as mesh exposure may occur, however this can be appropriately managed laparoscopically.
A Wattiez, J Castellano, R Fernandes, G Centini, C Meza Paul, K Afors
Surgical intervention
4 years ago
1780 views
37 likes
0 comments
23:25
Bowel obstruction: a late complication after laparoscopic colposacropexy
This video illustrates the case of a patient with bowel adherent to an exposed portion of mesh used for treatment of a previous apical prolapse. The patient presents with abdominal symptoms following a laparoscopic sacrocolpopexy.
In this video, Professor Wattiez performs an extensive pelvic adhesiolysis, detaching the bowel from the mesh, and identifying adequate correction of vaginal prolapse, without any sign of infection. Reperitonization of the vaginal vault and the long arm (sacrum arm) of the mesh was also performed.
This unique case highlights the importance of peritonization when using mesh. Complications such as mesh exposure may occur, however this can be appropriately managed laparoscopically.
Single port laparoscopy and extraperitoneal para-aortic lymphadenectomy
Background: To report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer before chemoradiotherapy. This procedure is used in our institution in patients with negative PET-CT imaging in the para-aortic area to define radiation field limits more accurately.
Methods: Prospective study of patients with stage IB1N+-IVA cervical cancer treated at the Institute Gustave Roussy from January 2011 to January 2013.
Results: There was no conversion to laparotomy or to conventional multiport laparoscopy among our 50 cases. Only one failure occurred after removal of 2 nodes. In this case, we chose to stop the procedure because of the risk of a vascular complication due to the vascular anatomic variation. The median and mean number of lymph nodes removed were 18 [2-47] and 19 respectively. Six (12%) patients had metastatic para-aortic nodes. Radiotherapy fields were extended when para-aortic nodes were involved.
Conclusion: Extraperitoneal staging via a single port left iliac approach is feasible with conventional tools; it is reproducible and safe, and offers a high degree of cosmetic satisfaction.
S Gouy, C Uzan, A Leary, P Morice
Surgical intervention
4 years ago
2371 views
40 likes
0 comments
09:54
Single port laparoscopy and extraperitoneal para-aortic lymphadenectomy
Background: To report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer before chemoradiotherapy. This procedure is used in our institution in patients with negative PET-CT imaging in the para-aortic area to define radiation field limits more accurately.
Methods: Prospective study of patients with stage IB1N+-IVA cervical cancer treated at the Institute Gustave Roussy from January 2011 to January 2013.
Results: There was no conversion to laparotomy or to conventional multiport laparoscopy among our 50 cases. Only one failure occurred after removal of 2 nodes. In this case, we chose to stop the procedure because of the risk of a vascular complication due to the vascular anatomic variation. The median and mean number of lymph nodes removed were 18 [2-47] and 19 respectively. Six (12%) patients had metastatic para-aortic nodes. Radiotherapy fields were extended when para-aortic nodes were involved.
Conclusion: Extraperitoneal staging via a single port left iliac approach is feasible with conventional tools; it is reproducible and safe, and offers a high degree of cosmetic satisfaction.
Robotic surgery training center, a Brazilian experience
Introduction:
As there is no training protocol for robotic microsurgery established by Intuitive Surgical®, we chose to prepare a bibliographic revision about microsurgery training protocols, associating training with inanimate objects and practical training in biological material (animal model).
Methods:
A systematic review was performed crossing the words education and robotics using the PUBMED database. The search presented a result of 249 articles. We considered articles published in English over the past 10 years, having as a selection criteria for inclusion, the description of one of the following items: 1) techniques of teaching; 2) the learning curve or the training of basic principles of surgery as the basis of a training program; 19 published articles were eligible.
Discussion:
The possibility to adapt teaching techniques which are used in robotic laparoscopic videos and connecting theory with practice. The learning process has been organized in different levels of teaching.
Conclusion:
The fact that there are no recognized protocols for robotic microsurgery by Intuitive Surgical®, creates a necessity to develop teaching methodology standards for the robotic microsurgeon in order to be trained in a safer, faster, more efficient and more intuitive way and having as a result a more positive patient clinical outcome.
M Cerdan Torres
Lecture
4 years ago
215 views
3 likes
0 comments
05:10
Robotic surgery training center, a Brazilian experience
Introduction:
As there is no training protocol for robotic microsurgery established by Intuitive Surgical®, we chose to prepare a bibliographic revision about microsurgery training protocols, associating training with inanimate objects and practical training in biological material (animal model).
Methods:
A systematic review was performed crossing the words education and robotics using the PUBMED database. The search presented a result of 249 articles. We considered articles published in English over the past 10 years, having as a selection criteria for inclusion, the description of one of the following items: 1) techniques of teaching; 2) the learning curve or the training of basic principles of surgery as the basis of a training program; 19 published articles were eligible.
Discussion:
The possibility to adapt teaching techniques which are used in robotic laparoscopic videos and connecting theory with practice. The learning process has been organized in different levels of teaching.
Conclusion:
The fact that there are no recognized protocols for robotic microsurgery by Intuitive Surgical®, creates a necessity to develop teaching methodology standards for the robotic microsurgeon in order to be trained in a safer, faster, more efficient and more intuitive way and having as a result a more positive patient clinical outcome.
Robotic thoracoscopy: intercostal nerves and phrenic nerve harvesting
The aim of this study was to report the feasibility of robotic intercostal nerve harvesting in a pig model. A surgical robot (the da Vinci S® system, Intuitive Surgical, Sunnyvale, CA) was installed with three ports on the pig’s left chest. The posterior edges of the 4th, 5th, and 6th intercostal nerves were isolated to the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvests were successfully performed in 40 minutes without major complications. The advantages of robotic microsurgery for intercostal nerve harvesting are motion scaling up to 5 times, elimination of physiological tremors, and free movement of joint-equipped robotic arms. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvesting for brachial plexus reconstruction.
H Miyamoto
Lecture
4 years ago
146 views
5 likes
0 comments
06:07
Robotic thoracoscopy: intercostal nerves and phrenic nerve harvesting
The aim of this study was to report the feasibility of robotic intercostal nerve harvesting in a pig model. A surgical robot (the da Vinci S® system, Intuitive Surgical, Sunnyvale, CA) was installed with three ports on the pig’s left chest. The posterior edges of the 4th, 5th, and 6th intercostal nerves were isolated to the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvests were successfully performed in 40 minutes without major complications. The advantages of robotic microsurgery for intercostal nerve harvesting are motion scaling up to 5 times, elimination of physiological tremors, and free movement of joint-equipped robotic arms. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvesting for brachial plexus reconstruction.
Image-guided surgery: the augmented reality assistance
Medical imaging quality and accuracy of the human body (MRI, CT-scan, US, PET-scan) currently enable practitioners to establish a very precise diagnosis and to plan surgical interventions (open and laparoscopic surgery). Additionally, from CT-scan or MRI sections, the latest systems allow to display organs and pathological structures of patients in 3 dimensions, thereby facilitating the spatial understanding of practitioners. However, fully exploiting this precious information remains a challenge. In this presentation, the author explains how 3D patient model can be used to improve surgical planning. The author then describes how these 3D models can be brought to the operating room using augmented reality. Finally, the author provides an overview of the latest techniques about augmented reality guidance during minimally invasive surgery, and the main problems that still need to be overcome.
S Nicolau
Lecture
4 years ago
326 views
5 likes
0 comments
08:23
Image-guided surgery: the augmented reality assistance
Medical imaging quality and accuracy of the human body (MRI, CT-scan, US, PET-scan) currently enable practitioners to establish a very precise diagnosis and to plan surgical interventions (open and laparoscopic surgery). Additionally, from CT-scan or MRI sections, the latest systems allow to display organs and pathological structures of patients in 3 dimensions, thereby facilitating the spatial understanding of practitioners. However, fully exploiting this precious information remains a challenge. In this presentation, the author explains how 3D patient model can be used to improve surgical planning. The author then describes how these 3D models can be brought to the operating room using augmented reality. Finally, the author provides an overview of the latest techniques about augmented reality guidance during minimally invasive surgery, and the main problems that still need to be overcome.
Plastic and reconstructive robotic surgery: 5 cases and a systematic review
Introduction
We sought to determine the feasibility of robotic microvascular surgery in reconstructive surgery. Additionally, we performed a systematic review to assess the current developments in robotic plastic surgery.

Methods
Between February 2009 and June 2010, five patients underwent robotic microvascular anastomoses for delayed, free-tissue breast reconstruction, using the deep inferior epigastric artery (DIEP) flap. A PubMed and MEDLINE search was also performed using specific search terms.

Results
Mean patient age was 55.4 years. Mean robotic anastomotic time was 96 minutes. There were no additional errors of management (EOM). Figure 1 shows anastomotic times. No intraoperative or postoperative flap-related complications were encountered.
The literature search yielded 338 articles. Only 19 publications were relevant and further analyzed. The majority of authors report outcomes of microvascular surgery in laboratory conditions. Robotic microsurgery is accurate but consistently takes longer than with the microscope. Investigators consistently report poor haptic feedback.

Conclusion
Robotic microsurgery is safe in our experience. The current literature illustrates comparable vascular patency rates at the cost of longer operative times. Comparing robotic and standard microsurgery may be hampering the evolution of robotic plastic surgery because of this focus. The ability to perform microsurgery in confined anatomical spaces will reduce patient morbidity and potentially reduce in-patient stay. The ability to raise and inset flaps and explore neural and vascular structures, whilst avoiding large access wounds at both donor and recipient sites, is very attractive. Consequently, we believe that there any many reconstructive applications, and collaboration to produce meaningful clinical outcomes is required.
D Saleh
Lecture
4 years ago
326 views
16 likes
0 comments
10:28
Plastic and reconstructive robotic surgery: 5 cases and a systematic review
Introduction
We sought to determine the feasibility of robotic microvascular surgery in reconstructive surgery. Additionally, we performed a systematic review to assess the current developments in robotic plastic surgery.

Methods
Between February 2009 and June 2010, five patients underwent robotic microvascular anastomoses for delayed, free-tissue breast reconstruction, using the deep inferior epigastric artery (DIEP) flap. A PubMed and MEDLINE search was also performed using specific search terms.

Results
Mean patient age was 55.4 years. Mean robotic anastomotic time was 96 minutes. There were no additional errors of management (EOM). Figure 1 shows anastomotic times. No intraoperative or postoperative flap-related complications were encountered.
The literature search yielded 338 articles. Only 19 publications were relevant and further analyzed. The majority of authors report outcomes of microvascular surgery in laboratory conditions. Robotic microsurgery is accurate but consistently takes longer than with the microscope. Investigators consistently report poor haptic feedback.

Conclusion
Robotic microsurgery is safe in our experience. The current literature illustrates comparable vascular patency rates at the cost of longer operative times. Comparing robotic and standard microsurgery may be hampering the evolution of robotic plastic surgery because of this focus. The ability to perform microsurgery in confined anatomical spaces will reduce patient morbidity and potentially reduce in-patient stay. The ability to raise and inset flaps and explore neural and vascular structures, whilst avoiding large access wounds at both donor and recipient sites, is very attractive. Consequently, we believe that there any many reconstructive applications, and collaboration to produce meaningful clinical outcomes is required.