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Monthly publications

#April 2014
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Laparoscopic gastric plication with intraoperative endoscopy: a guide for a correct procedure
The field of bariatric surgery is continually evolving. Laparoscopic gastric plication (LGP) is an experimental bariatric procedure developed with the intent to offer the same effect as sleeve gastrectomy in gastric restriction without the same degree of risk. The LGP procedure consists in a complete mobilization of the fundus and body, followed by an invagination of all the greater curvature of the stomach, maintained by a full-thickness suture, from the angle of His down to 6cm from the pylorus, in order to create a large intraluminal gastric fold.
The aim of the present video was to report our technique in LGP, presenting the role and all the advantages of intraoperative endoscopy.
The procedure was completed in a 37-year-old woman, with previous gastric banding. Due to limited weight loss, LGP was performed in a single step procedure after concomitant gastric banding removal.
The video shows all surgical steps: gastric banding isolation and removal, mobilization of the greater gastric curvature, gastric plication by double invagination suture lines controlled by intraoperative endoscopic evaluation. The endoscope was left in place during the whole plication procedure like a calibration tube to ensure a patent lumen, and the intragastric vision represents a three-fold guide: a guide for the surgeon in terms of size of the gastric fold, a guide in terms of shape of the gastric lumen, and a guide for a correct suture and position of full-thickness bite.
The video is also completed by a postoperative 8-month endoscopic evaluation, to assess the appearance of the fold and plication durability.
In our preliminary experience, intraoperative endoscopy is a mandatory combined procedure during LGP to achieve all the required information for a correct surgical procedure. The endoscopic evaluation also represents a fundamental step during follow-up, also considering the experimental phase of this surgical procedure.
N Perrotta, F Romana de Filippo, A Cappiello, N Andriulo, E Palladino, D Loffredo
Surgical intervention
4 years ago
2138 views
16 likes
1 comment
07:26
Laparoscopic gastric plication with intraoperative endoscopy: a guide for a correct procedure
The field of bariatric surgery is continually evolving. Laparoscopic gastric plication (LGP) is an experimental bariatric procedure developed with the intent to offer the same effect as sleeve gastrectomy in gastric restriction without the same degree of risk. The LGP procedure consists in a complete mobilization of the fundus and body, followed by an invagination of all the greater curvature of the stomach, maintained by a full-thickness suture, from the angle of His down to 6cm from the pylorus, in order to create a large intraluminal gastric fold.
The aim of the present video was to report our technique in LGP, presenting the role and all the advantages of intraoperative endoscopy.
The procedure was completed in a 37-year-old woman, with previous gastric banding. Due to limited weight loss, LGP was performed in a single step procedure after concomitant gastric banding removal.
The video shows all surgical steps: gastric banding isolation and removal, mobilization of the greater gastric curvature, gastric plication by double invagination suture lines controlled by intraoperative endoscopic evaluation. The endoscope was left in place during the whole plication procedure like a calibration tube to ensure a patent lumen, and the intragastric vision represents a three-fold guide: a guide for the surgeon in terms of size of the gastric fold, a guide in terms of shape of the gastric lumen, and a guide for a correct suture and position of full-thickness bite.
The video is also completed by a postoperative 8-month endoscopic evaluation, to assess the appearance of the fold and plication durability.
In our preliminary experience, intraoperative endoscopy is a mandatory combined procedure during LGP to achieve all the required information for a correct surgical procedure. The endoscopic evaluation also represents a fundamental step during follow-up, also considering the experimental phase of this surgical procedure.
Thoracoscopic middle lobectomy with sleeve resection for bulky carcinoid tumor
We report the case of a 35-year-old female patient presenting with hemoptysis from a bulky carcinoid tumor of the middle lobe protruding in the truncus intermedius.
A middle lobectomy with sleeve resection was performed, using a full thoracoscopic approach, i.e. without utility incision. Resection margins were free. The final pathologic examination confirmed a typical pT1bN0carcinoid tumor.
The patient was discharged on postoperative day 4, after an uneventful postoperative course.
The main steps of the procedure are described. The slightly hemorrhagic atmosphere of the operation is due to vascular compression from the tumor.
D Gossot, M Grigoroiu, E Brian
Surgical intervention
4 years ago
787 views
13 likes
0 comments
09:22
Thoracoscopic middle lobectomy with sleeve resection for bulky carcinoid tumor
We report the case of a 35-year-old female patient presenting with hemoptysis from a bulky carcinoid tumor of the middle lobe protruding in the truncus intermedius.
A middle lobectomy with sleeve resection was performed, using a full thoracoscopic approach, i.e. without utility incision. Resection margins were free. The final pathologic examination confirmed a typical pT1bN0carcinoid tumor.
The patient was discharged on postoperative day 4, after an uneventful postoperative course.
The main steps of the procedure are described. The slightly hemorrhagic atmosphere of the operation is due to vascular compression from the tumor.
Video-assisted thoracoscopic (VATS) lobectomy: middle 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 posterolateral 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 (Although we favor a fully thoracoscopic technique for all our cases, some centers may use a 4 to 5cm “working incision” near the axilla);
- 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 middle lobe in a 67-year-old patient (the video emphasizes the steps of lobe resection - 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 unfaltering dedication and continued support.
DD Masckauchan, G Rakovich
Surgical intervention
4 years ago
384 views
42 likes
0 comments
08:49
Video-assisted thoracoscopic (VATS) lobectomy: middle 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 posterolateral 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 (Although we favor a fully thoracoscopic technique for all our cases, some centers may use a 4 to 5cm “working incision” near the axilla);
- 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 middle lobe in a 67-year-old patient (the video emphasizes the steps of lobe resection - 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 unfaltering dedication and continued support.
Robotic single site left dismembered pyeloplasty for ureteropelvic junction obstruction
This video demonstrates the surgical steps for a left ureteropelvic junction (UPJ) reconstruction performed by means of the new da Vinci® robotic single site platform.
This surgery can be achieved by a 2cm single incision made in the umbilicus.
The system provides 2 robotic instruments crossing into the trocar in order to have an adequate triangulation. In this set-up, the left robotic instrument is placed into the surgical field on the right side while the right robotic instrument is on the left side of the surgical field. The software of the da Vinci™ system allows for the control of the right robotic arm to the left master into the robotic console in order to have the instrument placed in the right part of the surgical field controlled by the right master. This allows for a direct and natural control of the instruments, hence solving the problem of the crossing of the instruments.
This is a great advantage when compared to standard laparoscopic single site surgery.
F Annino, T Verdacchi, M de Angelis
Surgical intervention
4 years ago
2076 views
49 likes
1 comment
05:40
Robotic single site left dismembered pyeloplasty for ureteropelvic junction obstruction
This video demonstrates the surgical steps for a left ureteropelvic junction (UPJ) reconstruction performed by means of the new da Vinci® robotic single site platform.
This surgery can be achieved by a 2cm single incision made in the umbilicus.
The system provides 2 robotic instruments crossing into the trocar in order to have an adequate triangulation. In this set-up, the left robotic instrument is placed into the surgical field on the right side while the right robotic instrument is on the left side of the surgical field. The software of the da Vinci™ system allows for the control of the right robotic arm to the left master into the robotic console in order to have the instrument placed in the right part of the surgical field controlled by the right master. This allows for a direct and natural control of the instruments, hence solving the problem of the crossing of the instruments.
This is a great advantage when compared to standard laparoscopic single site surgery.
International Microsurgical Simulation Society- a new networking society of microsurgeons that can promote training in microsurgery and robotics
Training in specific skills such a microsurgery including robotic microsurgery has become an essential part of surgical training in many institutions around the world. IMSS is a great proof of that with a pronounced group of instructors and practicing microsurgeons who will be working towards standardization of the microsurgery training around the globe and the right skill assessments tools.
There is a vast wealth of expertise and experience that could and needs to be shared between masters and new upcoming instructors in microsurgery. Creating a golden standard for teaching basic microsurgery would help the new courses and centers to adopt the right structure and algorithm to teaching everyone at the very similar methods. Utilizing non-living and living models can be systematized too.
There is also an intense indication towards generating the assessments tools for the microsurgical skills that would allow to significantly improve the quality not only of the surgical training but of patients’ care as well.
One of the goals of IMSS is to stimulate this process and help with network between leading institutions and surgeons. Training in robotic microsurgery is one the aspects of collaboration between IMSS and RAMSES that can lead to successful creation of an assessment tool that can work both in conventional and robotic microsurgery.
Y Akelina
Lecture
4 years ago
90 views
2 likes
0 comments
13:54
International Microsurgical Simulation Society- a new networking society of microsurgeons that can promote training in microsurgery and robotics
Training in specific skills such a microsurgery including robotic microsurgery has become an essential part of surgical training in many institutions around the world. IMSS is a great proof of that with a pronounced group of instructors and practicing microsurgeons who will be working towards standardization of the microsurgery training around the globe and the right skill assessments tools.
There is a vast wealth of expertise and experience that could and needs to be shared between masters and new upcoming instructors in microsurgery. Creating a golden standard for teaching basic microsurgery would help the new courses and centers to adopt the right structure and algorithm to teaching everyone at the very similar methods. Utilizing non-living and living models can be systematized too.
There is also an intense indication towards generating the assessments tools for the microsurgical skills that would allow to significantly improve the quality not only of the surgical training but of patients’ care as well.
One of the goals of IMSS is to stimulate this process and help with network between leading institutions and surgeons. Training in robotic microsurgery is one the aspects of collaboration between IMSS and RAMSES that can lead to successful creation of an assessment tool that can work both in conventional and robotic microsurgery.
Transitioning from microsurgery to robotic microsurgery in reproductive urology
For years, people have been dreaming of robots. Whether for science fiction or for practical use, the idea of a robotic system to mechanically assist us with tasks has been sought after. We used to hear people say “someday robots will perform surgery for us”. It is not necessarily the case, but robots are certainly finding more utility in assisting us with different types of surgery.

The da Vinci® system began with uses for gross surgical procedures and has expanded its utility to microsurgery. In urology, this particularly lends itself to fertility surgery. This technology is primarily useful for vasectomy reversal and varicocelectomy in the realm of reproductive urology. Surgery that we initially tried with the naked eye, advanced through multiple technologies including optical loupes, operative microscopes, and now the operative robot.

The advantages of using robotics to assist with microsurgery in reproductive urology include the robotic endowrists allowing for seven degrees of freedom, which allow for movements that the human hand and wrist cannot make, an ergonomic design for the surgeon which is less fatiguing than an operative microscope which may enhance performance, and high definition 3D optimal visualization of a microsurgical field. The ability to stop operating for a few seconds and to take a breath during challenging microsurgical cases also allows for an unchanged operative field once the surgeon resumes work unlike the operative microscope.

Once the learning curve for robotic microsurgery has been mastered by microsurgeons it should improve operative times as well. My data on robotic vasectomy reversal shows comparable outcomes with robotic microsurgery, even in my very early case series, proving the feasibility of transitioning from pure microsurgery to robotic microsurgery for a formally trained microsurgeon.
P Kavoussi
Lecture
4 years ago
208 views
11 likes
0 comments
13:52
Transitioning from microsurgery to robotic microsurgery in reproductive urology
For years, people have been dreaming of robots. Whether for science fiction or for practical use, the idea of a robotic system to mechanically assist us with tasks has been sought after. We used to hear people say “someday robots will perform surgery for us”. It is not necessarily the case, but robots are certainly finding more utility in assisting us with different types of surgery.

The da Vinci® system began with uses for gross surgical procedures and has expanded its utility to microsurgery. In urology, this particularly lends itself to fertility surgery. This technology is primarily useful for vasectomy reversal and varicocelectomy in the realm of reproductive urology. Surgery that we initially tried with the naked eye, advanced through multiple technologies including optical loupes, operative microscopes, and now the operative robot.

The advantages of using robotics to assist with microsurgery in reproductive urology include the robotic endowrists allowing for seven degrees of freedom, which allow for movements that the human hand and wrist cannot make, an ergonomic design for the surgeon which is less fatiguing than an operative microscope which may enhance performance, and high definition 3D optimal visualization of a microsurgical field. The ability to stop operating for a few seconds and to take a breath during challenging microsurgical cases also allows for an unchanged operative field once the surgeon resumes work unlike the operative microscope.

Once the learning curve for robotic microsurgery has been mastered by microsurgeons it should improve operative times as well. My data on robotic vasectomy reversal shows comparable outcomes with robotic microsurgery, even in my very early case series, proving the feasibility of transitioning from pure microsurgery to robotic microsurgery for a formally trained microsurgeon.
New inside out harvest of flaps
Background:
The rectus abdominis muscle is a workhorse for free and pedicled muscle coverage. Traditional harvesting damages the anterior rectus sheath and requires an abdominal incision. Robotic harvesting can be reliably and efficiently performed using three ports, and no additional incisions. This method, better known as the “inside out” harvest has shown to remarkably reduce the morbidity and facilitate a more accurate dissection of the rectus muscle.
Methods:
Ten robotic rectus muscle harvests were performed at three institutions as free flaps for extremity coverage and pedicled flaps for minimally invasive pelvic surgery requiring soft tissue reconstruction. Three contralateral ports and an intraperitoneal approach were used in each harvest. In half of the free flap cases, a small pubic hairline incision was used to remove the muscle. In the other half, the muscle was removed using a laparoscopic “gallbladder bag.” Basic demographic information, operative variables, and outcomes were recorded.
Results
All cases were completed robotically by three different surgeons at three institutions. Four muscles were harvested for free flaps for lower extremity and 6 muscles were used as pedicled flaps, three for APR reconstruction and two for protection of visceral repair following radical cystoprostatectomy. Average robotic set-up time was 15 minutes. Average robotic harvest time was 45 minutes. Two 8mm ports and one 12mm port were in each case. One patient developed a grade I decubitus ulcer during surgery. There were no other complications. All muscles were completely viable following harvest. There were no conversions to open technique. No hernias noted.
Conclusions
Robotic rectus muscle harvesting is safe, efficient and reproducible. The anterior rectus sheath can be left completely intact, eliminating incisional morbidity, and the cumulative incisional length can be less than two inches for extensive, multi-service pelvic procedures, thus minimizing morbidity and perhaps shortening length of stay compared to open techniques.
JC Pedersen
Lecture
4 years ago
184 views
6 likes
0 comments
13:35
New inside out harvest of flaps
Background:
The rectus abdominis muscle is a workhorse for free and pedicled muscle coverage. Traditional harvesting damages the anterior rectus sheath and requires an abdominal incision. Robotic harvesting can be reliably and efficiently performed using three ports, and no additional incisions. This method, better known as the “inside out” harvest has shown to remarkably reduce the morbidity and facilitate a more accurate dissection of the rectus muscle.
Methods:
Ten robotic rectus muscle harvests were performed at three institutions as free flaps for extremity coverage and pedicled flaps for minimally invasive pelvic surgery requiring soft tissue reconstruction. Three contralateral ports and an intraperitoneal approach were used in each harvest. In half of the free flap cases, a small pubic hairline incision was used to remove the muscle. In the other half, the muscle was removed using a laparoscopic “gallbladder bag.” Basic demographic information, operative variables, and outcomes were recorded.
Results
All cases were completed robotically by three different surgeons at three institutions. Four muscles were harvested for free flaps for lower extremity and 6 muscles were used as pedicled flaps, three for APR reconstruction and two for protection of visceral repair following radical cystoprostatectomy. Average robotic set-up time was 15 minutes. Average robotic harvest time was 45 minutes. Two 8mm ports and one 12mm port were in each case. One patient developed a grade I decubitus ulcer during surgery. There were no other complications. All muscles were completely viable following harvest. There were no conversions to open technique. No hernias noted.
Conclusions
Robotic rectus muscle harvesting is safe, efficient and reproducible. The anterior rectus sheath can be left completely intact, eliminating incisional morbidity, and the cumulative incisional length can be less than two inches for extensive, multi-service pelvic procedures, thus minimizing morbidity and perhaps shortening length of stay compared to open techniques.
Large vessels: what is the robot's place in vascular surgery?
Since 2006, our vascular surgery team has developed an original program in the field of minimally invasive aortic surgery; for all cases of aortic disease unsuitable for endovascular treatment, we propose an alternative way to open surgery: using the da Vinci® surgical robotic system to perform aorto-aortic, aortobi-iliac and aorto-bifemoral bypasses, in more than 95 patients to date.

Contrarily to laparoscopy, the robot provides operating conditions, namely more comfort with a 3D vision, and operative steps very similar to open surgery. These key points account for a learning curve that is shorter than laparoscopy for aortic procedures.

For the first time in the literature, the robot was used by our team to perform the entire procedure including the retroperitoneal approach, aortic exposure, and the prosthetic suture.

We respect TASC recommendations for revascularizations by aorto-bifemoral bypasses, and surgery is always decided upon after failure of endovascular treatment.

For aneurysms, robotic surgery is proposed if the case is not suitable for endograft, and after informed patient consent.

The new design of the operating room with the robot, the training of the surgical team, the original design of the technique with placement of robotic ports, explain a mean operative time exceeding 6 hours, and a conversion rate with mini-lumbotomy of 30% of our learning curve in the first 30 cases. Currently, we treat more than 20 patients per year, with an average operative time of less than 5 hours, and with only 5% of surgical conversions by mini-lumbotomies. The progression of technology now allows us to clamp the suprarenal aorta and to perform cases of aneurysms with tubes or bifurcated grafts if we need to go on the primitive iliac arteries.

Our clinical results show a primary patency rate of 96% at the first year, 94% at the third year, and 86% at the fifth year. No postoperative death was related to the aortic pathology, the mortality rate was 96% at the first year, 83% at the third year, and 76% at the fifth year.

In addition, new surgical indications provide the opportunity to use the da Vinci® robot to deal with complex arterial disease: our team was able to treat cases of splenic aneurysms, with direct arterial reconstructions, arterial sutures performed entirely with the robot.

Our experience shows that arterial surgery for large vessels is entirely feasible with the da Vinci® robot. This opens valuable future perspectives, which will depend on the improvement of surgical robotic systems available.
F Thaveau
Lecture
4 years ago
165 views
1 like
0 comments
09:41
Large vessels: what is the robot's place in vascular surgery?
Since 2006, our vascular surgery team has developed an original program in the field of minimally invasive aortic surgery; for all cases of aortic disease unsuitable for endovascular treatment, we propose an alternative way to open surgery: using the da Vinci® surgical robotic system to perform aorto-aortic, aortobi-iliac and aorto-bifemoral bypasses, in more than 95 patients to date.

Contrarily to laparoscopy, the robot provides operating conditions, namely more comfort with a 3D vision, and operative steps very similar to open surgery. These key points account for a learning curve that is shorter than laparoscopy for aortic procedures.

For the first time in the literature, the robot was used by our team to perform the entire procedure including the retroperitoneal approach, aortic exposure, and the prosthetic suture.

We respect TASC recommendations for revascularizations by aorto-bifemoral bypasses, and surgery is always decided upon after failure of endovascular treatment.

For aneurysms, robotic surgery is proposed if the case is not suitable for endograft, and after informed patient consent.

The new design of the operating room with the robot, the training of the surgical team, the original design of the technique with placement of robotic ports, explain a mean operative time exceeding 6 hours, and a conversion rate with mini-lumbotomy of 30% of our learning curve in the first 30 cases. Currently, we treat more than 20 patients per year, with an average operative time of less than 5 hours, and with only 5% of surgical conversions by mini-lumbotomies. The progression of technology now allows us to clamp the suprarenal aorta and to perform cases of aneurysms with tubes or bifurcated grafts if we need to go on the primitive iliac arteries.

Our clinical results show a primary patency rate of 96% at the first year, 94% at the third year, and 86% at the fifth year. No postoperative death was related to the aortic pathology, the mortality rate was 96% at the first year, 83% at the third year, and 76% at the fifth year.

In addition, new surgical indications provide the opportunity to use the da Vinci® robot to deal with complex arterial disease: our team was able to treat cases of splenic aneurysms, with direct arterial reconstructions, arterial sutures performed entirely with the robot.

Our experience shows that arterial surgery for large vessels is entirely feasible with the da Vinci® robot. This opens valuable future perspectives, which will depend on the improvement of surgical robotic systems available.
Robotic microsurgery training
Robotic microsurgery is a newly emerging field, which offers several potential advantages to the operating surgeon, including the ability to perform challenging procedures in previously inaccessible locations. As with any new technique, robotic microsurgery requires the acquisition of a novel skillset with a need to overcome the associated learning curve. A review of the available literature suggests that compared to traditional techniques, initial experience with robotic-assisted microsurgery is associated with greater operative times and equivalent surgical outcomes. Although prior robotic experience may help to negate the initial learning curve with robotic microsurgery, existing microsurgical skills appear to be less relevant early on. Longer term, prospective, multi-institutional studies are required to determine if robotic assistance results in earlier technique mastery or improved outcomes as compared to traditional microsurgical approaches. Several modalities are currently available to assist surgeons in improving robotic microsurgical skills including didactics, laboratory simulation with synthetic, in vitro, or in vivo models, dry-dock robotic time, and simulators. Despite clear variability in fidelity of training modalities, performance measures correlate highly and are predictive of intraoperative performance. Given the increasing focus on outcome-based care, initial and subsequent recertification of robotic proficiency will likely be increasingly required.
L Trost
Lecture
4 years ago
189 views
2 likes
0 comments
09:42
Robotic microsurgery training
Robotic microsurgery is a newly emerging field, which offers several potential advantages to the operating surgeon, including the ability to perform challenging procedures in previously inaccessible locations. As with any new technique, robotic microsurgery requires the acquisition of a novel skillset with a need to overcome the associated learning curve. A review of the available literature suggests that compared to traditional techniques, initial experience with robotic-assisted microsurgery is associated with greater operative times and equivalent surgical outcomes. Although prior robotic experience may help to negate the initial learning curve with robotic microsurgery, existing microsurgical skills appear to be less relevant early on. Longer term, prospective, multi-institutional studies are required to determine if robotic assistance results in earlier technique mastery or improved outcomes as compared to traditional microsurgical approaches. Several modalities are currently available to assist surgeons in improving robotic microsurgical skills including didactics, laboratory simulation with synthetic, in vitro, or in vivo models, dry-dock robotic time, and simulators. Despite clear variability in fidelity of training modalities, performance measures correlate highly and are predictive of intraoperative performance. Given the increasing focus on outcome-based care, initial and subsequent recertification of robotic proficiency will likely be increasingly required.