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Monthly publications

#June 2014
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Laparoscopic D2 lymphadenectomy with preservation of an aberrant left hepatic artery during distal gastric resection for cancer
During laparoscopic D2 lymphadenectomy for gastric cancer, an aberrant left hepatic artery (ALHA) can be found arising from the left gastric artery (LGA). It is recommended to preserve this vessel since it is impossible to intraoperatively determine whether it is a “replaced” or “accessory” left hepatic artery. In the present video, we show the technique to preserve the ALHA during a laparoscopic distal gastrectomy performed for a cancer of the antrum in a 78-year-old male patient.
A typical D2 laparoscopic lymphadenectomy is performed until the division of the left gastric vein and the identification of the LGA: the ALHA is identified at this time and the anterior side of the LGA is exposed towards its origin; the branch of the LGA towards the stomach is clipped and resected and the lymph nodes located posterior to the ALHA are then dissected completely. Lymphadenectomy is then completed with the dissection of the lymph nodes along the lesser curvature and the right cardiac nodes.
Pathological examination revealed a T2N0M0 tumor with 56 lymph nodes examined. The present video demonstrates that preservation of the ALHA is laparoscopically feasible and does not decrease the extent of D2 lymph node dissection.
B Badii, F Staderini, I Skalamera, G Fiorenza, G Perigli, F Cianchi
Surgical intervention
4 years ago
3221 views
94 likes
0 comments
16:07
Laparoscopic D2 lymphadenectomy with preservation of an aberrant left hepatic artery during distal gastric resection for cancer
During laparoscopic D2 lymphadenectomy for gastric cancer, an aberrant left hepatic artery (ALHA) can be found arising from the left gastric artery (LGA). It is recommended to preserve this vessel since it is impossible to intraoperatively determine whether it is a “replaced” or “accessory” left hepatic artery. In the present video, we show the technique to preserve the ALHA during a laparoscopic distal gastrectomy performed for a cancer of the antrum in a 78-year-old male patient.
A typical D2 laparoscopic lymphadenectomy is performed until the division of the left gastric vein and the identification of the LGA: the ALHA is identified at this time and the anterior side of the LGA is exposed towards its origin; the branch of the LGA towards the stomach is clipped and resected and the lymph nodes located posterior to the ALHA are then dissected completely. Lymphadenectomy is then completed with the dissection of the lymph nodes along the lesser curvature and the right cardiac nodes.
Pathological examination revealed a T2N0M0 tumor with 56 lymph nodes examined. The present video demonstrates that preservation of the ALHA is laparoscopically feasible and does not decrease the extent of D2 lymph node dissection.
Laparoscopic redo Nissen posterior fundoplication
This video shows a reintervention after laparoscopic Nissen-Rossetti due to failure of the technique in a 70-year-old woman presenting with a history of dysphagia and weight loss beginning short after surgery.
First, dissection of the fundic wrap and esophageal hiatus are completed in order to expose specific anatomical landmarks that would help us understand the possible causes for the failure of the first procedure.
The original fundoplication is then unwrapped, rearranging it to the original anatomical position. This maneuver allows us to understand the causes for the technique’s failure, which can be accounted for by the asymmetrical position of the fundoplication caused by a series of elements. First, the short gastric vessels were not dissected during the first surgery, this probably contributed to the malposition of the right flap, which emerges from the posterior mid-stomach wall, distal to the fundus. On the other hand, the right flap emerges from the para-esophageal proximal edge of the lesser curvature; this causes the “valve” to be angulated and rotated clockwise, “hiding” the fundoplication on the posterior gastric wall.
To complete the procedure, a Toupet fundoplication is performed as a substituting anti-reflux technique.
P Vorwald, E York Pineda, E Bernal, M Posada, S Ayora González, R Restrepo
Surgical intervention
4 years ago
3391 views
74 likes
0 comments
10:37
Laparoscopic redo Nissen posterior fundoplication
This video shows a reintervention after laparoscopic Nissen-Rossetti due to failure of the technique in a 70-year-old woman presenting with a history of dysphagia and weight loss beginning short after surgery.
First, dissection of the fundic wrap and esophageal hiatus are completed in order to expose specific anatomical landmarks that would help us understand the possible causes for the failure of the first procedure.
The original fundoplication is then unwrapped, rearranging it to the original anatomical position. This maneuver allows us to understand the causes for the technique’s failure, which can be accounted for by the asymmetrical position of the fundoplication caused by a series of elements. First, the short gastric vessels were not dissected during the first surgery, this probably contributed to the malposition of the right flap, which emerges from the posterior mid-stomach wall, distal to the fundus. On the other hand, the right flap emerges from the para-esophageal proximal edge of the lesser curvature; this causes the “valve” to be angulated and rotated clockwise, “hiding” the fundoplication on the posterior gastric wall.
To complete the procedure, a Toupet fundoplication is performed as a substituting anti-reflux technique.
Laparoscopic left lateral sectionectomy for hepatocarcinoma on cirrhotic liver
We report the case of a 73-year old patient presenting with a Child-Pugh class A5, post-viral B cirrhosis, with no portal hypertension in which a laparoscopic left lateral sectionectomy is performed for hepatocarcinoma. Four ports are placed. Parenchymal transection is marked approximately 1cm to the left of the falciform ligament and parenchymal transection is initiated. With intermittent clamping, hepatotomy is performed painstakingly and progressively, and every vascular or biliary structure that one comes across is either clipped, or coagulated. The specimen is extracted using a suprapubic Pfannenstiel’s incision. Pathological findings confirm the presence of a hepatocarcinoma on a cirrhotic liver. No drainage was used. The postoperative outcome was uneventful. The patient was discharged on postoperative day 6.
P Pessaux, D Ntourakis, M Shen, J Marescaux
Surgical intervention
4 years ago
2056 views
53 likes
0 comments
10:24
Laparoscopic left lateral sectionectomy for hepatocarcinoma on cirrhotic liver
We report the case of a 73-year old patient presenting with a Child-Pugh class A5, post-viral B cirrhosis, with no portal hypertension in which a laparoscopic left lateral sectionectomy is performed for hepatocarcinoma. Four ports are placed. Parenchymal transection is marked approximately 1cm to the left of the falciform ligament and parenchymal transection is initiated. With intermittent clamping, hepatotomy is performed painstakingly and progressively, and every vascular or biliary structure that one comes across is either clipped, or coagulated. The specimen is extracted using a suprapubic Pfannenstiel’s incision. Pathological findings confirm the presence of a hepatocarcinoma on a cirrhotic liver. No drainage was used. The postoperative outcome was uneventful. The patient was discharged on postoperative day 6.
Laparoscopic ileocaecal and sigmoid resection with transanal natural orifice specimen extraction (NOSE) for endometriosis
In 12 to 30% of endometriosis cases, the disease is located in the bowel. Caecum and small bowel endometriosis are found in only 3.6% and 7% respectively of those cases while the sigmoid colon and the rectum are most commonly affected in 85% of cases. The laparoscopic management of this disease has evolved drastically over the last decade, and even delicate cases such as small bowel endometriosis can be completely managed by laparoscopy. It is key to be locally invasive towards the disease but conservative with regards to organ function preservation. The specimen will be extracted through natural orifices and without any ileostomy. Our patients are commonly young and healthy women who will certainly benefit from a tailored surgery with immediate symptom relief in addition to minimum abdominal scarring can have a significant positive impact on patient’s psychological well-being and subsequent recovery.
In the present case, we present a 36-year old woman who was diagnosed with endometriosis and presented with 3 episodes of bowel pseudo-obstruction and dyschezia, and put under medical treatment. She was found to have multiple endometriotic nodules, with concurrent ileocaecal and rectosigmoid disease, for which a double bowel resection with transanal natural orifice specimen extraction (NOSE) was performed without complications.
A Wattiez, J Leroy, C Meza Paul, K Afors, J Castellano, G Centini, R Fernandes, R Murtada
Surgical intervention
4 years ago
1818 views
45 likes
0 comments
38:15
Laparoscopic ileocaecal and sigmoid resection with transanal natural orifice specimen extraction (NOSE) for endometriosis
In 12 to 30% of endometriosis cases, the disease is located in the bowel. Caecum and small bowel endometriosis are found in only 3.6% and 7% respectively of those cases while the sigmoid colon and the rectum are most commonly affected in 85% of cases. The laparoscopic management of this disease has evolved drastically over the last decade, and even delicate cases such as small bowel endometriosis can be completely managed by laparoscopy. It is key to be locally invasive towards the disease but conservative with regards to organ function preservation. The specimen will be extracted through natural orifices and without any ileostomy. Our patients are commonly young and healthy women who will certainly benefit from a tailored surgery with immediate symptom relief in addition to minimum abdominal scarring can have a significant positive impact on patient’s psychological well-being and subsequent recovery.
In the present case, we present a 36-year old woman who was diagnosed with endometriosis and presented with 3 episodes of bowel pseudo-obstruction and dyschezia, and put under medical treatment. She was found to have multiple endometriotic nodules, with concurrent ileocaecal and rectosigmoid disease, for which a double bowel resection with transanal natural orifice specimen extraction (NOSE) was performed without complications.
Laparoscopic Burch procedure: colposuspension for stress urinary incontinence (SUI)
We present the case of a 53-year old patient diagnosed with stress urinary incontinence (SUI), who was initially managed by a tension-free vaginal tape obturator system (TVTO) operation one year earlier. Six months after the initial procedure, she reported a recurrence of her urinary symptoms. She was referred to our department and a urodynamic investigation revealed a type II SUI.

Decision is made to perform a laparoscopic Burch colposuspension to reinforce the urethral support. This procedure can be considered a therapeutic option in patients with recurrent symptoms of SUI following vaginal sling procedures.
A Wattiez, J Castellano, C Meza Paul, K Afors, G Centini, R Fernandes, R Murtada
Surgical intervention
4 years ago
3397 views
110 likes
0 comments
13:33
Laparoscopic Burch procedure: colposuspension for stress urinary incontinence (SUI)
We present the case of a 53-year old patient diagnosed with stress urinary incontinence (SUI), who was initially managed by a tension-free vaginal tape obturator system (TVTO) operation one year earlier. Six months after the initial procedure, she reported a recurrence of her urinary symptoms. She was referred to our department and a urodynamic investigation revealed a type II SUI.

Decision is made to perform a laparoscopic Burch colposuspension to reinforce the urethral support. This procedure can be considered a therapeutic option in patients with recurrent symptoms of SUI following vaginal sling procedures.
Robotics in hand and peripheral nerve surgery: Brazilian experience (3 years)
Our Brazilian experience using the da Vinci® robot in hand surgery and peripheral nerve starts in 2010. The first case was that of a male patient with brachial plexus upper roots injury in a motorcycle accident. The classical supraclavicular open approach was performed and the da Vinci® robot was used as a substitute of the microscope. Repair was performed by means of a sural nerve graft.
Another brachial plexus injury was treated with the same method. Two ulnar nerves transposition at elbow level was performed with endoscopic approach and using the da Vinci® robot. One digital nerve lesion was repaired with neural conduit using the da Vinci® robot as a substitute of the microscope. The main reasons for the few number of cases in Brazil are as follows:
- few numbers of hand and peripheral nerve surgeons with valid Intuitive Certificate of da Vinci® training;
- high costs and Brazilian economy problems;
- lack of evidence of better results with robotic surgery;
- only 6 da Vinci® robots in Brazil.
L Alves de Mendonça Jr.
Lecture
4 years ago
94 views
6 likes
0 comments
06:42
Robotics in hand and peripheral nerve surgery: Brazilian experience (3 years)
Our Brazilian experience using the da Vinci® robot in hand surgery and peripheral nerve starts in 2010. The first case was that of a male patient with brachial plexus upper roots injury in a motorcycle accident. The classical supraclavicular open approach was performed and the da Vinci® robot was used as a substitute of the microscope. Repair was performed by means of a sural nerve graft.
Another brachial plexus injury was treated with the same method. Two ulnar nerves transposition at elbow level was performed with endoscopic approach and using the da Vinci® robot. One digital nerve lesion was repaired with neural conduit using the da Vinci® robot as a substitute of the microscope. The main reasons for the few number of cases in Brazil are as follows:
- few numbers of hand and peripheral nerve surgeons with valid Intuitive Certificate of da Vinci® training;
- high costs and Brazilian economy problems;
- lack of evidence of better results with robotic surgery;
- only 6 da Vinci® robots in Brazil.
Optimization and new adjunctive tools
There is an increasing migration from standard microsurgical approach to robotic assistance. This evolution creates a demand for technological advances and novel adjunctive tools. The VITOM camera system (Karl Storz, Tuttlingen, Germany) is one such development for enhanced magnification. Micro-Doppler probe (VTI Vascular Technology, Inc., Nashua, NH) and micro-ultrasound probe (Hitachi-Aloka, Tokyo, Japan) allow for intraoperative real-time identification of the surrounding vasculature. The Vein Viewer (Christie Digital Systems, Cypress, CA) is also another adjunctive tool that allows intra-operative detection of small diameter veins. Flexible fiber optic carbon dioxide laser (Omni-Guide, Cambridge, MA) offers a novel ablation technique with precise and decreased thermal damage for robotic micro-surgical dissection. Single port orifice robot technology (SPORT, Titan Medical, Inc., Toronto, Ontario, Canada), the surgeons operating force-feedback interface Eindhoven (SOFIE, Eindhoven University of Technology, Eindhoven Netherland), Raven (University of California, Berkeley, CA) and Amadeus (Titan Medical, Inc., Toronto, Ontario, Canada) are upcoming novel robotic platforms that are still in their development process. In addition to such new adjunctive tools and robotic platforms, there is also a new framework called IDEAL recommendations in an effort to optimize surgical innovations.
A Gudeloglu
Lecture
4 years ago
72 views
2 likes
0 comments
12:25
Optimization and new adjunctive tools
There is an increasing migration from standard microsurgical approach to robotic assistance. This evolution creates a demand for technological advances and novel adjunctive tools. The VITOM camera system (Karl Storz, Tuttlingen, Germany) is one such development for enhanced magnification. Micro-Doppler probe (VTI Vascular Technology, Inc., Nashua, NH) and micro-ultrasound probe (Hitachi-Aloka, Tokyo, Japan) allow for intraoperative real-time identification of the surrounding vasculature. The Vein Viewer (Christie Digital Systems, Cypress, CA) is also another adjunctive tool that allows intra-operative detection of small diameter veins. Flexible fiber optic carbon dioxide laser (Omni-Guide, Cambridge, MA) offers a novel ablation technique with precise and decreased thermal damage for robotic micro-surgical dissection. Single port orifice robot technology (SPORT, Titan Medical, Inc., Toronto, Ontario, Canada), the surgeons operating force-feedback interface Eindhoven (SOFIE, Eindhoven University of Technology, Eindhoven Netherland), Raven (University of California, Berkeley, CA) and Amadeus (Titan Medical, Inc., Toronto, Ontario, Canada) are upcoming novel robotic platforms that are still in their development process. In addition to such new adjunctive tools and robotic platforms, there is also a new framework called IDEAL recommendations in an effort to optimize surgical innovations.
Robotic microsurgery and the future
Vasectomy is one of the most common urological procedures in the United States. Each year approximately five hundred thousand men undergo vasectomy. However, up to 6% of these patients desire a vasectomy reversal at some point in their lives in order to regain fertility. Vasectomy reversal is a challenging microsurgical procedure that requires re-anastomosis of the transected vas deferens using 9/0 and 10/0 sutures. Chronic groin or scrotal content pain is another entity that affects up to 100,000 patients annually. Targeted microsurgical denervation of the spermatic cord is a viable option for this condition. This presentation covers our work on the use of a robotic assisted microsurgical platform in over 1,000 such procedures. The use of robotics for microsurgery may provide advantages in terms of multi-view magnification, motion scaling, elimination of tremor, and additional surgical arms in a stable ergonomic platform. The additional fourth arm can improve surgeon efficiency (provides an extra microsurgical instrument handled simultaneously with less reliance on a skilled microsurgical assistant). Previously, we could perform only two standard microsurgical procedures a day due to surgeon fatigue limitations using the standard microscope. With the aid of the robotic system, the same microsurgeon has been able to routinely perform up to 4-5 microsurgical procedures a day due to the ergonomic advantages of the robot. Robotics may also help to inspire our youth and operating room staff and help to motivate their interest in our field. We also present collaborative programs to achieve these goals: a collegiate high-school program developed with Polk State College to engage our youth to pursue science and engineering careers, and a robotic nurse training credentialing program.
SJ Parekattil
Lecture
4 years ago
182 views
4 likes
0 comments
19:21
Robotic microsurgery and the future
Vasectomy is one of the most common urological procedures in the United States. Each year approximately five hundred thousand men undergo vasectomy. However, up to 6% of these patients desire a vasectomy reversal at some point in their lives in order to regain fertility. Vasectomy reversal is a challenging microsurgical procedure that requires re-anastomosis of the transected vas deferens using 9/0 and 10/0 sutures. Chronic groin or scrotal content pain is another entity that affects up to 100,000 patients annually. Targeted microsurgical denervation of the spermatic cord is a viable option for this condition. This presentation covers our work on the use of a robotic assisted microsurgical platform in over 1,000 such procedures. The use of robotics for microsurgery may provide advantages in terms of multi-view magnification, motion scaling, elimination of tremor, and additional surgical arms in a stable ergonomic platform. The additional fourth arm can improve surgeon efficiency (provides an extra microsurgical instrument handled simultaneously with less reliance on a skilled microsurgical assistant). Previously, we could perform only two standard microsurgical procedures a day due to surgeon fatigue limitations using the standard microscope. With the aid of the robotic system, the same microsurgeon has been able to routinely perform up to 4-5 microsurgical procedures a day due to the ergonomic advantages of the robot. Robotics may also help to inspire our youth and operating room staff and help to motivate their interest in our field. We also present collaborative programs to achieve these goals: a collegiate high-school program developed with Polk State College to engage our youth to pursue science and engineering careers, and a robotic nurse training credentialing program.
A structured assessment for robotic microsurgical training
Robotic surgery as a field has expanded rapidly over the past two decades and is being used widely among surgical subspecialties. Its applications in plastic surgery have emerged gradually over the last few years. One of those promising applications is robotic assisted microvascular anastomosis. The purpose of this study was to develop a validated assessment instrument, and then assess the learning curve for robotic assisted microvascular anastomoses. The authors hypothesized that the subjects would demonstrate measurable improvement across multiple domains of performance as a result of robotic practice.
Methods:
In part 1, an assessment instrument called SARMS (structured assessment of robotic microsurgical skills), which combines the previously validated SAMS (Structured Assessment of Microsurgical Skills) with validated skill domains in robotic surgery was tested. Four blinded expert evaluators graded 6 recorded videos and inter-rater reliability was determined. In part 2, a cohort of 5 microsurgery fellows and 5 Faculty members: each participant performed five robotic assisted micro-anastomotic sessions. All 50 sessions were subjected to blind evaluation using SARMS. Primary outcomes were changes in time required to complete an anastomosis for each participant over the 5 sessions, and trends in SARMS scores for each skill area for each participant over the 5 sessions.
Result:
Inter-rater reliability for the SARMS instrument was excellent for all skill areas rated among the 4 expert, blinded evaluators, demonstrated by Cronback alpha scores greater than 0.9 in each category. All skill areas and overall performance improved significantly for each participant over the 5 robotic assisted micro-anastomosis sessions, and operative time decreased over the study for all participants. The results showed an initial steep technical skill acquisition followed by more gradual improvement, and a steady decrease in operative times that ranged between 1.2 hours and 9 minutes.

Conclusion:
The Structured Assessment of Robotic Microsurgery Skills (SARMS) is a valid instrument for assessing microsurgical skills, with good inter-rater reliability. Subjects at all levels of training from very little microvascular experience to microsurgery experts gained proficiency over the course of 5 sessions.
T Alrasheed
Lecture
4 years ago
115 views
4 likes
0 comments
05:48
A structured assessment for robotic microsurgical training
Robotic surgery as a field has expanded rapidly over the past two decades and is being used widely among surgical subspecialties. Its applications in plastic surgery have emerged gradually over the last few years. One of those promising applications is robotic assisted microvascular anastomosis. The purpose of this study was to develop a validated assessment instrument, and then assess the learning curve for robotic assisted microvascular anastomoses. The authors hypothesized that the subjects would demonstrate measurable improvement across multiple domains of performance as a result of robotic practice.
Methods:
In part 1, an assessment instrument called SARMS (structured assessment of robotic microsurgical skills), which combines the previously validated SAMS (Structured Assessment of Microsurgical Skills) with validated skill domains in robotic surgery was tested. Four blinded expert evaluators graded 6 recorded videos and inter-rater reliability was determined. In part 2, a cohort of 5 microsurgery fellows and 5 Faculty members: each participant performed five robotic assisted micro-anastomotic sessions. All 50 sessions were subjected to blind evaluation using SARMS. Primary outcomes were changes in time required to complete an anastomosis for each participant over the 5 sessions, and trends in SARMS scores for each skill area for each participant over the 5 sessions.
Result:
Inter-rater reliability for the SARMS instrument was excellent for all skill areas rated among the 4 expert, blinded evaluators, demonstrated by Cronback alpha scores greater than 0.9 in each category. All skill areas and overall performance improved significantly for each participant over the 5 robotic assisted micro-anastomosis sessions, and operative time decreased over the study for all participants. The results showed an initial steep technical skill acquisition followed by more gradual improvement, and a steady decrease in operative times that ranged between 1.2 hours and 9 minutes.

Conclusion:
The Structured Assessment of Robotic Microsurgery Skills (SARMS) is a valid instrument for assessing microsurgical skills, with good inter-rater reliability. Subjects at all levels of training from very little microvascular experience to microsurgery experts gained proficiency over the course of 5 sessions.