Monthly publications

Background: The authors report the case of a 30-year-old woman who consulted for episodes of diverticulitis due to segmental diverticulosis of the splenic flexure. The patient was scheduled for a suprapubic single incision laparoscopic splenic flexure resection.

Video: A right suprapubic incision was performed and allowed for the introduction of three abdominal trocars (11mm, and two 6mm ones). DAPRI curved reusable instruments (Karl Storz Endoskope, Tuttlingen, Germany) were used, in addition to a 10mm, 30-degree regular length scope. The mobilization of the left mesocolon as well as of the transverse mesocolon was performed. After having completely freed the splenic flexure from its attachments, the transverse colon and the left colon were divided using an articulating linear stapler, introduced into the abdomen under a 5mm, 30-degree long scope. An intracorporeal end-to-end transverse sigmoid anastomosis was performed using two converging running sutures. The mesocolic defect was closed. The specimen was removed through a single access and final scar appeared to be 4cm.

Results: Laparoscopic time was 165 minutes and time to perform the anastomosis was 60 minutes. Operative bleeding was 10cc. The patient was discharged after 4 days, and at visit consultations, the symptoms were resolved.

Conclusion: Single incision laparoscopic splenic flexure resection can be safely performed using a suprapubic access, which enhances cosmetic outcomes, in addition to the advantages of minimally invasive surgery. A laparoscopic intracorporeal anastomosis is mandatory and can be performed using a hand-sewn method.

Background: Rectovaginal fistula is an abnormal connection between the rectum and the vagina, with leakage of rectal contents through the vagina. Different surgeries have been attempted such as direct repair, plug placement, advancement flap, muscle interposition, colostomy, proctectomy or delayed pull-through colo-anal anastomosis. Recently, transanal minimally invasive surgery has been described amongst the surgical options.

Video: The authors present a pure transanal laparoscopic repair of early rectovaginal fistula in a 74-year-old lady, submitted 3 weeks before to a laparoscopic anterior resection of the rectum with ‘en bloc’ hysterectomy for rectal adenocarcinoma (pT4aN0M0). A protective ileostomy was performed at the time of rectal surgery, and the postoperative course was uneventful. After having positioned the patient in a gynecologic position, a new reusable transanal platform according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany) was adopted. The exploration of the lower rectum put in evidence a 2cm rectovaginal fistula, located at a 3 o’clock position and at a 12cm distance from the anal margin. Absorbable figure-of-8 sutures using Vicryl 2/0 were performed to close the defect. Thanks to the curves of the instruments, the surgeon worked under ergonomic positions, without clashing of the instruments’ tips and any conflict of the surgeon’s hands. At the end of the procedure, injection of methylene blue through the vagina did not show any passage of the product into the lower rectum.

Results: The operative time was 120 minutes and intraoperative bleeding was insignificant. The postoperative course was uneventful, and patient discharge was allowed after 6 days. Due to the reusable nature of all the material implemented, no supplementary cost was necessary. The gastrograffin enema after 2 months showed a complete healing of the fistula. As a result, the protective ileostomy was closed.
Conclusion: Rectovaginal fistula can be repaired through a pure transanal laparoscopy, which prevents complicated and demolition surgeries usually performed through the abdomen.

A 72-year-old woman was addressed to the endocrinologist for arterial hypertension and US finding of a 5cm nodule in the aortocaval space of the celiac region. The diagnostic workup revealed raised urinary metanephrines. A CT-scan confirmed the US findings, and the nodule was also positive at PET CT-scan. A fine needle biopsy was performed, which was suggestive of a paraganglioma.
Medical treatment with Doxazosine 44mg qd was required for the adequate control of hypertension, and surgical excision was required.
A laparoscopic lateral transabdominal approach was chosen, to displace the hepatoduodenal ligament and allow for a wide access to the inferior vena cava. The operative time was 75 minutes. The patient recovered with no complications and was discharged on postoperative day 3.
Her symptoms recovered and she was found with normal metanephrines at follow-up.

Median arcuate ligament syndrome is caused by the extrinsic compression of the celiac trunk by the median arcuate ligament, prominent fibrous bands, and peri-aortic nodal tissue. In many cases, it is asymptomatic, even though postprandial abdominal pain or, during exercise, nauseas, vomiting, and weight loss could be found. Doppler ultrasound and angiotomography are used for diagnosis while arteriography is the gold standard. Only symptomatic patients might require surgical treatment, and the laparoscopic approach has been proposed as a safe and effective technique. We present a case of laparoscopic approach for the treatment of arcuate ligament syndrome.

This video shows the laparoscopic repair of a giant type III paraesophageal hernia (PEH). The 76-year-old patient underwent a chest CT-scan for dyspnea which revealed a type III PEH with mesenteroaxial volvulus of the stomach. The patient had no symptoms of gastroesophageal reflux disease (GERD) and esophageal function tests were normal. Dissection of the hernia sac was performed using a central approach and a fundophrenicopexy was performed since there was no evidence of GERD.

The laparoscopic approach to small bowel obstructions (SBO) may represent a challenge to the surgeon due to the lack of space and small bowel distension. Consequently, a high risk of iatrogenic injuries may occur. The laparoscopic approach allows to confirm the diagnosis of a simple fibrotic band, evolution of an oncologic disease or simple adhesions. Depending on the surgeon’s skills, the laparoscopic approach may also be therapeutic and offers the patient all the advantages of the minimally invasive approach such as fewer peritoneal adhesions.

Background: In this video, the authors report the case of a 65-year-old man who consulted for a subxiphoidal incisional hernia after open cardiac surgery. A transumbilical single access laparoscopic repair was proposed.

Video: The umbilical scar was incised and, after having placed a fascial umbilical purse-string suture, an 11mm reusable trocar was introduced. DAPRI curved reusable instruments (Karl Storz Endoskope, Tuttlingen, Germany) were introduced. The subxiphoidal hernia was put in evidence. The fatty tissue covering the defect was freed and the hernia defect was measured to be 8cm cranio-caudally and 6cm latero-laterally. A dual face mesh of 15 and 14cm (Surgimesh XB, Aspide Medical, Saint-Etienne, France) was chosen and introduced into the cavity through the 11mm trocar. The mesh was fixed against the abdominal wall using absorbable tacks (Sorbafix, Bard Davol Inc., Warwick, RI, US), and against the pericardial sheet using a polypropylene suture, in order to prevent any potential cardiac tamponade.

Results: The final umbilical scar was 15mm. Operative time was 65 minutes, and operative bleeding was insignificant. The patient was discharged on postoperative day 1. At visit consultations, no recurrence was evidenced.

Conclusion: Subxiphoidal incisional hernia after open cardiac surgery can be treated successfully using a transumbilical single access laparoscopy.

The laparoscopic repair of incarcerated incisional hernias is still debated in the literature. The recent EAES/EHS guidelines state that laparoscopic surgery is not contraindicated and may be considered in selected patients with incarcerated hernia. This video shows the case of an 83-year-old woman with an incarcerated incisional hernia in the left iliac fossa (L2 zone – W2) successfully managed laparoscopically with an intraperitoneal onlay mesh reinforcement (IPOM-plus).

Background: In this video, the authors report the case of a 74-year-old woman who consulted for episodes of intestinal occlusions following an abdomino-perineal resection for rectal adenocarcinoma (pT2N0M0), performed 6 years earlier. Abdomino-pelvic CT-scan showed a parastomal hernia with migrated small bowel loops and a perineal hernia with transposition of the caecum and bowel loops into the pelvis. Preoperative work-up was negative for tumor recurrence, hence a laparoscopic treatment using a double dual face prosthesis was proposed.

Video: Three trocars were placed into the abdomen. After adhesiolysis and removal of the viscera herniated into the hernia, the parastomal defect was exposed and measured intracorporeally 6cm (cranio-caudally) and 4cm (latero-laterally). An intracorporeal suture was used to close the defect, and a dual face prosthesis of 15cm in length and 10cm in width (Surgimesh XB, Aspide Medical, Saint-Etienne, France) was fixed by means of absorbable tacks (Sorbafix, Bard Davol Inc., Warwick, RI, US), according to the Sugarbaker technique. Successively, the pelvis was freed from adhesions, and the superior pelvic opening appeared to be 8cm (antero-posteriorly) and 7cm (latero-laterally). A dual face circular prosthesis of 10cm (Surgimesh XB, Aspide Medical) was fixed using two running sutures around the superior pelvic opening.

Results: Operative time was 72 minutes for parastomal hernia and 95 minutes for perineal hernia. Operative bleeding was unsignificant. The patient was discharged after 3 days, and at visit consultations, she did not present with any recurrence.

Conclusion: Prosthetic parastomal and perineal hernias repair can be performed simultaneously using laparoscopy with the same port positioning, adding the advantages of minimally invasive surgery and avoiding a large laparotomy.

Non-parasitic splenic lesions are a rare entity. Since they can generate signs and abdominal symptoms and cause many complications, their detection requires some form of treatment. The possibility of post-splenectomy fatal sepsis has led to the search for new therapeutic alternatives which simultaneously ensure the healing process and preserve the splenic tissue. The preservation of at least 25% of splenic tissue provides protection against pneumococcal bacteremia. One of the techniques used is partial cyst decapsulation with splenic preservation.
We report the case of a 17-year-old woman who was incidentally diagnosed with a 4cm splenic cystic with negative serological studies and tumor markers suggestive of an epidermal cyst. Radiological monitoring of the lesion is performed and a cystic growth of 7cm is observed. As a result, surgery is decided upon.
At laparoscopy, a splenic cyst of 7cm in diameter is found. However, it does not affect the splenic vessels. Lancing and draining the cyst is made and partial cyst decapsulation is performed with splenic preservation. The patient made an uneventful recovery.
Partial decapsulation of the cyst’s wall offers several advantages: it is technically easier to perform, involves minimal blood loss, it preserves the entire splenic tissue and has a high cure rate. It is an excellent therapeutic alternative for young people with splenic cysts because it eliminates the disease process without loss of splenic tissue and it is minimally invasive for the patient.

Conventional single incision laparoscopic surgery (SILS) with special ports and instruments has transformed the way people undergo cholecystectomy. However, it requires high costs as compared to routine laparoscopic cholecystectomies.
We present another way of performing a SILS cholecystectomy without any special SILS port or any special roticulating laparoscopic instruments.
One 10mm port is placed in the lower aspect of the umbilicus at a 6 o’clock position and the gallbladder is assessed for SILS suitability. Another 5mm port is placed at a 3 o’clock position through a separate incision. A mini-laparoscopic grasper (Mini-Lap Technologies) is inserted in the right subcostal region. Remaining operative steps are similar to the ones used for any standard laparoscopic cholecystectomy. Careful and skilful manipulation of the mini-laparoscopic grasper helps in anterior and posterior dissection of Calot’s triangle, while maintaining the triangle of instrumentation (which is not achievable in SILS port techniques). A critical view of safety is also nicely demonstrated before clipping and dividing any structure. For clipping the cystic artery (CA) and the cystic duct (CD), a 5mm scope is used through the 5mm port and a standard clip applicator is inserted through the 10mm port. The gallbladder is extracted through the 10mm port. The 10mm port fascia is closed.

Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.

Introduction and purpose: The shortage of cadaver donor organs and the progressive acceptation of laparoscopic procedures have significantly increased the number of living donor transplants. Laparoscopic nephrectomy has been rapidly and progressively incorporated as a therapeutic option in most hospitals. We describe the current surgical technique for living donor nephrectomy in our hospital.
Materials and methods: A 42-year-old woman with a medical history of hypertension and end-stage renal disease by IgA glomerulonephritis in predialysis program underwent a living donor transplantation. The donor was her sister, a woman aged 51, with no medical past history. We performed a left laparoscopic nephrectomy, and removal of the graft was performed using a hand-assisted device fixed in a supraumbilical 5cm laparotomy.
Results: Hospital stay was 3 days for the donor and 4 days for the receptor. The receptor had a postoperative creatinine of 1.76 mg/dL. In the third year of follow-up creatinine was 1.46 mg/dL.
Conclusions: Laparoscopic donor nephrectomy has proven to be a safe, less invasive, and effective technique for the renal graft. It has encouraged donation from living donors, given its esthetic results and comfort for the donor.

Pseudarthrosis of the proximal pole of the scaphoid is difficult to treat surgically. Although the reconstruction is always the best solution for patients, in some cases where the proximal pole is necrotic and often fragmented, it is simpler to replace it with an APSI pyrocarbon implant by arthroscopic technique, which makes it possible to obtain good functional long-term results.

This video shows a laparoscopic distal pancreatectomy and splenectomy.
This is the case of a woman with a cystic lesion in the body of the pancreas, diagnosed in the study of an abdominal pain.
She was submitted to a CT-scan which showed a regular, well-defined 45mm cystic lesion in the pancreatic body, with voluminous hepatic hemangiomas. The findings of endoscopic ultrasound-guided biopsy were inconclusive, with a CEA of 653ng/dL.
The patient underwent a laparoscopic distal pancreatectomy and splenectomy.
There were no postoperative complications. The patient was discharged on postoperative day 3.
Histological findings demonstrated the presence of a mucinous cystic neoplasm.

Mesenteric cysts are very rare entities (annually worldwide estimated incidence of 1/140 000 inhabitants). They do not have pathognomonic features and require a differential diagnosis with lymphangiomas, sarcomas, adenocarcinomas, and intestinal duplications. They typically appear more in women (twice the incidence) and are mostly benign swellings (malignancy rate of about 3%). The gold standard treatment is laparoscopic surgical resection.
The case is that of a 49-year-old female patient referred for an abdominal swelling in the periumbilical region, which was uncomfortable for the patient, namely in the contraction of the abdominals. She did not describe any changes in intestinal transit, anorexia, asthenia or associated weight loss. The imaging study by computer tomography documented a "cystic lesion of 13cm in the root of the mesentery in contact with great vessels and duodenum". The patient was resected laparoscopically in March 2016, discharged on the second postoperative day, without intercurrences. The video of the mesenteric cyst excision surgery demonstrates some of the risks of the laparoscopic approach of the mesentery and underlines the possibility of dissection of these cysts even when they are giant cysts and in close relation with vital structures such as the vena cava and the iliac arteries.

Diverticulosis of the left colon is an inflammatory benign disease associated with unpleasant morbidity which lead to pneumaturia and repetitive urinary infection. Computed tomography and colonoscopy may suggest the diagnosis but histology confirms it. The differential diagnosis evokes a malignant lesion and so it is mandatory to perform surgery with an oncological plane. This clinical case is that of a young man with a mass, which includes the left colon, the bladder, and the ileocaecal appendix. A ureteral stent was placed to make surgery safer and a sigmoidectomy with an ileocaecal appendectomy is performed.

Borderline ovarian tumors (BOTs) represent about 10 to 20% of all ovarian malignancies and differ from invasive ovarian cancers (IOCs) by many characters. The standard management of BOT is peritoneal washing cytology, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, complete peritoneal resection of macroscopic lesions; in case of mucinous BOTs, appendectomy should be performed. Because BOTs are often diagnosed at an earlier stage, in younger women and have a better prognosis and a higher survival rate than IOCs, fertility-sparing surgery is one of the options to preserve a childbearing capacity. However, conservative surgery is still controversial.
So far, postoperative chemotherapy, radiotherapy, and hormone therapy are not recommended. BOTs are characteristically difficult to diagnose using preoperative radiological methods, exhibit inconsistencies in expression of tumor markers, and are often inaccurately identified using frozen sections. In these slides, Dr. Marco Puga will discuss the controversial issues of BOTs and will present the management of BOTs.

In this key lecture, Dr. Puga defines the lateral pelvic spaces -- the paravesical and the pararectal space. He defines the anatomical landmarks of these spaces, explains the surgical importance of each of them, and illustrates how to approach them in clinical cases such as radical hysterectomy, lymphadenectomy, and endometriosis.

Endometrial cancer is the most common gynecologic malignancy. In the majority of patients, the disease will present at an early stage, without metastasis, and with an excellent prognosis.
Total hysterectomy and bilateral salpingo-oophorectomy with or without a lymph node dissection is the standard method in the management of endometrial cancer. Although the rate of metastasis in patients with early stage endometrial cancer is low, the standard of treatment still includes a complete or selective pelvic and para-aortic lymphadenectomy for staging, resulting in detrimental side-effects, including lower extremity lymphedema. SLN mapping is based on the concept that lymph node metastasis is the result of an orderly process, that is, the lymph drains in a specific pattern away from the tumor, and therefore if the SLN, or first node, is negative for metastasis, then the nodes after the SLN should also be negative. Among gynecological cancers, a variety of methods have been described to detect a sentinel node in situ including colored dyes and radioisotopes, the latter requiring a specialized gamma detection probe. In this key presentation, Dr. Querleu will talk about the SNL technique in uterine cancers.

Pelvic and para-aortic lymph node evaluation is a major component of the surgical staging procedure for several gynecologic malignancies. Cervical cancer is clinically staged, but assessment of pelvic and para-aortic lymph nodes is performed with lymphadenectomy and/or imaging. The surgical and oncologic goals of lymph node dissection are to define the extent of disease, and thereby, to guide further treatment. Lymphadenectomy may also have a therapeutic goal in conditions in which removing nodes harboring metastatic disease improves survival. The role of para-aortic lymph node dissection for women diagnosed with LACC had been described in these slides.

In the last century, numerous classifications of radical hysterectomy have been developed according to the knowledge gained from the anatomy. In addition, the way to perform surgery and the radicality of procedures changed over the last decades according to the development of new instruments and depending on the understanding of the pathologies.
This lecture explains the reasons why a classification is required and how it has led to the development of a new classification by Querleu-Morrow in 2008.
The lecture ends with a detailed explanation of limits and landmarks of the new 4 classes of radical hysterectomy.

The surgical management of endometrial cancer has been markedly changed by minimally invasive techniques. After three decades of laparoscopy, robotic surgery has built upon and expanded the population of patients able to benefit from minimally invasive techniques. Updates in the field of laparoscopy continue, including single site surgery. The emergence and rapid uptake of robotics continues to produce favorable outcomes while simultaneously expanding minimal access surgery to the obese and elderly populations. Sentinel lymph node detection and single port surgery are expanding areas which will continue to push the role of minimally invasive surgery (MIS) in endometrial cancer. In this key lecture, Dr. Querleu will discuss the role of MIS in the management of endometrial cancer.

The role of lymph node staging in high-risk endometrial cancer is a tricky subject as there is no strong evidence supporting it yet. This authoritative lecture provides a good overview of the application of this technique for these specific patients.