General and digestive surgery | WebSurg, the online university of IRCAD

Totally laparoscopic splenic flexure resection for cancer

The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.

G Basili, D Pietrasanta, N Romano, AF Costa

Surgical intervention

Totally laparoscopic splenic flexure resection for cancer

The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.

LIVE INTERACTIVE SURGERY: laparoscopic sigmoid resection for recurrent complicated sigmoid diverticulitis

In this live interactive surgery, Dr. Serra-Aracil presents a laparoscopic sigmoid resection for recurrent complicated sigmoid diverticulitis.

X Serra-Aracil, M Ignat, L Soler, B Seeliger, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: laparoscopic sigmoid resection for recurrent complicated sigmoid diverticulitis

In this live interactive surgery, Dr. Serra-Aracil presents a laparoscopic sigmoid resection for recurrent complicated sigmoid diverticulitis.

Laparoscopic coloproctectomy with ileal J pouch

This is a case of 35-year-old woman, with a history of familial adenomatous polyposis (FAP). She presented with diarrhea and mucous stools over the last 2 months. She had abandoned her controls 16 years ago. Fiber-colonoscopy showed multiple sessile and pedunculated polyps of the rectum up to 18mm in diameter, with ulcerated lesion and stenosis occupying the entire circumference. CT-scan showed a polypoid image of the middle rectum of 30 by 22mm in size, with eccentric parietal thickening of the rectosigmoid junction (40mm). It is possible to perform a laparoscopic coloproctectomy with an ileal J pouch.

M Viola Malet, M Laurini Zanola, P Rodríguez Goñi, N Muniz Locatelli, G Sanchez García

Surgical intervention

Laparoscopic coloproctectomy with ileal J pouch

This is a case of 35-year-old woman, with a history of familial adenomatous polyposis (FAP). She presented with diarrhea and mucous stools over the last 2 months. She had abandoned her controls 16 years ago. Fiber-colonoscopy showed multiple sessile and pedunculated polyps of the rectum up to 18mm in diameter, with ulcerated lesion and stenosis occupying the entire circumference. CT-scan showed a polypoid image of the middle rectum of 30 by 22mm in size, with eccentric parietal thickening of the rectosigmoid junction (40mm). It is possible to perform a laparoscopic coloproctectomy with an ileal J pouch.

Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis

Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.

J Magalhães, L Matos, J Costa, J Costa Pereira, G Gonçalves, M Nora

Surgical intervention

Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis

Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.

Focus on robot-assisted colorectal surgery

LIVE INTERACTIVE SURGERY: laparoscopic right partial colectomy with ileo ascending anastomosis

In this live interactive video, authors present a demonstration of a right partial colectomy with ileo ascending anastomosis in a patient with a sessile polyp in the ileocaecal junction not endoscopically resectable. A vascular 3D reconstruction is also included at the beginning of the video.

A Melani, A D'Urso, M Ignat, L Soler, C Gonzalez, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: laparoscopic right partial colectomy with ileo ascending anastomosis

In this live interactive video, authors present a demonstration of a right partial colectomy with ileo ascending anastomosis in a patient with a sessile polyp in the ileocaecal junction not endoscopically resectable. A vascular 3D reconstruction is also included at the beginning of the video.

Vascular approach to the middle colic artery during laparoscopic extended right hemicolectomy

This is the case of a 58-year-old woman who presented with polyposis coli and a colonic carcinoma at the level of the hepatic flexure. A proctocolectomy was performed laparoscopically. This video demonstrates the vascular approach to the middle colic artery as it is also performed during an extended right hemicolectomy.

A Wijsmuller, J Stiekema, JB Tuynman, J Bonjer

Surgical intervention

Vascular approach to the middle colic artery during laparoscopic extended right hemicolectomy

This is the case of a 58-year-old woman who presented with polyposis coli and a colonic carcinoma at the level of the hepatic flexure. A proctocolectomy was performed laparoscopically. This video demonstrates the vascular approach to the middle colic artery as it is also performed during an extended right hemicolectomy.

LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic right hemicolectomy for stenosing caecal cancer

In this live surgery, Dr. Francesco Corcione presents the case of a subocclusive caecal tumor associated with a large polyp in an obese patient (BMI of 30) with a past surgical history of open cholecystectomy. 3D reconstruction of the preoperative imaging showed a pronounced lymphadenopathy and the absence of a right colic artery. The operative technique shown includes an oncological ‘en bloc’ resection and intracorporeal anastomosis.

F Corcione, M Ignat, L Soler, B Seeliger, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic right hemicolectomy for stenosing caecal cancer

In this live surgery, Dr. Francesco Corcione presents the case of a subocclusive caecal tumor associated with a large polyp in an obese patient (BMI of 30) with a past surgical history of open cholecystectomy. 3D reconstruction of the preoperative imaging showed a pronounced lymphadenopathy and the absence of a right colic artery. The operative technique shown includes an oncological ‘en bloc’ resection and intracorporeal anastomosis.

LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic sigmoidectomy for recurrent sigmoiditis

In this live surgery, Dr. Barry Salky presents a case of sigmoid diverticular disease with multiple recurrent episodes of sigmoiditis, complicated by a sigmoid stricture. The operative technique shown includes transection of the sigmoid mesentery close to the bowel wall, preserving the superior rectal artery. Mobilization of the splenic flexure is not performed as a first step, but is adapted to the remaining colon length.

B Salky, M Ignat, L Soler, B Seeliger, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic sigmoidectomy for recurrent sigmoiditis

In this live surgery, Dr. Barry Salky presents a case of sigmoid diverticular disease with multiple recurrent episodes of sigmoiditis, complicated by a sigmoid stricture. The operative technique shown includes transection of the sigmoid mesentery close to the bowel wall, preserving the superior rectal artery. Mobilization of the splenic flexure is not performed as a first step, but is adapted to the remaining colon length.

LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient

In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.

S Morales-Conde, B Seeliger, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient

In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.

ReliaTack™ Articulating Reloadable Fixation Device

A fixation device with one-of-a-kind articulating technology, interchangeable reloads, and screw-like tack designs for hernia repair.

ReliaTack™ Articulating Reloadable Fixation Device

A fixation device with one-of-a-kind articulating technology, interchangeable reloads, and screw-like tack designs for hernia repair.

Instrument

Focus on laparoscopic colorectal surgery

Laparoscopic right colectomy: intracorporeal vs. extracorporeal anastomosis

In this key lecture, Dr. Barry Salky highlights laparoscopic right colectomy and describes intracorporeal vs. extracorporeal anastomosis.

B Salky

Laparoscopic right colectomy: intracorporeal vs. extracorporeal anastomosis

In this key lecture, Dr. Barry Salky highlights laparoscopic right colectomy and describes intracorporeal vs. extracorporeal anastomosis.

VIDEO SESSION - Vascular anatomy for D3 CME extended right hemicolectomy

In this key lecture and video session, Dr. Kim Seon-Hahn (MD, PhD, FACS) outlines the vascular anatomy for D3 CME extended right hemicolectomy.

SH Kim

VIDEO SESSION - Vascular anatomy for D3 CME extended right hemicolectomy

In this key lecture and video session, Dr. Kim Seon-Hahn (MD, PhD, FACS) outlines the vascular anatomy for D3 CME extended right hemicolectomy.

Laparoscopic mobilization of transverse mesocolon including splenic flexure and vascular approach

Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence

Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.

S Rua

Surgical intervention

Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence

Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.

Laparoscopic left colectomy with a lateral to medial dissection

Nowadays with the advent of new surgical instrumentation (such as transanal robotic surgery), old rules of oncological surgery (i.e., first vascular control, medial to lateral dissection) are no longer valid. A good oncological specimen with free margins and a lymph node number up to 12 is mandatory. As a result, it is essential to adapt the dissection in patients to allow for a safe dissection and to prevent morbidity. This clinical case is that of a young thin man with a Treitz’s flexure lower than usual, and subsequently the dissection occurs mostly lateral to medial.

S Rua

Surgical intervention

Laparoscopic left colectomy with a lateral to medial dissection

Nowadays with the advent of new surgical instrumentation (such as transanal robotic surgery), old rules of oncological surgery (i.e., first vascular control, medial to lateral dissection) are no longer valid. A good oncological specimen with free margins and a lymph node number up to 12 is mandatory. As a result, it is essential to adapt the dissection in patients to allow for a safe dissection and to prevent morbidity. This clinical case is that of a young thin man with a Treitz’s flexure lower than usual, and subsequently the dissection occurs mostly lateral to medial.

Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis

Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.

SAE Yeo

Surgical intervention

Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis

Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.

Segmental left colectomy: a modified caudal-to-cranial approach

Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.

M Milone, P Anoldo, M Manigrasso, F Milone

Surgical intervention

Segmental left colectomy: a modified caudal-to-cranial approach

Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.

Mobilization of the right colon for Chilaiditi syndrome in a 38-year-old patient

This video demonstrates our laparoscopic approach to the right colon for Chilaiditi syndrome with recurrent episodes of bowel obstruction.
A 38-year-old man with Down syndrome was admitted to our emergency department for acute abdominal pain and vomiting. The objective signs and radiographic findings were indicative of bowel obstruction. In his last few years, he was admitted multiple times to the emergency department for mechanical bowel obstruction. Both CT-scan and MRI showed medial dislocation of the liver and transposition of the right colon and small bowel loops in between the diaphragm and the liver. We propose a specific port-site layout and a counterclockwise approach, to allow for the correct triangulation of surgical instruments especially during the mobilization of the hepatic flexure, which is often the most critical phase of the operation. Starting from the mobilization of the transverse colon and proceeding towards the caecum we take advantage of gravity in handling the right colon. The operative time was 90 minutes. The patient recovered with no complications and was discharged on postoperative day 6. His symptoms disappeared completely.

M Lotti, E Poiasina, G Panyor, M Giulii Capponi

Surgical intervention

Mobilization of the right colon for Chilaiditi syndrome in a 38-year-old patient

This video demonstrates our laparoscopic approach to the right colon for Chilaiditi syndrome with recurrent episodes of bowel obstruction.
A 38-year-old man with Down syndrome was admitted to our emergency department for acute abdominal pain and vomiting. The objective signs and radiographic findings were indicative of bowel obstruction. In his last few years, he was admitted multiple times to the emergency department for mechanical bowel obstruction. Both CT-scan and MRI showed medial dislocation of the liver and transposition of the right colon and small bowel loops in between the diaphragm and the liver. We propose a specific port-site layout and a counterclockwise approach, to allow for the correct triangulation of surgical instruments especially during the mobilization of the hepatic flexure, which is often the most critical phase of the operation. Starting from the mobilization of the transverse colon and proceeding towards the caecum we take advantage of gravity in handling the right colon. The operative time was 90 minutes. The patient recovered with no complications and was discharged on postoperative day 6. His symptoms disappeared completely.

Laparoscopic right hemicolectomy: an emergency case

Appendicular abscess can usually be managed with a medical treatment, including a long hospital stay, high-dose antibiotic therapy, and sometimes parenteral nutrition. After abscess resolution, the ileocecal appendix is removed 2-3 months later. This strategy allows for a cecal preservation. Sometimes, this option is not possible. A sepsis may lead to a more aggressive strategy and a laparoscopic cecal resection and right hemicolectomy are performed. This radical surgery allows for a quicker and definitive resolution of the infection. A laparoscopic approach offers the patient all the advantages of this surgical option.

S Rua, F Cruz, P Mira

Surgical intervention

Laparoscopic right hemicolectomy: an emergency case

Appendicular abscess can usually be managed with a medical treatment, including a long hospital stay, high-dose antibiotic therapy, and sometimes parenteral nutrition. After abscess resolution, the ileocecal appendix is removed 2-3 months later. This strategy allows for a cecal preservation. Sometimes, this option is not possible. A sepsis may lead to a more aggressive strategy and a laparoscopic cecal resection and right hemicolectomy are performed. This radical surgery allows for a quicker and definitive resolution of the infection. A laparoscopic approach offers the patient all the advantages of this surgical option.

VITOM® 3D- 3D Visualization for Microsurgery and Open Surgery

Cameras, light sources and documentation

VITOM® 3D- 3D Visualization for Microsurgery and Open Surgery

Cameras, light sources and documentation

Unit

Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer

Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.

JL Ng, SAE Yeo

Surgical intervention

Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer

Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.

LIVE INTERACTIVE SURGERY: laparoscopic left colonic resection with complete mobilization of the splenic flexure for diverticular disease

To achieve a safe tension-free anastomosis during a laparoscopic left colonic resection, complete splenic flexure mobilization is mandatory. In this live interactive surgery, Dr. Salvador Morales-Conde performed a laparoscopic left colectomy with complete splenic flexure mobilization for diverticular disease showing his technical tips in each surgical step.

S Morales-Conde, M Ignat, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: laparoscopic left colonic resection with complete mobilization of the splenic flexure for diverticular disease

To achieve a safe tension-free anastomosis during a laparoscopic left colonic resection, complete splenic flexure mobilization is mandatory. In this live interactive surgery, Dr. Salvador Morales-Conde performed a laparoscopic left colectomy with complete splenic flexure mobilization for diverticular disease showing his technical tips in each surgical step.

Laparoscopic sigmoidectomy for cancer

In this educational video, Dr. Armando Melani briefly demonstrates the main principles of laparoscopic sigmoidectomy for cancer in a 67-year-old female patient in a live interactive surgery. He highlights the technical aspects, anatomical landmarks, and key steps of lesser sac opening, vascular identification and division, splenic flexure mobilization, lateral mobilization, mesorectal transection, suprapubic incision for specimen removal, and end-to-end anastomosis (EEA).

A Melani

Surgical intervention

Laparoscopic sigmoidectomy for cancer

In this educational video, Dr. Armando Melani briefly demonstrates the main principles of laparoscopic sigmoidectomy for cancer in a 67-year-old female patient in a live interactive surgery. He highlights the technical aspects, anatomical landmarks, and key steps of lesser sac opening, vascular identification and division, splenic flexure mobilization, lateral mobilization, mesorectal transection, suprapubic incision for specimen removal, and end-to-end anastomosis (EEA).

Laparoscopic sigmoidectomy for cancer - a critical analysis by P. Sylla, MD

Dr. P Sylla, MD (Massachusetts General Hospital, Boston, USA) provides a running comment on a laparoscopic sigmoidectomy for cancer performed by Dr. A Melani, MD, Scientific Director of IRCAD America Latina training centers in Barretos and Rio de Janeiro (Brazil). Dr. P Sylla provides an authoritative analysis of this colorectal procedure, with a large amount of tips and tricks.

A Melani, P Sylla

Surgical intervention

Laparoscopic sigmoidectomy for cancer - a critical analysis by P. Sylla, MD

Dr. P Sylla, MD (Massachusetts General Hospital, Boston, USA) provides a running comment on a laparoscopic sigmoidectomy for cancer performed by Dr. A Melani, MD, Scientific Director of IRCAD America Latina training centers in Barretos and Rio de Janeiro (Brazil). Dr. P Sylla provides an authoritative analysis of this colorectal procedure, with a large amount of tips and tricks.

Laparoscopic sigmoidectomy for diverticulitis

In this interactive live video, Dr. Melani briefly demonstrates the main principles, technical aspects, and key steps of a laparoscopic sigmoidectomy in a 34-year-old male patient presenting with diverticulitis. He describes the key maneuvers for correct plane dissection, mesenteric dissection preserving the vessels and the ureter, mobilization of colon, the EEA (end-to-end anastomosis) stapler technique, as well as complications. Dr. Melani also mentions his personal experience.

A Melani

Surgical intervention

Laparoscopic sigmoidectomy for diverticulitis

In this interactive live video, Dr. Melani briefly demonstrates the main principles, technical aspects, and key steps of a laparoscopic sigmoidectomy in a 34-year-old male patient presenting with diverticulitis. He describes the key maneuvers for correct plane dissection, mesenteric dissection preserving the vessels and the ureter, mobilization of colon, the EEA (end-to-end anastomosis) stapler technique, as well as complications. Dr. Melani also mentions his personal experience.

LIVE INTERACTIVE SURGERY: Interactive discussion around splenic flexure during laparoscopic sigmoidectomy for cancer

In this educational video, Professor Luc Soler gives a brief introduction of 3D reconstruction and modeling. Dr. Corcione introduces the main principles of trocar and port placement. He briefly demonstrates the technical aspects, main principles and key steps of laparoscopic sigmoidectomy for cancer in a 61-year-old male patient in a live interactive surgery. He highlights the technical aspects and main principles of lesser sac opening, vascular identification and division, splenic flexure mobilization, lateral mobilization, transection, suprapubic incision for specimen removal, and EEA anastomosis.

F Corcione, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: Interactive discussion around splenic flexure during laparoscopic sigmoidectomy for cancer

In this educational video, Professor Luc Soler gives a brief introduction of 3D reconstruction and modeling. Dr. Corcione introduces the main principles of trocar and port placement. He briefly demonstrates the technical aspects, main principles and key steps of laparoscopic sigmoidectomy for cancer in a 61-year-old male patient in a live interactive surgery. He highlights the technical aspects and main principles of lesser sac opening, vascular identification and division, splenic flexure mobilization, lateral mobilization, transection, suprapubic incision for specimen removal, and EEA anastomosis.

The 3 approaches to splenic flexure mobilization

Background: The mobilization of the splenic flexure during laparoscopic colorectal surgery can be a challenge, especially in anatomically difficult patients. In this video, the inframesocolic, the supramesocolic, and lateral-to-medial approaches are demonstrated.

Video: The first part of the video shows the inframesocolic approach where the opening of the transverse mesocolon, above the pancreatic body and tail, allows access to the lesser sac and the exposure of the spleen. The second part of the video shows the supramesocolic approach where reaching Gerota’s fascia allows the flexure to be taken down. The third part of the video shows the lateral-to-medial approach where opening the lesser sac allows the flexure to be mobilized.

Results: All three approaches are laparoscopically feasible and safe. The goal remains similar, that is to avoid anastomotic tension. The operative time for this step, during the entire colorectal procedure, is influenced by the patient’s characteristics (previous surgery, high splenic flexure, short mesentery, etc.) and obviously, by the surgeon’s learning curve.

Conclusions: The choice between the three approaches depends on the patient’s characteristics and on the surgeon’s habits.

G Dapri, NA Bascombe, GB Cadière, J Marks

Surgical intervention

The 3 approaches to splenic flexure mobilization

Background: The mobilization of the splenic flexure during laparoscopic colorectal surgery can be a challenge, especially in anatomically difficult patients. In this video, the inframesocolic, the supramesocolic, and lateral-to-medial approaches are demonstrated.

Video: The first part of the video shows the inframesocolic approach where the opening of the transverse mesocolon, above the pancreatic body and tail, allows access to the lesser sac and the exposure of the spleen. The second part of the video shows the supramesocolic approach where reaching Gerota’s fascia allows the flexure to be taken down. The third part of the video shows the lateral-to-medial approach where opening the lesser sac allows the flexure to be mobilized.

Results: All three approaches are laparoscopically feasible and safe. The goal remains similar, that is to avoid anastomotic tension. The operative time for this step, during the entire colorectal procedure, is influenced by the patient’s characteristics (previous surgery, high splenic flexure, short mesentery, etc.) and obviously, by the surgeon’s learning curve.

Conclusions: The choice between the three approaches depends on the patient’s characteristics and on the surgeon’s habits.

Laparoscopic left hemicolectomy for splenic flexure adenocarcinoma (from medial to lateral approach)

This film demonstrates an oncologic colon resection in a 36-year-old male patient presenting with an adenocarcinoma of the splenic flexure. This operation was performed using a medial-to-lateral mesocolic excision approach and an intracorporeal anastomosis technique.

I Ismayilov

Surgical intervention

Laparoscopic left hemicolectomy for splenic flexure adenocarcinoma (from medial to lateral approach)

This film demonstrates an oncologic colon resection in a 36-year-old male patient presenting with an adenocarcinoma of the splenic flexure. This operation was performed using a medial-to-lateral mesocolic excision approach and an intracorporeal anastomosis technique.

LIVE INTERACTIVE SURGERY: colorectal splenic flexure mobilization

Splenic flexure mobilization is technically challenging. However, it is necessary to achieve a tension-free anastomosis for any low rectal cancer resections or for a shortened sigmoid colon. In this live interactive surgical video, Dr. Armando Melani (Brazil) demonstrates a medial-to-lateral approach to splenic flexure mobilization for laparoscopic low anterior resection. He defines the main points of his procedure in a stepwise approach and provides technical tips to facilitate exposure and prevent any potential risks of splenic or vascular injuries.

A Melani, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: colorectal splenic flexure mobilization

Splenic flexure mobilization is technically challenging. However, it is necessary to achieve a tension-free anastomosis for any low rectal cancer resections or for a shortened sigmoid colon. In this live interactive surgical video, Dr. Armando Melani (Brazil) demonstrates a medial-to-lateral approach to splenic flexure mobilization for laparoscopic low anterior resection. He defines the main points of his procedure in a stepwise approach and provides technical tips to facilitate exposure and prevent any potential risks of splenic or vascular injuries.

Laparoscopic left complete mesocolic excision for stented descending colon cancer

Complete mesocolic excision (CME) with central vessel ligation (CVL) was first introduced with the aim to preserve an intact layer of mesocolon, containing all blood vessels, lymphatic vessels, lymph nodes, and surrounding soft tissue during colorectal cancer resection. The supplying vessels are also transected at their origin for optimal oncological outcomes. This method has been extensively studied in right colonic cancers with improvement in local recurrence and survival rates when compared to the conventional approach. Its excellent results are attributed to the superior lymph node harvest and removal of disseminated cancer cells in the surrounding soft tissue. Similarly, such advantages can be translated to left hemicolectomy with the use of CME with a CVL approach. Additionally, in left hemicolectomy, the vessels ligated (left branch of middle colic and left colic) are branches of vessels from the aorta rather than from the aorta directly, often limiting lymph node harvest. CME with CVL can help to overcome this limitation in left hemicolectomy. We present a video of a laparoscopic CME and CVL in a 48-year-old Chinese male with large bowel obstruction secondary to a descending colonic tumor which was successfully stented one week before.

SAE Yeo, MH Chang

Surgical intervention

Laparoscopic left complete mesocolic excision for stented descending colon cancer

Complete mesocolic excision (CME) with central vessel ligation (CVL) was first introduced with the aim to preserve an intact layer of mesocolon, containing all blood vessels, lymphatic vessels, lymph nodes, and surrounding soft tissue during colorectal cancer resection. The supplying vessels are also transected at their origin for optimal oncological outcomes. This method has been extensively studied in right colonic cancers with improvement in local recurrence and survival rates when compared to the conventional approach. Its excellent results are attributed to the superior lymph node harvest and removal of disseminated cancer cells in the surrounding soft tissue. Similarly, such advantages can be translated to left hemicolectomy with the use of CME with a CVL approach. Additionally, in left hemicolectomy, the vessels ligated (left branch of middle colic and left colic) are branches of vessels from the aorta rather than from the aorta directly, often limiting lymph node harvest. CME with CVL can help to overcome this limitation in left hemicolectomy. We present a video of a laparoscopic CME and CVL in a 48-year-old Chinese male with large bowel obstruction secondary to a descending colonic tumor which was successfully stented one week before.

LigaSure™ Small Jaw Open Sealer/Divider

A multifunctional tissue sealing system, featuring an integrated cutting mechanism for use in open procedures.

LigaSure™ Small Jaw Open Sealer/Divider

A multifunctional tissue sealing system, featuring an integrated cutting mechanism for use in open procedures.

Vessel sealing

Three-port Melani technique for splenic flexure mobilization

In this key lecture, Dr. Huscher briefly describes the three-port Melani technique for splenic flexture mobilization. He demonstrates trocar position as well as the main principles of gastrocolic ligament division and technical aspects of splenic flexure taking down according to the Melani technique along with a video case presentation.

Three-port Melani technique for splenic flexure mobilization

In this key lecture, Dr. Huscher briefly describes the three-port Melani technique for splenic flexture mobilization. He demonstrates trocar position as well as the main principles of gastrocolic ligament division and technical aspects of splenic flexure taking down according to the Melani technique along with a video case presentation.

Suprapubic single-incision laparoscopic splenic flexure resection with hand-sewn intracorporeal anastomosis

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.

G Dapri, L Cardinali, A Cadenas Febres, GB Cadière

Surgical intervention

Suprapubic single-incision laparoscopic splenic flexure resection with hand-sewn intracorporeal anastomosis

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.

Sigmoid diverticulosis with bladder fistula: laparoscopic management

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.

S Rua, P Mira

Surgical intervention

Sigmoid diverticulosis with bladder fistula: laparoscopic management

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.

Robotics for intracorporeal anastomosis in colon and rectal surgery

In this key lecture, Dr. Parra Davila looks into the use of robotics for intracorporeal anastomosis in colon and rectal surgery.

Robotics for intracorporeal anastomosis in colon and rectal surgery

In this key lecture, Dr. Parra Davila looks into the use of robotics for intracorporeal anastomosis in colon and rectal surgery.

Intracorporeal anastomosis

In this authoritative lecture, Dr. Salky focuses on intracorporeal anastomosis in laparoscopic colectomy.

B Salky

Intracorporeal anastomosis

In this authoritative lecture, Dr. Salky focuses on intracorporeal anastomosis in laparoscopic colectomy.

Left colectomy for cancer

In this key lecture, Dr. Armando Melani focuses on left colectomy for cancer.

Left colectomy for cancer

In this key lecture, Dr. Armando Melani focuses on left colectomy for cancer.

Colorectal and coloanal anastomoses

A Wijsmuller, J Leroy, D Mutter, J Marescaux

Mixed robotic laparoscopic synchronous left colectomy and left renal tumor enucleation

A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.

M Lotti, RLJ Naspro, L Rocchini, L Campanati, L Da Pozzo, L Ansaloni

Surgical intervention

Mixed robotic laparoscopic synchronous left colectomy and left renal tumor enucleation

A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.

Laparoscopic anterior resection for locally advanced sigmoid cancer with 'en bloc' excision of bladder cuff

We present an operative video of a 61-year-old Chinese gentleman with locally advanced sigmoid carcinoma. Preoperative histology from endoscopy revealed an adenocarcinoma. The patient underwent laparoscopic anterior resection. Intraoperatively, the sigmoid tumor was adherent to the bladder with surrounding inflammation and edema. The colectomy had to be performed with an ‘en bloc’ excision of a bladder cuff. The bladder defect was repaired laparoscopically in two layers. Operative time was 4 hours 15 minutes and total blood loss was less than 100mL. The patient was discharged in good health conditions, four days after the operation with an outpatient cystogram performed before subsequent successful removal of the indwelling catheter. Final histology was pT4bN0 (0/31 lymph nodes) with clear margins. This case demonstrates that laparoscopic colectomy with ‘en bloc’ bladder cuff excision and subsequent laparoscopic repair of bladder defect are both feasible and safe.

S Mantoo, E Yong

Surgical intervention

Laparoscopic anterior resection for locally advanced sigmoid cancer with 'en bloc' excision of bladder cuff

We present an operative video of a 61-year-old Chinese gentleman with locally advanced sigmoid carcinoma. Preoperative histology from endoscopy revealed an adenocarcinoma. The patient underwent laparoscopic anterior resection. Intraoperatively, the sigmoid tumor was adherent to the bladder with surrounding inflammation and edema. The colectomy had to be performed with an ‘en bloc’ excision of a bladder cuff. The bladder defect was repaired laparoscopically in two layers. Operative time was 4 hours 15 minutes and total blood loss was less than 100mL. The patient was discharged in good health conditions, four days after the operation with an outpatient cystogram performed before subsequent successful removal of the indwelling catheter. Final histology was pT4bN0 (0/31 lymph nodes) with clear margins. This case demonstrates that laparoscopic colectomy with ‘en bloc’ bladder cuff excision and subsequent laparoscopic repair of bladder defect are both feasible and safe.

Laparoscopic left hemicolectomy (medial to lateral approach)

This video presents the case of a 62-year old Chinese woman with descending colon carcinoma. Preoperative histological exam through endoscopy revealed an adenocarcinoma.
The patient underwent a laparoscopic left hemicolectomy, using a medial to lateral approach. This technique allows for precise dissection, early identification of the inferior mesenteric artery, and identification of the left ureter through virgin planes.
The surgery was performed smoothly. Operative time was 3 hours 45 min, with a total blood loss of less than 100mL.
She was discharged on postoperative day 3 and final histology was pT3N0 (0 out of 19 lymph nodes).

S Mantoo, E Yong

Surgical intervention

Laparoscopic left hemicolectomy (medial to lateral approach)

This video presents the case of a 62-year old Chinese woman with descending colon carcinoma. Preoperative histological exam through endoscopy revealed an adenocarcinoma.
The patient underwent a laparoscopic left hemicolectomy, using a medial to lateral approach. This technique allows for precise dissection, early identification of the inferior mesenteric artery, and identification of the left ureter through virgin planes.
The surgery was performed smoothly. Operative time was 3 hours 45 min, with a total blood loss of less than 100mL.
She was discharged on postoperative day 3 and final histology was pT3N0 (0 out of 19 lymph nodes).

RoTalock™ Trocars - The new Self-Retaining Trocar Especially Developed for Neonatal and Pediatric Laparoscopic Surgery

instrument

Acute diverticulitis management

D Ntourakis, J Leroy, D Mutter, J Marescaux

Can we reduce complications in laparoscopic colorectal surgery?

Laparoscopic colorectal surgery comprises many different types of procedures for various diseases. In general, surgical complications can be divided into intraoperative and postoperative complications, and usually occur while the patient is still in the hospital. Over the recent decade, the improvement of different treatment strategies and technical inventions has been tremendous. This is mainly attributable to the increase use of the laparoscopic approach, which is now well-accepted for many procedures. Training of the surgeon, hospital volume, and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise, and cost-effectiveness. The standardization of perioperative care is essential to minimize postoperative complications. In this key lecture, Dr. Barry Salky provides an overview, namely how to identify and minimize intraoperative and postoperative complications.

B Salky

Can we reduce complications in laparoscopic colorectal surgery?

Laparoscopic colorectal surgery comprises many different types of procedures for various diseases. In general, surgical complications can be divided into intraoperative and postoperative complications, and usually occur while the patient is still in the hospital. Over the recent decade, the improvement of different treatment strategies and technical inventions has been tremendous. This is mainly attributable to the increase use of the laparoscopic approach, which is now well-accepted for many procedures. Training of the surgeon, hospital volume, and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise, and cost-effectiveness. The standardization of perioperative care is essential to minimize postoperative complications. In this key lecture, Dr. Barry Salky provides an overview, namely how to identify and minimize intraoperative and postoperative complications.

Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)

Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.

S Puntambekar, V Sharma, H Parikh, G Joshi, S Mitkare, A Dokrimare

Surgical intervention

Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)

Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.

Transanal sigmoidectomy with TEO™ platform for adenocarcinoma

The video entitled "Transanal sigmoidectomy with TEO™ platform for adenocarcinoma", authored by J Leroy, A D'Urso, D Mutter, and J Marescaux is analyzed by Richard Whelan, MD (St. Luke's-Roosevelt Hospital Center, New York, NY, United States), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

RL Whelan

Surgical intervention

Transanal sigmoidectomy with TEO™ platform for adenocarcinoma

The video entitled "Transanal sigmoidectomy with TEO™ platform for adenocarcinoma", authored by J Leroy, A D'Urso, D Mutter, and J Marescaux is analyzed by Richard Whelan, MD (St. Luke's-Roosevelt Hospital Center, New York, NY, United States), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Laparoscopic segmental sigmoidectomy for colon cancer: how I do it?

The video entitled "Laparoscopic segmental sigmoidectomy for colon cancer: how I do it?", authored by J Leroy, A D'Urso, M Nedelcu, D Mutter, and J Marescaux is analyzed by Peter Marcello, MD (Lahey Clinic, Burlington, MA, United States), sharing his own personal experience and highlighting the different surgical approaches available with tips and tricks.

PW Marcello

Surgical intervention

Laparoscopic segmental sigmoidectomy for colon cancer: how I do it?

The video entitled "Laparoscopic segmental sigmoidectomy for colon cancer: how I do it?", authored by J Leroy, A D'Urso, M Nedelcu, D Mutter, and J Marescaux is analyzed by Peter Marcello, MD (Lahey Clinic, Burlington, MA, United States), sharing his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Successful closure of iatrogenic colonic perforation with Over-The-Scope Clip™ system (OVESCO™) after failed attempt with standard endoscopic clips

Iatrogenic colonic perforation is a rare complication which has been reported in 0.03%-0.8% of cases during diagnostic colonoscopy. The sigmoid colon and the rectosigmoid junction are the most common sites of perforation during diagnostic examination. Successful endoscopic closure of the defect has been reported using standard clips. However, in case of large defects, standard clips are often ineffective. OTSC™ clips are devices which are successfully used to close wall defects up to 25mm. They make it possible to continue the endoscopic procedure after wall defect closure. In this video, we show the successful closure of a sigmoid colonic iatrogenic perforation in a 50-year-old woman by means of the Over The Scope Clip™ system (OVESCO® Endoscopy, Germany) (11/6 t) after failed attempt with standard clips. OVESCO™ was applied with a standard gastroscope using the suction technique by pushing the cap against the edges of the defect. In order to prevent incarceration of adjacent structures a soft aspiration of the omentum was applied and the OVESCO™ was carefully deployed. Carbon dioxide insufflation was used. Antibiotic therapy was started and the patient was discharged 5 days later. In conclusion, the Over The Scope Clip™ (OTSC™) is a safe surgery-sparing tool which allows for a successful iatrogenic perforation closure of the GI tract, performing omentoplasty by means of a suction technique.

Gf Donatelli

Surgical intervention

Successful closure of iatrogenic colonic perforation with Over-The-Scope Clip™ system (OVESCO™) after failed attempt with standard endoscopic clips

Iatrogenic colonic perforation is a rare complication which has been reported in 0.03%-0.8% of cases during diagnostic colonoscopy. The sigmoid colon and the rectosigmoid junction are the most common sites of perforation during diagnostic examination. Successful endoscopic closure of the defect has been reported using standard clips. However, in case of large defects, standard clips are often ineffective. OTSC™ clips are devices which are successfully used to close wall defects up to 25mm. They make it possible to continue the endoscopic procedure after wall defect closure. In this video, we show the successful closure of a sigmoid colonic iatrogenic perforation in a 50-year-old woman by means of the Over The Scope Clip™ system (OVESCO® Endoscopy, Germany) (11/6 t) after failed attempt with standard clips. OVESCO™ was applied with a standard gastroscope using the suction technique by pushing the cap against the edges of the defect. In order to prevent incarceration of adjacent structures a soft aspiration of the omentum was applied and the OVESCO™ was carefully deployed. Carbon dioxide insufflation was used. Antibiotic therapy was started and the patient was discharged 5 days later. In conclusion, the Over The Scope Clip™ (OTSC™) is a safe surgery-sparing tool which allows for a successful iatrogenic perforation closure of the GI tract, performing omentoplasty by means of a suction technique.

Laparoscopic repair of colorectal leak and fistula using a new transanal reusable platform

Background: Transanal minimally invasive surgery has triggered much interest and investment in research over the last decade. This approach can be used not only to perform primary procedures (e.g., polypectomy, TME), but also to manage intraoperative complications such as leaks, bleedings, and late complications such as fistulas.
Video: The first part of the video shows the repair of an immediate colorectal leak using transanal laparoscopy, in a 50-year-old woman who underwent a laparoscopic anterior resection of the rectum. During anastomotic control, a posterior leak 4cm away from the anal margin was found. A new transanal reusable port, named DAPRI Port or D-Port (Karl Storz Endoskope, Tuttlingen, Germany), along with DAPRI monocurved reusable instruments, was implemented. The second part of the video shows a persisting and symptomatic colorectal fistula, located posteriorly 11cm away from the anal margin, in a 65-year-old man who had undergone a laparoscopic anterior resection of the rectum 4 weeks earlier.
Results: Operative time was 60 and 45 minutes respectively. Patients were discharged after 5 and 2 days respectively. Controls at 2 months (before ileostomy closure) showed a complete healing of the defects.
Conclusions: Complications after anterior resection of the rectum, such as intraoperative leak and late colorectal fistula, can be treated using transanal laparoscopy. This new transanal platform offers surgeons the possibility to work in ergonomic positions without increasing the cost of the procedure thanks to the reusable nature of the material adopted.

G Dapri, D Guta, K Grozdev, L Antolino, K Jottard, GB Cadière

Surgical intervention

Laparoscopic repair of colorectal leak and fistula using a new transanal reusable platform

Background: Transanal minimally invasive surgery has triggered much interest and investment in research over the last decade. This approach can be used not only to perform primary procedures (e.g., polypectomy, TME), but also to manage intraoperative complications such as leaks, bleedings, and late complications such as fistulas.
Video: The first part of the video shows the repair of an immediate colorectal leak using transanal laparoscopy, in a 50-year-old woman who underwent a laparoscopic anterior resection of the rectum. During anastomotic control, a posterior leak 4cm away from the anal margin was found. A new transanal reusable port, named DAPRI Port or D-Port (Karl Storz Endoskope, Tuttlingen, Germany), along with DAPRI monocurved reusable instruments, was implemented. The second part of the video shows a persisting and symptomatic colorectal fistula, located posteriorly 11cm away from the anal margin, in a 65-year-old man who had undergone a laparoscopic anterior resection of the rectum 4 weeks earlier.
Results: Operative time was 60 and 45 minutes respectively. Patients were discharged after 5 and 2 days respectively. Controls at 2 months (before ileostomy closure) showed a complete healing of the defects.
Conclusions: Complications after anterior resection of the rectum, such as intraoperative leak and late colorectal fistula, can be treated using transanal laparoscopy. This new transanal platform offers surgeons the possibility to work in ergonomic positions without increasing the cost of the procedure thanks to the reusable nature of the material adopted.

Tips: open surgery - anything to teach the laparoscopist?

The laparoscopic approach in now considered the gold standard for many digestive procedures. In this key lecture, Professor Heald provides some interesting tips originating from the open approach which surgeons must keep in mind.

Tips: open surgery - anything to teach the laparoscopist?

The laparoscopic approach in now considered the gold standard for many digestive procedures. In this key lecture, Professor Heald provides some interesting tips originating from the open approach which surgeons must keep in mind.

How to mobilize the left colonic flexure

In this lecture, Dr Walz presents his technique for left colonic flexure mobilization.

M Walz

How to mobilize the left colonic flexure

In this lecture, Dr Walz presents his technique for left colonic flexure mobilization.

Use of rectal tattoos

When using a laparoscopic approach, the goal is to create a tattoo which can be seen laparoscopically or endoscopically. In this lecture, Dr. Richard Whelan develops this point.

Use of rectal tattoos

When using a laparoscopic approach, the goal is to create a tattoo which can be seen laparoscopically or endoscopically. In this lecture, Dr. Richard Whelan develops this point.

LigaSure™ Blunt Tip Open and Laparoscopic Sealer/Divider with Nano-coating

Delivers reliable vessel sealing — now with nonstick nano-coating on the jaws.

LigaSure™ Blunt Tip Open and Laparoscopic Sealer/Divider with Nano-coating

Delivers reliable vessel sealing — now with nonstick nano-coating on the jaws.

instrument

Combined endo-laparoscopic surgery: less is more

Large colonic polyps and those on or behind a haustral fold can be very challenging to remove. EMR and ESD are performed for such polyps. In some selected cases, a combined endoscopic and laparoscopic approach (CELS) can be performed. In this lecture, Dr. Marcello outlines this approach.

Combined endo-laparoscopic surgery: less is more

Large colonic polyps and those on or behind a haustral fold can be very challenging to remove. EMR and ESD are performed for such polyps. In some selected cases, a combined endoscopic and laparoscopic approach (CELS) can be performed. In this lecture, Dr. Marcello outlines this approach.

Deep infiltrating endometriosis: the role of the general and digestive colorectal surgeon

Endometriosis is not an oncological disease but the involvemement of bowel sometimes requires an invasive approach. In this ley lecture, Professor Joël Leroy highlights the role of the digestive surgeon in the surgical management of endometriosis.

J Leroy

Deep infiltrating endometriosis: the role of the general and digestive colorectal surgeon

Endometriosis is not an oncological disease but the involvemement of bowel sometimes requires an invasive approach. In this ley lecture, Professor Joël Leroy highlights the role of the digestive surgeon in the surgical management of endometriosis.

Laparoscopic complete mesocolic excision for right hemi colon cancer: tips and tricks

The concept of complete excision of the organ within its primitive mesentery associated with central transection of the supplying blood vessels is currently considered the step towards modern surgical oncology. In this key lecture, Dr. Zheng provides some tips and tricks for the laparoscopic complete mesocolic excision in a right colectomy.

Laparoscopic complete mesocolic excision for right hemi colon cancer: tips and tricks

The concept of complete excision of the organ within its primitive mesentery associated with central transection of the supplying blood vessels is currently considered the step towards modern surgical oncology. In this key lecture, Dr. Zheng provides some tips and tricks for the laparoscopic complete mesocolic excision in a right colectomy.

Resection of the transverse colon for cancer

Laparoscopic transverse colon cancer resection is relatively difficult. The reasons for this are the anatomical variations of middle colic vessels, transverse mesocolon attachments with the pancreatic head, and some vein communications. In this key lecture, Dr. Martin Walz demonstrates the laparoscopic approach for this condition.

M Walz

Resection of the transverse colon for cancer

Laparoscopic transverse colon cancer resection is relatively difficult. The reasons for this are the anatomical variations of middle colic vessels, transverse mesocolon attachments with the pancreatic head, and some vein communications. In this key lecture, Dr. Martin Walz demonstrates the laparoscopic approach for this condition.

Comments from a beginner in robotic colorectal surgery

Laparoscopic colorectal surgery is currently a well-established approach. The robotic approach is emerging. In this lecture, Dr. Melani presents his early experience.

Comments from a beginner in robotic colorectal surgery

Laparoscopic colorectal surgery is currently a well-established approach. The robotic approach is emerging. In this lecture, Dr. Melani presents his early experience.

Obesity and laparoscopic colorectal surgery: what is different?

In the current surgical practice, surgeons are increasingly faced with obese patients in different conditions. In this lecture, Dr. Nahas presents the challenge of obesity in colorectal surgery.

Obesity and laparoscopic colorectal surgery: what is different?

In the current surgical practice, surgeons are increasingly faced with obese patients in different conditions. In this lecture, Dr. Nahas presents the challenge of obesity in colorectal surgery.

Laparoscopic resection for diverticulitis

In this authoritative lecture, Dr. Barry Salky reviews the laparoscopic management of sigmoid diverticulitis.

B Salky

Laparoscopic resection for diverticulitis

In this authoritative lecture, Dr. Barry Salky reviews the laparoscopic management of sigmoid diverticulitis.

Manual colorectal anastomosis during suprapubic single incision laparoscopic left hemicolectomy

Background: Single incision laparoscopic left hemicolectomy is a feasible procedure. A suprapubic access allows to offer satisfactory cosmetic results in case of an extended scar due to a large tumor. An intracorporeal circular mechanical anastomosis is the most common type. A manual anastomosis is feasible and allows to control lumen opening, potential bleeding, and overall to overcome the difficulty of transanal stapler insertion in case of high rectal transection.
Video: This video shows two different types of manual colorectal anastomosis, through a right suprapubic access.
1) Double-layer end-to-end
2) Monolayer end-to-end
Results: After an appropriate learning curve, time to perform the manual anastomosis is 40 minutes.
Conclusions: Different colorectal anastomoses can be performed and the surgeon has to choose the appropriate one, case by case.
To watch the video demonstrating the entire left hemicolectomy, please click here.

G Dapri

Surgical intervention

Manual colorectal anastomosis during suprapubic single incision laparoscopic left hemicolectomy

Background: Single incision laparoscopic left hemicolectomy is a feasible procedure. A suprapubic access allows to offer satisfactory cosmetic results in case of an extended scar due to a large tumor. An intracorporeal circular mechanical anastomosis is the most common type. A manual anastomosis is feasible and allows to control lumen opening, potential bleeding, and overall to overcome the difficulty of transanal stapler insertion in case of high rectal transection.
Video: This video shows two different types of manual colorectal anastomosis, through a right suprapubic access.
1) Double-layer end-to-end
2) Monolayer end-to-end
Results: After an appropriate learning curve, time to perform the manual anastomosis is 40 minutes.
Conclusions: Different colorectal anastomoses can be performed and the surgeon has to choose the appropriate one, case by case.
To watch the video demonstrating the entire left hemicolectomy, please click here.

Four different intracorporeal ileocolic anastomoses during suprapubic single incision laparoscopic right hemicolectomy

Background: Single incision laparoscopic right hemicolectomy is a feasible procedure. Suprapubic access allows to offer satisfactory cosmetic results in case of extended scar due to a large tumor. Intracorporeal anastomosis is mandatory through a suprapubic access, because it prevents traction on the mesentery and on the transverse mesocolon.
Video: This video shows four different types of intracorporeal ileocolic anastomoses.
1) Linear mechanical side-to-side
2) Completely manual side-to-side
3) Completely manual end-to-side
4) Completely manual end-to-end
At the end of each type of anastomosis, mesenteric defect closure is mandatory, to prevent intestinal obstruction caused by internal hernia.
Results: After an appropriate learning curve, time to perform linear mechanical anastomosis is 25 minutes and manual anastomosis takes 40 minutes.
Conclusions: Different ileocolic anastomoses can be performed and the surgeon has to choose the appropriate one, case by case.
To watch the video demonstrating the entire right hemicolectomy, please click here.

G Dapri

Surgical intervention

Four different intracorporeal ileocolic anastomoses during suprapubic single incision laparoscopic right hemicolectomy

Background: Single incision laparoscopic right hemicolectomy is a feasible procedure. Suprapubic access allows to offer satisfactory cosmetic results in case of extended scar due to a large tumor. Intracorporeal anastomosis is mandatory through a suprapubic access, because it prevents traction on the mesentery and on the transverse mesocolon.
Video: This video shows four different types of intracorporeal ileocolic anastomoses.
1) Linear mechanical side-to-side
2) Completely manual side-to-side
3) Completely manual end-to-side
4) Completely manual end-to-end
At the end of each type of anastomosis, mesenteric defect closure is mandatory, to prevent intestinal obstruction caused by internal hernia.
Results: After an appropriate learning curve, time to perform linear mechanical anastomosis is 25 minutes and manual anastomosis takes 40 minutes.
Conclusions: Different ileocolic anastomoses can be performed and the surgeon has to choose the appropriate one, case by case.
To watch the video demonstrating the entire right hemicolectomy, please click here.

Elective laparoscopic colectomy for diverticular disease: a plea for the standardization of the procedure

In this key lecture, Dr. Ambrosetti details different points of the elective laparoscopic approach for diverticular disease and focuses on the importance of IMA preservation.

Elective laparoscopic colectomy for diverticular disease: a plea for the standardization of the procedure

In this key lecture, Dr. Ambrosetti details different points of the elective laparoscopic approach for diverticular disease and focuses on the importance of IMA preservation.

Reusable Retractors for Endoscopic Vessel Harvesting

instrument

Chronic sigmoidovesical fistula: laparoscopic management

The most frequent underlying cause of sigmoidovesical fistula is complicated diverticular disease in 60% of cases followed by colorectal cancer and inflammatory bowel disease. It occurs in about 2 to 22% of patients with known diverticular disease. In diverticular sigmoid vesical chronic fistula, the preferred therapeutic management is represented by primary resection with anastomosis performed as a one-stage procedure. It is particularly true when the fistula is located between the vesical dome and the sigmoid colon distally from the trigone vesical. In this video, we demonstrate the laparoscopic management of a chronic sigmoidovesical fistula after acute sigmoid diverticulitis as a one-stage procedure.

J Leroy, A D'Urso, H Jeddou, D Mutter, J Marescaux

Surgical intervention

Chronic sigmoidovesical fistula: laparoscopic management

The most frequent underlying cause of sigmoidovesical fistula is complicated diverticular disease in 60% of cases followed by colorectal cancer and inflammatory bowel disease. It occurs in about 2 to 22% of patients with known diverticular disease. In diverticular sigmoid vesical chronic fistula, the preferred therapeutic management is represented by primary resection with anastomosis performed as a one-stage procedure. It is particularly true when the fistula is located between the vesical dome and the sigmoid colon distally from the trigone vesical. In this video, we demonstrate the laparoscopic management of a chronic sigmoidovesical fistula after acute sigmoid diverticulitis as a one-stage procedure.

Risk of anastomotic leakage

Anastomotic leakage after colorectal anastomosis could be a dramatic complication. In this key lecture, Dr. Bretagnol shows how to detect and treat this complication.

Risk of anastomotic leakage

Anastomotic leakage after colorectal anastomosis could be a dramatic complication. In this key lecture, Dr. Bretagnol shows how to detect and treat this complication.

How to ensure an adequate laparoscopic lymphadenectomy in colorectal surgery

Correct lymphadenectomy in colorectal cancer resection is a crucial point to improve oncological outcomes. In this key lecture, Professor Joël Leroy focuses on this topic.

J Leroy

How to ensure an adequate laparoscopic lymphadenectomy in colorectal surgery

Correct lymphadenectomy in colorectal cancer resection is a crucial point to improve oncological outcomes. In this key lecture, Professor Joël Leroy focuses on this topic.

How to manage and prevent ureteral injuries in laparoscopic surgery

Ureteral injuries during laparoscopic procedure are reported in about 1% of cases. In this key lecture, Professor Joël Leroy looks into the prevention, diagnosis and management of this challenging complication.

J Leroy

How to manage and prevent ureteral injuries in laparoscopic surgery

Ureteral injuries during laparoscopic procedure are reported in about 1% of cases. In this key lecture, Professor Joël Leroy looks into the prevention, diagnosis and management of this challenging complication.

Intraoperative endoscopy for safety testing of the anastomosis

Colorectal anastomosis testing is mandatory. Air and color tests are most commonly performed. In this key lecture, Dr. Shamiyeh presents his experience with intraoperative endoscopic anastomosis testing.

Intraoperative endoscopy for safety testing of the anastomosis

Colorectal anastomosis testing is mandatory. Air and color tests are most commonly performed. In this key lecture, Dr. Shamiyeh presents his experience with intraoperative endoscopic anastomosis testing.

Retroperitoneal adrenalectomy for colon cancer metastasis: a live demonstration

Laparoscopic adrenalectomy is considered to be the standard of care for the surgical excision of the adrenal gland. Transperitoneal and retroperitoneal approaches are the two major laparoscopic routes to the adrenal gland. Although the transperitoneal approach is used more widely, the retroperitoneal approach offers distinct advantages which make it a valuable alternative route to the adrenal gland. This video describes a retroperitoneal laparoscopic adrenalectomy for colon cancer metastasis in a 65-year-old patient who underwent a left colectomy 3 years earlier.

M Walz, L Soler, D Mutter, J Marescaux

Surgical intervention

Retroperitoneal adrenalectomy for colon cancer metastasis: a live demonstration

Laparoscopic adrenalectomy is considered to be the standard of care for the surgical excision of the adrenal gland. Transperitoneal and retroperitoneal approaches are the two major laparoscopic routes to the adrenal gland. Although the transperitoneal approach is used more widely, the retroperitoneal approach offers distinct advantages which make it a valuable alternative route to the adrenal gland. This video describes a retroperitoneal laparoscopic adrenalectomy for colon cancer metastasis in a 65-year-old patient who underwent a left colectomy 3 years earlier.

Laparoscopic colorectal surgery: where is the tumor?

The intraoperative identification of small colonic lesions during laparoscopic colorectal resection is difficult. In this key lecture, Dr. Shamiyeh demonstrates the potential solutions to this problem.

Laparoscopic colorectal surgery: where is the tumor?

The intraoperative identification of small colonic lesions during laparoscopic colorectal resection is difficult. In this key lecture, Dr. Shamiyeh demonstrates the potential solutions to this problem.

Tips and tricks for right and left colectomy

The laparoscopic approach to colonic cancer will replace open surgery in the majority of cases. In this key lecture, Professor Okuda provides some tips and tricks to perform a total laparoscopic approach for right and left colectomy.

J Okuda

Tips and tricks for right and left colectomy

The laparoscopic approach to colonic cancer will replace open surgery in the majority of cases. In this key lecture, Professor Okuda provides some tips and tricks to perform a total laparoscopic approach for right and left colectomy.

Laparoscopic segmental sigmoidectomy for colon cancer: how I do it?

In this video, authors demonstrate a standardized technique to perform a segmental sigmoidectomy for cancer. The operative steps are clearly outlined and shown in this high-definition film. The standardization of the procedure is a major step in the reproducibility of the technique and in the quality of results. In oncology, it is essential to respect consensus guidelines which have been advocated by scientific societies. This video highlights the different protocols used and demonstrate them, bearing in mind that the best method is the standardization of the surgical procedure.

J Leroy, A D'Urso, M Nedelcu, D Mutter, J Marescaux

Surgical intervention

Laparoscopic segmental sigmoidectomy for colon cancer: how I do it?

In this video, authors demonstrate a standardized technique to perform a segmental sigmoidectomy for cancer. The operative steps are clearly outlined and shown in this high-definition film. The standardization of the procedure is a major step in the reproducibility of the technique and in the quality of results. In oncology, it is essential to respect consensus guidelines which have been advocated by scientific societies. This video highlights the different protocols used and demonstrate them, bearing in mind that the best method is the standardization of the surgical procedure.

Complications in colorectal surgery

Some of the more common and serious surgical complications encountered by colorectal surgeons are enterocutaneous fistulas, anastomotic leaks and strictures, injuries to genitourinary structures, small bowel obstruction, pelvic bleeding, and wound infections. In this key lecture, Dr. Palanivelu outlines some of these complications.

Complications in colorectal surgery

Some of the more common and serious surgical complications encountered by colorectal surgeons are enterocutaneous fistulas, anastomotic leaks and strictures, injuries to genitourinary structures, small bowel obstruction, pelvic bleeding, and wound infections. In this key lecture, Dr. Palanivelu outlines some of these complications.

LigaSure Impact™ Curved, Large Jaw, Open Sealer/Divider with Nano-coating

A multifunctional tissue fusion system, featuring an integrated cutting mechanism for use in open procedures.

LigaSure Impact™ Curved, Large Jaw, Open Sealer/Divider with Nano-coating

A multifunctional tissue fusion system, featuring an integrated cutting mechanism for use in open procedures.

Vessel sealing

Transanal sigmoidectomy with TEO™ platform for adenocarcinoma

The objective of this film is to demonstrate the possibility of performing a purely transanal sigmoidectomy without laparoscopic assistance. The authors show that this approach, which has already been described for transanal rectal resection using the Perirectal Oncologic Gateway to Retroperitoneal Endoscopic Single-Site Surgery (PROGRESS) technique, is feasible and safe. Details as well as tips and tricks of this technique are clearly illustrated in a stepwise manner.

J Leroy, A D'Urso, D Mutter, J Marescaux

Surgical intervention

Transanal sigmoidectomy with TEO™ platform for adenocarcinoma

The objective of this film is to demonstrate the possibility of performing a purely transanal sigmoidectomy without laparoscopic assistance. The authors show that this approach, which has already been described for transanal rectal resection using the Perirectal Oncologic Gateway to Retroperitoneal Endoscopic Single-Site Surgery (PROGRESS) technique, is feasible and safe. Details as well as tips and tricks of this technique are clearly illustrated in a stepwise manner.

Intraoperative complications: everything you would NOT LIKE TO EXPERIENCE

Laparoscopic surgery is widely performed. It is crucial to have a perfect knowledge of all devices and adopt the correct operative strategy. In this video presentation, Dr. Cecilia Ponzano presents some unexpected intraoperative complications along with their management.

Intraoperative complications: everything you would NOT LIKE TO EXPERIENCE

Laparoscopic surgery is widely performed. It is crucial to have a perfect knowledge of all devices and adopt the correct operative strategy. In this video presentation, Dr. Cecilia Ponzano presents some unexpected intraoperative complications along with their management.

Surgical options in Hinchey III and IV diverticulitis

Peritonitis and failure of medical therapy represent the most common indications for emergency operative interventions in the treatment of sigmoid diverticulitis. Guidelines for the most adequate operative strategy, however, remain controversial and continue to evolve based on recent comparative reviews of surgical outcomes. In this key lecture, Dr. Cecilia Ponzano outlines the options available in Hinchey III and IV diverticulitis.

Surgical options in Hinchey III and IV diverticulitis

Peritonitis and failure of medical therapy represent the most common indications for emergency operative interventions in the treatment of sigmoid diverticulitis. Guidelines for the most adequate operative strategy, however, remain controversial and continue to evolve based on recent comparative reviews of surgical outcomes. In this key lecture, Dr. Cecilia Ponzano outlines the options available in Hinchey III and IV diverticulitis.

Hinchey II sigmoid diverticulitis with chronic abscess and sigmoidovesical fistula in a male patient: laparoscopic management

The video entitled "Hinchey II sigmoid diverticulitis with chronic abscess and sigmoidovesical fistula in a male patient: laparoscopic management", authored by J Leroy, D Ntourakis, D Mutter, and J Marescaux is analyzed by Barry Salky, MD, FACS (Mount Sinai Medical Center, New York, USA), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

B Salky

Surgical intervention

Hinchey II sigmoid diverticulitis with chronic abscess and sigmoidovesical fistula in a male patient: laparoscopic management

The video entitled "Hinchey II sigmoid diverticulitis with chronic abscess and sigmoidovesical fistula in a male patient: laparoscopic management", authored by J Leroy, D Ntourakis, D Mutter, and J Marescaux is analyzed by Barry Salky, MD, FACS (Mount Sinai Medical Center, New York, USA), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Single port laparoscopic-assisted ileocolic resection for recurrent Crohn's disease

Background: Here we demonstrate a single port laparoscopic ileocolic resection technique in a patient with Crohn’s disease and recurrent anastomotic stricturing despite prior ileocaecal resection and medication.
Procedure: The procedure is begun with a 3cm transumbilical incision. After safe peritoneal entry, a wound protector-retractor was placed into the wound and then sealed for laparoscopy with a surgical glove port. Thereafter, the operation proceeded using a 30-degree high definition laparoscope with sterile in-line cabling (EndoEYE™, Olympus Corporation) along with other standard, rigid instrumentation (primarily an atraumatic grasper and a LigaSure™ sealer-cutter, Covidien). The strictured anastomotic segment was cleared of an omental adhesion and mobilized laterally. The proximal colon was fully mobilized and the duodenum as well as right gonadal vessels and ureter were clearly preserved. After medialization of the diseased segment, the glove port was removed and the specimen extracted (without further fascial extension) via the single port access site. A side-to-side stapled anastomosis was performed in the usual fashion and re-laparoscopy done after return of the bowel into the peritoneum.
Comment: Single port laparoscopic-assisted surgery is applicable to the re-operative setting in selected patients. Its advantages particularly apply to young patients who value body image and reduced scarring.

F Narouz, R Cahill

Surgical intervention

Single port laparoscopic-assisted ileocolic resection for recurrent Crohn's disease

Background: Here we demonstrate a single port laparoscopic ileocolic resection technique in a patient with Crohn’s disease and recurrent anastomotic stricturing despite prior ileocaecal resection and medication.
Procedure: The procedure is begun with a 3cm transumbilical incision. After safe peritoneal entry, a wound protector-retractor was placed into the wound and then sealed for laparoscopy with a surgical glove port. Thereafter, the operation proceeded using a 30-degree high definition laparoscope with sterile in-line cabling (EndoEYE™, Olympus Corporation) along with other standard, rigid instrumentation (primarily an atraumatic grasper and a LigaSure™ sealer-cutter, Covidien). The strictured anastomotic segment was cleared of an omental adhesion and mobilized laterally. The proximal colon was fully mobilized and the duodenum as well as right gonadal vessels and ureter were clearly preserved. After medialization of the diseased segment, the glove port was removed and the specimen extracted (without further fascial extension) via the single port access site. A side-to-side stapled anastomosis was performed in the usual fashion and re-laparoscopy done after return of the bowel into the peritoneum.
Comment: Single port laparoscopic-assisted surgery is applicable to the re-operative setting in selected patients. Its advantages particularly apply to young patients who value body image and reduced scarring.

Original full laparoscopic reversal of Hartmann’s procedure after open subtotal colectomy

The objective of this film is to demonstrate a fully laparoscopic original technique for the restoration of the ileorectal continuity after total colectomy for colonic obstruction in a pT4aN0M0 advanced colonic cancer which was operated on 10 months earlier (Hartmann procedure) and then managed by chemotherapy.

J Leroy, G Sojod, D Mutter, J Marescaux

Surgical intervention

Original full laparoscopic reversal of Hartmann’s procedure after open subtotal colectomy

The objective of this film is to demonstrate a fully laparoscopic original technique for the restoration of the ileorectal continuity after total colectomy for colonic obstruction in a pT4aN0M0 advanced colonic cancer which was operated on 10 months earlier (Hartmann procedure) and then managed by chemotherapy.

Right colectomy: intracorporeal vs. extracorporeal anastomosis

Some controversies still persist regarding intracorporeal or extracorporeal anastomosis after right laparoscopic colectomy. In this lecture, Dr. Bianchi presents a review of the literature and presents his experience.

Right colectomy: intracorporeal vs. extracorporeal anastomosis

Some controversies still persist regarding intracorporeal or extracorporeal anastomosis after right laparoscopic colectomy. In this lecture, Dr. Bianchi presents a review of the literature and presents his experience.

Laparoscopic sigmoidectomy for benign diverticular disease

Dr. Armando Melani beautifully demonstrates a laparoscopic sigmoidectomy technique for a benign diverticular condition. He provides tips and tricks to perfectly expose the operating field and recommends an extensive approach to the left colon with primary mobilization of the splenic flexure using a posterior medial approach with a late vascular approach. The technique and its performance is amply discussed by the panel of experts present, hence providing a very instructive demonstration.
The operator also discusses the different types of energy devices available as well as the tricks to safely perform an upper colorectal anastomosis. This film provides plenty of detailed information for beginners and experts alike to allow them to perform a laparoscopic sigmoidectomy in a perfect fashion.

J Leroy, A Melani, J Marescaux

Surgical intervention

Laparoscopic sigmoidectomy for benign diverticular disease

Dr. Armando Melani beautifully demonstrates a laparoscopic sigmoidectomy technique for a benign diverticular condition. He provides tips and tricks to perfectly expose the operating field and recommends an extensive approach to the left colon with primary mobilization of the splenic flexure using a posterior medial approach with a late vascular approach. The technique and its performance is amply discussed by the panel of experts present, hence providing a very instructive demonstration.
The operator also discusses the different types of energy devices available as well as the tricks to safely perform an upper colorectal anastomosis. This film provides plenty of detailed information for beginners and experts alike to allow them to perform a laparoscopic sigmoidectomy in a perfect fashion.

Acute peritonitis: the interest of laparoscopy

In this lecture, Dr. Navez discusses the interest of laparoscopic exploration in acute peritonitis.

B Navez

Acute peritonitis: the interest of laparoscopy

In this lecture, Dr. Navez discusses the interest of laparoscopic exploration in acute peritonitis.

Single port colectomy

Current advances in single port laparoscopic surgery are difficult to define. The most common procedures are single port laparoscopic cholecystectomies and appendectomies. Significant clinical benefits have not yet been proven even in prospective, randomized studies. In this key lecture, Dr. Melani discusses the current status of single port colectomy and presents his experience.

Single port colectomy

Current advances in single port laparoscopic surgery are difficult to define. The most common procedures are single port laparoscopic cholecystectomies and appendectomies. Significant clinical benefits have not yet been proven even in prospective, randomized studies. In this key lecture, Dr. Melani discusses the current status of single port colectomy and presents his experience.

Rapid Tissue Ablation with a Small Diameter –

19 Fr. Intrauterine BIGATTI Shaver (IBS®) with HYSTEROMAT E.A.S.I.®

Rapid Tissue Ablation with a Small Diameter –

19 Fr. Intrauterine BIGATTI Shaver (IBS®) with HYSTEROMAT E.A.S.I.®

instrument

Laparoscopic simultaneous resection: liver metastases and colorectal cancer

In this lecture, Dr. Melani details the surgical laparoscopic approach of colorectal cancer presenting with simultaneous liver metastasis.

Laparoscopic simultaneous resection: liver metastases and colorectal cancer

In this lecture, Dr. Melani details the surgical laparoscopic approach of colorectal cancer presenting with simultaneous liver metastasis.

Laparoscopic oncologic right colectomy for cancer in an obese patient: interest of a full laparoscopic procedure with ileocolic “in“ anastomosis

In this video, the author demonstrates the possibilities of an laparoscopic oncologic approach to perform a right colectomy in an obese patient.
After a primary vascular approach, the colon is freed from its posterior and lateral attachments prior to being resected. The intracorporeal anastomosis is beautifully described and substantiated here.
Finally, the author underlines the benefit of using dissection instruments recently developed by the medical device Industry (Sonicision™, V-Loc™, and Tri-Staple™ Technology by Covidien).

F Corcione, J Leroy, J Marescaux

Surgical intervention

Laparoscopic oncologic right colectomy for cancer in an obese patient: interest of a full laparoscopic procedure with ileocolic “in“ anastomosis

In this video, the author demonstrates the possibilities of an laparoscopic oncologic approach to perform a right colectomy in an obese patient.
After a primary vascular approach, the colon is freed from its posterior and lateral attachments prior to being resected. The intracorporeal anastomosis is beautifully described and substantiated here.
Finally, the author underlines the benefit of using dissection instruments recently developed by the medical device Industry (Sonicision™, V-Loc™, and Tri-Staple™ Technology by Covidien).

Colonic stomal prolapse and parastomal incisional hernia: laparoscopic Sugarbaker repair procedure

The objective of this film is to demonstrate stoma prolapse and parastomal incisional hernia repair according to the technique described by Sugarbaker in open surgery, reproduced here with a laparoscopic approach.
Mesh placement into the abdominal cavity presents a risk that seems minimized by the development of dual-sided composite meshes, with one collagen coating that will be in contact with the digestive tract, hence limiting the risk of adhesions.
The principle of the Sugarbaker technique is to create a colonic zigzag route and to fix it on the non-absorbable side of the mesh, thereby preventing colonic prolapse. The mesh is also used as an obstacle to the passage of small bowel loops into the parastomal defect.
Here, the difficulty lies in the combined presence of an incisional hernia and prolapse on a diverting transverse colostomy. The risk of vascular injury is all the more important. Here, authors highlight pitfalls as well as tips and tricks to overcome them.

J Leroy, J Marescaux

Surgical intervention

Colonic stomal prolapse and parastomal incisional hernia: laparoscopic Sugarbaker repair procedure

The objective of this film is to demonstrate stoma prolapse and parastomal incisional hernia repair according to the technique described by Sugarbaker in open surgery, reproduced here with a laparoscopic approach.
Mesh placement into the abdominal cavity presents a risk that seems minimized by the development of dual-sided composite meshes, with one collagen coating that will be in contact with the digestive tract, hence limiting the risk of adhesions.
The principle of the Sugarbaker technique is to create a colonic zigzag route and to fix it on the non-absorbable side of the mesh, thereby preventing colonic prolapse. The mesh is also used as an obstacle to the passage of small bowel loops into the parastomal defect.
Here, the difficulty lies in the combined presence of an incisional hernia and prolapse on a diverting transverse colostomy. The risk of vascular injury is all the more important. Here, authors highlight pitfalls as well as tips and tricks to overcome them.

Challenges and recent developments in laparoscopic surgery: mini trocars and single port

Recently, some authors propose to use mini trocars to perform laparoscopic cholecystectomy while other authors recommend the use of the single port approach.
The objective of this lecture is to explore the potentialities and the rationale of these two concepts and techniques.

J Leroy

Challenges and recent developments in laparoscopic surgery: mini trocars and single port

Recently, some authors propose to use mini trocars to perform laparoscopic cholecystectomy while other authors recommend the use of the single port approach.
The objective of this lecture is to explore the potentialities and the rationale of these two concepts and techniques.

Laparoscopic sigmoidectomy for sigmoiditis with transanal specimen extraction

The objective of this video is to demonstrate a sigmoid colectomy technique for a diverticular sigmoiditis with a transanal extraction of the resected colonic segment. The goal of this video is to demonstrate the feasibility of this technique by means of only 3 trocars to further reduce parietal damage. The author reveals his tips and tricks for a perfectly standardized minimally invasive operative technique. In addition to colonic extraction, the different stages of mechanical anastomosis are perfectly outlined. This team recommends that this type of intervention should be used for benign pathologies.

J Leroy, J Marescaux

Surgical intervention

Laparoscopic sigmoidectomy for sigmoiditis with transanal specimen extraction

The objective of this video is to demonstrate a sigmoid colectomy technique for a diverticular sigmoiditis with a transanal extraction of the resected colonic segment. The goal of this video is to demonstrate the feasibility of this technique by means of only 3 trocars to further reduce parietal damage. The author reveals his tips and tricks for a perfectly standardized minimally invasive operative technique. In addition to colonic extraction, the different stages of mechanical anastomosis are perfectly outlined. This team recommends that this type of intervention should be used for benign pathologies.

Right hemicolectomy for appendicular mucocele

The appendicular mucocele is defined by a dilation of the appendix and an unusual accumulation of mucus within its lumen. It is a rare pathology which affects 0.25% of the population.
Its histological discovery is made during the postoperative phase in nearly 70% of cases. Appendicular mucoceles, which are secondary to a muco-secretive tumor, can potentially be a problem if they are malignant, especially in case of preoperative or intraoperative rupture, with a risk of gelatinous disease of the peritoneum.
The positive diagnosis is based on a histological study, which must be systematic, for all appendectomy specimens. Preoperatively, it is essential to recognize an appendicular mucocele, in order to properly adapt the surgical technique, and to potentially envisage a more global surgical resection technique.
We present the case of a 70-year-old man, treated in our unit for right iliac fossa abscess in which an explorative laparoscopy was decided upon after one month of medical treatment.

L Marx, F Costantino, J Marescaux

Surgical intervention

Right hemicolectomy for appendicular mucocele

The appendicular mucocele is defined by a dilation of the appendix and an unusual accumulation of mucus within its lumen. It is a rare pathology which affects 0.25% of the population.
Its histological discovery is made during the postoperative phase in nearly 70% of cases. Appendicular mucoceles, which are secondary to a muco-secretive tumor, can potentially be a problem if they are malignant, especially in case of preoperative or intraoperative rupture, with a risk of gelatinous disease of the peritoneum.
The positive diagnosis is based on a histological study, which must be systematic, for all appendectomy specimens. Preoperatively, it is essential to recognize an appendicular mucocele, in order to properly adapt the surgical technique, and to potentially envisage a more global surgical resection technique.
We present the case of a 70-year-old man, treated in our unit for right iliac fossa abscess in which an explorative laparoscopy was decided upon after one month of medical treatment.

Complicated sigmoiditis with sigmoido-vaginal fistula: laparoscopic management with Natural Orifice Specimen Extraction (NOSE)

The video entitled "Complicated sigmoiditis with sigmoido-vaginal fistula: laparoscopic management with Natural Orifice Specimen Extraction (NOSE)” authored by J Leroy, L Marx, J Marescaux is analyzed by Dr. Barry Salky, MD, FACS (Mount Sinai Medical Center, New York, USA) sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

B Salky

Surgical intervention

Complicated sigmoiditis with sigmoido-vaginal fistula: laparoscopic management with Natural Orifice Specimen Extraction (NOSE)

The video entitled "Complicated sigmoiditis with sigmoido-vaginal fistula: laparoscopic management with Natural Orifice Specimen Extraction (NOSE)” authored by J Leroy, L Marx, J Marescaux is analyzed by Dr. Barry Salky, MD, FACS (Mount Sinai Medical Center, New York, USA) sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Suprapubic single incision laparoscopic left hemicolectomy (SILLH): an alternative to the umbilical access

Background: Single incision laparoscopy (SIL) has been described for colorectal surgery because it mainly provides an improved cosmetic outcome. A suprapubic access can be considered an alternative to the umbilical site for left hemicolectomy (LH) because the scar remains under the bikini line and can be considered cosmetically acceptable.

Video: A 61-year-old man was admitted to hospital for adenocarcinoma of the sigmoid colon; preoperative work-up did not show the presence of secondary lesions. A suprapubic SILLH was proposed to the patient. The technique consisted in performing the procedure through an initial 3.5cm skin incision, localized suprapubically, with the insertion of 3 reusable trocars vertically in a pararectal axis along with DAPRI curved reusable instruments (Karl Storz Endoskope, Tüttlingen, Germany). The vascular plane was firstly controlled by clips and, after mobilization of the entire left colon, the upper rectum was transected and the specimen was removed using the same access; a conventional circular transanal anastomosis was performed.

Results: Laparoscopic time was 119 minutes, estimated blood loss was 20cc, and the final scar length measured 4.5cm. Pathology confirmed the presence of a colon adenocarcinoma (pT2N0Mx). Postoperative pain was minimal, allowing the patient to be discharged on postoperative day 4.

Conclusions: Suprapubic SILLH offers the option to enlarge the skin incision according to the specimen’s size without any cosmetic damage, because it remains under the bikini line. The dissection plane appears in front of the access and postoperative pain remains minimal.

G Dapri

Surgical intervention

Suprapubic single incision laparoscopic left hemicolectomy (SILLH): an alternative to the umbilical access

Background: Single incision laparoscopy (SIL) has been described for colorectal surgery because it mainly provides an improved cosmetic outcome. A suprapubic access can be considered an alternative to the umbilical site for left hemicolectomy (LH) because the scar remains under the bikini line and can be considered cosmetically acceptable.

Video: A 61-year-old man was admitted to hospital for adenocarcinoma of the sigmoid colon; preoperative work-up did not show the presence of secondary lesions. A suprapubic SILLH was proposed to the patient. The technique consisted in performing the procedure through an initial 3.5cm skin incision, localized suprapubically, with the insertion of 3 reusable trocars vertically in a pararectal axis along with DAPRI curved reusable instruments (Karl Storz Endoskope, Tüttlingen, Germany). The vascular plane was firstly controlled by clips and, after mobilization of the entire left colon, the upper rectum was transected and the specimen was removed using the same access; a conventional circular transanal anastomosis was performed.

Results: Laparoscopic time was 119 minutes, estimated blood loss was 20cc, and the final scar length measured 4.5cm. Pathology confirmed the presence of a colon adenocarcinoma (pT2N0Mx). Postoperative pain was minimal, allowing the patient to be discharged on postoperative day 4.

Conclusions: Suprapubic SILLH offers the option to enlarge the skin incision according to the specimen’s size without any cosmetic damage, because it remains under the bikini line. The dissection plane appears in front of the access and postoperative pain remains minimal.

APE and nerve preservation

Rectal cancer surgery is impaired by a high rate of postoperative sexual dysfunction, cause of frequent nerve injuries. In this lecture, Professor RJ Heald details all the key steps when performing rectal resection.

APE and nerve preservation

Rectal cancer surgery is impaired by a high rate of postoperative sexual dysfunction, cause of frequent nerve injuries. In this lecture, Professor RJ Heald details all the key steps when performing rectal resection.

Hinchey II sigmoid diverticulitis with chronic abscess and sigmoidovesical fistula in a male patient: laparoscopic management

The objective of this video is to demonstrate the laparoscopic management of complicated sigmoiditis. A persisting chronic abscess between the sigmoid loop and the bladder does not represent a contraindication to this minimally invasive approach. The authors outline the different technical points that will allow to resect the rectosigmoid and control the abscessed area as well as the bladder wall.

J Leroy, D Ntourakis, D Mutter, J Marescaux

Surgical intervention

Hinchey II sigmoid diverticulitis with chronic abscess and sigmoidovesical fistula in a male patient: laparoscopic management

The objective of this video is to demonstrate the laparoscopic management of complicated sigmoiditis. A persisting chronic abscess between the sigmoid loop and the bladder does not represent a contraindication to this minimally invasive approach. The authors outline the different technical points that will allow to resect the rectosigmoid and control the abscessed area as well as the bladder wall.

LigaSure Advance™ Monopolar Tip Laparoscopic Sealer/Divider

A monopolar tip laparoscopic vessel sealer and divider that offers multifunction capability in one instrument.

LigaSure Advance™ Monopolar Tip Laparoscopic Sealer/Divider

A monopolar tip laparoscopic vessel sealer and divider that offers multifunction capability in one instrument.

Vessel sealing

Laparoscopic revision of stenotic colorectal anastomosis

Background: Colorectal anastomosis is usually performed using a circular stapler inserted transanally. Postoperative complications such as strictures are rare and related to various factors like ischemia, poor vascularization, and previous leak. This video shows a laparoscopic revision of a stenotic colorectal anastomosis, solved with a new hand-sewn anastomosis.

Video: A 51-year-old man underwent laparoscopic sigmoidectomy for symptomatic diverticulosis. At that time, a transanal circular mechanical end-to-end colorectal anastomosis was performed using a 29mm circular stapler. After 3 months of follow-up, a symptomatic stenotic colorectal anastomosis was evidenced, and endoscopic dilatation (repeated 3 times) remained unsuccessful. Preoperative barium enema showed a stenotic anastomosis and some residual diverticulosis. A laparoscopic 3-trocar revision was scheduled. On exploration of the abdominal cavity, the anastomosis appeared thickened and strictly adherent to the left ureter. After proper mobilization, a segmental colorectal resection was performed and a new anastomosis was fashioned in an end-to-end hand-sewn technique.

Results: The procedure was completed by laparoscopy without additional trocars. Operative time was 202 minutes and blood loss 20cc. The patient was allowed to be discharged on the 4th postoperative day, and after 6 months, he is fine, without intestinal trouble.

Conclusions: Postoperative complications of colorectal anastomosis, such as strictures, can be managed laparoscopically. A new hand-sewn anastomosis is feasible and it allows for control of the vascularization and openings of both colonic and rectal lumens.

G Dapri

Surgical intervention

Laparoscopic revision of stenotic colorectal anastomosis

Background: Colorectal anastomosis is usually performed using a circular stapler inserted transanally. Postoperative complications such as strictures are rare and related to various factors like ischemia, poor vascularization, and previous leak. This video shows a laparoscopic revision of a stenotic colorectal anastomosis, solved with a new hand-sewn anastomosis.

Video: A 51-year-old man underwent laparoscopic sigmoidectomy for symptomatic diverticulosis. At that time, a transanal circular mechanical end-to-end colorectal anastomosis was performed using a 29mm circular stapler. After 3 months of follow-up, a symptomatic stenotic colorectal anastomosis was evidenced, and endoscopic dilatation (repeated 3 times) remained unsuccessful. Preoperative barium enema showed a stenotic anastomosis and some residual diverticulosis. A laparoscopic 3-trocar revision was scheduled. On exploration of the abdominal cavity, the anastomosis appeared thickened and strictly adherent to the left ureter. After proper mobilization, a segmental colorectal resection was performed and a new anastomosis was fashioned in an end-to-end hand-sewn technique.

Results: The procedure was completed by laparoscopy without additional trocars. Operative time was 202 minutes and blood loss 20cc. The patient was allowed to be discharged on the 4th postoperative day, and after 6 months, he is fine, without intestinal trouble.

Conclusions: Postoperative complications of colorectal anastomosis, such as strictures, can be managed laparoscopically. A new hand-sewn anastomosis is feasible and it allows for control of the vascularization and openings of both colonic and rectal lumens.

Complicated sigmoiditis with sigmoido-vaginal fistula: laparoscopic management with Natural Orifice Specimen Extraction (NOSE)

Sigmoiditis complicated by the presence of chronic sigmoido-vaginal fistula has become increasingly rare. Its laparoscopic management has long been considered to be a contraindication. This film demonstrates that surgery is feasible and a laparotomy can be avoided as the extraction of the sigmoid colon and the anastomosis are performed transvaginally. The outstanding quality of HD images enhances the visualization of all anatomical structures.

J Leroy, L Marx, J Marescaux

Surgical intervention

Complicated sigmoiditis with sigmoido-vaginal fistula: laparoscopic management with Natural Orifice Specimen Extraction (NOSE)

Sigmoiditis complicated by the presence of chronic sigmoido-vaginal fistula has become increasingly rare. Its laparoscopic management has long been considered to be a contraindication. This film demonstrates that surgery is feasible and a laparotomy can be avoided as the extraction of the sigmoid colon and the anastomosis are performed transvaginally. The outstanding quality of HD images enhances the visualization of all anatomical structures.

Rectal prolapse repair using laparoscopic Douglasectomy and indirect ventral rectopexy and posterior colpopexy with polyester meshes

For the authors of this film, the objective is to present the tips and tricks of their laparoscopic repair for rectal prolapse with elytrocele and rectocele. The procedure is outlined in a stepwise fashion and explained meticulously.

J Leroy, J Marescaux

Surgical intervention

Rectal prolapse repair using laparoscopic Douglasectomy and indirect ventral rectopexy and posterior colpopexy with polyester meshes

For the authors of this film, the objective is to present the tips and tricks of their laparoscopic repair for rectal prolapse with elytrocele and rectocele. The procedure is outlined in a stepwise fashion and explained meticulously.

Safe approach: transverse colon

The vascular approach for lesions located on the transverse colon is very challenging. In this lecture, Dr. Armondo Melani presents a safe laparoscopic approach.

Safe approach: transverse colon

The vascular approach for lesions located on the transverse colon is very challenging. In this lecture, Dr. Armondo Melani presents a safe laparoscopic approach.

Laparoscopic colectomy in colitis: an evidence-based approach

Despite recent advances in the medical treatment of ulcerative colitis (UC), approximately 25-40% of patients will need surgery while the disease is still in effect. The aim of elective surgical treatment of UC is to remove the colon/and rectum with minimal postoperative morbidity, and to offer a good long-term quality of life. In this lecture, Dr. Barry Salky presents the current status of the laparoscopic approach to this pathology.

B Salky

Laparoscopic colectomy in colitis: an evidence-based approach

Despite recent advances in the medical treatment of ulcerative colitis (UC), approximately 25-40% of patients will need surgery while the disease is still in effect. The aim of elective surgical treatment of UC is to remove the colon/and rectum with minimal postoperative morbidity, and to offer a good long-term quality of life. In this lecture, Dr. Barry Salky presents the current status of the laparoscopic approach to this pathology.

Single port access and single site incision: challenges with current instrumentation and recent development

In this key lecture, Professor Joël Leroy presents the most recent devices for single port surgery as well as new developments in instrumentation.

J Leroy

Single port access and single site incision: challenges with current instrumentation and recent development

In this key lecture, Professor Joël Leroy presents the most recent devices for single port surgery as well as new developments in instrumentation.