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General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
AM Pereira, J Magalhães, R Ferreira de Almeida, G Gonçalves, M Nora
Surgical intervention
1 year ago
2910 views
287 likes
2 comments
09:29
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
B Dallemagne, S Perretta, D Mutter, J Marescaux
Surgical intervention
1 year ago
1212 views
111 likes
0 comments
41:44
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
Minimally invasive management of an epiphrenic diverticulum
We present the case of a 65-year-old gentleman who was referred to our department with long standing symptoms of dysphagia, reflux, and regurgitation. An esophagogastroduodenoscopy (EGD) was initially performed to evaluate his symptoms and showed food residue in the esophagus and a wide-necked epiphrenic diverticulum extending from 38 to 41cm with superficial ulceration within it. The esophagogastric junction was at 45cm and appeared tight, which was consistent with the appearance of achalasia. A subsequent barium swallow and manometric studies confirmed the endoscopic findings. A minimally invasive laparoscopic approach was adopted for trans-hiatal dissection and diverticulectomy. Heller’s myotomy combined with an anti-reflux procedure was also performed to deal with the underlying achalasia as the cause of this pulsion diverticulum. The patient’s postoperative recovery was uneventful with complete resolution of his symptoms.
WT Butt, M Arumugasamy
Surgical intervention
1 year ago
1040 views
60 likes
0 comments
08:19
Minimally invasive management of an epiphrenic diverticulum
We present the case of a 65-year-old gentleman who was referred to our department with long standing symptoms of dysphagia, reflux, and regurgitation. An esophagogastroduodenoscopy (EGD) was initially performed to evaluate his symptoms and showed food residue in the esophagus and a wide-necked epiphrenic diverticulum extending from 38 to 41cm with superficial ulceration within it. The esophagogastric junction was at 45cm and appeared tight, which was consistent with the appearance of achalasia. A subsequent barium swallow and manometric studies confirmed the endoscopic findings. A minimally invasive laparoscopic approach was adopted for trans-hiatal dissection and diverticulectomy. Heller’s myotomy combined with an anti-reflux procedure was also performed to deal with the underlying achalasia as the cause of this pulsion diverticulum. The patient’s postoperative recovery was uneventful with complete resolution of his symptoms.
Laparoscopic enucleation of a horseshoe-shaped leiomyoma of the distal esophagus
This is the case of a 17-year-old girl, complaining of weight loss and dysphagia. In the preoperative work-up, gastroscopy and endoscopic ultrasonography revealed a 3-4cm multilobulated submucosal mass. Computed tomography and MRI showed a distal esophageal mass of 4cm in diameter. Fine needle aspiration biopsy was compatible with a leiomyoma. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal enucleation of the esophageal leiomyoma was performed. The patient was placed in a gynecologic position, with the surgeon standing between the patient’s legs. The first assistant stood on the right side of the patient and the second assistant on the left. The procedure was performed using 5 trocars. The phrenoesophageal membrane was divided. The distal esophagus was circumferentially mobilized. Dissection was started by separating the layer over the tumor. Blunt dissection was preferred. The use of energy devices discouraged to prevent any delayed mucosal burn injury. The leiomyoma was completely enucleated. Esophageal muscle layers were closed. The postoperative period was uneventful. This video demonstrates technical details of a laparoscopic enucleation of a hoseshoe-shaped leiomyoma of the distal esophagus.
K Karabulut, S Usta, E Sahin, Z Cetinkaya
Surgical intervention
1 year ago
575 views
42 likes
0 comments
11:21
Laparoscopic enucleation of a horseshoe-shaped leiomyoma of the distal esophagus
This is the case of a 17-year-old girl, complaining of weight loss and dysphagia. In the preoperative work-up, gastroscopy and endoscopic ultrasonography revealed a 3-4cm multilobulated submucosal mass. Computed tomography and MRI showed a distal esophageal mass of 4cm in diameter. Fine needle aspiration biopsy was compatible with a leiomyoma. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal enucleation of the esophageal leiomyoma was performed. The patient was placed in a gynecologic position, with the surgeon standing between the patient’s legs. The first assistant stood on the right side of the patient and the second assistant on the left. The procedure was performed using 5 trocars. The phrenoesophageal membrane was divided. The distal esophagus was circumferentially mobilized. Dissection was started by separating the layer over the tumor. Blunt dissection was preferred. The use of energy devices discouraged to prevent any delayed mucosal burn injury. The leiomyoma was completely enucleated. Esophageal muscle layers were closed. The postoperative period was uneventful. This video demonstrates technical details of a laparoscopic enucleation of a hoseshoe-shaped leiomyoma of the distal esophagus.
Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.
A Gomes, D Luis, T Carneiro, C Veiga
Surgical intervention
3 years ago
1839 views
56 likes
1 comment
06:40
Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.
When and how to manage esophageal diverticula: surgical and endoscopic procedures
Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), mid-esophagus, or distally (epiphrenic). Most patients with diverticula are asymptomatic. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery.
Surgical treatment has changed significantly with the development of minimally invasive methods which have increasingly replaced open surgery. If certain indications persist for open surgery, Zenker’s diverticulum is mainly treated with transoral endoscopic flexible or rigid techniques. This approach, which consists of a marsupialization of the diverticulum, also treats the concomitant motor disorder. These esophageal motor disorders are also present in the vast majority of patients with mid-esophageal or epiphrenic diverticula. These diseases are also treated mainly using a minimally invasive approach which consists of a diverticulectomy associated with an esophageal myotomy, which is widely recommended.
B Dallemagne
Lecture
3 years ago
781 views
28 likes
0 comments
24:26
When and how to manage esophageal diverticula: surgical and endoscopic procedures
Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), mid-esophagus, or distally (epiphrenic). Most patients with diverticula are asymptomatic. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery.
Surgical treatment has changed significantly with the development of minimally invasive methods which have increasingly replaced open surgery. If certain indications persist for open surgery, Zenker’s diverticulum is mainly treated with transoral endoscopic flexible or rigid techniques. This approach, which consists of a marsupialization of the diverticulum, also treats the concomitant motor disorder. These esophageal motor disorders are also present in the vast majority of patients with mid-esophageal or epiphrenic diverticula. These diseases are also treated mainly using a minimally invasive approach which consists of a diverticulectomy associated with an esophageal myotomy, which is widely recommended.
Laparoscopic resection of an epiphrenic diverticulum
This video shows a laparoscopic resection of a large epiphrenic diverticulum and an esophageal myotomy with partial posterior fundoplication. Abdominal obesity as well as an accessory left hepatic artery originating from the left gastric artery make dissection of the right para-esophageal area difficult. An anterior phrenotomy as well as the posterior retro-esophageal dissection towards the aorta make dissection of the diverticulum possible. The upper limit of the diverticulum is strongly attached to the esophagus and the pleura, and its dissection is difficult. After complete dissection of the diverticulum and with the guidance of an intraoperative endoscopy, resection is performed. As it is believed that an underlying motility disorder is present, a distal esophageal myotomy and partial fundoplication is added. The postoperative course was uneventful and the patient has no remaining symptoms.
P Vorwald, M Posada, S Ayora González, D Cortés, M de Vega Irañeta, C Ferrero, ML Sánchez de Molina
Surgical intervention
3 years ago
942 views
21 likes
0 comments
16:35
Laparoscopic resection of an epiphrenic diverticulum
This video shows a laparoscopic resection of a large epiphrenic diverticulum and an esophageal myotomy with partial posterior fundoplication. Abdominal obesity as well as an accessory left hepatic artery originating from the left gastric artery make dissection of the right para-esophageal area difficult. An anterior phrenotomy as well as the posterior retro-esophageal dissection towards the aorta make dissection of the diverticulum possible. The upper limit of the diverticulum is strongly attached to the esophagus and the pleura, and its dissection is difficult. After complete dissection of the diverticulum and with the guidance of an intraoperative endoscopy, resection is performed. As it is believed that an underlying motility disorder is present, a distal esophageal myotomy and partial fundoplication is added. The postoperative course was uneventful and the patient has no remaining symptoms.
Robot-assisted thoracic resection of an extended esophageal leiomyoma
Objective:
Leiomyomas represent approximately 70% of all benign esophageal tumors. In most cases, patients are asymptomatic, but others can present chest pain, dysphagia or weight loss. Even if malignization is rare, surgery is indicated. Laparoscopy is the most common approach because of the frequency of leiomyoma localization on the lower esophagus. However, thoracoscopy is also commonly performed with some difficulties in case of large tumors.
Our objective is to demonstrate the robotic approach and the bipolar Maryland forceps used for such a specific lesion.

Case presentation:
We present the case of a 58-year-old woman with no particular co-morbidity. On CT-scan, she was incidentally diagnosed with a leiomyoma for Guillain-Barre syndrome. A homogeneous 7cm tumor was found on the left side of the middle esophagus with a horseshoe-shaped aspect typical of leiomyoma. Check-up was completed by MRI and endoscopic ultrasonography, which tended to confirm the diagnosis.
In this video, the robot-assisted thoracic enucleation of the tumor performed by a left approach shows the quality of esophageal exposure and tumor dissection by means of a bipolar Maryland forceps. Blood loss was less than 30mL, and the postoperative period was uneventful. Histological analysis confirmed the diagnosis of leiomyoma.

Conclusion:
Robot-assisted resection of benign esophageal tumors is a safe procedure, especially for intrathoracic tumors. This technique provides a better view and easier dissection. The use of a bipolar Maryland forceps allows for a safer procedure. Day care surgery could then be expected for smaller lesions.
C Peillon, G Philouze, JM Baste
Surgical intervention
3 years ago
597 views
14 likes
0 comments
09:09
Robot-assisted thoracic resection of an extended esophageal leiomyoma
Objective:
Leiomyomas represent approximately 70% of all benign esophageal tumors. In most cases, patients are asymptomatic, but others can present chest pain, dysphagia or weight loss. Even if malignization is rare, surgery is indicated. Laparoscopy is the most common approach because of the frequency of leiomyoma localization on the lower esophagus. However, thoracoscopy is also commonly performed with some difficulties in case of large tumors.
Our objective is to demonstrate the robotic approach and the bipolar Maryland forceps used for such a specific lesion.

Case presentation:
We present the case of a 58-year-old woman with no particular co-morbidity. On CT-scan, she was incidentally diagnosed with a leiomyoma for Guillain-Barre syndrome. A homogeneous 7cm tumor was found on the left side of the middle esophagus with a horseshoe-shaped aspect typical of leiomyoma. Check-up was completed by MRI and endoscopic ultrasonography, which tended to confirm the diagnosis.
In this video, the robot-assisted thoracic enucleation of the tumor performed by a left approach shows the quality of esophageal exposure and tumor dissection by means of a bipolar Maryland forceps. Blood loss was less than 30mL, and the postoperative period was uneventful. Histological analysis confirmed the diagnosis of leiomyoma.

Conclusion:
Robot-assisted resection of benign esophageal tumors is a safe procedure, especially for intrathoracic tumors. This technique provides a better view and easier dissection. The use of a bipolar Maryland forceps allows for a safer procedure. Day care surgery could then be expected for smaller lesions.
Laparoscopic transhiatal resection of horseshoe-shaped leiomyoma of the thoracic esophagus
This is the case of a 36-year-old woman with symptoms which have been present for 18 months. Her main symptoms were the following: difficulty to swallow food accompanied by retrosternal discomfort. Upper endoscopy performed on September 29, 2011 found an extrinsic compression of the esophageal wall located 28cm away from the upper dental arcade with a mucosa which appeared to be normal. That extrinsic compression goes until 33cm from the upper dental arcade. The patient was evaluated by a gastroenterologist who performed an echo-endoscopy on March 7, 2012. The gastroenterologist observed a heterogeneous hypo-echoic mass coming from the muscular layer, 25 to 33cm away from the esophagus. The diagnosis of esophageal leiomyoma was established. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal resection of the esophageal leiomyoma was performed on May 22, 2012.
This case is essential because it shows the excision of a horseshoe-shaped leiomyoma of the thoracic esophagus. In addition, it shows a transfixing stitch, which is performed to exert traction on the tumor.
DU Castro Nuñez
Surgical intervention
4 years ago
740 views
4 likes
0 comments
10:18
Laparoscopic transhiatal resection of horseshoe-shaped leiomyoma of the thoracic esophagus
This is the case of a 36-year-old woman with symptoms which have been present for 18 months. Her main symptoms were the following: difficulty to swallow food accompanied by retrosternal discomfort. Upper endoscopy performed on September 29, 2011 found an extrinsic compression of the esophageal wall located 28cm away from the upper dental arcade with a mucosa which appeared to be normal. That extrinsic compression goes until 33cm from the upper dental arcade. The patient was evaluated by a gastroenterologist who performed an echo-endoscopy on March 7, 2012. The gastroenterologist observed a heterogeneous hypo-echoic mass coming from the muscular layer, 25 to 33cm away from the esophagus. The diagnosis of esophageal leiomyoma was established. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal resection of the esophageal leiomyoma was performed on May 22, 2012.
This case is essential because it shows the excision of a horseshoe-shaped leiomyoma of the thoracic esophagus. In addition, it shows a transfixing stitch, which is performed to exert traction on the tumor.
Laparoscopic median arcuate ligament release
The video demonstrates the case of a laparoscopic median arcuate ligament release for a patient presenting with median arcuate ligament syndrome. This is a 37-year-old woman who was admitted to our clinic with complaints of intermittent abdominal pain, especially with meals, for 3 years’ duration. Her physical examination was unremarkable, except for an epigastric bruit detected on auscultation. Investigations included a duplex ultrasound, which showed increased hemodynamic velocities in the celiac trunk. In addition, CT-angiogram of the abdomen revealed an 80% luminal narrowing and extrinsic compression of the celiac artery at its origin. Her symptoms could be a result of foregut ischemia caused by the vessel’s narrowing. A potential anatomical factor contributing to extrinsic compression is the median arcuate ligament. This video explains our operative approach and technique used to dissect the esophagus at the hiatus, creating a subsequent pathway to identify the median arcuate ligament inferiorly and transect it down to the level of the celiac trunk’s origin. This will allow for relief of the external vascular compression and increased blood flow to the foregut and relief of her abdominal pain. Postoperatively, the patient had complete resolution of her abdominal symptoms.
N De La Cruz-Munoz, K Mohammad
Surgical intervention
4 years ago
1375 views
37 likes
0 comments
13:19
Laparoscopic median arcuate ligament release
The video demonstrates the case of a laparoscopic median arcuate ligament release for a patient presenting with median arcuate ligament syndrome. This is a 37-year-old woman who was admitted to our clinic with complaints of intermittent abdominal pain, especially with meals, for 3 years’ duration. Her physical examination was unremarkable, except for an epigastric bruit detected on auscultation. Investigations included a duplex ultrasound, which showed increased hemodynamic velocities in the celiac trunk. In addition, CT-angiogram of the abdomen revealed an 80% luminal narrowing and extrinsic compression of the celiac artery at its origin. Her symptoms could be a result of foregut ischemia caused by the vessel’s narrowing. A potential anatomical factor contributing to extrinsic compression is the median arcuate ligament. This video explains our operative approach and technique used to dissect the esophagus at the hiatus, creating a subsequent pathway to identify the median arcuate ligament inferiorly and transect it down to the level of the celiac trunk’s origin. This will allow for relief of the external vascular compression and increased blood flow to the foregut and relief of her abdominal pain. Postoperatively, the patient had complete resolution of her abdominal symptoms.
Laparoscopic transhiatal resection of giant esophageal leiomyoma
This is the case of a 36-year-old male patient who had slowly progressing symptoms for 10 years. These symptoms were the following: hiccups, progressive dysphagia, first for solids, and then for liquids, and gastro-esophageal reflux. In 2003, the patient was first evaluated in a private clinic and diagnosed with esophageal wall hernia. In 2010, his symptoms were still present and he was evaluated by a physician who performed a new endoscopy, which demonstrated a 90% obstruction of the esophageal lumen. A biopsy was also performed. It was negative for malignancy, hence providing the diagnosis of esophageal leiomyoma.
In December 2011, a CT-scan and endoscopic ultrasound were performed leading to the conclusion of an esophageal leiomyoma. A laparoscopic transhiatal resection of the esophageal leiomyoma was decided upon in July 2012.
This case is essential because it shows the usefulness of a hook clamp to facilitate traction of the leiomyoma. Additionally, it shows an intraoperative complication consisting in a perforation of the esophageal mucosa, which was sutured by means of Vicryl 4/0.
DU Castro Nuñez, L Bao Romero, L Belloni Caceres
Surgical intervention
4 years ago
511 views
4 likes
0 comments
09:57
Laparoscopic transhiatal resection of giant esophageal leiomyoma
This is the case of a 36-year-old male patient who had slowly progressing symptoms for 10 years. These symptoms were the following: hiccups, progressive dysphagia, first for solids, and then for liquids, and gastro-esophageal reflux. In 2003, the patient was first evaluated in a private clinic and diagnosed with esophageal wall hernia. In 2010, his symptoms were still present and he was evaluated by a physician who performed a new endoscopy, which demonstrated a 90% obstruction of the esophageal lumen. A biopsy was also performed. It was negative for malignancy, hence providing the diagnosis of esophageal leiomyoma.
In December 2011, a CT-scan and endoscopic ultrasound were performed leading to the conclusion of an esophageal leiomyoma. A laparoscopic transhiatal resection of the esophageal leiomyoma was decided upon in July 2012.
This case is essential because it shows the usefulness of a hook clamp to facilitate traction of the leiomyoma. Additionally, it shows an intraoperative complication consisting in a perforation of the esophageal mucosa, which was sutured by means of Vicryl 4/0.
Collis Nissen procedure after lung transplantation and laparoscopic management of mediastinal hematoma
After lung transplantation, GERD causes inflammatory reactions, increasing risks for obliterating bronchiolitis and dysfunctioning graft. Authors first present a laparoscopic Collis Nissen procedure for hiatal hernia and severe esophagitis in a grafted patient. Because of a short esophagus despite extended dissection, a Collis gastroplasty is required. After stapling, cruroplasty is performed, finally followed by a Nissen fundoplication. In case of severe esophagitis, a difficult dissection and inflammatory tissues can lead to more complications such as leak, hemorrhage, slippage, and abscess. Mediastinal hematoma is diagnosed on postoperative day 9, mandating a redo emergency intervention. This rare complication will be managed laparoscopically.
B Dallemagne, S Perretta, HA Mercoli, L Marx, J Marescaux
Surgical intervention
4 years ago
1696 views
58 likes
1 comment
21:07
Collis Nissen procedure after lung transplantation and laparoscopic management of mediastinal hematoma
After lung transplantation, GERD causes inflammatory reactions, increasing risks for obliterating bronchiolitis and dysfunctioning graft. Authors first present a laparoscopic Collis Nissen procedure for hiatal hernia and severe esophagitis in a grafted patient. Because of a short esophagus despite extended dissection, a Collis gastroplasty is required. After stapling, cruroplasty is performed, finally followed by a Nissen fundoplication. In case of severe esophagitis, a difficult dissection and inflammatory tissues can lead to more complications such as leak, hemorrhage, slippage, and abscess. Mediastinal hematoma is diagnosed on postoperative day 9, mandating a redo emergency intervention. This rare complication will be managed laparoscopically.
SILS (single access) transhiatal esophagectomy for cancer
An 82-year-old man was referred to our department for a 3cm long esophageal cancer.
He was smoking 40 cigarettes a day and drinking 1.5L of wine a day. He had a BMI of 21 and he was ASA 2.
A CT-scan showed a 3cm tumor not entering the muscle layer and no nodes were found in the mediastinum.
No liver metastases were visible on CT-scan and ultrasonography (US).
During GI endoscopy, a biopsy showed an esophageal adenocarcinoma.
Ejection fraction (EF) during cardiac ultrasound was 55%.
After 15 days of gym workouts in our department (15 minutes of exercise bike in the morning and 20 minutes in the afternoon, and inflating 30 balloons in the morning, 30 at lunchtime and 30 before nighttime), the patient was operated on.
A laparoscopic transhiatal single port esophagectomy was performed according to Orringer’s technique.
Procedure time was 195 minutes. Estimated blood loss was nihil. Time in ICU was 24 hours and hospital stay was 7 days.
This was our 11th case using this technique.
C Huscher
Surgical intervention
4 years ago
2566 views
105 likes
0 comments
08:29
SILS (single access) transhiatal esophagectomy for cancer
An 82-year-old man was referred to our department for a 3cm long esophageal cancer.
He was smoking 40 cigarettes a day and drinking 1.5L of wine a day. He had a BMI of 21 and he was ASA 2.
A CT-scan showed a 3cm tumor not entering the muscle layer and no nodes were found in the mediastinum.
No liver metastases were visible on CT-scan and ultrasonography (US).
During GI endoscopy, a biopsy showed an esophageal adenocarcinoma.
Ejection fraction (EF) during cardiac ultrasound was 55%.
After 15 days of gym workouts in our department (15 minutes of exercise bike in the morning and 20 minutes in the afternoon, and inflating 30 balloons in the morning, 30 at lunchtime and 30 before nighttime), the patient was operated on.
A laparoscopic transhiatal single port esophagectomy was performed according to Orringer’s technique.
Procedure time was 195 minutes. Estimated blood loss was nihil. Time in ICU was 24 hours and hospital stay was 7 days.
This was our 11th case using this technique.
Thoracoscopic enucleation of a middle esophagus leiomyoma
Leiomyoma is the most frequent esophageal benign tumor. It represents 70% of these tumors and 1 to 8% of all esophageal tumors. The most frequent location is the distal esophagus. The majority of cases are asymptomatic and are discovered by chance in endoscopic or radiologic examinations. An endoscopic or surgical treatment can be applied in symptomatic cases (mainly dysphagia), basically depending on its size.
We present a thoracoscopic enucleation of a milddle esophagus leiomyoma in a 41-year-old woman. The operation was performed using a thoracoscopic approach. The patient was placed in a prone decubitus position. The tumor was enucleated by myotomy with subsequent suturing of the muscular gap through three trocars. There were no complications. After 48 hours postoperatively, a water-soluble contrast gastroduodenal study revealed normal passage through the esophageal lumen. The pathologist's diagnosis was esophageal leiomyoma.
F Ochando Cerdan, JM Fernandez Cebrian, L Vega Lopez
Surgical intervention
5 years ago
1259 views
16 likes
0 comments
16:15
Thoracoscopic enucleation of a middle esophagus leiomyoma
Leiomyoma is the most frequent esophageal benign tumor. It represents 70% of these tumors and 1 to 8% of all esophageal tumors. The most frequent location is the distal esophagus. The majority of cases are asymptomatic and are discovered by chance in endoscopic or radiologic examinations. An endoscopic or surgical treatment can be applied in symptomatic cases (mainly dysphagia), basically depending on its size.
We present a thoracoscopic enucleation of a milddle esophagus leiomyoma in a 41-year-old woman. The operation was performed using a thoracoscopic approach. The patient was placed in a prone decubitus position. The tumor was enucleated by myotomy with subsequent suturing of the muscular gap through three trocars. There were no complications. After 48 hours postoperatively, a water-soluble contrast gastroduodenal study revealed normal passage through the esophageal lumen. The pathologist's diagnosis was esophageal leiomyoma.
Laparoscopic enucleation of horseshoe-shaped esophageal leiomyoma: use of mini-instruments
Introduction:
Leiomyoma is the most common benign tumor of the esophagus, usually arising in the inner circular muscle layer of the distal esophagus. Middle-aged men are most frequently affected. Most patients remain asymptomatic and when they become symptomatic, the main signs are usually dysphagia and epigastric pain, but they are not specific to the disease. Malignization is rare but should not be ignored.
The minimally invasive approach to these tumors allows for complete extirpation with minimal morbidity and provides excellent results.

Materials and methods:
We present the case of a 31-year-old woman with no medical history, who underwent a CT-scan for other reasons, namely for urinary symptoms. A 3cm homogeneous, low attenuated mass was found at the gastroesophageal junction. Endoscopic ultrasound is performed and showed a 50mm horseshoe-shaped tumor affecting three quarters of the esophageal circumference. Because of clinical deterioration, and mainly of dysphagia, elective surgery was decided upon.

Results:
In this video, it is possible to appreciate the laparoscopic enucleation of this horseshoe-shaped tumor, which depends on the distal esophageal wall, mainly using blunt dissection. The intervention is completed with a Toupet fundoplication. The postoperative course was uneventful, and the patient is discharged on the third postoperative day, and symptoms are resolved.

Conclusions:
Minimally invasive laparoscopic resection of distal esophageal benign tumors is technically safe and provides the well-known advantages of laparoscopic access, achieving quick patient recovery and a short hospital stay.
Some authors recommend to perform an anti-reflux procedure in order to protect the surgical resection area and therefore prevent complications due to the weakening of the lower esophageal sphincter, such as reflux symptoms.
C Rodríguez-Otero Luppi, EM Targarona Soler, C Balagué Ponz, JL Pallarés Segura, M Trías Folch
Surgical intervention
5 years ago
773 views
4 likes
1 comment
08:45
Laparoscopic enucleation of horseshoe-shaped esophageal leiomyoma: use of mini-instruments
Introduction:
Leiomyoma is the most common benign tumor of the esophagus, usually arising in the inner circular muscle layer of the distal esophagus. Middle-aged men are most frequently affected. Most patients remain asymptomatic and when they become symptomatic, the main signs are usually dysphagia and epigastric pain, but they are not specific to the disease. Malignization is rare but should not be ignored.
The minimally invasive approach to these tumors allows for complete extirpation with minimal morbidity and provides excellent results.

Materials and methods:
We present the case of a 31-year-old woman with no medical history, who underwent a CT-scan for other reasons, namely for urinary symptoms. A 3cm homogeneous, low attenuated mass was found at the gastroesophageal junction. Endoscopic ultrasound is performed and showed a 50mm horseshoe-shaped tumor affecting three quarters of the esophageal circumference. Because of clinical deterioration, and mainly of dysphagia, elective surgery was decided upon.

Results:
In this video, it is possible to appreciate the laparoscopic enucleation of this horseshoe-shaped tumor, which depends on the distal esophageal wall, mainly using blunt dissection. The intervention is completed with a Toupet fundoplication. The postoperative course was uneventful, and the patient is discharged on the third postoperative day, and symptoms are resolved.

Conclusions:
Minimally invasive laparoscopic resection of distal esophageal benign tumors is technically safe and provides the well-known advantages of laparoscopic access, achieving quick patient recovery and a short hospital stay.
Some authors recommend to perform an anti-reflux procedure in order to protect the surgical resection area and therefore prevent complications due to the weakening of the lower esophageal sphincter, such as reflux symptoms.
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
S Perretta, LL Swanström, B Dallemagne, J Marescaux
Surgical intervention
5 years ago
2755 views
39 likes
0 comments
07:08
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
Laparoscopic stepwise approach of a tumor of the gastroesophageal junction
GISTs are rare neoplasms that account for less than 1% of all gastrointestinal malignancies. GISTs have the capability to become malignant and then metastasize, whereas leiomyomas are almost invariably benign. In clinical practice, preoperative differentiation between GISTs and leiomyomas is usually difficult, even if EUS-guided fine-needle aspiration or trucut biopsy is performed. Leiomyomas are rare in the stomach and duodenum while GIST are more frequent in the stomach.
This patient presented with a 6cm submucosal tumor below the gastroesophageal junction. This video demonstrates the stepwise laparoscopic approach taking into consideration the potentially (pre-)malignant nature of the tumor.
B Dallemagne, S Perretta, S Mandala, J Marescaux
Surgical intervention
5 years ago
1780 views
17 likes
0 comments
26:11
Laparoscopic stepwise approach of a tumor of the gastroesophageal junction
GISTs are rare neoplasms that account for less than 1% of all gastrointestinal malignancies. GISTs have the capability to become malignant and then metastasize, whereas leiomyomas are almost invariably benign. In clinical practice, preoperative differentiation between GISTs and leiomyomas is usually difficult, even if EUS-guided fine-needle aspiration or trucut biopsy is performed. Leiomyomas are rare in the stomach and duodenum while GIST are more frequent in the stomach.
This patient presented with a 6cm submucosal tumor below the gastroesophageal junction. This video demonstrates the stepwise laparoscopic approach taking into consideration the potentially (pre-)malignant nature of the tumor.
Repair of distal esophageal perforation (Boerhaave’s syndrome) by left thoracoscopy with the patient in prone position
Background: Boerhaave’s syndrome is an emergency disease related to a high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation treated by left thoracoscopy in prone position.

Clinical case: A 44-year-old man was admitted to our emergency room following a 14-hour episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated with a pneumomediastinum. The patient underwent a left thoracoscopy in a prone position, after induction of general anesthesia using a Carlens-type double lumen tube. Three trocars of 5mm, 10mm, and 5mm, were placed in the 5th, 7th, and 10th intercostal spaces respectively. Exploration of the chest cavity revealed the presence of free liquid and fibrin, with no evidence of esophageal perforation. However, the esophageal perforation was demonstrated after dissection of the mediastinal pleura, and appeared to be 2cm in length. A nasogastric tube was advanced into the stomach under visual control, and an additional trocarless grasper was placed in the 10th intercostal space to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleansed and the 5mm trocar was replaced with a chest tube in the 10th intercostal space, with its tip close to the suture.

Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was admitted to hospital in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardial drain was placed after 16 days for pericardial tamponade. A gastrograffin swallow test on postoperative day 10 revealed a residual sinus at the site of the perforation. Another gastrograffin swallow test on postoperative day 20 was negative for leakage. The patient was discharged after 32 days.

Conclusions: Esophageal perforation can be treated by thoracoscopy with the patient placed in a prone position as access is facilitated by the effect of gravity on the cardiopulmonary organs. The success of the primary suture depends on the timing between the incident and the treatment; however, morbidity remains high.
G Dapri, S Carandina, L Gerard, GB Cadière
Surgical intervention
6 years ago
2985 views
58 likes
0 comments
07:11
Repair of distal esophageal perforation (Boerhaave’s syndrome) by left thoracoscopy with the patient in prone position
Background: Boerhaave’s syndrome is an emergency disease related to a high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation treated by left thoracoscopy in prone position.

Clinical case: A 44-year-old man was admitted to our emergency room following a 14-hour episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated with a pneumomediastinum. The patient underwent a left thoracoscopy in a prone position, after induction of general anesthesia using a Carlens-type double lumen tube. Three trocars of 5mm, 10mm, and 5mm, were placed in the 5th, 7th, and 10th intercostal spaces respectively. Exploration of the chest cavity revealed the presence of free liquid and fibrin, with no evidence of esophageal perforation. However, the esophageal perforation was demonstrated after dissection of the mediastinal pleura, and appeared to be 2cm in length. A nasogastric tube was advanced into the stomach under visual control, and an additional trocarless grasper was placed in the 10th intercostal space to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleansed and the 5mm trocar was replaced with a chest tube in the 10th intercostal space, with its tip close to the suture.

Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was admitted to hospital in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardial drain was placed after 16 days for pericardial tamponade. A gastrograffin swallow test on postoperative day 10 revealed a residual sinus at the site of the perforation. Another gastrograffin swallow test on postoperative day 20 was negative for leakage. The patient was discharged after 32 days.

Conclusions: Esophageal perforation can be treated by thoracoscopy with the patient placed in a prone position as access is facilitated by the effect of gravity on the cardiopulmonary organs. The success of the primary suture depends on the timing between the incident and the treatment; however, morbidity remains high.
Thoracoscopic resection of an esophageal leiomyoma
Benign tumors of the esophagus are rare lesions that constitute less than 1% of esophageal neoplasms. Nearly two thirds of benign tumors are leiomyomas. They usually arise as intramural growths, most commonly along the distal two thirds of the esophagus. They have extremely small potential for malignant degeneration. Surgical excision is recommended for symptomatic great lesions. The video demonstrates the thoracoscopic resection of a leiomyoma on the upper thoracic third of the esophagus with the patient in a prone position, which brings an excellent exposure of the operative field and decreases lung injuries as we do not use any retractor.
J Torres Bermúdez, FC Becerra García, J Lopez Espejo, JL Martín, G Sánchez de la Villa
Surgical intervention
6 years ago
2118 views
18 likes
0 comments
07:22
Thoracoscopic resection of an esophageal leiomyoma
Benign tumors of the esophagus are rare lesions that constitute less than 1% of esophageal neoplasms. Nearly two thirds of benign tumors are leiomyomas. They usually arise as intramural growths, most commonly along the distal two thirds of the esophagus. They have extremely small potential for malignant degeneration. Surgical excision is recommended for symptomatic great lesions. The video demonstrates the thoracoscopic resection of a leiomyoma on the upper thoracic third of the esophagus with the patient in a prone position, which brings an excellent exposure of the operative field and decreases lung injuries as we do not use any retractor.
Laparoscopic resection of an esophageal leiomyoma
Leiomyomas represent a hyperproliferation of interlacing bundles of smooth muscle cells that are well demarcated by adjacent tissue or by a smooth connective tissue capsule. They usually arise as intramural growths and rarely cause symptoms when they are smaller than 5cm in diameter. In the distal esophagus, they may reach large proportions and may encroach on the cardia of the stomach. The majority of leiomyomas have been discovered during evaluation for dysphagia.
The traditional open thoracotomy for the enucleation of larger symptomatic esophageal leiomyomas has been gradually replaced by thoracoscopic or laparoscopic approaches. The video demonstrates the laparoscopic resection of a leiomyoma in a 50-year-old woman with a history of reflux esophagitis presenting with dysphagia.
J Torres Bermúdez, FC Becerra García, S del Valle Ruiz , AA Carrillo Sánchez, G Sánchez de la Villa
Surgical intervention
6 years ago
1230 views
8 likes
0 comments
09:13
Laparoscopic resection of an esophageal leiomyoma
Leiomyomas represent a hyperproliferation of interlacing bundles of smooth muscle cells that are well demarcated by adjacent tissue or by a smooth connective tissue capsule. They usually arise as intramural growths and rarely cause symptoms when they are smaller than 5cm in diameter. In the distal esophagus, they may reach large proportions and may encroach on the cardia of the stomach. The majority of leiomyomas have been discovered during evaluation for dysphagia.
The traditional open thoracotomy for the enucleation of larger symptomatic esophageal leiomyomas has been gradually replaced by thoracoscopic or laparoscopic approaches. The video demonstrates the laparoscopic resection of a leiomyoma in a 50-year-old woman with a history of reflux esophagitis presenting with dysphagia.
Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure
This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.
B Dallemagne, S Perretta, Gf Donatelli, J Marescaux
Surgical intervention
6 years ago
3297 views
72 likes
0 comments
24:49
Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure
This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.
Laparoscopic excision of a large leiomyoma of the esophagogastric junction
Esophageal leiomyomas represent a benign pathology that usually affects the distal third and the esophagogastric junction, and that is perfectly suitable for a laparoscopic enucleation. A correct preoperative diagnosis is mandatory, as the most common differential diagnosis in this localization is represented by gastrointestinal stromal tumors (GIST), a pathology that could benefit from neo-adjuvant therapy. Occasionally, leiomyomas can be adherent to the mucosal layer, in which case-limited mucosal excision is necessary.
We present a laparoscopic enucleation of a large leiomyoma of the esophagogastric junction, requiring the use of an endostapler for complete resection.
C Balagué Ponz, EM Targarona Soler, S Mocanu, S Fernandez Ananin, F Marinello, M Trías Folch
Surgical intervention
7 years ago
1489 views
7 likes
0 comments
09:00
Laparoscopic excision of a large leiomyoma of the esophagogastric junction
Esophageal leiomyomas represent a benign pathology that usually affects the distal third and the esophagogastric junction, and that is perfectly suitable for a laparoscopic enucleation. A correct preoperative diagnosis is mandatory, as the most common differential diagnosis in this localization is represented by gastrointestinal stromal tumors (GIST), a pathology that could benefit from neo-adjuvant therapy. Occasionally, leiomyomas can be adherent to the mucosal layer, in which case-limited mucosal excision is necessary.
We present a laparoscopic enucleation of a large leiomyoma of the esophagogastric junction, requiring the use of an endostapler for complete resection.
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy in obese patients
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy using a circular stapler or manual anastomosis has recently been described by a few authors.
We performed this challenging technique with a completely thoracoscopic hand-sewn esophagogastric anastomosis in two obese patients in prone position (one female and one male), affected by an adenocarcinoma of the lower third of the esophagus without lymph node invasion (pT2 N0) and with a BMI of 35 and 32 respectively. The first female patient is the subject of this video.
Thoracoscopy lasted 150 minutes (anastomosis was 50 minutes long), laparoscopy lasted 130 minutes, and second laparoscopy lasted 20 minutes. Blood loss was estimated at 150 mL.
The gastrografin swallows (on postoperative day 7 in both patients) showed absence of stenosis and leak. The patients had an uneventful postoperative course and were discharged on postoperative day 12 and 10, respectively.
Thoracoscopy in prone position allows the surgeon to perform a thoracoscopic esophagogastric anastomosis completely hand-sewn without selective lung exclusion, and using only three trocars.
In obese patients, although the technique is foremost challenging, the advantages of minimally invasive surgery are undeniable —better intraoperative respiratory function (avoiding selective lung exclusion) and less complicated postoperative course.
P Ubiali, M Andretta, M Ciocca Vasino, A Mancin, S Pastori, F Maffeis
Surgical intervention
7 years ago
8234 views
132 likes
0 comments
18:36
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy in obese patients
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy using a circular stapler or manual anastomosis has recently been described by a few authors.
We performed this challenging technique with a completely thoracoscopic hand-sewn esophagogastric anastomosis in two obese patients in prone position (one female and one male), affected by an adenocarcinoma of the lower third of the esophagus without lymph node invasion (pT2 N0) and with a BMI of 35 and 32 respectively. The first female patient is the subject of this video.
Thoracoscopy lasted 150 minutes (anastomosis was 50 minutes long), laparoscopy lasted 130 minutes, and second laparoscopy lasted 20 minutes. Blood loss was estimated at 150 mL.
The gastrografin swallows (on postoperative day 7 in both patients) showed absence of stenosis and leak. The patients had an uneventful postoperative course and were discharged on postoperative day 12 and 10, respectively.
Thoracoscopy in prone position allows the surgeon to perform a thoracoscopic esophagogastric anastomosis completely hand-sewn without selective lung exclusion, and using only three trocars.
In obese patients, although the technique is foremost challenging, the advantages of minimally invasive surgery are undeniable —better intraoperative respiratory function (avoiding selective lung exclusion) and less complicated postoperative course.
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
8 years ago
3466 views
87 likes
0 comments
17:25
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
Minimally invasive Ivor Lewis esophagectomy for cancer
Minimally invasive Ivor Lewis esophagectomy is technically challenging but feasible in experienced minimally invasive surgery centers. This video illustrates the surgical approach of an Ivor-Lewis esophagectomy. This surgery was carried out in a patient presenting with a type 2 cardia tumor according to Siewert’s classification. The preoperative workup confirmed the presence of an adenocarcinoma with locoregional lymph nodes. After neoadjuvant chemotherapy, a massive melt of the tumor was evidenced without any residual lesion or any local or distant metastasis. In this context, a curative resection has been proposed. Considering the tumor’s type, a resection combining an abdominal with a thoracic approach was decided upon.
B Dallemagne, J Marescaux
Surgical intervention
8 years ago
3044 views
225 likes
0 comments
18:46
Minimally invasive Ivor Lewis esophagectomy for cancer
Minimally invasive Ivor Lewis esophagectomy is technically challenging but feasible in experienced minimally invasive surgery centers. This video illustrates the surgical approach of an Ivor-Lewis esophagectomy. This surgery was carried out in a patient presenting with a type 2 cardia tumor according to Siewert’s classification. The preoperative workup confirmed the presence of an adenocarcinoma with locoregional lymph nodes. After neoadjuvant chemotherapy, a massive melt of the tumor was evidenced without any residual lesion or any local or distant metastasis. In this context, a curative resection has been proposed. Considering the tumor’s type, a resection combining an abdominal with a thoracic approach was decided upon.
Laparoscopic transhiatal esophagectomy for adenocarcinoma of the lower esophagus
Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
9 years ago
5507 views
159 likes
1 comment
21:14
Laparoscopic transhiatal esophagectomy for adenocarcinoma of the lower esophagus
Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.
Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus
Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus.
An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.
B Dallemagne, J Marescaux
Surgical intervention
9 years ago
760 views
14 likes
0 comments
13:18
Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus
Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus.
An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.
Laparoscopic Heller procedure for achalasia
This is a 'live' surgery performed by Dr. B Dallemagne demonstrating the key steps in performing a Heller procedure. Minimal dissection is carried out to expose the anterior surface of the esophagus, after which the myotomy is delicately performed with scissors. This video is recommended to upper GI surgeons.
Barium swallow showed the classic sign of achalasia at the level of the cardia in this elderly woman with gastroesophageal reflux disease. CT-scan of the chest showed a large sigmoid-like esophagus. Mobilization of the esophagus begins with the authors opening only the anterior aspect of the hiatus to gain access to the esophagus. They dissect the upper part of the esophagus and expose the azygos vein on the right, clearing the gastroesophageal junction on the gastric side of the cardia. They continue by opening the hypertrophic musculature to enable swallowing, then continue with a Heller myotomy.
B Dallemagne, J Marescaux
Surgical intervention
11 years ago
494 views
126 likes
0 comments
11:59
Laparoscopic Heller procedure for achalasia
This is a 'live' surgery performed by Dr. B Dallemagne demonstrating the key steps in performing a Heller procedure. Minimal dissection is carried out to expose the anterior surface of the esophagus, after which the myotomy is delicately performed with scissors. This video is recommended to upper GI surgeons.
Barium swallow showed the classic sign of achalasia at the level of the cardia in this elderly woman with gastroesophageal reflux disease. CT-scan of the chest showed a large sigmoid-like esophagus. Mobilization of the esophagus begins with the authors opening only the anterior aspect of the hiatus to gain access to the esophagus. They dissect the upper part of the esophagus and expose the azygos vein on the right, clearing the gastroesophageal junction on the gastric side of the cardia. They continue by opening the hypertrophic musculature to enable swallowing, then continue with a Heller myotomy.
Laparoscopic robotic-assisted Heller procedure for esophageal achalasia
This video demonstrates a robotic-assisted Heller procedure for treatment of esophageal achalasia. The surgeon starts by dissecting the gastroesophageal junction. The mobilization of the stomach is limited to the anterior and lateral aspect, leaving the posterior attachments intact. The myotomy is started just above the gastroesophageal junction and extended 6 cm proximally and 2 cm distally onto the stomach using robotic articulated scissors. The extension of the myotomy on the gastric side continues to be the most difficult part of the dissection. The change in direction of the muscular fibers, from circular at the esophagus, to oblique at the stomach, makes it difficult to develop the necessary submucosal plane for dividing the muscular fibers. The video demonstrates the freedom of movement of the articulated robotic instruments that allow the surgeon to divide each individual muscular fiber achieving a precise dissection of the gastroesophageal junction. Once the myotomy is completed a standard Dor Fundoplication is performed.
B Dallemagne
Surgical intervention
12 years ago
564 views
59 likes
0 comments
12:18
Laparoscopic robotic-assisted Heller procedure for esophageal achalasia
This video demonstrates a robotic-assisted Heller procedure for treatment of esophageal achalasia. The surgeon starts by dissecting the gastroesophageal junction. The mobilization of the stomach is limited to the anterior and lateral aspect, leaving the posterior attachments intact. The myotomy is started just above the gastroesophageal junction and extended 6 cm proximally and 2 cm distally onto the stomach using robotic articulated scissors. The extension of the myotomy on the gastric side continues to be the most difficult part of the dissection. The change in direction of the muscular fibers, from circular at the esophagus, to oblique at the stomach, makes it difficult to develop the necessary submucosal plane for dividing the muscular fibers. The video demonstrates the freedom of movement of the articulated robotic instruments that allow the surgeon to divide each individual muscular fiber achieving a precise dissection of the gastroesophageal junction. Once the myotomy is completed a standard Dor Fundoplication is performed.
Minimally invasive esophagectomy in a patient in a prone position
This video demonstrates a total esophagectomy for a cancer of distal esophagus. The surgeon starts with right thoracoscopy with the patient in a prone position. The esophagus and adjoining lymphatics are mobilized and separated from the adjoining structures. The azygos vein is divided. Once full mobilization of the thoracic esophagus is achieved, a chest tube is inserted and the trocars are removed and the patient is put in a supine position. The surgeon now performs laparoscopic dissection of the left gastric vessels and lymphatics. A gastric tube is created and duodenum is kocherized. After full mobilization of the gastroesophageal junction and the tumor at the hiatus, a cervicotomy is carried out and the esophagus is pulled out through the cervical incision. The esophagus is resected and a side-to-side stapled anastomosis is made between the cervical esophagus and the gastric tube.
GB Cadière, J Himpens
Surgical intervention
12 years ago
433 views
24 likes
1 comment
11:57
Minimally invasive esophagectomy in a patient in a prone position
This video demonstrates a total esophagectomy for a cancer of distal esophagus. The surgeon starts with right thoracoscopy with the patient in a prone position. The esophagus and adjoining lymphatics are mobilized and separated from the adjoining structures. The azygos vein is divided. Once full mobilization of the thoracic esophagus is achieved, a chest tube is inserted and the trocars are removed and the patient is put in a supine position. The surgeon now performs laparoscopic dissection of the left gastric vessels and lymphatics. A gastric tube is created and duodenum is kocherized. After full mobilization of the gastroesophageal junction and the tumor at the hiatus, a cervicotomy is carried out and the esophagus is pulled out through the cervical incision. The esophagus is resected and a side-to-side stapled anastomosis is made between the cervical esophagus and the gastric tube.
Totally laparoscopic Collis-Nissen operation for shortened esophagus
This video demonstrates a laparoscopic Collis-Nissen in a patient with a large hiatal hernia and shortened esophagus. The surgeon demonstrates the resection of the hernia sac and extensive mobilization of the esophagus through the hiatus to achieve an adequate length of intra-abdominal esophagus. Despite this, the esophagus was too short and the surgeon performs a Collis gastroplasty using the wedge gastrectomy technique over a 52 French bougie. A 2.5cm of tension-free intra-abdominal esophagus is achieved. The hiatus is repaired with interrupted non-absorbable sutures inserted posteriorly as well as an additional suture inserted anteriorly to the esophagus. The posterior repair is reinforced with use of a porcine biological mesh. A standard Nissen fundoplication is performed.
B Dallemagne
Surgical intervention
12 years ago
1541 views
2 likes
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08:54
Totally laparoscopic Collis-Nissen operation for shortened esophagus
This video demonstrates a laparoscopic Collis-Nissen in a patient with a large hiatal hernia and shortened esophagus. The surgeon demonstrates the resection of the hernia sac and extensive mobilization of the esophagus through the hiatus to achieve an adequate length of intra-abdominal esophagus. Despite this, the esophagus was too short and the surgeon performs a Collis gastroplasty using the wedge gastrectomy technique over a 52 French bougie. A 2.5cm of tension-free intra-abdominal esophagus is achieved. The hiatus is repaired with interrupted non-absorbable sutures inserted posteriorly as well as an additional suture inserted anteriorly to the esophagus. The posterior repair is reinforced with use of a porcine biological mesh. A standard Nissen fundoplication is performed.