We use cookies to offer you an optimal experience on our website. By browsing our website, you accept the use of cookies.

General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Laparoscopic excision of urachal cyst - a minimally invasive approach of a rare cause of abdominal pain in adults
Congenital abnormalities of the urachus are rare, with an incidence of 2:300000 children and 1:5000 adults. The urachus is a fibrous remnant of the allantois, usually occluded in the 4-5th gestational months, with the descent of the bladder towards the pelvis. It lies in the space of Retzius, between the transverse fascia anteriorly and the peritoneum posteriorly. The absence of its obliteration can result in an urachal cyst in 36% of cases. The main complication of the cyst is focal infection with associated risks of rupture and intestinal involvement. Diagnosis relies on clinical history, abdominopelvic ultrasonography and CT-scan. The treatment consists in complete excision of abnormal tissue and a small portion of adjacent bladder wall, therefore reducing the risk of malignant degeneration of the entire remnant.
A twenty-year-old healthy woman was referred to the emergency department with localized discomfort and a foul smelling purulent discharge from the umbilicus with three days of evolution. The patient was afebrile with periumbilical inflammatory signs, without signs of peritoneal irritation on physical exam. Blood tests were all normal, apart from a raised C-reactive protein (2.52mg/dL). Abdominal ultrasound was suggestive of an infected urachal cyst with umbilical fistulization. Empirical treatment with antibiotics was started and an abdominopelvic CT-scan, made as outpatient surgery, showed a probable 26mm urachal cyst, posterior and adjacent to the umbilicus, without bladder attachment.
The patient was treated surgically with a laparoscopic excision of the remainder of the urachus, without intraoperative complications. A good clinical evolution was observed during the hospital stay, and the patient was discharged on the fourth postoperative day. On follow-up, the patient did not complain of anything.
This clinical case emphasizes the importance of the high index of diagnostic suspicion in the management and treatment of the rare causes of abdominal pain, often with the possibility of a minimally invasive approach.
A Tojal, AR Loureiro, B Prata, R Patrão, N Carrilho, C Casimiro
Surgical intervention
26 days ago
513 views
2 likes
1 comment
10:34
Laparoscopic excision of urachal cyst - a minimally invasive approach of a rare cause of abdominal pain in adults
Congenital abnormalities of the urachus are rare, with an incidence of 2:300000 children and 1:5000 adults. The urachus is a fibrous remnant of the allantois, usually occluded in the 4-5th gestational months, with the descent of the bladder towards the pelvis. It lies in the space of Retzius, between the transverse fascia anteriorly and the peritoneum posteriorly. The absence of its obliteration can result in an urachal cyst in 36% of cases. The main complication of the cyst is focal infection with associated risks of rupture and intestinal involvement. Diagnosis relies on clinical history, abdominopelvic ultrasonography and CT-scan. The treatment consists in complete excision of abnormal tissue and a small portion of adjacent bladder wall, therefore reducing the risk of malignant degeneration of the entire remnant.
A twenty-year-old healthy woman was referred to the emergency department with localized discomfort and a foul smelling purulent discharge from the umbilicus with three days of evolution. The patient was afebrile with periumbilical inflammatory signs, without signs of peritoneal irritation on physical exam. Blood tests were all normal, apart from a raised C-reactive protein (2.52mg/dL). Abdominal ultrasound was suggestive of an infected urachal cyst with umbilical fistulization. Empirical treatment with antibiotics was started and an abdominopelvic CT-scan, made as outpatient surgery, showed a probable 26mm urachal cyst, posterior and adjacent to the umbilicus, without bladder attachment.
The patient was treated surgically with a laparoscopic excision of the remainder of the urachus, without intraoperative complications. A good clinical evolution was observed during the hospital stay, and the patient was discharged on the fourth postoperative day. On follow-up, the patient did not complain of anything.
This clinical case emphasizes the importance of the high index of diagnostic suspicion in the management and treatment of the rare causes of abdominal pain, often with the possibility of a minimally invasive approach.
Laparoscopic resection of inguinal recurrence of myxoid liposarcoma
This is the case of a laparoscopic resection of inguinal recurrence of myxoid liposarcoma (MLS). In 2003, a 29-year-old man presented with a 23cm right thigh mass, compatible with soft tissue sarcoma. He underwent radical surgery and the final pathological examination confirmed a grade 1 myxoid liposarcoma. He received adjuvant radiotherapy (70 Gy). Follow-up demonstrated that the patient was disease-free until 2015. In September 2017, he presented to the emergency room with a lower right extremity edema. Radiological examination demonstrated the presence of an 8cm inguinal mass compatible with a late inguinal recurrence of known sarcoma. Neoadjuvant chemotherapy was indicated and elective surgery was performed in January 2018. CT-scan revealed a mass in the preperitoneal space, displacing the urinary bladder medially, involving right external iliac vessels and getting into the femoral canal distally. A laparoscopic approach was decided upon.
C Rodríguez-Otero Luppi, M Rodríguez Blanco, E Ballester Vázquez, V Artigas Raventós
Surgical intervention
8 months ago
962 views
37 likes
2 comments
09:00
Laparoscopic resection of inguinal recurrence of myxoid liposarcoma
This is the case of a laparoscopic resection of inguinal recurrence of myxoid liposarcoma (MLS). In 2003, a 29-year-old man presented with a 23cm right thigh mass, compatible with soft tissue sarcoma. He underwent radical surgery and the final pathological examination confirmed a grade 1 myxoid liposarcoma. He received adjuvant radiotherapy (70 Gy). Follow-up demonstrated that the patient was disease-free until 2015. In September 2017, he presented to the emergency room with a lower right extremity edema. Radiological examination demonstrated the presence of an 8cm inguinal mass compatible with a late inguinal recurrence of known sarcoma. Neoadjuvant chemotherapy was indicated and elective surgery was performed in January 2018. CT-scan revealed a mass in the preperitoneal space, displacing the urinary bladder medially, involving right external iliac vessels and getting into the femoral canal distally. A laparoscopic approach was decided upon.
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
D Mutter, J Marescaux
Surgical intervention
1 year ago
16253 views
1388 likes
1 comment
25:14
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
A rare cause of abdominal pain (liposarcoma) treated by a minimally invasive approach
A 53-year-old woman is referred to the emergency department with complaints of an insidious pain in the left lower abdominal quadrant, with no associated fever, neither changes in her bowel habits, nor other complaints. She had a cardiac arrhythmia, medicated with atenolol, and no previous surgeries. Laboratory results showed no significant changes. Abdominal ultrasound demonstrated an inflammatory mass adjacent to the left colon. The abdominal and pelvic CT-scan showed a bulky and capsulated mass at the left iliac fossa extending along the left flank until the lower pole of the left kidney, measuring 9x12x20cm, probably corresponding to a peritoneal lipoma, with no signs of aggressiveness towards adjacent organs. The patient was admitted to hospital for clinical vigilance and complementary exams. Upper and lower endoscopic studies were performed and revealed no significant changes. The patient was then proposed for elective surgery – laparoscopic excision of the intra-abdominal mass, which was independent of the intra-abdominal visceral content. In the postoperative period, the patient had no complications with clinical discharge four days after surgery. The pathology report revealed a well-differentiated lipomatous neoplasia, a lipoma-like liposarcoma. In a multidisciplinary meeting, it was decided not to perform any adjuvant treatment. The patient remains with neither clinical nor imaging signs of the disease after 10 months of follow-up.
A Tojal, J Marques, S Coelho, M Fernandes, N Carrilho, H Oliveira, C Casimiro
Surgical intervention
1 year ago
966 views
63 likes
0 comments
07:41
A rare cause of abdominal pain (liposarcoma) treated by a minimally invasive approach
A 53-year-old woman is referred to the emergency department with complaints of an insidious pain in the left lower abdominal quadrant, with no associated fever, neither changes in her bowel habits, nor other complaints. She had a cardiac arrhythmia, medicated with atenolol, and no previous surgeries. Laboratory results showed no significant changes. Abdominal ultrasound demonstrated an inflammatory mass adjacent to the left colon. The abdominal and pelvic CT-scan showed a bulky and capsulated mass at the left iliac fossa extending along the left flank until the lower pole of the left kidney, measuring 9x12x20cm, probably corresponding to a peritoneal lipoma, with no signs of aggressiveness towards adjacent organs. The patient was admitted to hospital for clinical vigilance and complementary exams. Upper and lower endoscopic studies were performed and revealed no significant changes. The patient was then proposed for elective surgery – laparoscopic excision of the intra-abdominal mass, which was independent of the intra-abdominal visceral content. In the postoperative period, the patient had no complications with clinical discharge four days after surgery. The pathology report revealed a well-differentiated lipomatous neoplasia, a lipoma-like liposarcoma. In a multidisciplinary meeting, it was decided not to perform any adjuvant treatment. The patient remains with neither clinical nor imaging signs of the disease after 10 months of follow-up.
Transumbilical single-access laparoscopic subxiphoidal incisional hernia repair
Background: In this video, the authors report the case of a 65-year-old man who consulted for a subxiphoidal incisional hernia after open cardiac surgery. A transumbilical single access laparoscopic repair was proposed.

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

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

Conclusion: Subxiphoidal incisional hernia after open cardiac surgery can be treated successfully using a transumbilical single access laparoscopy.
G Dapri, A Cadenas Febres, L Cardinali, SH Sondji, I Surdeanu, GB Cadière
Surgical intervention
1 year ago
1392 views
132 likes
0 comments
06:30
Transumbilical single-access laparoscopic subxiphoidal incisional hernia repair
Background: In this video, the authors report the case of a 65-year-old man who consulted for a subxiphoidal incisional hernia after open cardiac surgery. A transumbilical single access laparoscopic repair was proposed.

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

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

Conclusion: Subxiphoidal incisional hernia after open cardiac surgery can be treated successfully using a transumbilical single access laparoscopy.
Laparoscopic prosthetic parastomal and perineal hernias repair after abdominoperineal resection
Background: In this video, the authors report the case of a 74-year-old woman who consulted for episodes of intestinal occlusions following an abdomino-perineal resection for rectal adenocarcinoma (pT2N0M0), performed 6 years earlier. Abdomino-pelvic CT-scan showed a parastomal hernia with migrated small bowel loops and a perineal hernia with transposition of the caecum and bowel loops into the pelvis. Preoperative work-up was negative for tumor recurrence, hence a laparoscopic treatment using a double dual face prosthesis was proposed.

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

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

Conclusion: Prosthetic parastomal and perineal hernias repair can be performed simultaneously using laparoscopy with the same port positioning, adding the advantages of minimally invasive surgery and avoiding a large laparotomy.
G Dapri, L Gerard, L Cardinali, D Repullo, I Surdeanu, SH Sondji, GB Cadière
Surgical intervention
1 year ago
1070 views
117 likes
0 comments
07:20
Laparoscopic prosthetic parastomal and perineal hernias repair after abdominoperineal resection
Background: In this video, the authors report the case of a 74-year-old woman who consulted for episodes of intestinal occlusions following an abdomino-perineal resection for rectal adenocarcinoma (pT2N0M0), performed 6 years earlier. Abdomino-pelvic CT-scan showed a parastomal hernia with migrated small bowel loops and a perineal hernia with transposition of the caecum and bowel loops into the pelvis. Preoperative work-up was negative for tumor recurrence, hence a laparoscopic treatment using a double dual face prosthesis was proposed.

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

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

Conclusion: Prosthetic parastomal and perineal hernias repair can be performed simultaneously using laparoscopy with the same port positioning, adding the advantages of minimally invasive surgery and avoiding a large laparotomy.
Laparoscopic repair of ventral hernia in complex locations
In this lecture, Dr. Morales Conde briefly outlines laparoscopic ventral hernia repair in complex locations (including lumbar, suprapubic, subcostal, subxiphoid, and parastomal hernias). He presents technical difficulties and complex anatomy in the lumbar area. The importance of appropriate identification of all nerves for mesh fixation is essential to prevent inguinodynia. The author also develops this identification issue based on the experience of surgeons, taking into account the indications and diagnostic imaging techniques and corresponding defect reconstructions based on anatomical landmarks in order to prevent recurrence and avoid complications.
S Morales-Conde
Lecture
2 years ago
2003 views
203 likes
0 comments
13:41
Laparoscopic repair of ventral hernia in complex locations
In this lecture, Dr. Morales Conde briefly outlines laparoscopic ventral hernia repair in complex locations (including lumbar, suprapubic, subcostal, subxiphoid, and parastomal hernias). He presents technical difficulties and complex anatomy in the lumbar area. The importance of appropriate identification of all nerves for mesh fixation is essential to prevent inguinodynia. The author also develops this identification issue based on the experience of surgeons, taking into account the indications and diagnostic imaging techniques and corresponding defect reconstructions based on anatomical landmarks in order to prevent recurrence and avoid complications.
Single incision laparoscopic peritoneal hole repair during right TEP procedure
Background: Laparoscopic inguinal hernia repair offers various advantages both to the patient and the surgeon. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs represent the two laparoscopic options. A personal technique of single incision laparoscopic TEP has already been published on WebSurg (Link: http://www.websurg.com/MEDIA/?noheader=1&doi=vd01en4054).
Video: This video demonstrates the single incision laparoscopic treatment of a peritoneal hole, which occurred accidentally during a right TEP procedure.
Results: The TEP procedure lasted 41 minutes and the peritoneal repair 8 minutes. The final umbilical scar length was 10mm and the patient was discharged within 24 hours.
Conclusions: Peroperative complications can occur during single incision laparoscopy, as well as during conventional laparoscopy and open surgery. The procedure can be performed without conversion or additional trocars, depending on the complications which occurred.
G Dapri
Surgical intervention
2 years ago
2143 views
148 likes
0 comments
04:03
Single incision laparoscopic peritoneal hole repair during right TEP procedure
Background: Laparoscopic inguinal hernia repair offers various advantages both to the patient and the surgeon. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs represent the two laparoscopic options. A personal technique of single incision laparoscopic TEP has already been published on WebSurg (Link: http://www.websurg.com/MEDIA/?noheader=1&doi=vd01en4054).
Video: This video demonstrates the single incision laparoscopic treatment of a peritoneal hole, which occurred accidentally during a right TEP procedure.
Results: The TEP procedure lasted 41 minutes and the peritoneal repair 8 minutes. The final umbilical scar length was 10mm and the patient was discharged within 24 hours.
Conclusions: Peroperative complications can occur during single incision laparoscopy, as well as during conventional laparoscopy and open surgery. The procedure can be performed without conversion or additional trocars, depending on the complications which occurred.
Laparoscopic intraperitoneal mesh repair of a parastomal hernia
A 73-year-old male patient, previously submitted to a radical cystoprostatectomy with ileal conduit as urinary diversion for urothelial cancer, was admitted to the emergency department because of stomal tumefaction and malfunction. There was no evidence of oncologic relapse.
CT-scan revealed an abscess in the parastomal area as well as a parastomal hernia. The abscess was treated with percutaneous drainage and antibiotics. In a second time, he was submitted to a laparoscopic correction of the parastomal defect.
The procedure was performed with no-flexible cameras and straight laparoscopic instruments. For defect correction, a laparoscopic intraperitoneal mesh repair (IPOM) technique was used.
No complications were observed and the patient was discharged on postoperative day 6.
P Mota, P Leão, E Lima, H Rios, E Dias, A Goulart
Surgical intervention
3 years ago
2376 views
77 likes
0 comments
08:27
Laparoscopic intraperitoneal mesh repair of a parastomal hernia
A 73-year-old male patient, previously submitted to a radical cystoprostatectomy with ileal conduit as urinary diversion for urothelial cancer, was admitted to the emergency department because of stomal tumefaction and malfunction. There was no evidence of oncologic relapse.
CT-scan revealed an abscess in the parastomal area as well as a parastomal hernia. The abscess was treated with percutaneous drainage and antibiotics. In a second time, he was submitted to a laparoscopic correction of the parastomal defect.
The procedure was performed with no-flexible cameras and straight laparoscopic instruments. For defect correction, a laparoscopic intraperitoneal mesh repair (IPOM) technique was used.
No complications were observed and the patient was discharged on postoperative day 6.
Laparoscopic treatment of parastomal hernia and concomitant midline incisional hernia
An individual approach to the treatment of patients with incisional hernia is essential. The objective of this video is to demonstrate the advantages of a laparoscopic parastomal hernia repair in a selected patient.
This video demonstrates the case of a 61-year-old female patient (BMI of 28.4 kg/m2) with a huge parastomal hernia compromising the stoma care, and with a suspected midline incisional hernia. After a complete adhesiolysis, we were able to detect and measure both abdominal wall defects. After narrowing the parastomal defect, a local hernioplasty was performed by applying the Sugarbaker technique with a Parietex™ Parastomal Mesh (PCOPM15). For a midline incisional hernia, we used a Parietex™ composite mesh (PPC1510). Both prostheses were fixed to the abdominal wall with transfascial sutures and tacks (ProTack™). Both operative and postoperative periods were uneventful.
The laparoscopic treatment of a parastomal hernia should be considered as a first option because it endeavors to join the advantages of a minimally invasive approach with a low incidence of infection and recurrence rate, and offers the opportunity of repairing a concomitant incisional hernia, if present.
M Panovski, I Roso Sazdovska
Surgical intervention
3 years ago
2284 views
72 likes
0 comments
10:13
Laparoscopic treatment of parastomal hernia and concomitant midline incisional hernia
An individual approach to the treatment of patients with incisional hernia is essential. The objective of this video is to demonstrate the advantages of a laparoscopic parastomal hernia repair in a selected patient.
This video demonstrates the case of a 61-year-old female patient (BMI of 28.4 kg/m2) with a huge parastomal hernia compromising the stoma care, and with a suspected midline incisional hernia. After a complete adhesiolysis, we were able to detect and measure both abdominal wall defects. After narrowing the parastomal defect, a local hernioplasty was performed by applying the Sugarbaker technique with a Parietex™ Parastomal Mesh (PCOPM15). For a midline incisional hernia, we used a Parietex™ composite mesh (PPC1510). Both prostheses were fixed to the abdominal wall with transfascial sutures and tacks (ProTack™). Both operative and postoperative periods were uneventful.
The laparoscopic treatment of a parastomal hernia should be considered as a first option because it endeavors to join the advantages of a minimally invasive approach with a low incidence of infection and recurrence rate, and offers the opportunity of repairing a concomitant incisional hernia, if present.
Stomal prolapse and parastomal incisional hernia treatment using laparoscopic Sugarbaker modified technique with intraperitoneal onlay mesh repair
Introduction: Prolapse stands for one of the most common complications of colostomy (>10%). Parastomal incisional hernia also represents 10 to 50% of complications. When both are present, the Sugarbaker technique represents a good indication due to mesh repair and pseudo-subperitonization, which can manage both prolapse and hernia. The laparoscopic modified Sugarbaker technique can be performed laparoscopically even in case of multiple previous laparotomies.
Clinical case: We report the case of a 71-year-old male patient presenting with parastomal incisional hernia and stomal prolapse after multiple abdominal procedures for ulcerative colitis, including rectosigmoidectomy, Hartmann procedure for anastomotic leak, left extended colectomy and stomal transposition for ischemic necrosis. An intra-abdominal proctectomy was attempted to manage the recurrence of colitis on the rectal stump. However, this attempt proved unsuccessful, and a local abdominoperineal resection was performed. Due to symptomatic hernia and prolapse, the laparoscopic Sugarbaker modified surgical technique with intraperitoneal onlay mesh (IPOM) repair is performed to manage prolapse by pseudo-subperitonization and to manage hernia using an IPOM repair. As shown in this video, this technique is safe, reproducible, and effective.
J Leroy, HA Mercoli, S Tzedakis, A D'Urso, D Mutter, J Marescaux
Surgical intervention
3 years ago
2185 views
98 likes
0 comments
10:54
Stomal prolapse and parastomal incisional hernia treatment using laparoscopic Sugarbaker modified technique with intraperitoneal onlay mesh repair
Introduction: Prolapse stands for one of the most common complications of colostomy (>10%). Parastomal incisional hernia also represents 10 to 50% of complications. When both are present, the Sugarbaker technique represents a good indication due to mesh repair and pseudo-subperitonization, which can manage both prolapse and hernia. The laparoscopic modified Sugarbaker technique can be performed laparoscopically even in case of multiple previous laparotomies.
Clinical case: We report the case of a 71-year-old male patient presenting with parastomal incisional hernia and stomal prolapse after multiple abdominal procedures for ulcerative colitis, including rectosigmoidectomy, Hartmann procedure for anastomotic leak, left extended colectomy and stomal transposition for ischemic necrosis. An intra-abdominal proctectomy was attempted to manage the recurrence of colitis on the rectal stump. However, this attempt proved unsuccessful, and a local abdominoperineal resection was performed. Due to symptomatic hernia and prolapse, the laparoscopic Sugarbaker modified surgical technique with intraperitoneal onlay mesh (IPOM) repair is performed to manage prolapse by pseudo-subperitonization and to manage hernia using an IPOM repair. As shown in this video, this technique is safe, reproducible, and effective.
eTEP (extended view) repair of a direct and a femoral hernia
The eTEP (extended view totally extraperitoneal) technique, a modification of the conventional TEP technique, is based on the anatomical fact that the inguinal preperitoneal space can be reached from almost anywhere on the abdominal wall. The camera port can be placed higher in the abdomen. Its most evident effect is the creation of a larger surgical field. It also allows for a more flexible distribution of ports.
In the case presented here, the patient has a midline infra-umbilical laparotomy and a post-bariatric surgery pendulous abdomen. The eTEP technique facilitated the creation of the preperitoneal space in this difficult abdomen, allowing for the diagnosis and repair of the patient’s femoral and direct hernias.
J Daes, B Jacob
Surgical intervention
4 years ago
3938 views
183 likes
2 comments
08:13
eTEP (extended view) repair of a direct and a femoral hernia
The eTEP (extended view totally extraperitoneal) technique, a modification of the conventional TEP technique, is based on the anatomical fact that the inguinal preperitoneal space can be reached from almost anywhere on the abdominal wall. The camera port can be placed higher in the abdomen. Its most evident effect is the creation of a larger surgical field. It also allows for a more flexible distribution of ports.
In the case presented here, the patient has a midline infra-umbilical laparotomy and a post-bariatric surgery pendulous abdomen. The eTEP technique facilitated the creation of the preperitoneal space in this difficult abdomen, allowing for the diagnosis and repair of the patient’s femoral and direct hernias.
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
5 years ago
4049 views
108 likes
0 comments
11:09
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.
Incisional hernia: laparoscopic hybrid repair
About 10% of laparotomies are complicated by the development of incisional hernia (1). The prosthetic repair is the rule in the treatment of incisional hernia and is reported to have a lower recurrence rate than primary suture repair (2). The laparoscopic approach proposed since the early nineties with intraperitoneal onlay mesh (IPOM) repair has gained popularity over years. The IPOM technique is easy in case of midline incisional hernia but is more complex in case of lateral suprailiac hernia. The laparoscopic repair is associated with fewer infections as compared to the open technique (3). There are only very few reports on laparoscopic-endoscopic sublay mesh repair of abdominal wall hernias (4, 5).
We present the case of a 66-year-old patient admitted for an incisional hernia subsequent to an open liver resection for gallbladder carcinoma in 2011. The patient developed a symptomatic lateral incisional hernia in the right side of his subcostal incision. The oncologic preoperative work-up was negative. The patient was scheduled for a laparoscopic approach with a hybrid onlay and sublay mesh repair.
Here, authors aim to propose an original technique with a combined onlay and sublay approach to this complicated lateral abdominal incisional hernia.
Bibliographic references:
1. Mudge M, Hughes LE. Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J Surg 1985;72:70-1.
2. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578-83.
3. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 2011;3:CD007781.
4. Schroeder AD, Debus ES, Schroeder M, Reinpold WM. Laparoscopic transperitoneal sublay mesh repair: a new technique for the cure of ventral and incisional hernias. Surg Endosc. 2013;27:648-54.
5. Miserez M, Penninckx F. Endoscopic totally preperitoneal ventral hernia repair. Surg Endosc 2002;16:1207-13.
A D'Urso, J Leroy, T Piardi, P Pessaux, J Marescaux
Surgical intervention
5 years ago
3652 views
54 likes
0 comments
07:27
Incisional hernia: laparoscopic hybrid repair
About 10% of laparotomies are complicated by the development of incisional hernia (1). The prosthetic repair is the rule in the treatment of incisional hernia and is reported to have a lower recurrence rate than primary suture repair (2). The laparoscopic approach proposed since the early nineties with intraperitoneal onlay mesh (IPOM) repair has gained popularity over years. The IPOM technique is easy in case of midline incisional hernia but is more complex in case of lateral suprailiac hernia. The laparoscopic repair is associated with fewer infections as compared to the open technique (3). There are only very few reports on laparoscopic-endoscopic sublay mesh repair of abdominal wall hernias (4, 5).
We present the case of a 66-year-old patient admitted for an incisional hernia subsequent to an open liver resection for gallbladder carcinoma in 2011. The patient developed a symptomatic lateral incisional hernia in the right side of his subcostal incision. The oncologic preoperative work-up was negative. The patient was scheduled for a laparoscopic approach with a hybrid onlay and sublay mesh repair.
Here, authors aim to propose an original technique with a combined onlay and sublay approach to this complicated lateral abdominal incisional hernia.
Bibliographic references:
1. Mudge M, Hughes LE. Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J Surg 1985;72:70-1.
2. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578-83.
3. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 2011;3:CD007781.
4. Schroeder AD, Debus ES, Schroeder M, Reinpold WM. Laparoscopic transperitoneal sublay mesh repair: a new technique for the cure of ventral and incisional hernias. Surg Endosc. 2013;27:648-54.
5. Miserez M, Penninckx F. Endoscopic totally preperitoneal ventral hernia repair. Surg Endosc 2002;16:1207-13.
TAPP laparoscopic repair of right inguinal hernia after artificial sphincter placement for post-prostatectomy urinary incontinence
Incapacitating post-prostatectomy urinary incontinence may be managed by the placement of an artificial sphincter. This sphincter is composed of an inflatable circular tape (the sphincter itself), a remote control located in the scrotum, and of a reservoir connected to the sphincter by a catheter. This reservoir is positioned within the preperitoneal space using an anterior inguinal approach through a mini-incision in the transversalis fascia which weakens the posterior wall of the inguinal canal, hence increasing the risk of inguinal hernia.
This film demonstrates a typical case management of such hernia. The anterior approach is delicate as repair of the inguinal canal may well induce trauma to the catheter connected to the retromuscular balloon. The posterior approach is therefore valuable as it allows to see the balloon prior to dissecting the preperitoneal space. The film highlights the specific issues to be dealt with as well as the tips and tricks related to this approach.
J Leroy, C Saussine, J Marescaux
Surgical intervention
5 years ago
5167 views
108 likes
1 comment
08:18
TAPP laparoscopic repair of right inguinal hernia after artificial sphincter placement for post-prostatectomy urinary incontinence
Incapacitating post-prostatectomy urinary incontinence may be managed by the placement of an artificial sphincter. This sphincter is composed of an inflatable circular tape (the sphincter itself), a remote control located in the scrotum, and of a reservoir connected to the sphincter by a catheter. This reservoir is positioned within the preperitoneal space using an anterior inguinal approach through a mini-incision in the transversalis fascia which weakens the posterior wall of the inguinal canal, hence increasing the risk of inguinal hernia.
This film demonstrates a typical case management of such hernia. The anterior approach is delicate as repair of the inguinal canal may well induce trauma to the catheter connected to the retromuscular balloon. The posterior approach is therefore valuable as it allows to see the balloon prior to dissecting the preperitoneal space. The film highlights the specific issues to be dealt with as well as the tips and tricks related to this approach.
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
G Dapri, L Gerard, V Zulian, M Bortes, J Bruyns, GB Cadière
Surgical intervention
5 years ago
4098 views
74 likes
2 comments
07:50
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
Image of the month: anterior abdominal mass after hysterectomy
This video demonstrates the case of a woman presenting with a mass appended to the anterior abdominal wall. In the patient’s surgical history, a hysterectomy performed a few years earlier can be noted. The operative report of that intervention is not available. Laparoscopy is therefore decided upon. The first impression is that of an ovarian lesion appended to the anterior abdominal wall. Consequently, an appendicular lesion must be ruled out. The appendix is therefore searched for and dissected. It remains distal from the mass and its pedicle. The presence of a tubular structure in the mass’s pedicle mandates the identification of the right ureter, which also remains distally. From then onwards, resection of the mass does not pose any particular problem. The pathological finding confirms the nature of the mass, namely a benign ovarian cystadenoma.
M Vix, J Marescaux
Surgical intervention
5 years ago
2570 views
40 likes
1 comment
10:47
Image of the month: anterior abdominal mass after hysterectomy
This video demonstrates the case of a woman presenting with a mass appended to the anterior abdominal wall. In the patient’s surgical history, a hysterectomy performed a few years earlier can be noted. The operative report of that intervention is not available. Laparoscopy is therefore decided upon. The first impression is that of an ovarian lesion appended to the anterior abdominal wall. Consequently, an appendicular lesion must be ruled out. The appendix is therefore searched for and dissected. It remains distal from the mass and its pedicle. The presence of a tubular structure in the mass’s pedicle mandates the identification of the right ureter, which also remains distally. From then onwards, resection of the mass does not pose any particular problem. The pathological finding confirms the nature of the mass, namely a benign ovarian cystadenoma.
TEP repair of a recurrent right inguinal hernia following failed TAPP repair: world’s first report
A 10mm paraumbilical balloon-tipped port was inserted into the preperitoneal space under direct vision and CO2 was insufflated.
Blunt dissection of the preperitoneal space to the pubis inferiorly and towards the left hernial orifices was performed using the 10mm laparoscope.
A further 10mm port was introduced into the pre-peritoneal space midway between the pubic symphysis and umbilicus. An atraumatic grasper was used to aid with further pre-peritoneal dissection. An indirect sac was identified on the left, freed from the adherent cord and then reduced. After excluding a direct hernia on the ipsilateral side and ensuring adequate clearance for mesh placement, a third 5mm port was introduced. This was inserted 1cm above and medial to the left anterior superior iliac spine
Dissection of the right pre-peritoneal space was performed using a combination of atraumatic graspers, scissors and diathermy. The mesh from the previous repair was identified and noted to be very adherent to the anterior abdominal wall. Careful and patient mobilisation revealed that this mesh had curled up and formed part of the contents of a direct inguinal hernia on the right. After meticulous dissection, the mesh was entirely freed from the anterior abdominal wall and direct space and reduced inferiorly remaining adherent to the underlying peritoneum. The inferior epigastric vessels were then identified. Preperitoneal dissection had resulted in distortion of their position such that they had been pulled down away from the anterior abdominal wall. Care was required not to injure these vessels as they were mobilised and lifted up to their normal anatomical position. The cord on this side was examined and after confirming the absence of an indirect sac, further preperitoneal dissection was performed to ensure adequate space for mesh placement.
Bilateral Bard™ 3D meshes were inserted ensuring adequate cover of all hernial orifices with overlapping of meshes in the midline. The left indirect sac and right direct hernia contents, consisting mainly of old mesh, were well clear of the new meshes. No tackers were used. CO2 insufflation was stopped and the preperitoneal space was allowed to close under vision ensuring no mesh displacement. Ports were closed via a standard technique.
MH Mobasheri, A Wan, G Vasilikostas , KM Reddy
Surgical intervention
7 years ago
5406 views
42 likes
0 comments
10:26
TEP repair of a recurrent right inguinal hernia following failed TAPP repair: world’s first report
A 10mm paraumbilical balloon-tipped port was inserted into the preperitoneal space under direct vision and CO2 was insufflated.
Blunt dissection of the preperitoneal space to the pubis inferiorly and towards the left hernial orifices was performed using the 10mm laparoscope.
A further 10mm port was introduced into the pre-peritoneal space midway between the pubic symphysis and umbilicus. An atraumatic grasper was used to aid with further pre-peritoneal dissection. An indirect sac was identified on the left, freed from the adherent cord and then reduced. After excluding a direct hernia on the ipsilateral side and ensuring adequate clearance for mesh placement, a third 5mm port was introduced. This was inserted 1cm above and medial to the left anterior superior iliac spine
Dissection of the right pre-peritoneal space was performed using a combination of atraumatic graspers, scissors and diathermy. The mesh from the previous repair was identified and noted to be very adherent to the anterior abdominal wall. Careful and patient mobilisation revealed that this mesh had curled up and formed part of the contents of a direct inguinal hernia on the right. After meticulous dissection, the mesh was entirely freed from the anterior abdominal wall and direct space and reduced inferiorly remaining adherent to the underlying peritoneum. The inferior epigastric vessels were then identified. Preperitoneal dissection had resulted in distortion of their position such that they had been pulled down away from the anterior abdominal wall. Care was required not to injure these vessels as they were mobilised and lifted up to their normal anatomical position. The cord on this side was examined and after confirming the absence of an indirect sac, further preperitoneal dissection was performed to ensure adequate space for mesh placement.
Bilateral Bard™ 3D meshes were inserted ensuring adequate cover of all hernial orifices with overlapping of meshes in the midline. The left indirect sac and right direct hernia contents, consisting mainly of old mesh, were well clear of the new meshes. No tackers were used. CO2 insufflation was stopped and the preperitoneal space was allowed to close under vision ensuring no mesh displacement. Ports were closed via a standard technique.