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General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.


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Totally laparoscopic splenic flexure resection for cancer
The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.
G Basili, D Pietrasanta, N Romano, AF Costa
Surgical intervention
23 days ago
942 views
4 likes
0 comments
10:12
Totally laparoscopic splenic flexure resection for cancer
The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
J Magalhães, L Matos, J Costa, J Costa Pereira, G Gonçalves, M Nora
Surgical intervention
27 days ago
678 views
6 likes
3 comments
10:31
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
Laparoscopic rectal resection with ICG-guided nodal navigation
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of a 66-year-old woman with a sigmoid-rectal junction early stage cancer submitted to laparoscopic resection. Before surgery, the patient was submitted to endoscopy with the objective to mark the distal margin of the neoplasia, and 2mL of ICG were injected into the mucosa of the rectum, 2cm distal to the inferior border of the tumor.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588 camera system), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
It was possible to verify the good perfusion of the proximal stump of the anastomosis before the Knight-Griffen anastomosis was performed, thanks to an intravenous injection of ICG.
This technique could allow for a more precise and radical nodal dissection, a safer work respecting vascular and nerve structures, and could be related with a lower risk of anastomotic fistula, controlling the adequate perfusion of the stump.
G Baiocchi, S Molfino, B Molteni, A Titi, G Gaverini
Surgical intervention
1 month ago
2332 views
5 likes
1 comment
11:48
Laparoscopic rectal resection with ICG-guided nodal navigation
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of a 66-year-old woman with a sigmoid-rectal junction early stage cancer submitted to laparoscopic resection. Before surgery, the patient was submitted to endoscopy with the objective to mark the distal margin of the neoplasia, and 2mL of ICG were injected into the mucosa of the rectum, 2cm distal to the inferior border of the tumor.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588 camera system), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
It was possible to verify the good perfusion of the proximal stump of the anastomosis before the Knight-Griffen anastomosis was performed, thanks to an intravenous injection of ICG.
This technique could allow for a more precise and radical nodal dissection, a safer work respecting vascular and nerve structures, and could be related with a lower risk of anastomotic fistula, controlling the adequate perfusion of the stump.
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
S Qian, P Tejedor, M Leon, M Ortega, C Pastor
Surgical intervention
1 month ago
2666 views
3 likes
2 comments
06:45
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
Laparoscopic splenic flexure mobilization during low anterior resection (LAR), extra central connection between the superior and inferior mesenteric arterial systems
This is the case of two adult patients who presented with a low rectal carcinoma. A low anterior resection was performed laparoscopically. In both cases, the procedure was begun with a mobilization of the splenic flexure to ensure sufficient length on the proximal colonic segment to facilitate a tension-free low colorectal anastomosis. In the first case, a small aberrant artery, and during the second case, an aberrant artery of greater caliber can be appreciated. Anatomical studies report an extra central arterial connection between the superior and inferior mesenteric arterial systems in addition to the marginal artery of Drummond in 10 to 30% of cases. In such cases, there is an extra connection from the ascending branch of the left colic artery to the middle colic artery or the marginal artery of Drummond. Different names have been given to these connections, such as for example the meandering mesenteric artery, the artery of Moskovitch and Riolan’s arch.
A Wijsmuller, RJ Franken, JB Tuynman, J Bonjer
Surgical intervention
1 month ago
3457 views
5 likes
0 comments
19:49
Laparoscopic splenic flexure mobilization during low anterior resection (LAR), extra central connection between the superior and inferior mesenteric arterial systems
This is the case of two adult patients who presented with a low rectal carcinoma. A low anterior resection was performed laparoscopically. In both cases, the procedure was begun with a mobilization of the splenic flexure to ensure sufficient length on the proximal colonic segment to facilitate a tension-free low colorectal anastomosis. In the first case, a small aberrant artery, and during the second case, an aberrant artery of greater caliber can be appreciated. Anatomical studies report an extra central arterial connection between the superior and inferior mesenteric arterial systems in addition to the marginal artery of Drummond in 10 to 30% of cases. In such cases, there is an extra connection from the ascending branch of the left colic artery to the middle colic artery or the marginal artery of Drummond. Different names have been given to these connections, such as for example the meandering mesenteric artery, the artery of Moskovitch and Riolan’s arch.
LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient
In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.
S Morales-Conde, B Seeliger, D Mutter, J Marescaux
Surgical intervention
1 month ago
3275 views
3 likes
0 comments
47:01
LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient
In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.
Laparoscopic distal pancreatectomy with splenectomy for a recurrent GIST
GISTs are tumors of the gastrointestinal stroma which, although rare, are the most common mesenchymal neoplasms of the digestive tract. They are most common in the stomach and small intestine, in patients aged between 50 and 70 years. The definitive diagnosis is established with immunohistochemistry (CD117), and the risk of postoperative recurrence should be estimated. Studies relate small intestine’s lesions with greater aggressiveness; however, more recent studies emphasize mitotic index and lesion size.
The clinical case is that of a 53-year-old woman with a stage TNM IIIb, AFIP 6b gastric GIST. In 2013, she underwent a sleeve gastrectomy followed by the daily administration of Imatinib (400mg). After 3 years of adjuvant therapy, she stopped treatment. In May 2017, in a follow-up CT-scan, a solid, heterogeneous 6.7cm lesion appeared in the left hypochondrium, separated from the metal suture, invading the lower pole of the spleen, with no evidence of adenopathies or free liquid.
Surgical resection was planned. A splenectomy with distal pancreatectomy, documented in the video, was performed with no complications. The histological examination confirmed a 5.8cm tumor implant, located in the splenic cord, compatible with GIST recurrence (>50 mitoses/50 fields, free margins, prognostic group 6b).
JP Pinto, T Moreno, D Poletto, A Toscano, M Lozano
Surgical intervention
3 months ago
1407 views
2 likes
0 comments
14:02
Laparoscopic distal pancreatectomy with splenectomy for a recurrent GIST
GISTs are tumors of the gastrointestinal stroma which, although rare, are the most common mesenchymal neoplasms of the digestive tract. They are most common in the stomach and small intestine, in patients aged between 50 and 70 years. The definitive diagnosis is established with immunohistochemistry (CD117), and the risk of postoperative recurrence should be estimated. Studies relate small intestine’s lesions with greater aggressiveness; however, more recent studies emphasize mitotic index and lesion size.
The clinical case is that of a 53-year-old woman with a stage TNM IIIb, AFIP 6b gastric GIST. In 2013, she underwent a sleeve gastrectomy followed by the daily administration of Imatinib (400mg). After 3 years of adjuvant therapy, she stopped treatment. In May 2017, in a follow-up CT-scan, a solid, heterogeneous 6.7cm lesion appeared in the left hypochondrium, separated from the metal suture, invading the lower pole of the spleen, with no evidence of adenopathies or free liquid.
Surgical resection was planned. A splenectomy with distal pancreatectomy, documented in the video, was performed with no complications. The histological examination confirmed a 5.8cm tumor implant, located in the splenic cord, compatible with GIST recurrence (>50 mitoses/50 fields, free margins, prognostic group 6b).
Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence
Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.
S Rua
Surgical intervention
3 months ago
2309 views
9 likes
0 comments
13:14
Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence
Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
C Viana, M Lozano, D Poletto, T Moreno, C Varela, A Toscano
Surgical intervention
3 months ago
2093 views
5 likes
0 comments
15:27
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
SAE Yeo
Surgical intervention
3 months ago
1226 views
5 likes
0 comments
15:36
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
C Sposito, D Citterio, C Battiston, V Mazzaferro
Surgical intervention
3 months ago
1650 views
5 likes
0 comments
10:57
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
Background: Minimally invasive surgery (MIS) was shown to offer advantages in general and oncologic surgery (1). Over the last decade, reduced port laparoscopy (RPL) has been introduced to reduce the risks related to ports and abdominal wall trauma, with enhanced cosmetic outcomes (2). In this video, the authors report the case of a 59-year-old man with a small bowel neuroendocrine tumor, and who underwent a three-trocar right ileocolectomy.
Video: Preoperative work-up, including endoscopic ultrasound, octreoscan, PET-scan, and FDG PET-CT, showed a 15mm small bowel tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the third portion of the duodenum. The biopsy revealed a low-grade well-differentiated neuroendocrine tumor. The procedure was performed using three abdominal trocars: a 12mm one in the umbilicus, a 5mm one in the right flank, and a 5mm port in the left flank (Figure 1). Abdominal cavity exploration demonstrated the presence of a tumor located in the mesentery of the last small bowel loop, with consequent bowel retraction, dislocation of the caecum and appendix, located under the right lobe of the liver, and tumoral extension into the proximal transverse mesocolon. After mobilization of the right colon from laterally to medially, the second and third duodenal segments were exposed, showing tumor extension towards the anterior duodenal wall of these segments. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape (Figure 2), an endoscopic linear stapler was inserted through the umbilical trocar under the visual guidance of a 5mm scope in the left flank (Figure 3a), and it was fired (Figure 3b). The specimen was removed through a suprapubic access. Perioperative frozen section biopsy showed a free duodenal margin, and the procedure was subsequently completed with an ileocolic anastomosis, performed in a side-to-side handsewn intracorporeal fashion. At the end, the mesocolic defect was closed.

Results: Operative time was 4 hours. No added trocars were necessary. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Pathological findings showed a grade I well-differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration (1/20 metastatic nodes, free margins, stage: pT3N1 (8 UICC edition). A follow-up under somatostatin therapy was put forward.

Conclusions: RPL is a feasible option when performing advanced oncological surgery. Patients benefit from all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
G Dapri
Surgical intervention
6 months ago
4573 views
91 likes
2 comments
11:10
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
Background: Minimally invasive surgery (MIS) was shown to offer advantages in general and oncologic surgery (1). Over the last decade, reduced port laparoscopy (RPL) has been introduced to reduce the risks related to ports and abdominal wall trauma, with enhanced cosmetic outcomes (2). In this video, the authors report the case of a 59-year-old man with a small bowel neuroendocrine tumor, and who underwent a three-trocar right ileocolectomy.
Video: Preoperative work-up, including endoscopic ultrasound, octreoscan, PET-scan, and FDG PET-CT, showed a 15mm small bowel tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the third portion of the duodenum. The biopsy revealed a low-grade well-differentiated neuroendocrine tumor. The procedure was performed using three abdominal trocars: a 12mm one in the umbilicus, a 5mm one in the right flank, and a 5mm port in the left flank (Figure 1). Abdominal cavity exploration demonstrated the presence of a tumor located in the mesentery of the last small bowel loop, with consequent bowel retraction, dislocation of the caecum and appendix, located under the right lobe of the liver, and tumoral extension into the proximal transverse mesocolon. After mobilization of the right colon from laterally to medially, the second and third duodenal segments were exposed, showing tumor extension towards the anterior duodenal wall of these segments. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape (Figure 2), an endoscopic linear stapler was inserted through the umbilical trocar under the visual guidance of a 5mm scope in the left flank (Figure 3a), and it was fired (Figure 3b). The specimen was removed through a suprapubic access. Perioperative frozen section biopsy showed a free duodenal margin, and the procedure was subsequently completed with an ileocolic anastomosis, performed in a side-to-side handsewn intracorporeal fashion. At the end, the mesocolic defect was closed.

Results: Operative time was 4 hours. No added trocars were necessary. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Pathological findings showed a grade I well-differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration (1/20 metastatic nodes, free margins, stage: pT3N1 (8 UICC edition). A follow-up under somatostatin therapy was put forward.

Conclusions: RPL is a feasible option when performing advanced oncological surgery. Patients benefit from all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
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
6 months ago
928 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.
Transanal minimally invasive full-thickness middle rectum polyp resection with the patient in a prone position
Background: Nowadays, rectal preservation has gained popularity when it comes to the management of degenerated rectal polyps or early rectal cancer (1, 2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment via transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report the case of a 60-year-old woman who underwent a TAMIS procedure for a large polyp located anteriorly in the middle rectum, which was 7cm away from the pectineal line and staged as uTisN0M0 preoperatively.
Video: The patient was placed in a prone position with a split-leg kneeling position. A reusable transanal D-Port (Karl Storz Endoskope, Tuttlingen, Germany) was introduced into the anus together with DAPRI monocurved instruments (Figure 1). The polyp was put in evidence (Figure 2) and resection margins were defined circumferentially using the monocurved coagulating hook. A full-thickness resection was performed with a complete removal of the rectal serosa and exposure of the peritoneal cavity, due to the anatomical polyp positioning (Figure 3). The rectal opening was subsequently closed using two converging full-thickness running sutures using 3/0 V-loc™ sutures (Figure 4a). The two sutures were started laterally and joined together medially (Figure 4b).
Results: Total operative time was 60 minutes whereas suturing time was 35 minutes. There was no perioperative bleeding. The postoperative course was uneventful, and the patient was discharged after 2 days. The pathological report showed a tubular adenoma with high-grade dysplasia and clear margins.
Conclusions: In the presence of degenerated rectal polyps, full-thickness TAMIS is oncologically safe and feasible. The final rectal flap can be safely closed by means of laparoscopic endoluminal sutures.
G Dapri, L Qin Yi, A Wong, P Tan Enjiu, S Hsien Lin, D Lee, T Kok Yang, S Mantoo
Surgical intervention
7 months ago
711 views
195 likes
0 comments
05:53
Transanal minimally invasive full-thickness middle rectum polyp resection with the patient in a prone position
Background: Nowadays, rectal preservation has gained popularity when it comes to the management of degenerated rectal polyps or early rectal cancer (1, 2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment via transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report the case of a 60-year-old woman who underwent a TAMIS procedure for a large polyp located anteriorly in the middle rectum, which was 7cm away from the pectineal line and staged as uTisN0M0 preoperatively.
Video: The patient was placed in a prone position with a split-leg kneeling position. A reusable transanal D-Port (Karl Storz Endoskope, Tuttlingen, Germany) was introduced into the anus together with DAPRI monocurved instruments (Figure 1). The polyp was put in evidence (Figure 2) and resection margins were defined circumferentially using the monocurved coagulating hook. A full-thickness resection was performed with a complete removal of the rectal serosa and exposure of the peritoneal cavity, due to the anatomical polyp positioning (Figure 3). The rectal opening was subsequently closed using two converging full-thickness running sutures using 3/0 V-loc™ sutures (Figure 4a). The two sutures were started laterally and joined together medially (Figure 4b).
Results: Total operative time was 60 minutes whereas suturing time was 35 minutes. There was no perioperative bleeding. The postoperative course was uneventful, and the patient was discharged after 2 days. The pathological report showed a tubular adenoma with high-grade dysplasia and clear margins.
Conclusions: In the presence of degenerated rectal polyps, full-thickness TAMIS is oncologically safe and feasible. The final rectal flap can be safely closed by means of laparoscopic endoluminal sutures.
Laparoscopic repair of giant left Bochdalek hernia in adults: resolution of 2 cases
A Bochdalek hernia is a congenital diaphragmatic defect which results from the improper fusion of the septum transversum and of the pleuroperitoneal folds. It rarely persists asymptomatically until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases, using open surgery or laparoscopy/thoracoscopy.
We present two cases of fully laparoscopic repair of a giant Bochdalek hernia in adults. In both cases, we used a GORE® DUALMESH® biomaterial and we had no complications and no recurrence. It is worth mentioning that the hernia sac was not found in any of the cases. This has been described as a distinct characteristic, which confirms the diagnosis.
Bochdalek hernia in adults is a rare entity, which requires surgical treatment to prevent any complications.
F Signorini, S Reimondez, P Maldonado, V Gorodner, L Obeide, F Moser, N Bollati
Surgical intervention
7 months ago
1790 views
176 likes
0 comments
10:10
Laparoscopic repair of giant left Bochdalek hernia in adults: resolution of 2 cases
A Bochdalek hernia is a congenital diaphragmatic defect which results from the improper fusion of the septum transversum and of the pleuroperitoneal folds. It rarely persists asymptomatically until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases, using open surgery or laparoscopy/thoracoscopy.
We present two cases of fully laparoscopic repair of a giant Bochdalek hernia in adults. In both cases, we used a GORE® DUALMESH® biomaterial and we had no complications and no recurrence. It is worth mentioning that the hernia sac was not found in any of the cases. This has been described as a distinct characteristic, which confirms the diagnosis.
Bochdalek hernia in adults is a rare entity, which requires surgical treatment to prevent any complications.
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
F Signorini, S Reimondez, M España, L Obeide, F Moser
Surgical intervention
7 months ago
5897 views
416 likes
5 comments
06:41
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
D Lipski, D Garcilazo Arismendi, S Targa
Surgical intervention
8 months ago
2393 views
422 likes
1 comment
07:37
Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
B Dallemagne, S Perretta, B Seeliger, D Mutter, J Marescaux
Surgical intervention
8 months ago
890 views
351 likes
0 comments
21:18
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
Laparoscopic ileocecal resection for unresectable appendix
This is the case of a 36-year-old woman who has had an exploratory laparoscopy in another institution 2 months earlier. Acute appendicitis was suspected, based on ultrasound exam. However, exploration has shown an inflammatory appendicular mass, impossible to dissect. The patient was administered antibiotics for a period of 3 weeks. A laparoscopic appendectomy was decided upon at an interval of 2 months. Work-up included CT-scan and colonoscopy, which did not demonstrate anything specific.
Laparoscopic exploration demonstrated important fibrotic and scarry tissues around the appendix and the cecum. Despite painstaking dissection, appendectomy was impossible. Ileocecal resection was decided upon. Operative steps, namely exposure, division of the last ileal loop, division of the meso, division of the right colon above the ampulla coli and the intracorporeal side-to-side stapled anastomosis are demonstrated. Pathological findings evidenced an endometriotic nodule. The postoperative course was uneventful.
D Mutter, M Ignat, J Marescaux
Surgical intervention
9 months ago
2785 views
325 likes
0 comments
08:23
Laparoscopic ileocecal resection for unresectable appendix
This is the case of a 36-year-old woman who has had an exploratory laparoscopy in another institution 2 months earlier. Acute appendicitis was suspected, based on ultrasound exam. However, exploration has shown an inflammatory appendicular mass, impossible to dissect. The patient was administered antibiotics for a period of 3 weeks. A laparoscopic appendectomy was decided upon at an interval of 2 months. Work-up included CT-scan and colonoscopy, which did not demonstrate anything specific.
Laparoscopic exploration demonstrated important fibrotic and scarry tissues around the appendix and the cecum. Despite painstaking dissection, appendectomy was impossible. Ileocecal resection was decided upon. Operative steps, namely exposure, division of the last ileal loop, division of the meso, division of the right colon above the ampulla coli and the intracorporeal side-to-side stapled anastomosis are demonstrated. Pathological findings evidenced an endometriotic nodule. The postoperative course was uneventful.
Laparoscopic appendectomy and fenestration of hemorrhagic ovarian cyst
This is the case of a 19-year-old female patient who was admitted to the emergency department for lower abdominal pain going on for 24 hours. No abdominal guarding was noted. Biological findings showed an inflammation with leukocytes at 16,000 and CRP levels at 112. CT-scan showed the presence of an enlarged appendix (9mm thick) along with a voluminous adnexal cyst, which may be suggestive of a tubo-ovarian abscess. Laparoscopic exploration is performed. Congestive appendicitis is confirmed, as well as the presence of a hemorrhagic right ovarian cyst. Laparoscopic appendectomy is performed and the hemorrhagic ovarian cyst is fenestrated.
M Ignat, D Mutter, J Marescaux
Surgical intervention
9 months ago
2585 views
407 likes
1 comment
04:57
Laparoscopic appendectomy and fenestration of hemorrhagic ovarian cyst
This is the case of a 19-year-old female patient who was admitted to the emergency department for lower abdominal pain going on for 24 hours. No abdominal guarding was noted. Biological findings showed an inflammation with leukocytes at 16,000 and CRP levels at 112. CT-scan showed the presence of an enlarged appendix (9mm thick) along with a voluminous adnexal cyst, which may be suggestive of a tubo-ovarian abscess. Laparoscopic exploration is performed. Congestive appendicitis is confirmed, as well as the presence of a hemorrhagic right ovarian cyst. Laparoscopic appendectomy is performed and the hemorrhagic ovarian cyst is fenestrated.
Laparoscopic appendectomy for recurrent appendicitis after medical treatment
Appendectomy is the only curative treatment of appendicitis. However, the management of patients with an appendiceal mass or abscess can be temporarily managed medically with intravenous antibiotic therapy and/or percutaneous drainage. And yet, there are many controversies over the non-operative management of acute appendicitis. In 2015, Fair et al. used data from the American College of Surgeons National Surgical Quality Improvement Project to evaluate 30-day morbidity and mortality of intervention (laparoscopic and open appendectomy) at different time periods. A delay of operative intervention longer than 48 hours was associated with a doubling of complication rates. Elective appendectomy can be performed after 6 to 8 weeks later, which proves successful in the vast majority of patients.
This is the case of an 83-year-old man who presented with an acute appendicitis treated medically in another hospital. The patient had a past medical history of arterial hypertension, cardiomyopathy, previous cerebral ischemia, and rectal polyp. A delayed appendectomy was planned. However, before the procedure, a total colonoscopy was performed because of the history of polyps. This elderly patient was hospitalized for colonoscopy. At admission, he presented with fever, right iliac fossa tenderness, and a biological inflammatory syndrome. A CT-scan was performed. It showed a recurrent acute appendicitis without mass, with a 2cm abscess on the tip of the appendix. An appendectomy was performed in this case.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
9 months ago
2584 views
335 likes
0 comments
05:00
Laparoscopic appendectomy for recurrent appendicitis after medical treatment
Appendectomy is the only curative treatment of appendicitis. However, the management of patients with an appendiceal mass or abscess can be temporarily managed medically with intravenous antibiotic therapy and/or percutaneous drainage. And yet, there are many controversies over the non-operative management of acute appendicitis. In 2015, Fair et al. used data from the American College of Surgeons National Surgical Quality Improvement Project to evaluate 30-day morbidity and mortality of intervention (laparoscopic and open appendectomy) at different time periods. A delay of operative intervention longer than 48 hours was associated with a doubling of complication rates. Elective appendectomy can be performed after 6 to 8 weeks later, which proves successful in the vast majority of patients.
This is the case of an 83-year-old man who presented with an acute appendicitis treated medically in another hospital. The patient had a past medical history of arterial hypertension, cardiomyopathy, previous cerebral ischemia, and rectal polyp. A delayed appendectomy was planned. However, before the procedure, a total colonoscopy was performed because of the history of polyps. This elderly patient was hospitalized for colonoscopy. At admission, he presented with fever, right iliac fossa tenderness, and a biological inflammatory syndrome. A CT-scan was performed. It showed a recurrent acute appendicitis without mass, with a 2cm abscess on the tip of the appendix. An appendectomy was performed in this case.
Laparoscopic appendectomy for appendicitis with peritonitis
This is the case of a 37-year-old male patient who presented with abdominal pain and fever at 39.4°C. The work-up demonstrated important inflammation with leukocytes at 16,000 and CRP levels at 169. CT-scan confirmed an acute appendicitis with an appendicolith at the base. The appendix is probably perforated as the CT-scan also demonstrated a pneumoperitoneum. Laparoscopic appendectomy is decided upon. The operative set-up is standard with an optical port placed at the umbilicus, a port in the left iliac fossa, and a suprapubic port. Exposure, appendectomy with stapling of the appendicular base, and cleansing of the peritoneal cavity are thoroughly demonstrated.
M Ignat, D Mutter, J Marescaux
Surgical intervention
9 months ago
3229 views
473 likes
0 comments
05:03
Laparoscopic appendectomy for appendicitis with peritonitis
This is the case of a 37-year-old male patient who presented with abdominal pain and fever at 39.4°C. The work-up demonstrated important inflammation with leukocytes at 16,000 and CRP levels at 169. CT-scan confirmed an acute appendicitis with an appendicolith at the base. The appendix is probably perforated as the CT-scan also demonstrated a pneumoperitoneum. Laparoscopic appendectomy is decided upon. The operative set-up is standard with an optical port placed at the umbilicus, a port in the left iliac fossa, and a suprapubic port. Exposure, appendectomy with stapling of the appendicular base, and cleansing of the peritoneal cavity are thoroughly demonstrated.
Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
SAE Yeo
Surgical intervention
9 months ago
8552 views
1071 likes
0 comments
13:33
Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
Segmental left colectomy: a modified caudal-to-cranial approach
Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.
M Milone, P Anoldo, M Manigrasso, F Milone
Surgical intervention
9 months ago
2933 views
504 likes
0 comments
09:27
Segmental left colectomy: a modified caudal-to-cranial approach
Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.
Double transanal laparoscopic resection of large anal canal and low rectum polyps
Background: Rectal polyps, and especially small and medium-sized lesions are removed via conventional endoscopy. Large rectal polyps can be approached using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In more recent years, laparoscopic surgery underwent an evolution and a new application for endoluminal resection called transanal minimally invasive surgery (TAMIS) was introduced. The authors report the case of a 79-year-old man presenting with two large polyps of the anal canal (uTisN0) and low rectum (uTis vs T1N0), which were removed through TAMIS.
Video: The patient was placed in a prone, jackknife position with legs apart. The reusable transanal D-Port was introduced into the anus. Exploration of the cavity showed the presence of a large polyp involving the entire length of the anal canal and part of the lower third of the rectum and a second large polyp located 1cm above in the lower third of the rectum. The anal canal polyp was removed with the preservation of the muscular layer. The lower third rectal polyp was removed by resecting the full-thickness of the rectal wall. During the entire procedure, the surgeon worked under satisfactory ergonomics. The polyps were removed through the D-Port. The mucosal and submucosal flaps for anal canal resection, as well as the entire rectal wall opening for low rectal resection, were closed by means of two converging absorbable sutures.
Results: Operative time was 78 minutes for the anal canal polyp and 53 minutes for the low rectum polyp. Perioperative bleeding was 10cc. The postoperative course was uneventful, and the patient was discharged after 1 day. The pathological report for both polyps showed a tubulovillous adenoma with high-grade dysplasia and free margins (stage: pTis, 8 UICC edition).
Conclusions: TAMIS for double and large polyps located in the anal canal and low rectum offers advantages, such as excellent field exposure, safe en bloc polypectomy, and final endoluminal defect closure.
G Dapri
Surgical intervention
9 months ago
1030 views
232 likes
1 comment
07:49
Double transanal laparoscopic resection of large anal canal and low rectum polyps
Background: Rectal polyps, and especially small and medium-sized lesions are removed via conventional endoscopy. Large rectal polyps can be approached using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In more recent years, laparoscopic surgery underwent an evolution and a new application for endoluminal resection called transanal minimally invasive surgery (TAMIS) was introduced. The authors report the case of a 79-year-old man presenting with two large polyps of the anal canal (uTisN0) and low rectum (uTis vs T1N0), which were removed through TAMIS.
Video: The patient was placed in a prone, jackknife position with legs apart. The reusable transanal D-Port was introduced into the anus. Exploration of the cavity showed the presence of a large polyp involving the entire length of the anal canal and part of the lower third of the rectum and a second large polyp located 1cm above in the lower third of the rectum. The anal canal polyp was removed with the preservation of the muscular layer. The lower third rectal polyp was removed by resecting the full-thickness of the rectal wall. During the entire procedure, the surgeon worked under satisfactory ergonomics. The polyps were removed through the D-Port. The mucosal and submucosal flaps for anal canal resection, as well as the entire rectal wall opening for low rectal resection, were closed by means of two converging absorbable sutures.
Results: Operative time was 78 minutes for the anal canal polyp and 53 minutes for the low rectum polyp. Perioperative bleeding was 10cc. The postoperative course was uneventful, and the patient was discharged after 1 day. The pathological report for both polyps showed a tubulovillous adenoma with high-grade dysplasia and free margins (stage: pTis, 8 UICC edition).
Conclusions: TAMIS for double and large polyps located in the anal canal and low rectum offers advantages, such as excellent field exposure, safe en bloc polypectomy, and final endoluminal defect closure.
Laparoscopic gastric bypass with unexpected intestinal malrotation
There are only a few descriptions of laparoscopic Roux-en-Y gastric bypass (LRYGB) in the setting of intestinal malrotation and these are limited to clinical case reports. Intestinal malrotations usually present in the first months of life with symptoms of bowel obstruction. However, in rare cases, it can persist undetected into adulthood when it could be incidentally identified. The anatomical abnormalities which should alert us to this possibility are an absent duodenojejunal angle, the small bowel on the right side of the abdomen, the caecum on the left, and the absence of a transverse colon crossing the abdomen. Identification and adjustment of the surgical technique at the time of laparoscopic Roux-en-Y gastric bypass (RYGB) is crucial to prevent a very distal RYGB or avoid confusion between the Roux limb and the common channel. The construction of the laparoscopic Roux limb can be safely performed with adjustments to the standard technique.
We present the case of a 45-year-old woman with a long history of morbid obesity, hypertension, and hyperlipidemia. The patient had no complaints and presented a normal preoperative evaluation. After a multidisciplinary evaluation, she was elected to undergo a LRYGB. We report an intestinal malrotation discovered at the time of LRYGB, and detail the incidental findings and the technical aspects which require to be incorporated in order to complete the operation safely.
A Laranjeira, S Silva, M Amaro, M Carvalho, J Caravana
Surgical intervention
11 months ago
1772 views
418 likes
0 comments
08:33
Laparoscopic gastric bypass with unexpected intestinal malrotation
There are only a few descriptions of laparoscopic Roux-en-Y gastric bypass (LRYGB) in the setting of intestinal malrotation and these are limited to clinical case reports. Intestinal malrotations usually present in the first months of life with symptoms of bowel obstruction. However, in rare cases, it can persist undetected into adulthood when it could be incidentally identified. The anatomical abnormalities which should alert us to this possibility are an absent duodenojejunal angle, the small bowel on the right side of the abdomen, the caecum on the left, and the absence of a transverse colon crossing the abdomen. Identification and adjustment of the surgical technique at the time of laparoscopic Roux-en-Y gastric bypass (RYGB) is crucial to prevent a very distal RYGB or avoid confusion between the Roux limb and the common channel. The construction of the laparoscopic Roux limb can be safely performed with adjustments to the standard technique.
We present the case of a 45-year-old woman with a long history of morbid obesity, hypertension, and hyperlipidemia. The patient had no complaints and presented a normal preoperative evaluation. After a multidisciplinary evaluation, she was elected to undergo a LRYGB. We report an intestinal malrotation discovered at the time of LRYGB, and detail the incidental findings and the technical aspects which require to be incorporated in order to complete the operation safely.
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
P Pessaux, R Memeo, J Hallet, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
11 months ago
6293 views
936 likes
0 comments
32:12
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
O Soubrane, P Pessaux, R Memeo, L Soler, D Mutter, J Marescaux
Surgical intervention
11 months ago
3883 views
565 likes
0 comments
51:19
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
B Dallemagne, S Perretta, R Araujo
Surgical intervention
11 months ago
4664 views
593 likes
1 comment
38:09
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
Laparoscopic distal pancreatectomy with spleen resection
We reported a laparoscopic distal pancreatectomy with spleen resection for a mucinous cystic lesion. Four ports were positioned. The greater omentum was retracted to the superior part of the abdomen in order to detach the colon from the omentum and approach the lesser sac. The stomach was dissected. A tape was placed around the stomach through the abdominal wall, making it possible to retract the stomach at the level of the pyloric junction towards the upper part of the abdomen. A second tape was placed at the antral part in order to achieve a retraction towards the left hypochondrium at the superior part of the abdomen. The mesentericoportal axis was identified and dissected at the inferior border of the pancreas. The right gastroepiploic vein was one of the landmarks. The superior border of the pancreas was dissected in order to identify the splenic artery and a tape was positioned around it. The dissection was performed progressively at the anterior aspect of the mesentericoportal axis through an avascular channel. A tape was subsequently positioned around the pancreatic isthmus. The pancreas was divided with a stapler. The stapling was performed very progressively to avoid crushing the pancreas. The splenic vein was dissected in order to preserve the left gastric vein and a tape was positioned around it. The splenic artery was first divided between two clips on the remaining surface. The splenic vein was also divided. Dissection was pursued from the right to the left, making it possible to mobilize the pancreas. The inferior mesenteric vein was dissected and divided. Dissection of the posterior mesogastrium was initiated, making it possible to mobilize the splenopancreatic block. The dissection was performed anteriorly to the plane of Gerota’s fascia, anteriorly to the kidney. Since the posterior dissection was almost complete, our attention was turned to the superior part to complete the dissection of lesser sac adhesions at the superior border of the pancreas. It was necessary to divide the greater omentum by gradually dividing the short gastric vessels. Due to venous derivations linked to segmental portal hypertension, this dissection was performed through the application of the Endo GIA™ linear stapler. Since the entire specimen had been divided and freed, it was placed in a bag to be extracted through a suprapubic Pfannenstiel’s incision.
P Pessaux, X Untereiner, Z Cherkaoui, V Louis, D Mutter, J Marescaux
Surgical intervention
11 months ago
4333 views
599 likes
0 comments
45:34
Laparoscopic distal pancreatectomy with spleen resection
We reported a laparoscopic distal pancreatectomy with spleen resection for a mucinous cystic lesion. Four ports were positioned. The greater omentum was retracted to the superior part of the abdomen in order to detach the colon from the omentum and approach the lesser sac. The stomach was dissected. A tape was placed around the stomach through the abdominal wall, making it possible to retract the stomach at the level of the pyloric junction towards the upper part of the abdomen. A second tape was placed at the antral part in order to achieve a retraction towards the left hypochondrium at the superior part of the abdomen. The mesentericoportal axis was identified and dissected at the inferior border of the pancreas. The right gastroepiploic vein was one of the landmarks. The superior border of the pancreas was dissected in order to identify the splenic artery and a tape was positioned around it. The dissection was performed progressively at the anterior aspect of the mesentericoportal axis through an avascular channel. A tape was subsequently positioned around the pancreatic isthmus. The pancreas was divided with a stapler. The stapling was performed very progressively to avoid crushing the pancreas. The splenic vein was dissected in order to preserve the left gastric vein and a tape was positioned around it. The splenic artery was first divided between two clips on the remaining surface. The splenic vein was also divided. Dissection was pursued from the right to the left, making it possible to mobilize the pancreas. The inferior mesenteric vein was dissected and divided. Dissection of the posterior mesogastrium was initiated, making it possible to mobilize the splenopancreatic block. The dissection was performed anteriorly to the plane of Gerota’s fascia, anteriorly to the kidney. Since the posterior dissection was almost complete, our attention was turned to the superior part to complete the dissection of lesser sac adhesions at the superior border of the pancreas. It was necessary to divide the greater omentum by gradually dividing the short gastric vessels. Due to venous derivations linked to segmental portal hypertension, this dissection was performed through the application of the Endo GIA™ linear stapler. Since the entire specimen had been divided and freed, it was placed in a bag to be extracted through a suprapubic Pfannenstiel’s incision.
Transhepatic percutaneous biliary tract drainage
Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary strictures. It is a procedure which includes the cannulation of an intrahepatic biliary tree using image-guided wire and catheter manipulation, and placement of a tube or stent for external and/or internal drainage. This video shows this technique applied in a patient with a pancreatic tumor.
This is the case of an 80-year-old male patient with signs of jaundice and a diagnosis of intrahepatic and extrahepatic bile duct dilatation and pancreatic tumor.
A transhepatic percutaneous biliary tract drainage was the therapeutic strategy.
F Davrieux, ME Gimenez, EJ Houghton, M Palermo, D Mutter, J Marescaux
Surgical intervention
11 months ago
3258 views
588 likes
0 comments
20:25
Transhepatic percutaneous biliary tract drainage
Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary strictures. It is a procedure which includes the cannulation of an intrahepatic biliary tree using image-guided wire and catheter manipulation, and placement of a tube or stent for external and/or internal drainage. This video shows this technique applied in a patient with a pancreatic tumor.
This is the case of an 80-year-old male patient with signs of jaundice and a diagnosis of intrahepatic and extrahepatic bile duct dilatation and pancreatic tumor.
A transhepatic percutaneous biliary tract drainage was the therapeutic strategy.
Mobilization of the right colon for Chilaiditi syndrome in a 38-year-old patient
This video demonstrates our laparoscopic approach to the right colon for Chilaiditi syndrome with recurrent episodes of bowel obstruction.
A 38-year-old man with Down syndrome was admitted to our emergency department for acute abdominal pain and vomiting. The objective signs and radiographic findings were indicative of bowel obstruction. In his last few years, he was admitted multiple times to the emergency department for mechanical bowel obstruction. Both CT-scan and MRI showed medial dislocation of the liver and transposition of the right colon and small bowel loops in between the diaphragm and the liver. We propose a specific port-site layout and a counterclockwise approach, to allow for the correct triangulation of surgical instruments especially during the mobilization of the hepatic flexure, which is often the most critical phase of the operation. Starting from the mobilization of the transverse colon and proceeding towards the caecum we take advantage of gravity in handling the right colon. The operative time was 90 minutes. The patient recovered with no complications and was discharged on postoperative day 6. His symptoms disappeared completely.
M Lotti, E Poiasina, G Panyor, M Giulii Capponi
Surgical intervention
11 months ago
2429 views
443 likes
0 comments
11:18
Mobilization of the right colon for Chilaiditi syndrome in a 38-year-old patient
This video demonstrates our laparoscopic approach to the right colon for Chilaiditi syndrome with recurrent episodes of bowel obstruction.
A 38-year-old man with Down syndrome was admitted to our emergency department for acute abdominal pain and vomiting. The objective signs and radiographic findings were indicative of bowel obstruction. In his last few years, he was admitted multiple times to the emergency department for mechanical bowel obstruction. Both CT-scan and MRI showed medial dislocation of the liver and transposition of the right colon and small bowel loops in between the diaphragm and the liver. We propose a specific port-site layout and a counterclockwise approach, to allow for the correct triangulation of surgical instruments especially during the mobilization of the hepatic flexure, which is often the most critical phase of the operation. Starting from the mobilization of the transverse colon and proceeding towards the caecum we take advantage of gravity in handling the right colon. The operative time was 90 minutes. The patient recovered with no complications and was discharged on postoperative day 6. His symptoms disappeared completely.
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
JL Ng, SAE Yeo
Surgical intervention
1 year ago
11278 views
1169 likes
0 comments
05:37
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.