Laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions. The benefits of a minimally invasive approach to adrenal resection such as decreased hospital stay, shorter recovery time and improved patient satisfaction are widely accepted. In this lecture, Dr. Brunaud presents the indications of robotic assistance for transperitoneal adrenalectomy.
Performing wrist arthroscopy requires a good knowledge of anatomy, arthroscopic equipment and patient positioning.
E-learning has been developed to teach this basic knowledge to residents in orthopedic or plastic surgery who wish to perform wrist arthroscopies.
The subjects of this module are proper positioning of the patient, names and use of arthroscopic instruments, relevant anatomy, creation of portals and a description of the diagnostic inspection of the wrist.
After having assimilated the facts of this e-learning lecture, a resident should be able to perform his or her first arthroscopy in a cadaver or a wrist arthroscopy simulator.
To better visualize the expert's powerpoint presentation, please click here.
Currently, EMR and ESD are carried out alone in endoscopy suites. If a perforation is noted, an attempt may be made to close the hole with endoscopic clips. If a large perforation is made or if clips are not adequate, surgery is then necessary to deal with the problem. There is inevitably a delay before surgery is carried out, which is not ideal. The simultaneous use of laparoscopic and advanced endoscopic methods in the operating room setting allows a surgical endoscopist to rationally employ ESD methods for large right-sided polyps.
In this authoritative lecture, Professor Joel Leroy explains the basic principles in laparoscopic colorectal surgery from operative room settings to laparoscopic techniques.
Laparoscopic cholecystectomy is one of the most performed laparoscopic procedures. It seems to be an easy operation but when complications happen, they could be dramatic. In this lecture, Dr. Bernard Dallemagne presents the different types of complications and injury during cholecystectomy and their corresponding treatment.
There are several advanced situations in antireflux surgery: these include giant hiatal hernias (PEH), the short esophagus and the use of meshes to minimize recurrences.
PEH is a disease of the diaphragm more than one of the esophagus, recurrence rates at 5 to 10 years are very high (>50%) due to intrinsic defects of the connective tissue of the diaphragm. Keys to surgical repair include: reduction of the mediastinal hernia sac, extensive mobilization of the esophagus to bring the GE junction into the abdomen, reinforced repair of the diaphragm. Gastropexy can occasionally be a useful adjunct. Reinforced repair of the diaphragm can involve pledgets, relaxing incisions, or mesh. Mesh remains a controversial subject. The lowest reherniation rates in the literature are with plastic mesh but such a mesh is associated with esophageal erosions. The existence of the short esophagus is controversial, most agree it exists 3 to 5% of the time. The optimal treatment is extensive mediastinal mobilization and, if that fails, to perform a laparoscopic Collis gastroplasty. There are several techniques for Collis including transthoracic or wedge gastroplasty. All result in good functional results but the ectopic gastric mucosa that results often secretes acid and requires the patient to stay on anti-acid medication.
This lecture presents ureteral endometriosis, which is a rare pathology (0.1% of cases). In 50% of cases, the condition is asymptomatic and can lead to loss of renal functions. In the literature, ureteral endometriosis increases with the presence of rectovaginal endometriosis, which does not appear in the study presented (221 cases of endometriosis, 19.5% of which are ureteral tract endometriosis). It seems to be significantly associated with uterosacral ligament (USL) endometriosis (p=0.01) but not with bladder endometriosis. Medical treatment is not indicated and conservative laparoscopic surgical management shows a long-term relief of symptoms and a low rate of anatomical recurrence (0-11%).
This lecture focuses on complications in laparoscopic surgery for endometriosis. First, the expert addresses how to define complications. Surgeons sometimes need to remove part of the adjacent structures such as bowel, vagina and ureter, which should be included in the surgery – to achieve a complete excision of the disease. Complications can always occur and the most important thing to be borne in mind is to know how to deal with them by laparoscopy.
Complications may include adhesions, bowel, ureter and vascular injuries. The rate of complications in rectal shaving ranges from 0.2 to 1.4%. In case of discoid bowel resection, the morbidity rate published in the literature is 13%. Regarding rectal segmental resection, the rate of complications in laparoscopy (4.25%) is similar to that of laparotomy (4.5%). The rate of rectovaginal fistula in case of rectal shaving is 8.3%, and in rectal segmental resection 3.1%, which is not associated with the distance between the anastomosis and the rectum. Voiding problems are frequent and the incidence of urinary retention ranges from 1 to 29% and depends on the interval of observation. Finally, in case of ureteral endometriosis, a double J catheter should be always placed in order to decrease the risk of ureteral fistula.
This lecture addresses the etiopathogenesis of endometriosis, as defined by the presence of endometrial glands and stroma out of the uterine cavity. Endometriosis is present in 6-10% of women worldwide, 50-70% of women with pelvic pain and 30-50% of women with infertility. The main risk factors are early menarche, nulliparity and family history. Diagnosis frequently takes a long time from the onset of the first symptoms and constitutes a major healthcare problem in the United States. The most popular theory is retrograde menstruation, but other explanations are coelomic metaplasia, genetic predisposition, immune system dysfunction and environmental factors, which by means of inflammation, prostaglandin production and nerve regeneration could lead to pain and infertility. Endometriosis lesions have a known dependence with ovarian estrogens, but local conversion of androstenedione to estradiol inside the implants has been demonstrated, leading to proliferation of nerve fibers even after oophorectomy. Medical treatment aims to decrease inflammation, estrogen synthesis and local conversion of androgens to estrogens for a limited period of time. Surgical treatment aims to remove lesions and disrupt nerve production in the tissue, but there is a high percentage of symptom recurrence. Regarding infertility, endometriosis can cause adhesions affecting the ovary and the tube, but can also affect spermatozoa motility, migration of the embryo and prevent implantation, accounting for poor pregnancy outcomes in women with endometriosis.
To better visualize the expert's powerpoint presentation, please click here.
Complications after laparoscopic surgery for endometriosis may occur even with a skilled surgeon and ideal circumstances. Success is linked to many factors, and not only to the surgeon’s experience. It is necessary to inform the patient in order to avoid medico-legal problems. An appropriate diagnosis must be performed, including clinical examination and all other necessary investigations. Proper instruments, anatomical knowledge, and exposure help to prevent severe complications. Make sure that you visualize the ureters at the beginning of the surgery as they always tend to go medially. In addition, ureterosacral resection should be avoided in order to prevent bladder dysfunction. Always prefer discoid excision of the bowel rather than bowel resection and make sure the suture does not exceed 3cm on the bowel, and avoid any vertical suturing when possible. If there is a history of surgery or a lesion near the ostia or a ureteral stenosis, ureteral stents should be placed. At the end of the procedure, it is recommended to carry out a blue dye or an air test, a cystoscopy or to place drains. A postoperative consultation is essential.
During deep endometriosis surgery, bladder and ureter lesions are the most frequent complications.
Bladder lesions. The cystoscopy must be first carried out to assess the location of the endometriosis. If the nodule is close to the ureter, a stent is needed. To prevent lesion to the intramural part of the ureter, it is advisable to enter the bladder at its upper part. To minimize complications, an adequate surgical technique is necessary, a catheter must be placed for 1 to 3 weeks, a large catheter must be placed to drain clots, and control cystoscopy must be achieved before catheter removal. Intraoperative bladder lesions are never a major problem since the bladder wall heals well. Late complications are as follows: vesicovaginal fistula, rare but more frequent after hysterectomy, and the clinical sign is continuous leakage from the vagina, and the treatment is laparoscopy immediately or 50 days after surgery (with, in the last case, treatment with antibiotics until laparoscopic treatment begins). In addition, urinary retention is another late complication, more frequent, especially after resection of large nodules with lateral extension; it is due to parasympathetic nerve injury. Nerve-sparing prevention in endometriosis is not possible; the important thing is not to resect bilaterally. If injury is monolateral, it heals spontaneously in 3 months, rarely longer than 6-12 months.
Ureteral lesions. They occur mainly in cases of hydronephrosis or nodules bigger than 3 centimeters. In case of hydronephrosis, it is necessary to stent the patient before surgery; in all cases, especially when dealing with a nodule, the ureter should be isolated. After surgery a control cystoscopy must be carried out if the ureter works properly. It is important to monitor drain volume and CRP daily. CRP increases on the second day, and decreases on the third day. If CRP increases again, it means there is a complication (infection, ureteral lesion, leakage from rectum). Treatment is immediate laparoscopy with stitch and stent. Another complication is urinoma; symptoms are pain, diarrhea and high temperature. In these cases laparoscopy should be repeated. In case of ureterovaginal fistula, the leakage is intermittent. It usually becomes evident after 1 to 3 weeks. The diagnosis is made by intravenous pyelogram (IVP); treatment is carried out through laparoscopy. In case of unrecognized ureteral transection, there is a late ureteral leak (even after 25 days); ureteral re-anastomosis is the first-line treatment.
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