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Hall of Fame

Participate in the Hall of Fame contest of WebSurg.

The last winner - 2018

Surgical intervention
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.
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
JL Ng, SAE Yeo
10121 views
11 months ago
Jia Lin NG, MD
Singapore, Singapore
Dr. Ng Jia Lin is an Associate Consultant at the Department of Colorectal Surgery in Singapore General Hospital, Singapore. Having completed her general surgical residency training and colorectal surgery fellowship training in Singapore, she is currently pursuing a fellowship program in advanced laparoscopic and open pelvic surgery in Bangkok, Thailand.
Shen-Ann Eugene YEO, MBBS, MMed (Surg), FRCS (Ed)
Singapore, Singapore
Dr. Eugene Yeo is currently a Consultant Colorectal Surgeon in the Department of Colorectal Surgery, Singapore General Hospital. He completed his basic medical degree and his surgical training in Singapore and spent one year in Seoul, South Korea attending a fellowship in robotics and advanced laparoscopic surgical procedures. Dr. Yeo has a special interest in minimally invasive colorectal surgery, particularly in laparoscopic and robotic approaches, including transanal work. He has also interest in advanced endoscopic procedures such as colonic stenting and resection of advanced colonic polyps.
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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.
S Targa
Surgical intervention
6 months ago
2052 views
422 likes
0 comments
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.
Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
H Altuntaş
Surgical intervention
7 months ago
3308 views
479 likes
0 comments
06:58
Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
Laparoscopic complete parametrectomy associated with upper vaginectomy and bilateral pelvic lymphadenectomy
This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.
H Camuzcuoglu, B Sezgin
Surgical intervention
7 months ago
3116 views
446 likes
0 comments
11:55
Laparoscopic complete parametrectomy associated with upper vaginectomy and bilateral pelvic lymphadenectomy
This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.
Use of visual cues in hysteroscopic management of Asherman's syndrome
The normal uterine cavity is distorted or obliterated due to severe adhesions in Asherman’s syndrome, which makes surgery difficult to perform. The high-definition vision of the camera can help to identify visual cues and clues during hysteroscopy, which can guide the surgery.
The objective of this video is to demonstrate that the information gathered from various visual cues during hysteroscopy is really helpful to the surgeon.
The video focuses on the use of the following seven visual cues: color of fibrous bands and endometrium which imparts a white spectrum; thread-like texture of fibrotic bands; lacunae and their dilatation in scar tissue; probing and post-probing analysis using scissors (5 French); color and appearance of myometrial fibers which impart a pink spectrum; vascularity differentiation; matching analysis with a normal uterine cavity.
Various techniques described for the management of this condition include fluorescence-guided, ultrasonography-guided, and hysteroscopic adhesiolysis under laparoscopic control, which are expensive procedures. We suggest that the high-definition vision and visual cues during hysteroscopy should be initially used intraoperatively for guidance purposes before using such options. It may be sufficient to achieve the desired result in most cases.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
7 months ago
1964 views
383 likes
0 comments
06:01
Use of visual cues in hysteroscopic management of Asherman's syndrome
The normal uterine cavity is distorted or obliterated due to severe adhesions in Asherman’s syndrome, which makes surgery difficult to perform. The high-definition vision of the camera can help to identify visual cues and clues during hysteroscopy, which can guide the surgery.
The objective of this video is to demonstrate that the information gathered from various visual cues during hysteroscopy is really helpful to the surgeon.
The video focuses on the use of the following seven visual cues: color of fibrous bands and endometrium which imparts a white spectrum; thread-like texture of fibrotic bands; lacunae and their dilatation in scar tissue; probing and post-probing analysis using scissors (5 French); color and appearance of myometrial fibers which impart a pink spectrum; vascularity differentiation; matching analysis with a normal uterine cavity.
Various techniques described for the management of this condition include fluorescence-guided, ultrasonography-guided, and hysteroscopic adhesiolysis under laparoscopic control, which are expensive procedures. We suggest that the high-definition vision and visual cues during hysteroscopy should be initially used intraoperatively for guidance purposes before using such options. It may be sufficient to achieve the desired result in most cases.
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
8 months ago
2738 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.
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
8 months ago
7109 views
1067 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.
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
8 months ago
948 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.
Thoracoscopic repair of pure esophageal atresia
A full-term baby weighing 2.8 kg was diagnosed with pure esophageal atresia. No other associated anomalies were found by abdominal sonography and echocardiography. The primary anastomosis was completed thoracoscopically after mobilization of both esophageal pouches. The patient was placed in a prone position at the edge of the operating table. A 5mm, 30-degree angled scope was introduced one fingerbreadth below the lower angle of the scapula. Two 3mm working ports were also inserted; the first in the same costal space as the camera port 3cm from the middle line and the second as high as possible in the axilla. A thin fibrous strand was found connecting both ends of the esophagus. The azygos vein was left intact. Blunt dissection was used throughout the whole procedure to preserve the aortic branches to the lower pouch, dissecting in between them. Without traction, the distance between both pouches was approximately 4cm or 4 vertebral bodies. No tracheoesophageal fistula (TEF) was identified. Nine polyglactin 5/0 sliding tumble square knots were used to complete the anastomosis. The operative time was 85 minutes. The postoperative period was uneventful. Nasogatric tube feeding started on postoperative day 2, and the patient was discharged on postoperative day 6 after performing a contrast swallow test ensuring that there is no leakage.
MM Elbarbary, KHK Bahaaeldin, AE Fares, H Seleim, A Shalaby, M Elseoudi, MM Ragab
Surgical intervention
10 months ago
1478 views
228 likes
0 comments
18:13
Thoracoscopic repair of pure esophageal atresia
A full-term baby weighing 2.8 kg was diagnosed with pure esophageal atresia. No other associated anomalies were found by abdominal sonography and echocardiography. The primary anastomosis was completed thoracoscopically after mobilization of both esophageal pouches. The patient was placed in a prone position at the edge of the operating table. A 5mm, 30-degree angled scope was introduced one fingerbreadth below the lower angle of the scapula. Two 3mm working ports were also inserted; the first in the same costal space as the camera port 3cm from the middle line and the second as high as possible in the axilla. A thin fibrous strand was found connecting both ends of the esophagus. The azygos vein was left intact. Blunt dissection was used throughout the whole procedure to preserve the aortic branches to the lower pouch, dissecting in between them. Without traction, the distance between both pouches was approximately 4cm or 4 vertebral bodies. No tracheoesophageal fistula (TEF) was identified. Nine polyglactin 5/0 sliding tumble square knots were used to complete the anastomosis. The operative time was 85 minutes. The postoperative period was uneventful. Nasogatric tube feeding started on postoperative day 2, and the patient was discharged on postoperative day 6 after performing a contrast swallow test ensuring that there is no leakage.
Thoracoscopic treatment of pulmonary hydatid cyst in children
Introduction: The hydatid cyst is an anthropozoonosis caused by the development of the Echinococcus granulosus tapeworm larva in humans. It is endemic in the Mediterranean, South America, Middle East, Australia, New Zealand, and India. Lung localization is ranked second in order of frequency for all age groups after liver localization.
Treatment is mainly surgical and consists in the resection of the protruding dome after cyst puncture, suction, and sterilization using a Scolicide solution followed by proligerous membrane extraction and bronchial fistulas obstruction. This surgery can be performed through a thoracotomy or a thoracoscopy.
We report the highlights of a thoracoscopic surgical management of a bilateral pulmonary hydatid cyst in a 6-year-old boy. The cyst was discovered following exploration for chest pain associated with a dry cough, as demonstrated by chest CT-scan findings and confirmed by serum chemistries positive for pulmonary hydatid cyst.
Materials and methods: The patient was first operated on for his two hydatid cysts of the right lung, followed by another left-side intervention a month later. Intubation was selective and was performed with a standard intubation cannula.
The patient was placed in a strict lateral decubitus position.
Four ports (10, 5, 5, and 5mm in size) were used for the right lung and three ports (10, 5, and 5mm) were used for the left lung, making sure to respect the rule of triangulation.
After partial filling of the pleural cavity with a 10% hypertonic saline solution, the surgical principles of the thoracoscopic treatment of pulmonary hydatid cysts are performed as follows: puncture of the cyst at its dome using a Veress needle, suction, and sterilization with a 10% hypertonic saline solution for 15 minutes; resection of the protruding dome; extraction of the proligerous membrane through an Endobag®; closure of bronchial fistulas by means of intracorporeal stitches; no padding necessary; double chest drainage (anterior and posterior).
Results: Immediate postoperative outcomes were uneventful. Paracetamol was sufficient to manage postoperative pain in the first 24 hours. Chest drains were removed on postoperative day 3, and the patient was discharged on postoperative day 4.
After 5 years, late postoperative outcomes were extremely favorable clinically, radiologically, and cosmetically speaking.
Conclusion: The thoracoscopic approach to the management of pulmonary hydatid cysts is feasible. It completely changed the postoperative evolution of thoracotomy, which causes pain and parietal sequelae in children.
AM Benaired
Surgical intervention
10 months ago
893 views
141 likes
0 comments
04:03
Thoracoscopic treatment of pulmonary hydatid cyst in children
Introduction: The hydatid cyst is an anthropozoonosis caused by the development of the Echinococcus granulosus tapeworm larva in humans. It is endemic in the Mediterranean, South America, Middle East, Australia, New Zealand, and India. Lung localization is ranked second in order of frequency for all age groups after liver localization.
Treatment is mainly surgical and consists in the resection of the protruding dome after cyst puncture, suction, and sterilization using a Scolicide solution followed by proligerous membrane extraction and bronchial fistulas obstruction. This surgery can be performed through a thoracotomy or a thoracoscopy.
We report the highlights of a thoracoscopic surgical management of a bilateral pulmonary hydatid cyst in a 6-year-old boy. The cyst was discovered following exploration for chest pain associated with a dry cough, as demonstrated by chest CT-scan findings and confirmed by serum chemistries positive for pulmonary hydatid cyst.
Materials and methods: The patient was first operated on for his two hydatid cysts of the right lung, followed by another left-side intervention a month later. Intubation was selective and was performed with a standard intubation cannula.
The patient was placed in a strict lateral decubitus position.
Four ports (10, 5, 5, and 5mm in size) were used for the right lung and three ports (10, 5, and 5mm) were used for the left lung, making sure to respect the rule of triangulation.
After partial filling of the pleural cavity with a 10% hypertonic saline solution, the surgical principles of the thoracoscopic treatment of pulmonary hydatid cysts are performed as follows: puncture of the cyst at its dome using a Veress needle, suction, and sterilization with a 10% hypertonic saline solution for 15 minutes; resection of the protruding dome; extraction of the proligerous membrane through an Endobag®; closure of bronchial fistulas by means of intracorporeal stitches; no padding necessary; double chest drainage (anterior and posterior).
Results: Immediate postoperative outcomes were uneventful. Paracetamol was sufficient to manage postoperative pain in the first 24 hours. Chest drains were removed on postoperative day 3, and the patient was discharged on postoperative day 4.
After 5 years, late postoperative outcomes were extremely favorable clinically, radiologically, and cosmetically speaking.
Conclusion: The thoracoscopic approach to the management of pulmonary hydatid cysts is feasible. It completely changed the postoperative evolution of thoracotomy, which causes pain and parietal sequelae in children.
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
10 months ago
1697 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.
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.
ME Gimenez, EJ Houghton, M Palermo, D Mutter, J Marescaux
Surgical intervention
10 months ago
3120 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, M Giulii Capponi
Surgical intervention
10 months ago
2247 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.
Laparoscopy for peritonitis of gynecological origin, how far can we go?
This video shows the second and final laparoscopic treatment of a generalized peritonitis. The case is that of a 38-year-old woman who was initially managed with a first laparoscopy for peritonitis due to a pyosalpinx with left salpingectomy, adhesiolysis, and lavage. In the postoperative course, despite medical treatment, she continues to complain of a persistent severe biologic inflammatory syndrome (multidrug-resistant Bacteroides fragilis). At day 8, a second laparoscopy was decided upon, with suction, lavage, collapse, and lavage of residual pockets, adhesiolysis of bowel and both ovaries and remnant tube, and drainage. The patient recovered quickly.
JB Dubuisson
Surgical intervention
10 months ago
3419 views
573 likes
0 comments
08:01
Laparoscopy for peritonitis of gynecological origin, how far can we go?
This video shows the second and final laparoscopic treatment of a generalized peritonitis. The case is that of a 38-year-old woman who was initially managed with a first laparoscopy for peritonitis due to a pyosalpinx with left salpingectomy, adhesiolysis, and lavage. In the postoperative course, despite medical treatment, she continues to complain of a persistent severe biologic inflammatory syndrome (multidrug-resistant Bacteroides fragilis). At day 8, a second laparoscopy was decided upon, with suction, lavage, collapse, and lavage of residual pockets, adhesiolysis of bowel and both ovaries and remnant tube, and drainage. The patient recovered quickly.
Robotic left lateral sectionectomy in cirrhotic liver
Background: Laparoscopy for cirrhotic patients can reduce intraoperative bleeding and postoperative morbidity when compared to open surgery. Liver robotic surgery remains a work in progress and only few series reported this approach for cirrhotic patients.
Methods: This is the case of a 62-year-old man with hepatitis C virus and alcoholic cirrhosis (MELD score 10, Child-Pugh score A6) with a single lesion in liver segment III and close to its pedicle.
Results: Intraoperative ultrasound was used to confirm findings on preoperative imaging.
Parenchymal transection was made with an ultrasonic scalpel, monopolar and bipolar cautery with no Pringle’s maneuver. Linear staplers were used to control left lobe inflow and outflow. The specimen was removed through a Pfannenstiel incision. The estimated blood loss was 100mL, and the postoperative course was uneventful. Pathological findings confirmed a 2.5cm hepatocellular carcinoma, with negative margins, and a cirrhotic parenchyma.
Conclusion: Robotic left lateral sectionectomy seems to be as feasible as the conventional laparoscopic approach in selected cirrhotic patients.
R Araujo, LA de Castro, F Felippe, D Burgardt, D Wohnrath
Surgical intervention
11 months ago
1423 views
165 likes
0 comments
07:47
Robotic left lateral sectionectomy in cirrhotic liver
Background: Laparoscopy for cirrhotic patients can reduce intraoperative bleeding and postoperative morbidity when compared to open surgery. Liver robotic surgery remains a work in progress and only few series reported this approach for cirrhotic patients.
Methods: This is the case of a 62-year-old man with hepatitis C virus and alcoholic cirrhosis (MELD score 10, Child-Pugh score A6) with a single lesion in liver segment III and close to its pedicle.
Results: Intraoperative ultrasound was used to confirm findings on preoperative imaging.
Parenchymal transection was made with an ultrasonic scalpel, monopolar and bipolar cautery with no Pringle’s maneuver. Linear staplers were used to control left lobe inflow and outflow. The specimen was removed through a Pfannenstiel incision. The estimated blood loss was 100mL, and the postoperative course was uneventful. Pathological findings confirmed a 2.5cm hepatocellular carcinoma, with negative margins, and a cirrhotic parenchyma.
Conclusion: Robotic left lateral sectionectomy seems to be as feasible as the conventional laparoscopic approach in selected cirrhotic patients.
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
11 months ago
10121 views
1165 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.
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
AM Pereira, R Ferreira de Almeida, G Gonçalves
Surgical intervention
11 months ago
2090 views
284 likes
2 comments
09:29
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
Concurrent laparoscopic RYGB with a paraesophageal hernia (PEH) repair
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
A Duro, F Wright, PJ Castellaro, A Beskow, D Cavadas, J Montagné
Surgical intervention
1 year ago
914 views
178 likes
0 comments
06:23
Concurrent laparoscopic RYGB with a paraesophageal hernia (PEH) repair
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
Laparoscopic Roux-en-Y gastric bypass (RYGB) after failed Nissen
This is the case of a 62-year old female patient with a BMI of 35 and a history of high blood pressure, dyslipidemia, and morbid obesity. She underwent a laparoscopic Nissen surgery 8 years earlier and presented with recurrent GERD symptoms.

A CT-scan, an endoscopy, and a barium swallow showed a hiatal hernia. It was decided to perform a paraesophageal hernia repair as well as a gastric bypass. A laparoscopic surgery was performed.

There were no complications and the patient was discharged on the second postoperative day. An esogastroduodenal contrast examination was performed 1 month after the procedure. It showed the absence of hiatal hernia. The patient was controlled 3 months after surgery and was found asymptomatic with an Excess Weight Loss (EWL) of 42%.
A Duro, V Cano Busnelli, A Beskow, D Cavadas, F Wright, P Saleg, PJ Castellaro
Surgical intervention
1 year ago
1800 views
171 likes
0 comments
06:12
Laparoscopic Roux-en-Y gastric bypass (RYGB) after failed Nissen
This is the case of a 62-year old female patient with a BMI of 35 and a history of high blood pressure, dyslipidemia, and morbid obesity. She underwent a laparoscopic Nissen surgery 8 years earlier and presented with recurrent GERD symptoms.

A CT-scan, an endoscopy, and a barium swallow showed a hiatal hernia. It was decided to perform a paraesophageal hernia repair as well as a gastric bypass. A laparoscopic surgery was performed.

There were no complications and the patient was discharged on the second postoperative day. An esogastroduodenal contrast examination was performed 1 month after the procedure. It showed the absence of hiatal hernia. The patient was controlled 3 months after surgery and was found asymptomatic with an Excess Weight Loss (EWL) of 42%.
A stepwise personal technique of RYGB with hand-sewn gastrojejunostomy
With more than 25 years of experience, we have created a unique laparoscopic Roux-en-Y gastric bypass technique with hand-sewn gastrojejunostomy and several additional steps which offer our patients a safe and reliable procedure.
We routinely use 5 bladeless 12mm trocars. The procedure begins with the creation of a 15-20mL gastric pouch with a tilted orientation for the first stapling (not horizontal), and staple lines are oversewn for both gastric pouch and gastric remnant. A blue dye test is always performed at this stage. The second stage of the procedure includes the creation of a 75cm biliopancreatic limb with division of the mesentery and creation of a mechanical jejunojejunostomy with a 100cm alimentary limb, and hand-sewn closure of the enterotomy. Anti-torsion stitches are mandatory at this point. Closure of mesenteric defects (intermesenteric space and Petersen's space) is accomplished with non-absorbable sutures performed in a routine manner. The third and final stage of the procedure involves the creation of the hand-sewn gastrojejunostomy with an interposed limb and 4 layers of absorbable sutures over a 28-30 French bougie.
Closure of all trocar defects is performed in every patient.
L Zorrilla-Nunez, P Zorrilla
Surgical intervention
1 year ago
1125 views
216 likes
0 comments
10:05
A stepwise personal technique of RYGB with hand-sewn gastrojejunostomy
With more than 25 years of experience, we have created a unique laparoscopic Roux-en-Y gastric bypass technique with hand-sewn gastrojejunostomy and several additional steps which offer our patients a safe and reliable procedure.
We routinely use 5 bladeless 12mm trocars. The procedure begins with the creation of a 15-20mL gastric pouch with a tilted orientation for the first stapling (not horizontal), and staple lines are oversewn for both gastric pouch and gastric remnant. A blue dye test is always performed at this stage. The second stage of the procedure includes the creation of a 75cm biliopancreatic limb with division of the mesentery and creation of a mechanical jejunojejunostomy with a 100cm alimentary limb, and hand-sewn closure of the enterotomy. Anti-torsion stitches are mandatory at this point. Closure of mesenteric defects (intermesenteric space and Petersen's space) is accomplished with non-absorbable sutures performed in a routine manner. The third and final stage of the procedure involves the creation of the hand-sewn gastrojejunostomy with an interposed limb and 4 layers of absorbable sutures over a 28-30 French bougie.
Closure of all trocar defects is performed in every patient.
Surgical approach to intragastric migrated hiatal mesh
Mesh use in the laparoscopic repair of hiatal hernia is associated with fewer recurrences. However, it may cause some complications such as dysphagia, stenosis or even erosion with esophageal or gastric migration.
A 61-year-old woman with a large type III hiatal hernia underwent a laparoscopic Toupet fundoplication with closure of the hiatal crura with a dual U-shaped mesh.
She was symptom-free for 1 year, subsequently developing dysphagia and weight loss. An esophagogastric barium test revealed minimal contrast passage and endoscopy showed partial intragastric mesh migration.
The patient was submitted to a laparoscopic removal of migrated mesh with a transgastric approach. Hiatus inspection demonstrated significant fibrosis, with plication integrity and no evidence of recurrent hernia. A gastrotomy was performed allowing to identify and remove a migrated intra-gastric mesh. Careful evaluation did not show any gastric fistula and pressure test with methylene blue showed no evidence of leak.
This unusual approach avoided hiatus dissection, decreasing the risks of local complications such as perforation and bleeding. The patient had no postoperative complications, recovered well, and remained asymptomatic.
A Trovão, L Costa, M Costa, R Ferreira de Almeida, M Nora
Surgical intervention
1 year ago
555 views
106 likes
0 comments
09:55
Surgical approach to intragastric migrated hiatal mesh
Mesh use in the laparoscopic repair of hiatal hernia is associated with fewer recurrences. However, it may cause some complications such as dysphagia, stenosis or even erosion with esophageal or gastric migration.
A 61-year-old woman with a large type III hiatal hernia underwent a laparoscopic Toupet fundoplication with closure of the hiatal crura with a dual U-shaped mesh.
She was symptom-free for 1 year, subsequently developing dysphagia and weight loss. An esophagogastric barium test revealed minimal contrast passage and endoscopy showed partial intragastric mesh migration.
The patient was submitted to a laparoscopic removal of migrated mesh with a transgastric approach. Hiatus inspection demonstrated significant fibrosis, with plication integrity and no evidence of recurrent hernia. A gastrotomy was performed allowing to identify and remove a migrated intra-gastric mesh. Careful evaluation did not show any gastric fistula and pressure test with methylene blue showed no evidence of leak.
This unusual approach avoided hiatus dissection, decreasing the risks of local complications such as perforation and bleeding. The patient had no postoperative complications, recovered well, and remained asymptomatic.
Minimally invasive management of an epiphrenic diverticulum
We present the case of a 65-year-old gentleman who was referred to our department with long standing symptoms of dysphagia, reflux, and regurgitation. An esophagogastroduodenoscopy (EGD) was initially performed to evaluate his symptoms and showed food residue in the esophagus and a wide-necked epiphrenic diverticulum extending from 38 to 41cm with superficial ulceration within it. The esophagogastric junction was at 45cm and appeared tight, which was consistent with the appearance of achalasia. A subsequent barium swallow and manometric studies confirmed the endoscopic findings. A minimally invasive laparoscopic approach was adopted for trans-hiatal dissection and diverticulectomy. Heller’s myotomy combined with an anti-reflux procedure was also performed to deal with the underlying achalasia as the cause of this pulsion diverticulum. The patient’s postoperative recovery was uneventful with complete resolution of his symptoms.
M Arumugasamy
Surgical intervention
1 year ago
942 views
60 likes
0 comments
08:19
Minimally invasive management of an epiphrenic diverticulum
We present the case of a 65-year-old gentleman who was referred to our department with long standing symptoms of dysphagia, reflux, and regurgitation. An esophagogastroduodenoscopy (EGD) was initially performed to evaluate his symptoms and showed food residue in the esophagus and a wide-necked epiphrenic diverticulum extending from 38 to 41cm with superficial ulceration within it. The esophagogastric junction was at 45cm and appeared tight, which was consistent with the appearance of achalasia. A subsequent barium swallow and manometric studies confirmed the endoscopic findings. A minimally invasive laparoscopic approach was adopted for trans-hiatal dissection and diverticulectomy. Heller’s myotomy combined with an anti-reflux procedure was also performed to deal with the underlying achalasia as the cause of this pulsion diverticulum. The patient’s postoperative recovery was uneventful with complete resolution of his symptoms.
Laparoscopic enucleation of a horseshoe-shaped leiomyoma of the distal esophagus
This is the case of a 17-year-old girl, complaining of weight loss and dysphagia. In the preoperative work-up, gastroscopy and endoscopic ultrasonography revealed a 3-4cm multilobulated submucosal mass. Computed tomography and MRI showed a distal esophageal mass of 4cm in diameter. Fine needle aspiration biopsy was compatible with a leiomyoma. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal enucleation of the esophageal leiomyoma was performed. The patient was placed in a gynecologic position, with the surgeon standing between the patient’s legs. The first assistant stood on the right side of the patient and the second assistant on the left. The procedure was performed using 5 trocars. The phrenoesophageal membrane was divided. The distal esophagus was circumferentially mobilized. Dissection was started by separating the layer over the tumor. Blunt dissection was preferred. The use of energy devices discouraged to prevent any delayed mucosal burn injury. The leiomyoma was completely enucleated. Esophageal muscle layers were closed. The postoperative period was uneventful. This video demonstrates technical details of a laparoscopic enucleation of a hoseshoe-shaped leiomyoma of the distal esophagus.
K Karabulut, S Usta, E Sahin, Z Cetinkaya
Surgical intervention
1 year ago
534 views
42 likes
0 comments
11:21
Laparoscopic enucleation of a horseshoe-shaped leiomyoma of the distal esophagus
This is the case of a 17-year-old girl, complaining of weight loss and dysphagia. In the preoperative work-up, gastroscopy and endoscopic ultrasonography revealed a 3-4cm multilobulated submucosal mass. Computed tomography and MRI showed a distal esophageal mass of 4cm in diameter. Fine needle aspiration biopsy was compatible with a leiomyoma. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal enucleation of the esophageal leiomyoma was performed. The patient was placed in a gynecologic position, with the surgeon standing between the patient’s legs. The first assistant stood on the right side of the patient and the second assistant on the left. The procedure was performed using 5 trocars. The phrenoesophageal membrane was divided. The distal esophagus was circumferentially mobilized. Dissection was started by separating the layer over the tumor. Blunt dissection was preferred. The use of energy devices discouraged to prevent any delayed mucosal burn injury. The leiomyoma was completely enucleated. Esophageal muscle layers were closed. The postoperative period was uneventful. This video demonstrates technical details of a laparoscopic enucleation of a hoseshoe-shaped leiomyoma of the distal esophagus.
A rare cause of abdominal pain (liposarcoma) treated by a minimally invasive approach
A 53-year-old woman is referred to the emergency department with complaints of an insidious pain in the left lower abdominal quadrant, with no associated fever, neither changes in her bowel habits, nor other complaints. She had a cardiac arrhythmia, medicated with atenolol, and no previous surgeries. Laboratory results showed no significant changes. Abdominal ultrasound demonstrated an inflammatory mass adjacent to the left colon. The abdominal and pelvic CT-scan showed a bulky and capsulated mass at the left iliac fossa extending along the left flank until the lower pole of the left kidney, measuring 9x12x20cm, probably corresponding to a peritoneal lipoma, with no signs of aggressiveness towards adjacent organs. The patient was admitted to hospital for clinical vigilance and complementary exams. Upper and lower endoscopic studies were performed and revealed no significant changes. The patient was then proposed for elective surgery – laparoscopic excision of the intra-abdominal mass, which was independent of the intra-abdominal visceral content. In the postoperative period, the patient had no complications with clinical discharge four days after surgery. The pathology report revealed a well-differentiated lipomatous neoplasia, a lipoma-like liposarcoma. In a multidisciplinary meeting, it was decided not to perform any adjuvant treatment. The patient remains with neither clinical nor imaging signs of the disease after 10 months of follow-up.
A Tojal, J Marques, S Coelho, M Fernandes, N Carrilho, H Oliveira, C Casimiro
Surgical intervention
1 year ago
870 views
62 likes
0 comments
07:41
A rare cause of abdominal pain (liposarcoma) treated by a minimally invasive approach
A 53-year-old woman is referred to the emergency department with complaints of an insidious pain in the left lower abdominal quadrant, with no associated fever, neither changes in her bowel habits, nor other complaints. She had a cardiac arrhythmia, medicated with atenolol, and no previous surgeries. Laboratory results showed no significant changes. Abdominal ultrasound demonstrated an inflammatory mass adjacent to the left colon. The abdominal and pelvic CT-scan showed a bulky and capsulated mass at the left iliac fossa extending along the left flank until the lower pole of the left kidney, measuring 9x12x20cm, probably corresponding to a peritoneal lipoma, with no signs of aggressiveness towards adjacent organs. The patient was admitted to hospital for clinical vigilance and complementary exams. Upper and lower endoscopic studies were performed and revealed no significant changes. The patient was then proposed for elective surgery – laparoscopic excision of the intra-abdominal mass, which was independent of the intra-abdominal visceral content. In the postoperative period, the patient had no complications with clinical discharge four days after surgery. The pathology report revealed a well-differentiated lipomatous neoplasia, a lipoma-like liposarcoma. In a multidisciplinary meeting, it was decided not to perform any adjuvant treatment. The patient remains with neither clinical nor imaging signs of the disease after 10 months of follow-up.
Laparoscopic partial splenectomy
A 39-year-old male patient was referred to our institution for a total laparoscopic splenectomy. The patient presented a CT-scan with a heterogeneous lesion in the lower aspect of the spleen. Two different hematologists-oncologists recommended a total splenectomy due the characteristics of the lesion. We discussed this recommendation during the oncological committee at our institution and due to the anatomical variation of the splenic artery and the absence of characterization of the lesion as 100% malignant, a laparoscopic partial splenectomy was decided upon with an intraoperative frozen analysis to determine if any further resection would be necessary. In this video, the authors present the technical aspects of a complex surgical resection.
D Awruch, M Grimoldi, M Blanco, R Sanchez Almeyra
Surgical intervention
1 year ago
1942 views
177 likes
0 comments
05:28
Laparoscopic partial splenectomy
A 39-year-old male patient was referred to our institution for a total laparoscopic splenectomy. The patient presented a CT-scan with a heterogeneous lesion in the lower aspect of the spleen. Two different hematologists-oncologists recommended a total splenectomy due the characteristics of the lesion. We discussed this recommendation during the oncological committee at our institution and due to the anatomical variation of the splenic artery and the absence of characterization of the lesion as 100% malignant, a laparoscopic partial splenectomy was decided upon with an intraoperative frozen analysis to determine if any further resection would be necessary. In this video, the authors present the technical aspects of a complex surgical resection.
Laparoscopic Ladd’s procedure for intestinal malrotation in an 18-month-old boy
Performing Ladd’s procedure for intestinal malrotation using a laparoscopic approach can be confusing and challenging. This can be attributed to the small working space in children as compared to the length of small and large bowel to be handled. The procedure also requires some understanding of the overall anatomical disorder in order to separate it into smaller steps of correction. The first step is to confirm the diagnosis. The operator has to identify the ligament of Treitz and the presence of Ladd’s bands stretching between the colon and the right abdomen. The bands are divided first to the left of the duodenum, and then between the duodenum and the colon. As a result, the mesentery is widened. Bowel derotation is then started placing the small bowel in the right side and the colon in the left side of the abdomen. The procedure is concluded with an appendectomy.
TA Wafa, S Abdelmaksoud
Surgical intervention
1 year ago
717 views
139 likes
0 comments
06:00
Laparoscopic Ladd’s procedure for intestinal malrotation in an 18-month-old boy
Performing Ladd’s procedure for intestinal malrotation using a laparoscopic approach can be confusing and challenging. This can be attributed to the small working space in children as compared to the length of small and large bowel to be handled. The procedure also requires some understanding of the overall anatomical disorder in order to separate it into smaller steps of correction. The first step is to confirm the diagnosis. The operator has to identify the ligament of Treitz and the presence of Ladd’s bands stretching between the colon and the right abdomen. The bands are divided first to the left of the duodenum, and then between the duodenum and the colon. As a result, the mesentery is widened. Bowel derotation is then started placing the small bowel in the right side and the colon in the left side of the abdomen. The procedure is concluded with an appendectomy.
Complete cytoreductive surgery (CRS) and HIPEC using a minimally invasive approach with NOTES extraction for peritoneal carcinomatosis from primary ovarian cancer
This is the case of a 60-year old woman who sought medical advice for constipation and increased abdominal perimeter in October 2016. The abdominal CT-scan suggested a peritoneal carcinomatosis of ovarian origin along with an ascites.
The PET-scan did not show any other lesions. CA125 levels were high (1265 U/mL). The biopsy was positive and immunohistochemistry (IHC) showed a high-grade ovarian peritoneal serous carcinoma (CK7: (+), CK20: (-), WTI: (+), P53: (+), PAX8: (+), CA125: (+), RE: (+)). The diagnosis of a FIGO stage IIIc peritoneal carcinomatosis of ovarian origin was established. The patient was treated with neoadjuvant chemotherapy (Carboplatin-Paclitaxel- Bevacizumab, 4 cycles).
The patient showed a favorable clinical response with ascites disappearance. The radiological imaging also showed the disappearance of peritoneal implants. Only a 3cm right parauterine mass persisted and a biochemical response was noted with CA125 decrease (32 U/mL). A radical cytoreductive surgery is decided upon using a minimally invasive intraperitoneal hyperthermia chemotherapy. A complete cytoreduction (CC0) was performed after tumor load determination with a Peritoneal Cancer Index (PCI) of 4. It showed a greater pelvic affectation and a minimal involvement of the greater omentum. We performed a hysterectomy, a double adnexectomy, and a bilateral pelvic and parietal peritonectomy. Complete omentectomy with a gastro-omental arcade preservation, round ligament resection, bilateral iliac lymphadenectomy, and appendectomy were performed. The surgical specimens were extracted through the vagina. The patient underwent an intraoperative hyperthermic intraperitoneal chemotherapy (42ºC) with Paclitaxel (60mg/m2). Postoperative outcomes were uneventful.
A Arjona-Sánchez, S Rufian Pena, D Garcilazo Arismendi, A Cosano Alvarez, A Moreno Navas, JM Sanchez Hidalgo, FJ Briceño Delgado
Surgical intervention
1 year ago
4857 views
395 likes
0 comments
32:37
Complete cytoreductive surgery (CRS) and HIPEC using a minimally invasive approach with NOTES extraction for peritoneal carcinomatosis from primary ovarian cancer
This is the case of a 60-year old woman who sought medical advice for constipation and increased abdominal perimeter in October 2016. The abdominal CT-scan suggested a peritoneal carcinomatosis of ovarian origin along with an ascites.
The PET-scan did not show any other lesions. CA125 levels were high (1265 U/mL). The biopsy was positive and immunohistochemistry (IHC) showed a high-grade ovarian peritoneal serous carcinoma (CK7: (+), CK20: (-), WTI: (+), P53: (+), PAX8: (+), CA125: (+), RE: (+)). The diagnosis of a FIGO stage IIIc peritoneal carcinomatosis of ovarian origin was established. The patient was treated with neoadjuvant chemotherapy (Carboplatin-Paclitaxel- Bevacizumab, 4 cycles).
The patient showed a favorable clinical response with ascites disappearance. The radiological imaging also showed the disappearance of peritoneal implants. Only a 3cm right parauterine mass persisted and a biochemical response was noted with CA125 decrease (32 U/mL). A radical cytoreductive surgery is decided upon using a minimally invasive intraperitoneal hyperthermia chemotherapy. A complete cytoreduction (CC0) was performed after tumor load determination with a Peritoneal Cancer Index (PCI) of 4. It showed a greater pelvic affectation and a minimal involvement of the greater omentum. We performed a hysterectomy, a double adnexectomy, and a bilateral pelvic and parietal peritonectomy. Complete omentectomy with a gastro-omental arcade preservation, round ligament resection, bilateral iliac lymphadenectomy, and appendectomy were performed. The surgical specimens were extracted through the vagina. The patient underwent an intraoperative hyperthermic intraperitoneal chemotherapy (42ºC) with Paclitaxel (60mg/m2). Postoperative outcomes were uneventful.
Laparoscopic peritoneal dialysis catheter placement: step by step approach
This is the case of an 87-year-old man with a history of chronic kidney disease stage 5 proposed for dialysis.
The patient had a medical history of diabetes mellitus type 2 over 10 years, hypertension, anemia treated with erythropoietin. The patient was a former smoker.
After explaining to the patient and his family the option between hemodialysis and peritoneal dialysis, the patient opted for the peritoneal one.
He was admitted electively and submitted to 3D laparoscopic peritoneal dialysis catheter placement. The surgery and post-operative period were uneventful. The patient was discharged on postoperative day 2.
F Cabral, J Grenho, R Roque, R Maio
Surgical intervention
1 year ago
1722 views
152 likes
0 comments
06:36
Laparoscopic peritoneal dialysis catheter placement: step by step approach
This is the case of an 87-year-old man with a history of chronic kidney disease stage 5 proposed for dialysis.
The patient had a medical history of diabetes mellitus type 2 over 10 years, hypertension, anemia treated with erythropoietin. The patient was a former smoker.
After explaining to the patient and his family the option between hemodialysis and peritoneal dialysis, the patient opted for the peritoneal one.
He was admitted electively and submitted to 3D laparoscopic peritoneal dialysis catheter placement. The surgery and post-operative period were uneventful. The patient was discharged on postoperative day 2.
Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
J Dubuisson
Surgical intervention
1 year ago
3858 views
307 likes
1 comment
05:12
Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
Pure laparoscopic Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
J Pekolj, F Alvarez, P Huespe, J Montagné, M Palavecino
Surgical intervention
1 year ago
1109 views
75 likes
0 comments
08:17
Pure laparoscopic Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
Transanal minimally invasive surgical anal canal polyp resection
Background: Endoscopic submucosal dissection (ESD) has been known for a long time. Recently, transanal minimally invasive surgery (TAMIS) started to be popularized and it can be used in front of difficult cases for ESD.

Video: A 36-year-old woman underwent a TAMIS resection, after unsuccessful ESD, for a 2cm polyp located anteriorly in the anal canal, just beside the pectineal line. Preoperative work-up showed a uT1m versus T1sm N0 M0 lesion. The patient was placed in a prone position with a split leg kneeling position. The procedure was performed with a new reusable transanal platform, a monocurved coagulating hook, and a grasping forceps. The mucosal flap was closed using two absorbable running sutures, a monocurved needle holder, and a grasping forceps.

Results: Operative time was 90 minutes, and perioperative bleeding was 20cc. No perioperative complications were noted, and the patient was discharged on postoperative day 1. Pathological findings showed a 2 by 1.3 by 0.5cm villotubular adenoma with high-grade dysplasia and free margins.

Conclusions: TAMIS anal canal polyp resection allows for a meticulous dissection under a magnified exposure of the operative field, with a final mucosal flap closure in adequate ergonomic conditions.
G Dapri
Surgical intervention
1 year ago
1819 views
102 likes
0 comments
05:13
Transanal minimally invasive surgical anal canal polyp resection
Background: Endoscopic submucosal dissection (ESD) has been known for a long time. Recently, transanal minimally invasive surgery (TAMIS) started to be popularized and it can be used in front of difficult cases for ESD.

Video: A 36-year-old woman underwent a TAMIS resection, after unsuccessful ESD, for a 2cm polyp located anteriorly in the anal canal, just beside the pectineal line. Preoperative work-up showed a uT1m versus T1sm N0 M0 lesion. The patient was placed in a prone position with a split leg kneeling position. The procedure was performed with a new reusable transanal platform, a monocurved coagulating hook, and a grasping forceps. The mucosal flap was closed using two absorbable running sutures, a monocurved needle holder, and a grasping forceps.

Results: Operative time was 90 minutes, and perioperative bleeding was 20cc. No perioperative complications were noted, and the patient was discharged on postoperative day 1. Pathological findings showed a 2 by 1.3 by 0.5cm villotubular adenoma with high-grade dysplasia and free margins.

Conclusions: TAMIS anal canal polyp resection allows for a meticulous dissection under a magnified exposure of the operative field, with a final mucosal flap closure in adequate ergonomic conditions.
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
1 year ago
1754 views
176 likes
0 comments
07:49
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Laparoscopic left complete mesocolic excision for stented descending colon cancer
Complete mesocolic excision (CME) with central vessel ligation (CVL) was first introduced with the aim to preserve an intact layer of mesocolon, containing all blood vessels, lymphatic vessels, lymph nodes, and surrounding soft tissue during colorectal cancer resection. The supplying vessels are also transected at their origin for optimal oncological outcomes. This method has been extensively studied in right colonic cancers with improvement in local recurrence and survival rates when compared to the conventional approach. Its excellent results are attributed to the superior lymph node harvest and removal of disseminated cancer cells in the surrounding soft tissue. Similarly, such advantages can be translated to left hemicolectomy with the use of CME with a CVL approach. Additionally, in left hemicolectomy, the vessels ligated (left branch of middle colic and left colic) are branches of vessels from the aorta rather than from the aorta directly, often limiting lymph node harvest. CME with CVL can help to overcome this limitation in left hemicolectomy. We present a video of a laparoscopic CME and CVL in a 48-year-old Chinese male with large bowel obstruction secondary to a descending colonic tumor which was successfully stented one week before.
SAE Yeo, MH Chang
Surgical intervention
1 year ago
2814 views
314 likes
0 comments
08:47
Laparoscopic left complete mesocolic excision for stented descending colon cancer
Complete mesocolic excision (CME) with central vessel ligation (CVL) was first introduced with the aim to preserve an intact layer of mesocolon, containing all blood vessels, lymphatic vessels, lymph nodes, and surrounding soft tissue during colorectal cancer resection. The supplying vessels are also transected at their origin for optimal oncological outcomes. This method has been extensively studied in right colonic cancers with improvement in local recurrence and survival rates when compared to the conventional approach. Its excellent results are attributed to the superior lymph node harvest and removal of disseminated cancer cells in the surrounding soft tissue. Similarly, such advantages can be translated to left hemicolectomy with the use of CME with a CVL approach. Additionally, in left hemicolectomy, the vessels ligated (left branch of middle colic and left colic) are branches of vessels from the aorta rather than from the aorta directly, often limiting lymph node harvest. CME with CVL can help to overcome this limitation in left hemicolectomy. We present a video of a laparoscopic CME and CVL in a 48-year-old Chinese male with large bowel obstruction secondary to a descending colonic tumor which was successfully stented one week before.
Subtotal gastrectomy and D1+ lymphadenectomy for distal stage IB gastric cancer with preservation of an accessory left hepatic artery
This video shows a partial gastrectomy in a 63-year-old woman with a stage IB gastric cancer located at the distal third of the stomach. The lesion was located using intraoperatory endoscopy. We found an accessory left hepatic artery originating from the left gastric artery, which was preserved. The gastrojejunostomy was performed in a Roux-en-Y fashion. The alimentary limb was ascended through the transverse mesocolon. The jejunojejunostomy was performed in a latero-lateral fashion with closure of the ostium with simple Ethibond 2/0 stitches. The skin incision used for trocar placement in the upper left abdomen (right hand of the surgeon) was slightly enlarged to allow for specimen extraction.
P Vorwald, R Restrepo, G Salcedo, M Posada
Surgical intervention
1 year ago
1967 views
227 likes
0 comments
11:41
Subtotal gastrectomy and D1+ lymphadenectomy for distal stage IB gastric cancer with preservation of an accessory left hepatic artery
This video shows a partial gastrectomy in a 63-year-old woman with a stage IB gastric cancer located at the distal third of the stomach. The lesion was located using intraoperatory endoscopy. We found an accessory left hepatic artery originating from the left gastric artery, which was preserved. The gastrojejunostomy was performed in a Roux-en-Y fashion. The alimentary limb was ascended through the transverse mesocolon. The jejunojejunostomy was performed in a latero-lateral fashion with closure of the ostium with simple Ethibond 2/0 stitches. The skin incision used for trocar placement in the upper left abdomen (right hand of the surgeon) was slightly enlarged to allow for specimen extraction.
Intraglissonian approach to the round ligament for left lateral segmentectomy in a large hemangioma
In this video, we present the clinical case of a 65-year-old woman with a large hemangioma involving liver segments II and III. The patient consulted because of epigastric pain and dyspepsia. A laparoscopic approach was performed. Instead of using the conventional extraglissonian approach for left lateral segmentectomy, in this video, we described a new approach which consisted in dissecting and dividing the portal and arterial branches for segments II and III selectively.
The CT-scan shows a large hemangioma occupying almost entirely the left lateral segments. Under general anesthesia, the laparoscopic approach was performed with 4 trocars. By selectively dividing the inflow for these left lateral segments (segments II and III), the parenchymal transection was performed safely, without bleeding, and the left suprahepatic vein could be transected with a stapler very easily. The extraction of the specimen was carried out increasing the incision for the 12mm trocar in the midline. The patient was discharged on postoperative day 4 without complications.
J Aguirrezabalaga, JF Noguera, MD, PhD, M Gomez, I Rey, JI Rivas
Surgical intervention
1 year ago
1477 views
113 likes
0 comments
16:09
Intraglissonian approach to the round ligament for left lateral segmentectomy in a large hemangioma
In this video, we present the clinical case of a 65-year-old woman with a large hemangioma involving liver segments II and III. The patient consulted because of epigastric pain and dyspepsia. A laparoscopic approach was performed. Instead of using the conventional extraglissonian approach for left lateral segmentectomy, in this video, we described a new approach which consisted in dissecting and dividing the portal and arterial branches for segments II and III selectively.
The CT-scan shows a large hemangioma occupying almost entirely the left lateral segments. Under general anesthesia, the laparoscopic approach was performed with 4 trocars. By selectively dividing the inflow for these left lateral segments (segments II and III), the parenchymal transection was performed safely, without bleeding, and the left suprahepatic vein could be transected with a stapler very easily. The extraction of the specimen was carried out increasing the incision for the 12mm trocar in the midline. The patient was discharged on postoperative day 4 without complications.
Reduced port laparoscopic pyloroduodenectomy with handsewn Roux-en-Y reconstruction
Background: Reduced port laparoscopic surgery (RPLS) is an evolution of conventional laparoscopic surgery, allowing for enhanced cosmetic outcomes, in addition to a reduced abdominal wall trauma. Tips and tricks are required to complete a procedure using a RPLS.

Video: This video shows a 55-year-old lady who underwent a laparoscopic pyloro-duodenectomy for a duodenal bulb lesion increased in size at endoscopic follow-up. Three trocars were used (a 12mm one in the umbilicus, a 5mm one in the right flank, a 5mm one in the left flank). The exposure of the operative field was enhanced thanks to a temporary percutaneous suture placed into the hepatic round ligament. Perioperative gastroscopy allowed for an adequate resection without too much distance from the margins, and preservation of the entire gastric antrum. The reconstruction was performed through a handsewn end-to-end gastrojejunostomy, with a 50cm alimentary limb, and a semi-mechanical side-to-side jejunojejunostomy. Finally, a gastroscopy was used to test the gastrojejunostomy.

Results: Total operative time was 190 minutes. Perioperative bleeding was 50cc. Postoperative course was uneventful, and the patient was discharged on postoperative day 7. Pathological findings demonstrated a Brunner’s gland hamartoma, with safe distance from the margins.

Conclusions: RPLS is a step forward of conventional laparoscopy. Perioperative gastroscopy is essential to perform safe upper GI resections. br>
G Dapri, NA Bascombe, S Targa
Surgical intervention
1 year ago
725 views
25 likes
0 comments
09:01
Reduced port laparoscopic pyloroduodenectomy with handsewn Roux-en-Y reconstruction
Background: Reduced port laparoscopic surgery (RPLS) is an evolution of conventional laparoscopic surgery, allowing for enhanced cosmetic outcomes, in addition to a reduced abdominal wall trauma. Tips and tricks are required to complete a procedure using a RPLS.

Video: This video shows a 55-year-old lady who underwent a laparoscopic pyloro-duodenectomy for a duodenal bulb lesion increased in size at endoscopic follow-up. Three trocars were used (a 12mm one in the umbilicus, a 5mm one in the right flank, a 5mm one in the left flank). The exposure of the operative field was enhanced thanks to a temporary percutaneous suture placed into the hepatic round ligament. Perioperative gastroscopy allowed for an adequate resection without too much distance from the margins, and preservation of the entire gastric antrum. The reconstruction was performed through a handsewn end-to-end gastrojejunostomy, with a 50cm alimentary limb, and a semi-mechanical side-to-side jejunojejunostomy. Finally, a gastroscopy was used to test the gastrojejunostomy.

Results: Total operative time was 190 minutes. Perioperative bleeding was 50cc. Postoperative course was uneventful, and the patient was discharged on postoperative day 7. Pathological findings demonstrated a Brunner’s gland hamartoma, with safe distance from the margins.

Conclusions: RPLS is a step forward of conventional laparoscopy. Perioperative gastroscopy is essential to perform safe upper GI resections. br>
Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.
G Dapri, NA Bascombe, L Gerard, C Samaniego Ballar, C Jiménez Viñas
Surgical intervention
1 year ago
2212 views
215 likes
0 comments
10:22
Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.
Totally endoscopic left hemithyroidectomy: axillary approach for papillary carcinoma, including a critical analysis by M Vix, MD, and point by point answer by Dr. Shah
Introduction:
Endoscopic thyroidectomy is a novel approach used to avoid cervical scar, which represents sequelae of conventional thyroidectomies. This technique is feasible providing equal results under expert hands.
Case presentation:
This is the case of a 20 year-old woman with cervical swelling, a 3 by 3cm solitary nodule in the left thyroid lobe, which was evaluated clinically, radiologically, and withfine-needle aspiration cytology (FNAC). She was diagnosed with a low-risk papillary carcinoma.
Discussion:
The patient underwent an endoscopic transaxillary left hemithyroidectomy under general anesthesia. The recurrent laryngeal nerve and the parathyroid gland were preserved. The patient was discharged with a normal tone on postoperative day 1.
Conclusion:
Endoscopic transaxillary thyroidectomy is a feasible good technique with equal results, which can be considered for patients with small thyroid lesions. Conventional laparoscopic instruments are used without the need for extra instrumentation.

This video is commented upon by Dr. M Vix, MD (University Hospital, Strasbourg, France), providing a comprehensive outline of Dr. Shah's original technique.


Point by point answer by Dr. Shah:

1. Carbon dioxide causing surgical emphysema, especially of an incapacitating nature, has not been experienced since intracavitary pressures are generally maintained at a low level by the almost continuous low-grade suction used throughout the surgery.

2. In our experience, adequate visualization of the thyroid pedicles in close proximity to the gland precludes the need for a deeper and more lateral dissection to identify the jugulocarotid vessels. This potentially decreases the risk of a major vascular mishap.

3. As is the norm with open thyroidectomy, division of the superior thyroid pedicle close to the gland usually does not require the identification of the superior laryngeal nerve.

4. In this approach, the recurrent laryngeal nerve is identified very early on in the dissection. Subsequent dissection is performed in a plane anterior to the visualized nerve, hence preventing any injuries. The recurrent laryngeal nerve is visualized in its entire extent up to Berry's ligament.



AR Shah
Surgical intervention
1 year ago
801 views
113 likes
0 comments
11:09
Totally endoscopic left hemithyroidectomy: axillary approach for papillary carcinoma, including a critical analysis by M Vix, MD, and point by point answer by Dr. Shah
Introduction:
Endoscopic thyroidectomy is a novel approach used to avoid cervical scar, which represents sequelae of conventional thyroidectomies. This technique is feasible providing equal results under expert hands.
Case presentation:
This is the case of a 20 year-old woman with cervical swelling, a 3 by 3cm solitary nodule in the left thyroid lobe, which was evaluated clinically, radiologically, and withfine-needle aspiration cytology (FNAC). She was diagnosed with a low-risk papillary carcinoma.
Discussion:
The patient underwent an endoscopic transaxillary left hemithyroidectomy under general anesthesia. The recurrent laryngeal nerve and the parathyroid gland were preserved. The patient was discharged with a normal tone on postoperative day 1.
Conclusion:
Endoscopic transaxillary thyroidectomy is a feasible good technique with equal results, which can be considered for patients with small thyroid lesions. Conventional laparoscopic instruments are used without the need for extra instrumentation.

This video is commented upon by Dr. M Vix, MD (University Hospital, Strasbourg, France), providing a comprehensive outline of Dr. Shah's original technique.


Point by point answer by Dr. Shah:

1. Carbon dioxide causing surgical emphysema, especially of an incapacitating nature, has not been experienced since intracavitary pressures are generally maintained at a low level by the almost continuous low-grade suction used throughout the surgery.

2. In our experience, adequate visualization of the thyroid pedicles in close proximity to the gland precludes the need for a deeper and more lateral dissection to identify the jugulocarotid vessels. This potentially decreases the risk of a major vascular mishap.

3. As is the norm with open thyroidectomy, division of the superior thyroid pedicle close to the gland usually does not require the identification of the superior laryngeal nerve.

4. In this approach, the recurrent laryngeal nerve is identified very early on in the dissection. Subsequent dissection is performed in a plane anterior to the visualized nerve, hence preventing any injuries. The recurrent laryngeal nerve is visualized in its entire extent up to Berry's ligament.



Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.
JM Cabada Lee
Surgical intervention
1 year ago
1584 views
104 likes
1 comment
10:55
Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.