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#February 2009
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Giant hiatal hernia: acute presentation with gastric volvulus
Hiatal hernia is a common disorder of the digestive tract. Most patients are elderly and with significant co-morbidities. Historically, the surgical repair of paraesophageal hernias (PHH) has been advocated regardless of the presence of symptoms. In fact, despite patients being symptom-free, the development of potentially life-threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the stomach mucosa, is well-known and has proven to be fatal in 27% of cases. Nevertheless, patients with asymptomatic PHH are likely to develop symptoms needing emergency surgery in only 1.16% of cases with a 5.4% mortality rate. Recently, several authors have questioned the indication for repair in asymptomatic patients and prefer to monitor asymptomatic or minimally symptomatic PHH by ‘watchful waiting’. Our current practice is to operate only in the case symptoms or complications. The laparoscopic repair of PHH is certainly technically challenging. It requires considerable experience with minimally invasive surgery of the foregut, and a complete understanding of esophageal pathophysiology. The basic principles of surgical repair are the reduction of herniated stomach and distal esophagus into the abdominal cavity with tension-free repositioning of 2cm of lower esophagus in a subphrenic position, complete excision of the peritoneal hernia sac from the mediastinum and the repair of the diaphragmatic hiatus.
This is the case of a woman admitted to the emergency room for complete acute dysphagia associated with type IV paraesophageal hernia. The preoperative work-up (CT-scan, upper GI series) showed the migration of the stomach, left transverse colon and omentum into the chest.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
9 years ago
2525 views
74 likes
0 comments
15:02
Giant hiatal hernia: acute presentation with gastric volvulus
Hiatal hernia is a common disorder of the digestive tract. Most patients are elderly and with significant co-morbidities. Historically, the surgical repair of paraesophageal hernias (PHH) has been advocated regardless of the presence of symptoms. In fact, despite patients being symptom-free, the development of potentially life-threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the stomach mucosa, is well-known and has proven to be fatal in 27% of cases. Nevertheless, patients with asymptomatic PHH are likely to develop symptoms needing emergency surgery in only 1.16% of cases with a 5.4% mortality rate. Recently, several authors have questioned the indication for repair in asymptomatic patients and prefer to monitor asymptomatic or minimally symptomatic PHH by ‘watchful waiting’. Our current practice is to operate only in the case symptoms or complications. The laparoscopic repair of PHH is certainly technically challenging. It requires considerable experience with minimally invasive surgery of the foregut, and a complete understanding of esophageal pathophysiology. The basic principles of surgical repair are the reduction of herniated stomach and distal esophagus into the abdominal cavity with tension-free repositioning of 2cm of lower esophagus in a subphrenic position, complete excision of the peritoneal hernia sac from the mediastinum and the repair of the diaphragmatic hiatus.
This is the case of a woman admitted to the emergency room for complete acute dysphagia associated with type IV paraesophageal hernia. The preoperative work-up (CT-scan, upper GI series) showed the migration of the stomach, left transverse colon and omentum into the chest.
Laparoscopic antrectomy and vagotomy for stenotic pyloric peptic ulcer
Peptic ulcer disease is the major cause of benign gastro-duodenal obstruction or gastric outlet obstruction (GOO) in the adult population. Patients often present with abdominal pain and distension, vomiting, dehydration, and weight loss. Previous studies have demonstrated that the incidence of GOO varies from 5% to 10% of all hospital admissions for ulcer-related complications.
Today surgeons are performing fewer elective ulcer surgeries, as H2 receptor blockers and the eradication of Helicobacter pylori represent a major step in the treatment of this disease. Nevertheless, patients with complications and those resistant to medical therapy can be offered surgical options. When surgery is required, a laparoscopic approach is possible with its well-known advantages.
Surgical procedures include highly selective vagotomy with some form of pyloroplasty, truncal vagotomy and antrectomy, and truncal vagotomy with gastroenterostomy. Proponents of highly selective vagotomy advocate an acceptably low recurrence rate (0 to 5% at follow-up of 24 to 90 months) and a relative paucity of post-gastrectomy sequelae. Those recommending vagotomy and antrectomy stress the superiority of the acid-reducing procedure, the virtual absence of recurrent ulceration, and the rarity of postoperative symptoms other than post-vagotomy diarrhea, which is usually a self-limited process. Finally, truncal vagotomy with gastroenterostomy avoids what can be a treacherous duodenal stump, but can result in higher ulcer recurrence rates.
We present the case of a young male patient not compliant to medical treatment who was referred to us for gastric outlet obstruction. The selected approach consisted in a laparoscopic Billroth II antrectomy and vagotomy using four ports.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
9 years ago
1346 views
159 likes
0 comments
12:58
Laparoscopic antrectomy and vagotomy for stenotic pyloric peptic ulcer
Peptic ulcer disease is the major cause of benign gastro-duodenal obstruction or gastric outlet obstruction (GOO) in the adult population. Patients often present with abdominal pain and distension, vomiting, dehydration, and weight loss. Previous studies have demonstrated that the incidence of GOO varies from 5% to 10% of all hospital admissions for ulcer-related complications.
Today surgeons are performing fewer elective ulcer surgeries, as H2 receptor blockers and the eradication of Helicobacter pylori represent a major step in the treatment of this disease. Nevertheless, patients with complications and those resistant to medical therapy can be offered surgical options. When surgery is required, a laparoscopic approach is possible with its well-known advantages.
Surgical procedures include highly selective vagotomy with some form of pyloroplasty, truncal vagotomy and antrectomy, and truncal vagotomy with gastroenterostomy. Proponents of highly selective vagotomy advocate an acceptably low recurrence rate (0 to 5% at follow-up of 24 to 90 months) and a relative paucity of post-gastrectomy sequelae. Those recommending vagotomy and antrectomy stress the superiority of the acid-reducing procedure, the virtual absence of recurrent ulceration, and the rarity of postoperative symptoms other than post-vagotomy diarrhea, which is usually a self-limited process. Finally, truncal vagotomy with gastroenterostomy avoids what can be a treacherous duodenal stump, but can result in higher ulcer recurrence rates.
We present the case of a young male patient not compliant to medical treatment who was referred to us for gastric outlet obstruction. The selected approach consisted in a laparoscopic Billroth II antrectomy and vagotomy using four ports.
Stepwise approach for intersphincteric dissection in colo-anal anastomosis
The surgical technique of intersphincteric resection (ISR) with colo-anal anastomosis has been proposed to offer sphincter preservation and to avoid permanent colostomy in patients with very low rectal carcinoma. Several studies have reported that functional results and local recurrence rates after ISR are satisfactory.
The goal of intersphincteric resection is to perform a dissection between the internal sphincter and the external sphincter by beginning the dissection either at the pectinate line or underneath the pectinate line to obtain adequate distal margins as in this case.
The trans-anal approach appears to be the optimal way because the dissection is more anatomic and visual and permits a more accurate evaluation of the lower edge of the tumor. In addition, this enables to obtain optimal distal and lateral margins respecting oncological principles and restore bowel continuity in a difficult narrow pelvis and in obese patients.
The objective of this video is to show the correct intersphincteric dissection technique used to perform colo-anal anastomosis after complete total mesorectal excision.
J Leroy, J Marescaux
Surgical intervention
9 years ago
2212 views
131 likes
0 comments
03:54
Stepwise approach for intersphincteric dissection in colo-anal anastomosis
The surgical technique of intersphincteric resection (ISR) with colo-anal anastomosis has been proposed to offer sphincter preservation and to avoid permanent colostomy in patients with very low rectal carcinoma. Several studies have reported that functional results and local recurrence rates after ISR are satisfactory.
The goal of intersphincteric resection is to perform a dissection between the internal sphincter and the external sphincter by beginning the dissection either at the pectinate line or underneath the pectinate line to obtain adequate distal margins as in this case.
The trans-anal approach appears to be the optimal way because the dissection is more anatomic and visual and permits a more accurate evaluation of the lower edge of the tumor. In addition, this enables to obtain optimal distal and lateral margins respecting oncological principles and restore bowel continuity in a difficult narrow pelvis and in obese patients.
The objective of this video is to show the correct intersphincteric dissection technique used to perform colo-anal anastomosis after complete total mesorectal excision.
Totally endoscopic right apico-posterior segmentectomy for stage I lung carcinoma
This is the case of a 56-year-old male patient presenting with stage I (cT1N0) adenocarcinoma of the posterior segment of the right upper pulmonary lobe.
In this case, we will perform a totally endoscopic segmentectomy, namely only video display and endoscopic instrumentation without utility incision. A 3cm incision is made at completion of the segmentectomy by enlarging one of the ports for specimen extraction.
In this video, only the main steps of the pulmonary resection will be demonstrated. The lymphadenectomy will be shown in another video.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1
D Gossot
Surgical intervention
9 years ago
1527 views
21 likes
0 comments
06:08
Totally endoscopic right apico-posterior segmentectomy for stage I lung carcinoma
This is the case of a 56-year-old male patient presenting with stage I (cT1N0) adenocarcinoma of the posterior segment of the right upper pulmonary lobe.
In this case, we will perform a totally endoscopic segmentectomy, namely only video display and endoscopic instrumentation without utility incision. A 3cm incision is made at completion of the segmentectomy by enlarging one of the ports for specimen extraction.
In this video, only the main steps of the pulmonary resection will be demonstrated. The lymphadenectomy will be shown in another video.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1