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Monthly publications

#December 2011
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Laparoscopic sigmoidectomy for T3N2M1 sigmoid cancer
Introduction:
This is the case of a 65-year-old gentleman who presented with blood per rectum (PR) and symptoms of subacute obstruction. He was diagnosed with a stenotic invasive adenocarcinoma at 15cm from the anal verge and with liver metastases. After discussion at our multidisclipinary meeting, he was recommended to undergo palliative chemotherapy in the form of FOLFIRI and Avastin. Unfortunately, his symptoms of subacute obstruction worsened and it was recommended that he undergo a palliative resection.

Methods:
He underwent a palliative Laparoscopic Anterior Resection (LAR). Professor Armondo Melani utilized a 4-port technique with a 10mm umbilical optical port and 3 by 5mm working ports (2 on the right-hand side and one on the left). He used a medial to lateral approach starting with the splenic flexure takedown. This was achieved by entering the retroperitoneal plane cephalad to the inferior mesenteric artery (IMA) and inferior to the inferior mesenteric vein (IMV). Once the correct plane has been entered, the IMV was skeletonized and divided with a Ligasure® vessel-sealing device. The lesser sac was then entered superior and cephalad to the IMV, superior to the pancreas and to the left of the middle colic vessels. This novel approach allowed for easy identification of the pancreas and retroperitoneal mobilization of the mesocolon from the pancreas. The lesser sac was then entered above the transverse colon, the omental attachments divided and splenic flexure mobilization completed. The retroperitoneal plane was then entered caudally to the IMA, which was subsequently skeletonized and divided after identification of the left ureter and gonadal vessels. The rectum was then mobilized to >5cm below the tumor, the mesorectum divided, the rectum transected with an articulating linear stapling device. The specimen was delivered through a Pfannenstiel incision (with a wound protector). The specimen was transected and the anvil of a circular stapler inserted into the proximal colon with a purse-string suture. The colon was returned to the abdomen and the colorectal anastomosis was completed with the insertion of the circular stapler transanally.
A Melani, J Marescaux
Surgical intervention
6 years ago
8304 views
128 likes
0 comments
28:38
Laparoscopic sigmoidectomy for T3N2M1 sigmoid cancer
Introduction:
This is the case of a 65-year-old gentleman who presented with blood per rectum (PR) and symptoms of subacute obstruction. He was diagnosed with a stenotic invasive adenocarcinoma at 15cm from the anal verge and with liver metastases. After discussion at our multidisclipinary meeting, he was recommended to undergo palliative chemotherapy in the form of FOLFIRI and Avastin. Unfortunately, his symptoms of subacute obstruction worsened and it was recommended that he undergo a palliative resection.

Methods:
He underwent a palliative Laparoscopic Anterior Resection (LAR). Professor Armondo Melani utilized a 4-port technique with a 10mm umbilical optical port and 3 by 5mm working ports (2 on the right-hand side and one on the left). He used a medial to lateral approach starting with the splenic flexure takedown. This was achieved by entering the retroperitoneal plane cephalad to the inferior mesenteric artery (IMA) and inferior to the inferior mesenteric vein (IMV). Once the correct plane has been entered, the IMV was skeletonized and divided with a Ligasure® vessel-sealing device. The lesser sac was then entered superior and cephalad to the IMV, superior to the pancreas and to the left of the middle colic vessels. This novel approach allowed for easy identification of the pancreas and retroperitoneal mobilization of the mesocolon from the pancreas. The lesser sac was then entered above the transverse colon, the omental attachments divided and splenic flexure mobilization completed. The retroperitoneal plane was then entered caudally to the IMA, which was subsequently skeletonized and divided after identification of the left ureter and gonadal vessels. The rectum was then mobilized to >5cm below the tumor, the mesorectum divided, the rectum transected with an articulating linear stapling device. The specimen was delivered through a Pfannenstiel incision (with a wound protector). The specimen was transected and the anvil of a circular stapler inserted into the proximal colon with a purse-string suture. The colon was returned to the abdomen and the colorectal anastomosis was completed with the insertion of the circular stapler transanally.
Laparoscopic management of a perforated ulcer at the gastrojejunal anastomosis after LGBP
Anastomotic ulcers (also known as ‘‘marginal’’ ulcers) develop as a complication of Roux-en-Y gastric bypass for treatment of obesity, they are almost always found to arise in the jejunal Roux limb directly abutting the gastrojejunal anastomosis. Marginal ulcers have been reported in 1–16% of patients after gastric bypass surgery, developing in both the early and late postoperative periods.
Recommended references:
1. Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–516.
2. Csendes A, Burgos AM, Altuve J, Bonacic S. Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg 2009;19:135–138.
3. Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009;5:317–322.
4. St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668.
5. Goitein D. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;13(6):880–882.
V Podelski, L Marx, J Marescaux
Surgical intervention
6 years ago
3139 views
63 likes
0 comments
05:30
Laparoscopic management of a perforated ulcer at the gastrojejunal anastomosis after LGBP
Anastomotic ulcers (also known as ‘‘marginal’’ ulcers) develop as a complication of Roux-en-Y gastric bypass for treatment of obesity, they are almost always found to arise in the jejunal Roux limb directly abutting the gastrojejunal anastomosis. Marginal ulcers have been reported in 1–16% of patients after gastric bypass surgery, developing in both the early and late postoperative periods.
Recommended references:
1. Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–516.
2. Csendes A, Burgos AM, Altuve J, Bonacic S. Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg 2009;19:135–138.
3. Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009;5:317–322.
4. St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668.
5. Goitein D. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;13(6):880–882.
Transumbilical single-access perforated gastric ulcer repair
Background: Single-access laparoscopy (SAL) can be proposed in patients presenting peritonitis both for diagnosis and treatment. This video shows a transumbilical SAL performed for perforated gastric ulcer.

Video: A 30 year-old woman with a body mass index of 22.9 kg/m2 was admitted to the emergency room for diffuse abdominal pain. Preoperative work-up showed a pneumoperitoneum, hence a SAL was proposed to the patient. The procedure was performed using a standard 11mm reusable trocar for a 10mm, standard length, 30-degree scope, and curved reusable instruments inserted transumbilically without trocars. The cavity exploration showed a perforated gastric ulcer at the anterior surface of the prepyloric area. A suture repair, omentoplasty and lavage of the cavity was performed.

Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 108 minutes and laparoscopic time 86 minutes. Final umbilical incision length was 15mm. The patient’s pain medication could be kept low and the patient was allowed to be discharged on the 5th postoperative day. After 6 months, the patient was well with no visible umbilical scar.

Conclusion: Transumbilical SAL can be proposed in selected patients for suspicion of perforated gastric ulcer, with the main advantage of cosmetic result.
G Dapri, J Himpens, GB Cadière
Surgical intervention
6 years ago
3755 views
49 likes
2 comments
05:17
Transumbilical single-access perforated gastric ulcer repair
Background: Single-access laparoscopy (SAL) can be proposed in patients presenting peritonitis both for diagnosis and treatment. This video shows a transumbilical SAL performed for perforated gastric ulcer.

Video: A 30 year-old woman with a body mass index of 22.9 kg/m2 was admitted to the emergency room for diffuse abdominal pain. Preoperative work-up showed a pneumoperitoneum, hence a SAL was proposed to the patient. The procedure was performed using a standard 11mm reusable trocar for a 10mm, standard length, 30-degree scope, and curved reusable instruments inserted transumbilically without trocars. The cavity exploration showed a perforated gastric ulcer at the anterior surface of the prepyloric area. A suture repair, omentoplasty and lavage of the cavity was performed.

Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 108 minutes and laparoscopic time 86 minutes. Final umbilical incision length was 15mm. The patient’s pain medication could be kept low and the patient was allowed to be discharged on the 5th postoperative day. After 6 months, the patient was well with no visible umbilical scar.

Conclusion: Transumbilical SAL can be proposed in selected patients for suspicion of perforated gastric ulcer, with the main advantage of cosmetic result.
Robotic thymectomy for autoimmune myasthenia gravis
We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.
N Santelmo, S Renaud, J Marescaux
Surgical intervention
6 years ago
1876 views
18 likes
0 comments
12:14
Robotic thymectomy for autoimmune myasthenia gravis
We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.
Laparoscopic management of endometriosis
This lecture reviews the surgical treatment of endometriosis from an evidence-based perspective focusing on outcomes such as pain and infertility in order to provide practical guidelines and recommendations.
The main endometriotic symptoms are pelvic pain (dysmenorrhea and dyspareunia) and infertility. Randomized controlled trials provide evidence that it is better to perform laparoscopy in patients with pain as compared to a wait and see approach. Regarding fertility, laparoscopic ablation or resection of lesions in minimal and mild endometriosis is significantly better than diagnostic laparoscopy alone. Laparoscopic uterosacral nerve ablation (LUNA) is not effective for relief of pain symptoms, but presacral neurectomy might be useful. In contrast, conservative surgery for rectovaginal septum endometriosis is beneficial for pain improvement, quality of life and sexual life, but do not improve fertility. Regarding radical surgery and bowel resection in endometriosis, there is a clear benefit in terms of pain improvement, but not on fertility. Regarding endometrial cyst treatment, excision is better than drainage in terms of risk of relapse, and the use of anti-adhesion barriers (Interceed®) have demonstrated a decreased risk of adhesion formation after endometriosis surgery.
Keys for surgical treatment of endometriosis should be identification of the disease, restoration of normal anatomy, excision of endometriosis, and finally reconstruction.
RP Pasic
Lecture
6 years ago
1965 views
26 likes
0 comments
44:23
Laparoscopic management of endometriosis
This lecture reviews the surgical treatment of endometriosis from an evidence-based perspective focusing on outcomes such as pain and infertility in order to provide practical guidelines and recommendations.
The main endometriotic symptoms are pelvic pain (dysmenorrhea and dyspareunia) and infertility. Randomized controlled trials provide evidence that it is better to perform laparoscopy in patients with pain as compared to a wait and see approach. Regarding fertility, laparoscopic ablation or resection of lesions in minimal and mild endometriosis is significantly better than diagnostic laparoscopy alone. Laparoscopic uterosacral nerve ablation (LUNA) is not effective for relief of pain symptoms, but presacral neurectomy might be useful. In contrast, conservative surgery for rectovaginal septum endometriosis is beneficial for pain improvement, quality of life and sexual life, but do not improve fertility. Regarding radical surgery and bowel resection in endometriosis, there is a clear benefit in terms of pain improvement, but not on fertility. Regarding endometrial cyst treatment, excision is better than drainage in terms of risk of relapse, and the use of anti-adhesion barriers (Interceed®) have demonstrated a decreased risk of adhesion formation after endometriosis surgery.
Keys for surgical treatment of endometriosis should be identification of the disease, restoration of normal anatomy, excision of endometriosis, and finally reconstruction.
Endoscopic management of cystic duct leakage after cholecystectomy
Biliary leaks still represent a significant problem following open or laparoscopic cholecystectomy. The incidence of bile duct leaks after such operations was reported to range between 0.3 and 1%. This video presents the case of a 75-year-old man who was referred to our department for fever, jaundice, and abdominal pain 12 days after laparoscopic cholecystectomy. A cholangio-MRI was carried out. It demonstrated an intra-abdominal biliary collection at the level of the gallbladder bed. A leak from the cystic duct was suspected. A radiological drainage of the collection was performed, and an endoscopic sphincterotomy with plastic stenting of the common bile duct was achieved. The patient went clinically well and at 2 months, the stent was removed. Two months after stent removal, he is totally symptom-free.
Gf Donatelli, L Marx, D Mutter, J Marescaux
Surgical intervention
6 years ago
1861 views
4 likes
1 comment
02:55
Endoscopic management of cystic duct leakage after cholecystectomy
Biliary leaks still represent a significant problem following open or laparoscopic cholecystectomy. The incidence of bile duct leaks after such operations was reported to range between 0.3 and 1%. This video presents the case of a 75-year-old man who was referred to our department for fever, jaundice, and abdominal pain 12 days after laparoscopic cholecystectomy. A cholangio-MRI was carried out. It demonstrated an intra-abdominal biliary collection at the level of the gallbladder bed. A leak from the cystic duct was suspected. A radiological drainage of the collection was performed, and an endoscopic sphincterotomy with plastic stenting of the common bile duct was achieved. The patient went clinically well and at 2 months, the stent was removed. Two months after stent removal, he is totally symptom-free.
Explorative laparoscopy: resection of small bowel for vascular tumor
The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge. In about 5% of cases, upper endoscopy and colonoscopy are nondiagnostic, and the small intestine is the site of bleeding,
This is the case of a 55-year-old patient admitted to the emergency department for a digestive hemorrhagic syndrome. The patient’s hemoglobin levels dropped to 6 grams per 100mL. The patient’s resuscitation allowed for the stabilization and restoration of blood volume.
Gastroscopy and colonoscopy did not demonstrate any etiology of bleeding. An emergency CT-scan found a suspected lesion at the level of the small bowel with contrast medium extravasation.
A video-endoscopic capsule was administered to the patient. It helped to identify the presence of a bleeding polypoid lesion on the middle portion of the jejunum. This video shows the laparoscopid resection of the lesion.
M Vix, J Marescaux
Surgical intervention
6 years ago
1794 views
14 likes
0 comments
11:59
Explorative laparoscopy: resection of small bowel for vascular tumor
The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge. In about 5% of cases, upper endoscopy and colonoscopy are nondiagnostic, and the small intestine is the site of bleeding,
This is the case of a 55-year-old patient admitted to the emergency department for a digestive hemorrhagic syndrome. The patient’s hemoglobin levels dropped to 6 grams per 100mL. The patient’s resuscitation allowed for the stabilization and restoration of blood volume.
Gastroscopy and colonoscopy did not demonstrate any etiology of bleeding. An emergency CT-scan found a suspected lesion at the level of the small bowel with contrast medium extravasation.
A video-endoscopic capsule was administered to the patient. It helped to identify the presence of a bleeding polypoid lesion on the middle portion of the jejunum. This video shows the laparoscopid resection of the lesion.
Para-aortic nodal staging in advanced cervical cancer, IRCAD 2011
In this key lecture, para-aortic (PA) lymph node staging in advanced cervical cancer is discussed. The treatment of advanced cervical cancer cannot be covered by surgery alone for the primary tumor. MRI is the best option to characterize the volume of the disease and its potential extension in the parametrium. Chemoradiation is superior to radiation, as a standard of care for primary disease. In advanced cervical cancer, pelvic lymph nodes are found positive in 25% of patients; consequently they have to be irradiated. Depending on the study, 10 to 40% of para-aortic lymph nodes are invaded. The question is whether we have to extend the field of irradiation systematically with the associated morbidity and the risk of exaggerated treatment in 60 to 90% of cases or treat only the pelvis systematically, with inadequate treatment of para-aortic nodes in 10 to 40% of cases. In nodal staging, MRI gives a sensitivity of 60 to 70%; PET-scan is even better with a sensitivity of 90%. Nodal staging is important to ensure individual treatment planning. Dissection of para-aortic nodes has been proposed in order to confirm the histological status and help with decision-making for each patient: pelvic treatment only is considered if para-aortic nodes are negative; extended-field radiation should be carried out in cases when nodes are positive. In Eric Blanc’s study, patients with negative para-aortic nodes (case 1) had pelvic radiation with concomitant chemoradiation, while patients with positive para-aortic nodes (case 2) were treated by extended-field radiation with chemotherapy. Survival curves in case 1 were similar to those with microscopic para-aortic nodes that had extended-field radiation; cases with bulky nodes had deleterious results. In conclusion, staging of the primary tumor is essential to optimize radiation planning and local control success and node staging is important to ensure individual treatment planning. PET-scan in PA nodal staging is specific but lacks approximately 10% sensitivity. PA node dissection needs further evaluation: it can be performed with controlled morbidity by experienced teams and for selected patients, with a precise definition of histological and nodal status, and impact on treatment planning and potentially on patient’s outcome.
F Kridelka
Lecture
6 years ago
714 views
2 likes
0 comments
11:15
Para-aortic nodal staging in advanced cervical cancer, IRCAD 2011
In this key lecture, para-aortic (PA) lymph node staging in advanced cervical cancer is discussed. The treatment of advanced cervical cancer cannot be covered by surgery alone for the primary tumor. MRI is the best option to characterize the volume of the disease and its potential extension in the parametrium. Chemoradiation is superior to radiation, as a standard of care for primary disease. In advanced cervical cancer, pelvic lymph nodes are found positive in 25% of patients; consequently they have to be irradiated. Depending on the study, 10 to 40% of para-aortic lymph nodes are invaded. The question is whether we have to extend the field of irradiation systematically with the associated morbidity and the risk of exaggerated treatment in 60 to 90% of cases or treat only the pelvis systematically, with inadequate treatment of para-aortic nodes in 10 to 40% of cases. In nodal staging, MRI gives a sensitivity of 60 to 70%; PET-scan is even better with a sensitivity of 90%. Nodal staging is important to ensure individual treatment planning. Dissection of para-aortic nodes has been proposed in order to confirm the histological status and help with decision-making for each patient: pelvic treatment only is considered if para-aortic nodes are negative; extended-field radiation should be carried out in cases when nodes are positive. In Eric Blanc’s study, patients with negative para-aortic nodes (case 1) had pelvic radiation with concomitant chemoradiation, while patients with positive para-aortic nodes (case 2) were treated by extended-field radiation with chemotherapy. Survival curves in case 1 were similar to those with microscopic para-aortic nodes that had extended-field radiation; cases with bulky nodes had deleterious results. In conclusion, staging of the primary tumor is essential to optimize radiation planning and local control success and node staging is important to ensure individual treatment planning. PET-scan in PA nodal staging is specific but lacks approximately 10% sensitivity. PA node dissection needs further evaluation: it can be performed with controlled morbidity by experienced teams and for selected patients, with a precise definition of histological and nodal status, and impact on treatment planning and potentially on patient’s outcome.