We use cookies to offer you an optimal experience on our website. By browsing our website, you accept the use of cookies.

Monthly publications

#April 2012
Filter by
Specialty

Type
Category
Technical aspects of the dissection of the anterior parametrium
The parametrium is defined by the tissues that surround the uterine artery between the uterine corpus and the pelvic sidewall cranial to the ureter.
It has two portions, the medial portion corresponding to the vesicouterine ligament, and the lateral portion corresponding to the lateral ligament of the bladder.
It is a very complex area and its dissection is commonly performed in laparoscopic radical hysterectomy. It requires a perfect knowledge of the specific anatomy as this site is a known risk area for major complications such as bleeding and functional disorders.
Concerning functional disorders of bladder, rectum and genital organs, three main sites should be identified in order to avoid damaging the nerves: the external leaf of the uterosacral ligament (inferior hypogastric plexus), the inferior third of the parametrium (pelvic splanchnic root nerves), and the posterior leaf of the lateral ligament of the bladder.
CY Akladios
Lecture
6 years ago
2771 views
37 likes
2 comments
17:49
Technical aspects of the dissection of the anterior parametrium
The parametrium is defined by the tissues that surround the uterine artery between the uterine corpus and the pelvic sidewall cranial to the ureter.
It has two portions, the medial portion corresponding to the vesicouterine ligament, and the lateral portion corresponding to the lateral ligament of the bladder.
It is a very complex area and its dissection is commonly performed in laparoscopic radical hysterectomy. It requires a perfect knowledge of the specific anatomy as this site is a known risk area for major complications such as bleeding and functional disorders.
Concerning functional disorders of bladder, rectum and genital organs, three main sites should be identified in order to avoid damaging the nerves: the external leaf of the uterosacral ligament (inferior hypogastric plexus), the inferior third of the parametrium (pelvic splanchnic root nerves), and the posterior leaf of the lateral ligament of the bladder.
Radical excision or bowel resection for deep endometriosis
In this key lecture, the author focuses on bowel endometriosis. This disease is often multifocal and there are 8% of resection margins which are not free despite segmental resection. Although bowel resection is widely performed, indications are poorly documented regarding nodule size or localization. Segmental resection at the level of the rectum is associated with bowel, bladder, and sexual complications as found in other conditions (such as cancer). The author insists on the need to first perform a discoid resection except if the size of the lesion takes up more than 50% of the wall area and exceeds 2-3cm. For this procedure, it is recommended that the operation be carried out by pelvic surgeons with perfect expertise in endometriosis.
P Koninckx
Lecture
6 years ago
1325 views
5 likes
1 comment
21:48
Radical excision or bowel resection for deep endometriosis
In this key lecture, the author focuses on bowel endometriosis. This disease is often multifocal and there are 8% of resection margins which are not free despite segmental resection. Although bowel resection is widely performed, indications are poorly documented regarding nodule size or localization. Segmental resection at the level of the rectum is associated with bowel, bladder, and sexual complications as found in other conditions (such as cancer). The author insists on the need to first perform a discoid resection except if the size of the lesion takes up more than 50% of the wall area and exceeds 2-3cm. For this procedure, it is recommended that the operation be carried out by pelvic surgeons with perfect expertise in endometriosis.
Gasless transaxillary robotic thyroidectomy
Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.
WY Chung
Lecture
6 years ago
1710 views
6 likes
0 comments
31:16
Gasless transaxillary robotic thyroidectomy
Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.
Hand-sewn retrogastric retrocolic gastric bypass
Nowadays, the Roux-en-Y gastric bypass has become a gold standard in bariatric surgery. In this procedure, the stomach is divided into a small gastric pouch and a Y-shaped section of the intestine is then fashioned and joined to the gastric pouch. A jejunojejunal anastomosis allows for a restoration of the duodenal continuity. This video demonstrates several technical options for these two anastomoses. Dr. Higa has an outstanding experience in the field and has subsequently been able to ergonomically improve every operative step, which is being shown in detail in the video. Authoritative interaction of the expert with the operating room staff is ideal to promote clear and stepwise explanations throughout the procedure. Antecolic or retrocolic approaches, the necessity to look for a hiatal hernia as well as which type of gastrojejunal anastomosis is required are being discussed. This intervention allows for a true teaching lesson in the field of morbid obesity surgery.
KD Higa, M Vix, J Marescaux
Surgical intervention
6 years ago
2051 views
22 likes
0 comments
36:38
Hand-sewn retrogastric retrocolic gastric bypass
Nowadays, the Roux-en-Y gastric bypass has become a gold standard in bariatric surgery. In this procedure, the stomach is divided into a small gastric pouch and a Y-shaped section of the intestine is then fashioned and joined to the gastric pouch. A jejunojejunal anastomosis allows for a restoration of the duodenal continuity. This video demonstrates several technical options for these two anastomoses. Dr. Higa has an outstanding experience in the field and has subsequently been able to ergonomically improve every operative step, which is being shown in detail in the video. Authoritative interaction of the expert with the operating room staff is ideal to promote clear and stepwise explanations throughout the procedure. Antecolic or retrocolic approaches, the necessity to look for a hiatal hernia as well as which type of gastrojejunal anastomosis is required are being discussed. This intervention allows for a true teaching lesson in the field of morbid obesity surgery.
Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure
This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.
B Dallemagne, S Perretta, Gf Donatelli, J Marescaux
Surgical intervention
6 years ago
3240 views
71 likes
0 comments
24:49
Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure
This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.
Appendicular mucocele: laparoscopic management
Appendicular mucocele is a rare, yet typical tumor of the appendix. Its potentially malignant nature, the risk of pseudomyxoma peritonei (PMP) in case of rupture mandates a surgical resection without damage. In this case, diagnosis was suspected during colonoscopy performed because of right iliac fossa pain. The exam revealed an appendicular protrusion. CT-scan demonstrated the presence of an appendicular mucocele. A laparoscopic approach was decided upon. Parietal adhesions were identified. A primary vascular approach is then carried out. Once the ileocolic division has been achieved, a medial approach allows to complete the dissection within the wall keeping away from the lesion. Following the complete specimen resection, an ileocolic anastomosis is performed laparoscopically. At the end of the intervention, a small bowel exploration helps to identify a Meckel’s diverticulum that will be resected.
M Vix, D Mutter, J Leroy, J Marescaux
Surgical intervention
6 years ago
6746 views
91 likes
0 comments
15:47
Appendicular mucocele: laparoscopic management
Appendicular mucocele is a rare, yet typical tumor of the appendix. Its potentially malignant nature, the risk of pseudomyxoma peritonei (PMP) in case of rupture mandates a surgical resection without damage. In this case, diagnosis was suspected during colonoscopy performed because of right iliac fossa pain. The exam revealed an appendicular protrusion. CT-scan demonstrated the presence of an appendicular mucocele. A laparoscopic approach was decided upon. Parietal adhesions were identified. A primary vascular approach is then carried out. Once the ileocolic division has been achieved, a medial approach allows to complete the dissection within the wall keeping away from the lesion. Following the complete specimen resection, an ileocolic anastomosis is performed laparoscopically. At the end of the intervention, a small bowel exploration helps to identify a Meckel’s diverticulum that will be resected.
Sentinel node technique in uterine cancers
Standard full pelvic lymph node dissection is a simple operation but with potential complications, such as lymphedema, which can be very disturbing for the patient. Additionally, even full pelvic dissection may miss the so-called “ectopic nodes”. Moreover, if a large number of nodes are sent for pathological exam, the pathologist is unable to perform serial sections and immunohistochemistry (IHC) to all nodes. For that reason, the pathologist could well miss positive nodes.
On the other hand, the sentinel node technique is able to detect the nodes that are not included in standard pelvic node dissection. It is also able to diagnose micro-metastasis on serial sections.
This technique, which is performed laparoscopically, uses blue dye combined with radio-isotopic identification and mapping, potentially associated with planar lymphoscintigraphy and SPECT-CT. In this way, it is possible to also detect “hot” nodes that are not colored by blue dye. The injection is performed in each quadrant of the cervix, approximately 2mm deep in the stroma.
In the near future, the sentinel node will probably have become the only one to be removed in early cervical cancer as well as in low and intermediate risk endometrial cancer.
D Querleu
Lecture
6 years ago
1605 views
19 likes
0 comments
28:53
Sentinel node technique in uterine cancers
Standard full pelvic lymph node dissection is a simple operation but with potential complications, such as lymphedema, which can be very disturbing for the patient. Additionally, even full pelvic dissection may miss the so-called “ectopic nodes”. Moreover, if a large number of nodes are sent for pathological exam, the pathologist is unable to perform serial sections and immunohistochemistry (IHC) to all nodes. For that reason, the pathologist could well miss positive nodes.
On the other hand, the sentinel node technique is able to detect the nodes that are not included in standard pelvic node dissection. It is also able to diagnose micro-metastasis on serial sections.
This technique, which is performed laparoscopically, uses blue dye combined with radio-isotopic identification and mapping, potentially associated with planar lymphoscintigraphy and SPECT-CT. In this way, it is possible to also detect “hot” nodes that are not colored by blue dye. The injection is performed in each quadrant of the cervix, approximately 2mm deep in the stroma.
In the near future, the sentinel node will probably have become the only one to be removed in early cervical cancer as well as in low and intermediate risk endometrial cancer.
Breast endoscopic single-site surgery for nipple-sparing mastectomy in oncological patient
Minimally invasive breast surgery has recently been proposed although the optimal technique still has not been determined. We report for the first time the new technique of video-assisted nipple-sparing mastectomy (V-NSM) performed through an axillary single port access with gas flow for breast cancer. The technique was named BESS: breast endoscopic single site surgery. A 3cm skin incision in the axilla was used for all surgical procedures. If indicated, axillary operative steps (sentinel lymph node biopsy, full dissection) were performed under direct vision as well as the preparation of the breast tail. A single port device that can hold up to 3 instruments was then inserted into the axillary incision. Trocars were used for the placement of a 30-degree, 5mm scope and 2 operative instruments. The use of carbon dioxide gas flow allowed for an optimal operative field to easily separate the mammary gland from the superficial skin layer along the stretched Cooper’s ligaments, by using Ultracision 5-plus during the whole endoscopic time.
A Ferrari, A Sgarella, S Zonta, P Dionigi
Surgical intervention
6 years ago
7111 views
169 likes
2 comments
12:56
Breast endoscopic single-site surgery for nipple-sparing mastectomy in oncological patient
Minimally invasive breast surgery has recently been proposed although the optimal technique still has not been determined. We report for the first time the new technique of video-assisted nipple-sparing mastectomy (V-NSM) performed through an axillary single port access with gas flow for breast cancer. The technique was named BESS: breast endoscopic single site surgery. A 3cm skin incision in the axilla was used for all surgical procedures. If indicated, axillary operative steps (sentinel lymph node biopsy, full dissection) were performed under direct vision as well as the preparation of the breast tail. A single port device that can hold up to 3 instruments was then inserted into the axillary incision. Trocars were used for the placement of a 30-degree, 5mm scope and 2 operative instruments. The use of carbon dioxide gas flow allowed for an optimal operative field to easily separate the mammary gland from the superficial skin layer along the stretched Cooper’s ligaments, by using Ultracision 5-plus during the whole endoscopic time.
Technique of arthroscopic-assisted foveal repair for TFCC 1B lesion
Three classes of TFCC peripheral 1B tears are recognized in a treatment-orientated algorithm based on arthroscopic findings. Distal tear (class 1), associated with minimal instability of the DRUJ, requires ligament to capsule suture. Complete (class 2) and proximal tears (class 3) are associated with major DRUJ instability and require foveal re-attachment of the TFCC. A new arthroscopic-assisted technique to repair the foveal attachment of the TFCC by using a suture anchor is described. It is indicated for class 2 and 3 TFCC peripheral tears, instead of an open repair. The technique requires a dedicated working portal called Direct Foveal (DF) to approach the ulnar fovea. This DF portal is used to prepare the ligament and bone and to drill and insert a suture anchor loaded with a pair of sutures. Under arthroscopic vision, a suture is passed through each limb of the ligament and tied using a small knot-pusher or a simple mosquito forceps. This arthroscopic technique restores original TFCC anatomy and adequate DRUJ stability with less morbidity and easier rehabilitation as compared to open repair.
R Luchetti, A Atzei
Surgical intervention
6 years ago
529 views
8 likes
0 comments
15:25
Technique of arthroscopic-assisted foveal repair for TFCC 1B lesion
Three classes of TFCC peripheral 1B tears are recognized in a treatment-orientated algorithm based on arthroscopic findings. Distal tear (class 1), associated with minimal instability of the DRUJ, requires ligament to capsule suture. Complete (class 2) and proximal tears (class 3) are associated with major DRUJ instability and require foveal re-attachment of the TFCC. A new arthroscopic-assisted technique to repair the foveal attachment of the TFCC by using a suture anchor is described. It is indicated for class 2 and 3 TFCC peripheral tears, instead of an open repair. The technique requires a dedicated working portal called Direct Foveal (DF) to approach the ulnar fovea. This DF portal is used to prepare the ligament and bone and to drill and insert a suture anchor loaded with a pair of sutures. Under arthroscopic vision, a suture is passed through each limb of the ligament and tied using a small knot-pusher or a simple mosquito forceps. This arthroscopic technique restores original TFCC anatomy and adequate DRUJ stability with less morbidity and easier rehabilitation as compared to open repair.
Management of scapholunate tears: open versus arthroscopic treatment
The understanding of scapholunate ligament lesions has made great strides in recent years, largely thanks to the work undertaken by the two wrist surgery "heavyweights" who are Dr. Marc Garcia-Elias and Dr. Christophe Mathoulin.
Although they do not use the same approach to treat scapholunate ligament lesions (Marc Garcia-Elias opens the wrist and Christopher Mathoulin tries to process them arthroscopically), they have both reached the same conclusion:
- the scapholunate ligament is more than just an interosseous ligament but rather a real scapholunate ligament complex with intrinsic and extrinsic components;
- proprioception is involved in the stability of scapholunate space;
- and early diagnosis and treatment seem essential to obtain good results.
This peer-to-peer conversation between these two friends is not a battle, but rather an extremely modern development on a long debated topic... have fun!
Moderator: Riccardo Luchetti, MD
M Garcia-Elias, C Mathoulin, R Luchetti
Lecture
6 years ago
634 views
3 likes
0 comments
37:58
Management of scapholunate tears: open versus arthroscopic treatment
The understanding of scapholunate ligament lesions has made great strides in recent years, largely thanks to the work undertaken by the two wrist surgery "heavyweights" who are Dr. Marc Garcia-Elias and Dr. Christophe Mathoulin.
Although they do not use the same approach to treat scapholunate ligament lesions (Marc Garcia-Elias opens the wrist and Christopher Mathoulin tries to process them arthroscopically), they have both reached the same conclusion:
- the scapholunate ligament is more than just an interosseous ligament but rather a real scapholunate ligament complex with intrinsic and extrinsic components;
- proprioception is involved in the stability of scapholunate space;
- and early diagnosis and treatment seem essential to obtain good results.
This peer-to-peer conversation between these two friends is not a battle, but rather an extremely modern development on a long debated topic... have fun!
Moderator: Riccardo Luchetti, MD