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Monthly publications

#January 2013
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Laparoscopic total colectomy for T4N0M0 right colonic cancer and Lynch syndrome
The authors demonstrate their technique of laparoscopic total colectomy indicated for T3 tumors of the right transverse colon in a 40-year-old man with a family history of Lynch syndrome. Colonoscopy performed 3 years earlier ruled out the presence of polyps. Due to the tumor's invasiveness and the necessity to perform repeated endoscopic monitoring, it was decided to perform a total colectomy. The intervention is begun to the right and is completed to the left making sure to avoid any tumor manipulation. The different steps of the procedure are clearly outlined with images of outstanding quality. The vascular approach, especially to the right along the superior mesenteric axis, is beautifully exposed.
J Leroy, J Marescaux
Surgical intervention
5 years ago
5580 views
112 likes
0 comments
28:29
Laparoscopic total colectomy for T4N0M0 right colonic cancer and Lynch syndrome
The authors demonstrate their technique of laparoscopic total colectomy indicated for T3 tumors of the right transverse colon in a 40-year-old man with a family history of Lynch syndrome. Colonoscopy performed 3 years earlier ruled out the presence of polyps. Due to the tumor's invasiveness and the necessity to perform repeated endoscopic monitoring, it was decided to perform a total colectomy. The intervention is begun to the right and is completed to the left making sure to avoid any tumor manipulation. The different steps of the procedure are clearly outlined with images of outstanding quality. The vascular approach, especially to the right along the superior mesenteric axis, is beautifully exposed.
Transumbilical single access laparoscopic Toupet fundoplication
Background: Different procedures have been reported to be feasible and safe through single access laparoscopy (SAL). A transumbilical SAL Toupet fundoplication is demonstrated here.

Video: A young lady sought care for gastroesophageal reflux disease associated with grade B esophagitis, hiatal hernia and esophageal dyskinesia. The SAL procedure was performed by the opening of the umbilicus through Hasson’s technique. An 11mm reusable trocar was inserted for a 10mm, 30-degree angled, non-flexible, and standard length scope. Curved reusable instruments according to Dapri (Karl Storz Endoskope) were introduced through the same scar without trocars. The gastroesophageal junction was exposed thanks to the insertion of a 2mm wire under the xiphoid access. Crura repair and fundoplication were performed using intracorporeal knots, with a curved needle-holder. The umbilicus was finally closed in layers.

Results: No extra-umbilical trocar was necessary, and no intraoperative complications were registered. Operative time was 172 minutes and the final umbilical scar was 15mm. Postoperative pain was kept minimal, and the patient was discharged on the third postoperative day after a satisfying gastrograffin swallow.

Conclusions: Transumbilical SAL Toupet fundoplication is feasible. Use of curved and reusable instruments permits to avoid the conflict between the instruments’ tips intracorporeally or between the surgeons’ hands externally. Thanks to this technique, the cost of SAL is similar to multi-trocar laparoscopy.
G Dapri, L Gerard, S Carandina, GB Cadière
Surgical intervention
5 years ago
2712 views
35 likes
1 comment
08:05
Transumbilical single access laparoscopic Toupet fundoplication
Background: Different procedures have been reported to be feasible and safe through single access laparoscopy (SAL). A transumbilical SAL Toupet fundoplication is demonstrated here.

Video: A young lady sought care for gastroesophageal reflux disease associated with grade B esophagitis, hiatal hernia and esophageal dyskinesia. The SAL procedure was performed by the opening of the umbilicus through Hasson’s technique. An 11mm reusable trocar was inserted for a 10mm, 30-degree angled, non-flexible, and standard length scope. Curved reusable instruments according to Dapri (Karl Storz Endoskope) were introduced through the same scar without trocars. The gastroesophageal junction was exposed thanks to the insertion of a 2mm wire under the xiphoid access. Crura repair and fundoplication were performed using intracorporeal knots, with a curved needle-holder. The umbilicus was finally closed in layers.

Results: No extra-umbilical trocar was necessary, and no intraoperative complications were registered. Operative time was 172 minutes and the final umbilical scar was 15mm. Postoperative pain was kept minimal, and the patient was discharged on the third postoperative day after a satisfying gastrograffin swallow.

Conclusions: Transumbilical SAL Toupet fundoplication is feasible. Use of curved and reusable instruments permits to avoid the conflict between the instruments’ tips intracorporeally or between the surgeons’ hands externally. Thanks to this technique, the cost of SAL is similar to multi-trocar laparoscopy.
Laparoscopic resection of an esophageal leiomyoma
Leiomyomas represent a hyperproliferation of interlacing bundles of smooth muscle cells that are well demarcated by adjacent tissue or by a smooth connective tissue capsule. They usually arise as intramural growths and rarely cause symptoms when they are smaller than 5cm in diameter. In the distal esophagus, they may reach large proportions and may encroach on the cardia of the stomach. The majority of leiomyomas have been discovered during evaluation for dysphagia.
The traditional open thoracotomy for the enucleation of larger symptomatic esophageal leiomyomas has been gradually replaced by thoracoscopic or laparoscopic approaches. The video demonstrates the laparoscopic resection of a leiomyoma in a 50-year-old woman with a history of reflux esophagitis presenting with dysphagia.
J Torres Bermúdez, FC Becerra García, S del Valle Ruiz , AA Carrillo Sánchez, G Sánchez de la Villa
Surgical intervention
5 years ago
1216 views
8 likes
0 comments
09:13
Laparoscopic resection of an esophageal leiomyoma
Leiomyomas represent a hyperproliferation of interlacing bundles of smooth muscle cells that are well demarcated by adjacent tissue or by a smooth connective tissue capsule. They usually arise as intramural growths and rarely cause symptoms when they are smaller than 5cm in diameter. In the distal esophagus, they may reach large proportions and may encroach on the cardia of the stomach. The majority of leiomyomas have been discovered during evaluation for dysphagia.
The traditional open thoracotomy for the enucleation of larger symptomatic esophageal leiomyomas has been gradually replaced by thoracoscopic or laparoscopic approaches. The video demonstrates the laparoscopic resection of a leiomyoma in a 50-year-old woman with a history of reflux esophagitis presenting with dysphagia.
Robotic assisted thymectomy for the management of autoimmune myasthenia gravis
We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months.

Symptoms are generalized to her four arms. Anti-acetylcholine antibodies and the therapeutic test of Mestinon® (Pyridostigmine) are positive.
In recent months, her symptoms worsened with the onset of swallowing disorders.

Immunoglobulin treatment was poorly effective and was complicated by the appearance of jaundice. CT-scan showed a mediastinal thymic hyperplasia.
Thymectomy is indicated. To do so, a left thoracoscopy is performed and assisted by means of the Da Vinci™ robot.

Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.

The use of the Da Vinci® robot for this type of intervention has been recognized many years ago now with the works of Federico Rea and Jens Ruckert among 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 to 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.
N Santelmo, A Olland
Surgical intervention
5 years ago
1792 views
23 likes
0 comments
11:26
Robotic assisted thymectomy for the management of autoimmune myasthenia gravis
We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months.

Symptoms are generalized to her four arms. Anti-acetylcholine antibodies and the therapeutic test of Mestinon® (Pyridostigmine) are positive.
In recent months, her symptoms worsened with the onset of swallowing disorders.

Immunoglobulin treatment was poorly effective and was complicated by the appearance of jaundice. CT-scan showed a mediastinal thymic hyperplasia.
Thymectomy is indicated. To do so, a left thoracoscopy is performed and assisted by means of the Da Vinci™ robot.

Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.

The use of the Da Vinci® robot for this type of intervention has been recognized many years ago now with the works of Federico Rea and Jens Ruckert among 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 to 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.
Laparoscopic right lymphadenectomy (R-LND) for non-seminomatous testis tumors
This video aims to demonstrate the right side of a laparoscopic technique for the treatment of non-seminomatous testicular germ cell tumors (NSGCT). A laparoscopic left lymphadenectomy (L-LND) was published last October 2012. This video shows the right side which could be reproduced laparoscopically at our urology center. A minimally invasive procedure such as this one can be performed with experience, resulting in a magnified anatomy provided by visual optics. Careful dissection of all vascular structures will provide full access to the templates described for lymph node dissections of this kind of tumor. It is essential to consider that treatment will depend on some parameters such as histology, tumor markers, lymphovascular invasion, and in case surgery is decided upon, the patient’s preference.
References
1. Valero Fuentealba G. [Antegrade ejaculation alter modified lumboaortic laparoscopic lymphadenectomy]. Arch Esp Urol 2008;61:517-20.

2. Castillo OA, Sánchez-Salas R, Secin FP, Campero JM, Foneron A, Vidal-Mora I. Linfadenectomía retroperitoneal laparoscópica primaria para el tumor testicular de células germinales no seminomatoso en estadio clínico I. Actas Urol Esp 2011;35:22-8.
3. Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Primary retroperitoneal lymph node dissection in clinical stage A non-seminomatous germ cell testis cancer. Review of the Indiana University experience 1965-1989. Br J Urol 1993;71:326-35.
4. Yoon GH, Stein JP, Skinner DG. Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle: an update. Urol Oncol 2005;23:168-77.

5. Carver BS, Sheinfeld J. The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors. Nat Clin Pract Urol 2005;2:330-5.

6. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

7. Nelson JB, Chen RN, Bishoff JT, Oh WK, Kantoff PW, Donehower RC, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors. Urology 1999;54:1064-7.

8. Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003;62:324-7.

9. Donohue JP, Zachary JM, Maynard BR. Distribution of nodal metastases in nonseminomatous testis cancer. J Urol 1982;128:315-20.

10. Weissbach L, Boedefeld EA. Localization of solitary and multiple metastases in stage II nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I. J Urol 1987;138:77-82.

11. Höltl L, Peschel R, Knapp R, Janetschek G, Steiner H, Hittmair A, Rogatsch H, Bartsch G, Hobisch A. Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels. Urology 2002;59:114-8.

12. Chang SS, Mohseni HF, Leon A, Sheinfeld J. Paracolic recurrence: the importance of wide excision of the spermatic cord at retroperitoneal lymph node dissection. J Urol 2002;167:94-6.

13. Beck SD, Cheng L, Bihrle R, Donohue JP, Foster RS. Does the presence of extranodal extension in pathological stage B1 nonseminomatous germ cell tumor necessitate adjuvant chemotherapy? J Urol 2007;177:944-6.

14. Richie JP. Clinical stage I testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol 1990;144:1160-3.

14. Janetschek G, Peschel R, Hobisch A, Bartsch G. Laparoscopic retroperitoneal lymph node dissection. J Endourol 2001;15:449-53.

15. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

16. Poulakis V, Skriapas K, de Vries R, Dillenburg W, Ferakis N, Witzsch U, Becht E. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006;68:154-60.

17. Abdel-Aziz KF, Anderson JK, Svatek R, Margulis V, Sagalowsky AI, Cadeddu JA. Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors. J Endourol 2006;20:627-31.

18. Bhayani SB, Allaf ME, Kavoussi LR. Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status. Urol Oncol 2004;22:145-8.

19. Eggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfeld J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol 2007;177:937-42.

20. Nielsen ME, Lima G, Schaeffer EM, Porter J, Cadeddu JA, Tuerk I, Kavoussi LR. Oncologic efficacy of laparoscopic RPLND in treatment of clinical stage I nonseminomatous germ cell testicular cancer. Urology 2007;70:1168-72.

21. Valdevenito Sepulveda JP, Merhe Nieva E, Valdevenito Sepulveda R, Cuevas Toro M, Gómez Gallo A, Bermúdez Luna H, Contreras Meléndez L, Gallegos Méndez I, Gallardo Escobar J. Palma Ceppi C. [Reduced retroperitoneal lymphadenectomy for clinical stage I non seminomatous germ cell testicular cancer]. Arch Esp Urol 2007;60:245-54.

22. Neyer M, Peschel R, Akkad T, Springer-Stöhr B, Berger A, Bartsch G, Steiner H. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180-3.
JB Roche, VE Corona Montes, JL Hoepffner, T Piéchaud
Surgical intervention
5 years ago
3622 views
70 likes
0 comments
13:36
Laparoscopic right lymphadenectomy (R-LND) for non-seminomatous testis tumors
This video aims to demonstrate the right side of a laparoscopic technique for the treatment of non-seminomatous testicular germ cell tumors (NSGCT). A laparoscopic left lymphadenectomy (L-LND) was published last October 2012. This video shows the right side which could be reproduced laparoscopically at our urology center. A minimally invasive procedure such as this one can be performed with experience, resulting in a magnified anatomy provided by visual optics. Careful dissection of all vascular structures will provide full access to the templates described for lymph node dissections of this kind of tumor. It is essential to consider that treatment will depend on some parameters such as histology, tumor markers, lymphovascular invasion, and in case surgery is decided upon, the patient’s preference.
References
1. Valero Fuentealba G. [Antegrade ejaculation alter modified lumboaortic laparoscopic lymphadenectomy]. Arch Esp Urol 2008;61:517-20.

2. Castillo OA, Sánchez-Salas R, Secin FP, Campero JM, Foneron A, Vidal-Mora I. Linfadenectomía retroperitoneal laparoscópica primaria para el tumor testicular de células germinales no seminomatoso en estadio clínico I. Actas Urol Esp 2011;35:22-8.
3. Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Primary retroperitoneal lymph node dissection in clinical stage A non-seminomatous germ cell testis cancer. Review of the Indiana University experience 1965-1989. Br J Urol 1993;71:326-35.
4. Yoon GH, Stein JP, Skinner DG. Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle: an update. Urol Oncol 2005;23:168-77.

5. Carver BS, Sheinfeld J. The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors. Nat Clin Pract Urol 2005;2:330-5.

6. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

7. Nelson JB, Chen RN, Bishoff JT, Oh WK, Kantoff PW, Donehower RC, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors. Urology 1999;54:1064-7.

8. Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003;62:324-7.

9. Donohue JP, Zachary JM, Maynard BR. Distribution of nodal metastases in nonseminomatous testis cancer. J Urol 1982;128:315-20.

10. Weissbach L, Boedefeld EA. Localization of solitary and multiple metastases in stage II nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I. J Urol 1987;138:77-82.

11. Höltl L, Peschel R, Knapp R, Janetschek G, Steiner H, Hittmair A, Rogatsch H, Bartsch G, Hobisch A. Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels. Urology 2002;59:114-8.

12. Chang SS, Mohseni HF, Leon A, Sheinfeld J. Paracolic recurrence: the importance of wide excision of the spermatic cord at retroperitoneal lymph node dissection. J Urol 2002;167:94-6.

13. Beck SD, Cheng L, Bihrle R, Donohue JP, Foster RS. Does the presence of extranodal extension in pathological stage B1 nonseminomatous germ cell tumor necessitate adjuvant chemotherapy? J Urol 2007;177:944-6.

14. Richie JP. Clinical stage I testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol 1990;144:1160-3.

14. Janetschek G, Peschel R, Hobisch A, Bartsch G. Laparoscopic retroperitoneal lymph node dissection. J Endourol 2001;15:449-53.

15. Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol 2005;19:683-92.

16. Poulakis V, Skriapas K, de Vries R, Dillenburg W, Ferakis N, Witzsch U, Becht E. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006;68:154-60.

17. Abdel-Aziz KF, Anderson JK, Svatek R, Margulis V, Sagalowsky AI, Cadeddu JA. Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors. J Endourol 2006;20:627-31.

18. Bhayani SB, Allaf ME, Kavoussi LR. Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status. Urol Oncol 2004;22:145-8.

19. Eggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfeld J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol 2007;177:937-42.

20. Nielsen ME, Lima G, Schaeffer EM, Porter J, Cadeddu JA, Tuerk I, Kavoussi LR. Oncologic efficacy of laparoscopic RPLND in treatment of clinical stage I nonseminomatous germ cell testicular cancer. Urology 2007;70:1168-72.

21. Valdevenito Sepulveda JP, Merhe Nieva E, Valdevenito Sepulveda R, Cuevas Toro M, Gómez Gallo A, Bermúdez Luna H, Contreras Meléndez L, Gallegos Méndez I, Gallardo Escobar J. Palma Ceppi C. [Reduced retroperitoneal lymphadenectomy for clinical stage I non seminomatous germ cell testicular cancer]. Arch Esp Urol 2007;60:245-54.

22. Neyer M, Peschel R, Akkad T, Springer-Stöhr B, Berger A, Bartsch G, Steiner H. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180-3.
Laparoscopic management of Mirizzi syndrome
The surgical management of acute cholecystitis continues to be a matter of personal choice. At our institution, we perform early laparoscopic cholecystectomy electively after treatment with intravenous fluids and antibiotics.
We present the case of a 35-year-old man who was admitted with a history of pain in the right upper abdomen for one day. He was managed with analgesics, intravenous fluids, and antibiotics. Despite relief from pain with aggressive medical therapy, he developed jaundice. An ultrasound examination confirmed a small stone impacted in the neck of the gallbladder and non-dilated biliary radicles. In view of increased serum bilirubin, the patient was scheduled for laparoscopic cholecystectomy.
Laparoscopic cholecystectomy revealed a gangrenous gallbladder with dilated cystic and common bile ducts. Intraoperative cholangiogram showed a suspicious filling defect at the lower end of the common bile duct. The ureteric catheter was therefore left indwelling and removed after one month.
Aa Rai, R Singh, S Rai, Sa Rai
Surgical intervention
5 years ago
6021 views
101 likes
3 comments
16:58
Laparoscopic management of Mirizzi syndrome
The surgical management of acute cholecystitis continues to be a matter of personal choice. At our institution, we perform early laparoscopic cholecystectomy electively after treatment with intravenous fluids and antibiotics.
We present the case of a 35-year-old man who was admitted with a history of pain in the right upper abdomen for one day. He was managed with analgesics, intravenous fluids, and antibiotics. Despite relief from pain with aggressive medical therapy, he developed jaundice. An ultrasound examination confirmed a small stone impacted in the neck of the gallbladder and non-dilated biliary radicles. In view of increased serum bilirubin, the patient was scheduled for laparoscopic cholecystectomy.
Laparoscopic cholecystectomy revealed a gangrenous gallbladder with dilated cystic and common bile ducts. Intraoperative cholangiogram showed a suspicious filling defect at the lower end of the common bile duct. The ureteric catheter was therefore left indwelling and removed after one month.