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Monthly publications

#March 2013
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Laparoscopic gastroesophageal resection after mesh migration
In this video, we describe a laparoscopic gastroesophageal resection after a mesh migration in a 47-year-old woman diagnosed with a giant paraesophageal hernia. Preoperatively, a barium esophagogram, an upper endoscopy and an esophageal manometry were performed to define the anatomy of the esophagus, stomach and gastroesophageal junction, the esophageal peristalsis and the function of the lower esophageal sphincter (LES) to confirm the diagnosis of paraesophageal hernia. Additionally, a 24-hour pH-monitoring was performed to determine the magnitude of gastroesophageal reflux.
Five months after the first operation, the patient presented with fever and dysphagia for solids with a 15 Kg weight loss.
She underwent a CT-scan of the thorax and the abdomen, a gastrografin X-ray examination and an upper endoscopy, which showed the presence of a mediastinal fistula secondary to mesh migration.
For that reason, the patient received a second surgical treatment consisting in a laparoscopic gastroesophageal resection.
F Corcione, F Pirozzi, L Barra, V Cimmino, E Minona
Surgical intervention
5 years ago
2161 views
8 likes
0 comments
16:00
Laparoscopic gastroesophageal resection after mesh migration
In this video, we describe a laparoscopic gastroesophageal resection after a mesh migration in a 47-year-old woman diagnosed with a giant paraesophageal hernia. Preoperatively, a barium esophagogram, an upper endoscopy and an esophageal manometry were performed to define the anatomy of the esophagus, stomach and gastroesophageal junction, the esophageal peristalsis and the function of the lower esophageal sphincter (LES) to confirm the diagnosis of paraesophageal hernia. Additionally, a 24-hour pH-monitoring was performed to determine the magnitude of gastroesophageal reflux.
Five months after the first operation, the patient presented with fever and dysphagia for solids with a 15 Kg weight loss.
She underwent a CT-scan of the thorax and the abdomen, a gastrografin X-ray examination and an upper endoscopy, which showed the presence of a mediastinal fistula secondary to mesh migration.
For that reason, the patient received a second surgical treatment consisting in a laparoscopic gastroesophageal resection.
PROGRESS - Transanal TME with colo-anal anastomosis without trans-abdominal assistance for rectal cancer in a male patient
The authors put forward an original oncologic Total Mesorectal Excision (TME) technique combined with distal sigmoidectomy followed by a mechanical colo-anal side-to-end anastomosis using a purely transanal route.
The originality of this technique lies in the strictly transanal approach without any laparoscopic assistance as well as in the oncologic dissection of the rectum around its fascia propria. In addition, the technique is outstanding in the mobilization of the sigmoid mesocolon’s root as well as in the retroperitoneal mobilization of the vascular inferior mesenteric axis, hence avoiding contact with intra-abdominal organs.
This technique is called PROGRESS (Peri Rectal Oncologic Gateway for Retroperitoneal EndoScopic Surgery) due to the retroperitoneal endoscopic dissection using a perirectal access.
The video shows images of remarkable quality, especially of anatomical nerve structures, due to the use of a 4mm, 30-degree scope and a Karl Storz High-Definition camera introduced through the TEO™ device.
J Leroy, D Ntourakis, J Marescaux
Surgical intervention
5 years ago
5862 views
34 likes
1 comment
18:55
PROGRESS - Transanal TME with colo-anal anastomosis without trans-abdominal assistance for rectal cancer in a male patient
The authors put forward an original oncologic Total Mesorectal Excision (TME) technique combined with distal sigmoidectomy followed by a mechanical colo-anal side-to-end anastomosis using a purely transanal route.
The originality of this technique lies in the strictly transanal approach without any laparoscopic assistance as well as in the oncologic dissection of the rectum around its fascia propria. In addition, the technique is outstanding in the mobilization of the sigmoid mesocolon’s root as well as in the retroperitoneal mobilization of the vascular inferior mesenteric axis, hence avoiding contact with intra-abdominal organs.
This technique is called PROGRESS (Peri Rectal Oncologic Gateway for Retroperitoneal EndoScopic Surgery) due to the retroperitoneal endoscopic dissection using a perirectal access.
The video shows images of remarkable quality, especially of anatomical nerve structures, due to the use of a 4mm, 30-degree scope and a Karl Storz High-Definition camera introduced through the TEO™ device.
Laparoscopic cholecystectomy 2 months after acute cholecystitis with intra-abdominal abscess
Cholecystectomy for symptomatic gallstones is mainly performed as soon as an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
Acute cholecystitis is generally caused by gallstones. Gallstones affect about 10% of the population in the Western world but over 80% of people with gallstones are asymptomatic. Acute cholecystitis develops in 1 to 3% of patients with symptomatic gallstones. Cholecystectomy can be performed by laparotomy or by laparoscopy, either at the time of the initial attack (early treatment) or 2 to 3 months after the initial attack has subsided (delayed treatment). A factor complicating the assessment of outcomes of early treatment is that “early” has been variably defined as anywhere from 24 hours to 5 days after either the onset of symptoms or the time of diagnosis. If a delayed or conservative treatment is selected, patients are treated during the acute phase with antibiotics, very occasionally patients undergo percutaneous cholecystostomy (placement of a tube in the gallbladder). Fifteen to 20% of patients who underwent delayed procedures had persistent or recurrent symptoms requiring intervention before the planned operation. Today early laparoscopic cholecystectomy is considered to be the treatment of choice for most patients.
L Marx, A D'Urso, D Mutter, J Marescaux
Surgical intervention
5 years ago
7965 views
117 likes
1 comment
07:53
Laparoscopic cholecystectomy 2 months after acute cholecystitis with intra-abdominal abscess
Cholecystectomy for symptomatic gallstones is mainly performed as soon as an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
Acute cholecystitis is generally caused by gallstones. Gallstones affect about 10% of the population in the Western world but over 80% of people with gallstones are asymptomatic. Acute cholecystitis develops in 1 to 3% of patients with symptomatic gallstones. Cholecystectomy can be performed by laparotomy or by laparoscopy, either at the time of the initial attack (early treatment) or 2 to 3 months after the initial attack has subsided (delayed treatment). A factor complicating the assessment of outcomes of early treatment is that “early” has been variably defined as anywhere from 24 hours to 5 days after either the onset of symptoms or the time of diagnosis. If a delayed or conservative treatment is selected, patients are treated during the acute phase with antibiotics, very occasionally patients undergo percutaneous cholecystostomy (placement of a tube in the gallbladder). Fifteen to 20% of patients who underwent delayed procedures had persistent or recurrent symptoms requiring intervention before the planned operation. Today early laparoscopic cholecystectomy is considered to be the treatment of choice for most patients.
Repair of distal esophageal perforation (Boerhaave’s syndrome) by left thoracoscopy with the patient in prone position
Background: Boerhaave’s syndrome is an emergency disease related to a high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation treated by left thoracoscopy in prone position.

Clinical case: A 44-year-old man was admitted to our emergency room following a 14-hour episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated with a pneumomediastinum. The patient underwent a left thoracoscopy in a prone position, after induction of general anesthesia using a Carlens-type double lumen tube. Three trocars of 5mm, 10mm, and 5mm, were placed in the 5th, 7th, and 10th intercostal spaces respectively. Exploration of the chest cavity revealed the presence of free liquid and fibrin, with no evidence of esophageal perforation. However, the esophageal perforation was demonstrated after dissection of the mediastinal pleura, and appeared to be 2cm in length. A nasogastric tube was advanced into the stomach under visual control, and an additional trocarless grasper was placed in the 10th intercostal space to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleansed and the 5mm trocar was replaced with a chest tube in the 10th intercostal space, with its tip close to the suture.

Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was admitted to hospital in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardial drain was placed after 16 days for pericardial tamponade. A gastrograffin swallow test on postoperative day 10 revealed a residual sinus at the site of the perforation. Another gastrograffin swallow test on postoperative day 20 was negative for leakage. The patient was discharged after 32 days.

Conclusions: Esophageal perforation can be treated by thoracoscopy with the patient placed in a prone position as access is facilitated by the effect of gravity on the cardiopulmonary organs. The success of the primary suture depends on the timing between the incident and the treatment; however, morbidity remains high.
G Dapri, S Carandina, L Gerard, GB Cadière
Surgical intervention
5 years ago
2912 views
58 likes
0 comments
07:11
Repair of distal esophageal perforation (Boerhaave’s syndrome) by left thoracoscopy with the patient in prone position
Background: Boerhaave’s syndrome is an emergency disease related to a high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation treated by left thoracoscopy in prone position.

Clinical case: A 44-year-old man was admitted to our emergency room following a 14-hour episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated with a pneumomediastinum. The patient underwent a left thoracoscopy in a prone position, after induction of general anesthesia using a Carlens-type double lumen tube. Three trocars of 5mm, 10mm, and 5mm, were placed in the 5th, 7th, and 10th intercostal spaces respectively. Exploration of the chest cavity revealed the presence of free liquid and fibrin, with no evidence of esophageal perforation. However, the esophageal perforation was demonstrated after dissection of the mediastinal pleura, and appeared to be 2cm in length. A nasogastric tube was advanced into the stomach under visual control, and an additional trocarless grasper was placed in the 10th intercostal space to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleansed and the 5mm trocar was replaced with a chest tube in the 10th intercostal space, with its tip close to the suture.

Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was admitted to hospital in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardial drain was placed after 16 days for pericardial tamponade. A gastrograffin swallow test on postoperative day 10 revealed a residual sinus at the site of the perforation. Another gastrograffin swallow test on postoperative day 20 was negative for leakage. The patient was discharged after 32 days.

Conclusions: Esophageal perforation can be treated by thoracoscopy with the patient placed in a prone position as access is facilitated by the effect of gravity on the cardiopulmonary organs. The success of the primary suture depends on the timing between the incident and the treatment; however, morbidity remains high.
Image of the month: anterior abdominal mass after hysterectomy
This video demonstrates the case of a woman presenting with a mass appended to the anterior abdominal wall. In the patient’s surgical history, a hysterectomy performed a few years earlier can be noted. The operative report of that intervention is not available. Laparoscopy is therefore decided upon. The first impression is that of an ovarian lesion appended to the anterior abdominal wall. Consequently, an appendicular lesion must be ruled out. The appendix is therefore searched for and dissected. It remains distal from the mass and its pedicle. The presence of a tubular structure in the mass’s pedicle mandates the identification of the right ureter, which also remains distally. From then onwards, resection of the mass does not pose any particular problem. The pathological finding confirms the nature of the mass, namely a benign ovarian cystadenoma.
M Vix, J Marescaux
Surgical intervention
5 years ago
2523 views
40 likes
1 comment
10:47
Image of the month: anterior abdominal mass after hysterectomy
This video demonstrates the case of a woman presenting with a mass appended to the anterior abdominal wall. In the patient’s surgical history, a hysterectomy performed a few years earlier can be noted. The operative report of that intervention is not available. Laparoscopy is therefore decided upon. The first impression is that of an ovarian lesion appended to the anterior abdominal wall. Consequently, an appendicular lesion must be ruled out. The appendix is therefore searched for and dissected. It remains distal from the mass and its pedicle. The presence of a tubular structure in the mass’s pedicle mandates the identification of the right ureter, which also remains distally. From then onwards, resection of the mass does not pose any particular problem. The pathological finding confirms the nature of the mass, namely a benign ovarian cystadenoma.
Lumbo-aortic lymphadenectomy: improving exposure with the T’lift™ device
Lymph node dissection in the lumbo-aortic area is a challenging procedure. The main concerns during surgery include the risk of major vascular injury and the potential lesion of other structures such as the ureter or the duodenum. A thorough surgical strategy and adequate exposure are mandatory to reduce the possibility of complications.
During this surgical demonstration, the most important aspects of the strategy are discussed. Special emphasis is put on exposure and the use of the T’lift™ device is shown. This simple technique allows for a fast and safe suspension of the peritoneum, improving the visualization of the operative field.
A Wattiez, M Puga, CY Akladios, C Redondo Guisasola, Al Ussia
Surgical intervention
5 years ago
4131 views
58 likes
0 comments
15:01
Lumbo-aortic lymphadenectomy: improving exposure with the T’lift™ device
Lymph node dissection in the lumbo-aortic area is a challenging procedure. The main concerns during surgery include the risk of major vascular injury and the potential lesion of other structures such as the ureter or the duodenum. A thorough surgical strategy and adequate exposure are mandatory to reduce the possibility of complications.
During this surgical demonstration, the most important aspects of the strategy are discussed. Special emphasis is put on exposure and the use of the T’lift™ device is shown. This simple technique allows for a fast and safe suspension of the peritoneum, improving the visualization of the operative field.
Endoscopic repair of a large inguino-scrotal hernia with the e-TEP (enhanced view) technique
In this video, we describe the e-TEP (extended view) repair of a left, large, chronic inguinoscrotal hernia in a 35-year-old man.
There are two main difficulties in dealing with large inguinoscrotal hernias: the limited surgical field and the management of the distal sac to avoid seroma formation.
The e-TEP technique has three principles: a high camera trocar placement, a flexible distribution of trocars, and often the division of the posterior aponeurosis at the level of the line of Douglas. The reasons for this approach are that it facilitates the creation of the surgical space and provides a larger surgical field. This technique has allowed us to expand the indications for extraperitoneal repair of inguinal hernia to large inguinoscrotal hernias, incarcerated hernias and sliding hernias. The description and the results of the e-TEP technique have been published in Surgical Endoscopy (2012).
This video shows in detail the dissection of the large indirect sac free from the structures of the spermatic cord and the management of the distal sac to avoid seromas or pseudo-hydroceles by reducing the distal sac and fixing it high and lateral to the posterior inguinal wall. This approach has been recently published in Hernia.
J Daes
Surgical intervention
5 years ago
2669 views
31 likes
0 comments
09:29
Endoscopic repair of a large inguino-scrotal hernia with the e-TEP (enhanced view) technique
In this video, we describe the e-TEP (extended view) repair of a left, large, chronic inguinoscrotal hernia in a 35-year-old man.
There are two main difficulties in dealing with large inguinoscrotal hernias: the limited surgical field and the management of the distal sac to avoid seroma formation.
The e-TEP technique has three principles: a high camera trocar placement, a flexible distribution of trocars, and often the division of the posterior aponeurosis at the level of the line of Douglas. The reasons for this approach are that it facilitates the creation of the surgical space and provides a larger surgical field. This technique has allowed us to expand the indications for extraperitoneal repair of inguinal hernia to large inguinoscrotal hernias, incarcerated hernias and sliding hernias. The description and the results of the e-TEP technique have been published in Surgical Endoscopy (2012).
This video shows in detail the dissection of the large indirect sac free from the structures of the spermatic cord and the management of the distal sac to avoid seromas or pseudo-hydroceles by reducing the distal sac and fixing it high and lateral to the posterior inguinal wall. This approach has been recently published in Hernia.