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Monthly publications

#March 2015
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Laparoscopic transhiatal resection of horseshoe-shaped leiomyoma of the thoracic esophagus
This is the case of a 36-year-old woman with symptoms which have been present for 18 months. Her main symptoms were the following: difficulty to swallow food accompanied by retrosternal discomfort. Upper endoscopy performed on September 29, 2011 found an extrinsic compression of the esophageal wall located 28cm away from the upper dental arcade with a mucosa which appeared to be normal. That extrinsic compression goes until 33cm from the upper dental arcade. The patient was evaluated by a gastroenterologist who performed an echo-endoscopy on March 7, 2012. The gastroenterologist observed a heterogeneous hypo-echoic mass coming from the muscular layer, 25 to 33cm away from the esophagus. The diagnosis of esophageal leiomyoma was established. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal resection of the esophageal leiomyoma was performed on May 22, 2012.
This case is essential because it shows the excision of a horseshoe-shaped leiomyoma of the thoracic esophagus. In addition, it shows a transfixing stitch, which is performed to exert traction on the tumor.
DU Castro Nuñez
Surgical intervention
3 years ago
725 views
4 likes
0 comments
10:18
Laparoscopic transhiatal resection of horseshoe-shaped leiomyoma of the thoracic esophagus
This is the case of a 36-year-old woman with symptoms which have been present for 18 months. Her main symptoms were the following: difficulty to swallow food accompanied by retrosternal discomfort. Upper endoscopy performed on September 29, 2011 found an extrinsic compression of the esophageal wall located 28cm away from the upper dental arcade with a mucosa which appeared to be normal. That extrinsic compression goes until 33cm from the upper dental arcade. The patient was evaluated by a gastroenterologist who performed an echo-endoscopy on March 7, 2012. The gastroenterologist observed a heterogeneous hypo-echoic mass coming from the muscular layer, 25 to 33cm away from the esophagus. The diagnosis of esophageal leiomyoma was established. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal resection of the esophageal leiomyoma was performed on May 22, 2012.
This case is essential because it shows the excision of a horseshoe-shaped leiomyoma of the thoracic esophagus. In addition, it shows a transfixing stitch, which is performed to exert traction on the tumor.
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
P Pessaux, J Hallet, R Memeo, JB Delhorme, D Mutter, J Marescaux
Surgical intervention
3 years ago
1195 views
26 likes
0 comments
12:38
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
Robotic assisted resection of a complex thymoma
Our objective is to demonstrate the management of a very complex mediastinal tumor. To do so, a minimally invasive resection is used, highlighting the benefit of a robotic approach.
The present case is that of a 64-year-old patient diagnosed with an anterior mediastinal mass discovered during myasthenia assessment with positive antibodies.
The tumor was in contact with the aorta, pulmonary artery, and the innominate vein with probable pericardial invasion.
Given such a complex localization, the challenge was to propose a radical resection using minimally invasive surgery with robotic assistance.
As compared to a VATS approach, a robotic approach provides a better view and instruments to achieve complete resection in complex mediastinal tumor. What is important to first control on the CT-scan is the size of the tumor as compared to the thoracic cavity’s size which will allow robotic surgery with a good operative field.
Pericardial resection associated with a lateral plasty of the innominate vein were required to achieved complete R0 resection. The entire resection was performed using a bipolar forceps.
The postoperative course was uneventful. The patient is discharged on postopeartive day 3. The phrenic nerve was preserved.
Pathological analysis of the operative specimen is evocative of a B1 thymoma classified IIb on the Masaoka staging system with complete R0 resection (margins were clear).
The entire file was discussed at the Rhythmic meeting, which is the national meeting for thymoma tumor management held every two weeks. A simple survey was put forward without any adjuvant radiotherapy.
JM Baste, E Roussel, L Haddad, C Peillon
Surgical intervention
3 years ago
1130 views
26 likes
0 comments
07:19
Robotic assisted resection of a complex thymoma
Our objective is to demonstrate the management of a very complex mediastinal tumor. To do so, a minimally invasive resection is used, highlighting the benefit of a robotic approach.
The present case is that of a 64-year-old patient diagnosed with an anterior mediastinal mass discovered during myasthenia assessment with positive antibodies.
The tumor was in contact with the aorta, pulmonary artery, and the innominate vein with probable pericardial invasion.
Given such a complex localization, the challenge was to propose a radical resection using minimally invasive surgery with robotic assistance.
As compared to a VATS approach, a robotic approach provides a better view and instruments to achieve complete resection in complex mediastinal tumor. What is important to first control on the CT-scan is the size of the tumor as compared to the thoracic cavity’s size which will allow robotic surgery with a good operative field.
Pericardial resection associated with a lateral plasty of the innominate vein were required to achieved complete R0 resection. The entire resection was performed using a bipolar forceps.
The postoperative course was uneventful. The patient is discharged on postopeartive day 3. The phrenic nerve was preserved.
Pathological analysis of the operative specimen is evocative of a B1 thymoma classified IIb on the Masaoka staging system with complete R0 resection (margins were clear).
The entire file was discussed at the Rhythmic meeting, which is the national meeting for thymoma tumor management held every two weeks. A simple survey was put forward without any adjuvant radiotherapy.
Laparoscopic dissection of sacral promontory for sacrocolpopexy
Objective: To describe the laparoscopic dissection of the sacral promontory during a laparoscopic sacrocolpopexy, with a special focus on anatomical landmarks and surgical traps.
Setting: Department of Gynecology, CMCO, Strasbourg University Hospital, France.
Patients: Women with invalidating genital prolapse
Interventions: Laparoscopic sacrocolpopexy is performed using three operative ports (one midline, suprapubic port and two lateral ports) and a 0-degree umbilical Karl Storz optical port. In order to suture a polypropylene mesh to the anterior vertebral ligament, the promontory area must be dissected. To improve sacral promontory exposure, the rectum is usually suspended to the left anterior abdominal wall by means of T’Lift™ tissue retraction systems. By palpating the area under the aortic bifurcation and the confluence of iliac veins, the sacral promontory is identified. The right ureter is also identified. Using two duck jaw fenestrated forceps, the peritoneum is lifted --retroperitoneal vessels are fixed to the vertebral elements, and widely opened. The promontory is carefully dissected until the anterior vertebral ligament becomes visible. As the presacral space is rich in blood vessels and nerve elements, surgeons are advised to preserve it.
However, the surgical approach to the vertebral ligament is sometimes difficult in obese women, when patients present anatomical variations such as a low iliac venous circulation confluence, a duplicity of middle sacral vessels, periosteal perforators, a winding right common iliac artery, or in the presence of lymph nodes.
Discussion: Laparoscopic sacrocolpopexy complications rates such as bleeding originating from the promontory varying from 0 to 4.7%, which sometimes require conversion to open abdominal sacrocolpopexy. Described by radiologists at almost 3cm from the sacral promontory, the right ureter can also be injured during reperitonization.
Conclusion: Laparoscopic dissection of the promontory requires specific and careful attention to be paid to non-infrequent anatomical variations.
V Gabriele, AJ Carin, K Afors, O Garbin
Surgical intervention
3 years ago
4970 views
224 likes
0 comments
07:24
Laparoscopic dissection of sacral promontory for sacrocolpopexy
Objective: To describe the laparoscopic dissection of the sacral promontory during a laparoscopic sacrocolpopexy, with a special focus on anatomical landmarks and surgical traps.
Setting: Department of Gynecology, CMCO, Strasbourg University Hospital, France.
Patients: Women with invalidating genital prolapse
Interventions: Laparoscopic sacrocolpopexy is performed using three operative ports (one midline, suprapubic port and two lateral ports) and a 0-degree umbilical Karl Storz optical port. In order to suture a polypropylene mesh to the anterior vertebral ligament, the promontory area must be dissected. To improve sacral promontory exposure, the rectum is usually suspended to the left anterior abdominal wall by means of T’Lift™ tissue retraction systems. By palpating the area under the aortic bifurcation and the confluence of iliac veins, the sacral promontory is identified. The right ureter is also identified. Using two duck jaw fenestrated forceps, the peritoneum is lifted --retroperitoneal vessels are fixed to the vertebral elements, and widely opened. The promontory is carefully dissected until the anterior vertebral ligament becomes visible. As the presacral space is rich in blood vessels and nerve elements, surgeons are advised to preserve it.
However, the surgical approach to the vertebral ligament is sometimes difficult in obese women, when patients present anatomical variations such as a low iliac venous circulation confluence, a duplicity of middle sacral vessels, periosteal perforators, a winding right common iliac artery, or in the presence of lymph nodes.
Discussion: Laparoscopic sacrocolpopexy complications rates such as bleeding originating from the promontory varying from 0 to 4.7%, which sometimes require conversion to open abdominal sacrocolpopexy. Described by radiologists at almost 3cm from the sacral promontory, the right ureter can also be injured during reperitonization.
Conclusion: Laparoscopic dissection of the promontory requires specific and careful attention to be paid to non-infrequent anatomical variations.
Endoscopic biliary stones extraction using a forward viewing standard gastroscope in a patient with altered anatomy (partial gastrectomy with Billroth II reconstruction)
Endoscopic retrograde cholangiography in case of altered anatomy such as partial gastrectomy with Billroth II reconstruction has a success rate of 85% due to different factors such as failure to cross the anastomosis and the presence of an important length of afferent loop with a high risk of jejunal perforation at (or near) the anastomotic site while advancing the duodenoscope. The use of a front-view scope is the safest and could be used theoretically. However, the lack of elevator, the inability to see the papilla in a direct view, and the limited number of catheters available for cannulation and therapeutic procedures in the standard gastroscope with the 2.8mm working channel, can make this kind of procedure quite challenging. In this video, we present a case of successful biliary stone extraction in a patient with Billroth II reconstruction using a standard 2.8mm working channel front-viewing scope.
Gf Donatelli, BM Vergeau, B Meduri
Surgical intervention
3 years ago
828 views
14 likes
0 comments
04:47
Endoscopic biliary stones extraction using a forward viewing standard gastroscope in a patient with altered anatomy (partial gastrectomy with Billroth II reconstruction)
Endoscopic retrograde cholangiography in case of altered anatomy such as partial gastrectomy with Billroth II reconstruction has a success rate of 85% due to different factors such as failure to cross the anastomosis and the presence of an important length of afferent loop with a high risk of jejunal perforation at (or near) the anastomotic site while advancing the duodenoscope. The use of a front-view scope is the safest and could be used theoretically. However, the lack of elevator, the inability to see the papilla in a direct view, and the limited number of catheters available for cannulation and therapeutic procedures in the standard gastroscope with the 2.8mm working channel, can make this kind of procedure quite challenging. In this video, we present a case of successful biliary stone extraction in a patient with Billroth II reconstruction using a standard 2.8mm working channel front-viewing scope.