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Monthly publications

#September 2015
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Can we reduce complications in laparoscopic colorectal surgery?
Laparoscopic colorectal surgery comprises many different types of procedures for various diseases. In general, surgical complications can be divided into intraoperative and postoperative complications, and usually occur while the patient is still in the hospital. Over the recent decade, the improvement of different treatment strategies and technical inventions has been tremendous. This is mainly attributable to the increase use of the laparoscopic approach, which is now well-accepted for many procedures. Training of the surgeon, hospital volume, and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise, and cost-effectiveness. The standardization of perioperative care is essential to minimize postoperative complications. In this key lecture, Dr. Barry Salky provides an overview, namely how to identify and minimize intraoperative and postoperative complications.
B Salky
Lecture
3 years ago
1070 views
16 likes
0 comments
20:59
Can we reduce complications in laparoscopic colorectal surgery?
Laparoscopic colorectal surgery comprises many different types of procedures for various diseases. In general, surgical complications can be divided into intraoperative and postoperative complications, and usually occur while the patient is still in the hospital. Over the recent decade, the improvement of different treatment strategies and technical inventions has been tremendous. This is mainly attributable to the increase use of the laparoscopic approach, which is now well-accepted for many procedures. Training of the surgeon, hospital volume, and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise, and cost-effectiveness. The standardization of perioperative care is essential to minimize postoperative complications. In this key lecture, Dr. Barry Salky provides an overview, namely how to identify and minimize intraoperative and postoperative complications.
Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)
Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.
S Puntambekar, V Sharma, H Parikh, G Joshi, S Mitkare, A Dokrimare
Surgical intervention
3 years ago
14670 views
591 likes
2 comments
11:00
Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)
Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.
Successful closure of iatrogenic colonic perforation with Over-The-Scope Clip™ system (OVESCO™) after failed attempt with standard endoscopic clips
Iatrogenic colonic perforation is a rare complication which has been reported in 0.03%-0.8% of cases during diagnostic colonoscopy. The sigmoid colon and the rectosigmoid junction are the most common sites of perforation during diagnostic examination. Successful endoscopic closure of the defect has been reported using standard clips. However, in case of large defects, standard clips are often ineffective. OTSC™ clips are devices which are successfully used to close wall defects up to 25mm. They make it possible to continue the endoscopic procedure after wall defect closure. In this video, we show the successful closure of a sigmoid colonic iatrogenic perforation in a 50-year-old woman by means of the Over The Scope Clip™ system (OVESCO® Endoscopy, Germany) (11/6 t) after failed attempt with standard clips. OVESCO™ was applied with a standard gastroscope using the suction technique by pushing the cap against the edges of the defect. In order to prevent incarceration of adjacent structures a soft aspiration of the omentum was applied and the OVESCO™ was carefully deployed. Carbon dioxide insufflation was used. Antibiotic therapy was started and the patient was discharged 5 days later. In conclusion, the Over The Scope Clip™ (OTSC™) is a safe surgery-sparing tool which allows for a successful iatrogenic perforation closure of the GI tract, performing omentoplasty by means of a suction technique.
Gf Donatelli
Surgical intervention
3 years ago
1274 views
31 likes
1 comment
02:28
Successful closure of iatrogenic colonic perforation with Over-The-Scope Clip™ system (OVESCO™) after failed attempt with standard endoscopic clips
Iatrogenic colonic perforation is a rare complication which has been reported in 0.03%-0.8% of cases during diagnostic colonoscopy. The sigmoid colon and the rectosigmoid junction are the most common sites of perforation during diagnostic examination. Successful endoscopic closure of the defect has been reported using standard clips. However, in case of large defects, standard clips are often ineffective. OTSC™ clips are devices which are successfully used to close wall defects up to 25mm. They make it possible to continue the endoscopic procedure after wall defect closure. In this video, we show the successful closure of a sigmoid colonic iatrogenic perforation in a 50-year-old woman by means of the Over The Scope Clip™ system (OVESCO® Endoscopy, Germany) (11/6 t) after failed attempt with standard clips. OVESCO™ was applied with a standard gastroscope using the suction technique by pushing the cap against the edges of the defect. In order to prevent incarceration of adjacent structures a soft aspiration of the omentum was applied and the OVESCO™ was carefully deployed. Carbon dioxide insufflation was used. Antibiotic therapy was started and the patient was discharged 5 days later. In conclusion, the Over The Scope Clip™ (OTSC™) is a safe surgery-sparing tool which allows for a successful iatrogenic perforation closure of the GI tract, performing omentoplasty by means of a suction technique.
Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome
Purpose:
The superior mesenteric artery (SMA) syndrome is a rare disease in which the third portion of the duodenum is compressed by the narrow space of the SMA and the aorta. Surgical treatment such as duodenojejunostomy (DJS) could resolve this problem. Here we report our experience of laparoscopic DJS with a video demonstration.

Materials and Methods:
This 18-year-old woman suffered from vomiting, abdominal distention and progressive weight loss during 6 months before admission. The abdominal discomfort usually occurred after meals and it could be alleviated by a decubitus position. Endoscopic exams revealed gastritis and reflux esophagitis. Computed tomography (CT) with contrast identified the distended stomach and the proximal duodenum obstructed by the SMA. Surgical treatment was advised after a complete preoperative survey, including a series of image survey, psychological evaluation and nutrition status. A three-port laparoscopic approach was used. After opening a small window through the mesocolon, a side-to-side DJS was created with a linear stapler and the common channel was closed with a hand-sewn suture.

Results:
There were no intraoperative complications. The laparoscopic DJS tooks 52 mins and blood loss was minimal. The nasogastric tube was removed on postoperative day 3 and she was discharged uneventfully on postoperative day 7. The postoperative upper GI series showed a smooth contrast passage from the DJS to the intestine and the patient gained 6 kg within 4 months after surgery.

Conclusion:
Laparoscopic DJS is a surgical option for SMA syndrome after conservative treatment failure. It is safe, feasible and provides the benefits of a minimally invasive approach.
CH Hsu, KH Liu, CY Tsai, TS Yeh
Surgical intervention
3 years ago
1790 views
65 likes
0 comments
08:42
Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome
Purpose:
The superior mesenteric artery (SMA) syndrome is a rare disease in which the third portion of the duodenum is compressed by the narrow space of the SMA and the aorta. Surgical treatment such as duodenojejunostomy (DJS) could resolve this problem. Here we report our experience of laparoscopic DJS with a video demonstration.

Materials and Methods:
This 18-year-old woman suffered from vomiting, abdominal distention and progressive weight loss during 6 months before admission. The abdominal discomfort usually occurred after meals and it could be alleviated by a decubitus position. Endoscopic exams revealed gastritis and reflux esophagitis. Computed tomography (CT) with contrast identified the distended stomach and the proximal duodenum obstructed by the SMA. Surgical treatment was advised after a complete preoperative survey, including a series of image survey, psychological evaluation and nutrition status. A three-port laparoscopic approach was used. After opening a small window through the mesocolon, a side-to-side DJS was created with a linear stapler and the common channel was closed with a hand-sewn suture.

Results:
There were no intraoperative complications. The laparoscopic DJS tooks 52 mins and blood loss was minimal. The nasogastric tube was removed on postoperative day 3 and she was discharged uneventfully on postoperative day 7. The postoperative upper GI series showed a smooth contrast passage from the DJS to the intestine and the patient gained 6 kg within 4 months after surgery.

Conclusion:
Laparoscopic DJS is a surgical option for SMA syndrome after conservative treatment failure. It is safe, feasible and provides the benefits of a minimally invasive approach.
Laparoscopic repair of colorectal leak and fistula using a new transanal reusable platform
Background: Transanal minimally invasive surgery has triggered much interest and investment in research over the last decade. This approach can be used not only to perform primary procedures (e.g., polypectomy, TME), but also to manage intraoperative complications such as leaks, bleedings, and late complications such as fistulas.
Video: The first part of the video shows the repair of an immediate colorectal leak using transanal laparoscopy, in a 50-year-old woman who underwent a laparoscopic anterior resection of the rectum. During anastomotic control, a posterior leak 4cm away from the anal margin was found. A new transanal reusable port, named DAPRI Port or D-Port (Karl Storz Endoskope, Tuttlingen, Germany), along with DAPRI monocurved reusable instruments, was implemented. The second part of the video shows a persisting and symptomatic colorectal fistula, located posteriorly 11cm away from the anal margin, in a 65-year-old man who had undergone a laparoscopic anterior resection of the rectum 4 weeks earlier.
Results: Operative time was 60 and 45 minutes respectively. Patients were discharged after 5 and 2 days respectively. Controls at 2 months (before ileostomy closure) showed a complete healing of the defects.
Conclusions: Complications after anterior resection of the rectum, such as intraoperative leak and late colorectal fistula, can be treated using transanal laparoscopy. This new transanal platform offers surgeons the possibility to work in ergonomic positions without increasing the cost of the procedure thanks to the reusable nature of the material adopted.
G Dapri, D Guta, K Grozdev, L Antolino, K Jottard, GB Cadière
Surgical intervention
3 years ago
1598 views
33 likes
0 comments
05:55
Laparoscopic repair of colorectal leak and fistula using a new transanal reusable platform
Background: Transanal minimally invasive surgery has triggered much interest and investment in research over the last decade. This approach can be used not only to perform primary procedures (e.g., polypectomy, TME), but also to manage intraoperative complications such as leaks, bleedings, and late complications such as fistulas.
Video: The first part of the video shows the repair of an immediate colorectal leak using transanal laparoscopy, in a 50-year-old woman who underwent a laparoscopic anterior resection of the rectum. During anastomotic control, a posterior leak 4cm away from the anal margin was found. A new transanal reusable port, named DAPRI Port or D-Port (Karl Storz Endoskope, Tuttlingen, Germany), along with DAPRI monocurved reusable instruments, was implemented. The second part of the video shows a persisting and symptomatic colorectal fistula, located posteriorly 11cm away from the anal margin, in a 65-year-old man who had undergone a laparoscopic anterior resection of the rectum 4 weeks earlier.
Results: Operative time was 60 and 45 minutes respectively. Patients were discharged after 5 and 2 days respectively. Controls at 2 months (before ileostomy closure) showed a complete healing of the defects.
Conclusions: Complications after anterior resection of the rectum, such as intraoperative leak and late colorectal fistula, can be treated using transanal laparoscopy. This new transanal platform offers surgeons the possibility to work in ergonomic positions without increasing the cost of the procedure thanks to the reusable nature of the material adopted.
In bag morcellation of a uterine fibroid
For a long time, morcellation of an undiagnosed malignancy, an old and frightening topic, has been a matter of extensive discussions. Clinicians and pathologists still lack instruments to clearly diagnose specific pathologies such as leiomyosarcomas. Minimally invasive surgery brought numerous advantages for the patient. However, morcellation is a key issue for the extraction of a large uterus and myomas. In this video, we present an option for the extraction of myomas. By insufflating a large Endobag®, a virtual abdominal cavity is created, and the mass is morcellated under direct vision. The resistant bag works not only as a protection for the abdominal cavity in case of an undiagnosed malignancy, but also serves to deviate organs from the morcellator.
R Fernandes, A Silva e Silva, JP Carvalho
Surgical intervention
3 years ago
3193 views
130 likes
0 comments
06:37
In bag morcellation of a uterine fibroid
For a long time, morcellation of an undiagnosed malignancy, an old and frightening topic, has been a matter of extensive discussions. Clinicians and pathologists still lack instruments to clearly diagnose specific pathologies such as leiomyosarcomas. Minimally invasive surgery brought numerous advantages for the patient. However, morcellation is a key issue for the extraction of a large uterus and myomas. In this video, we present an option for the extraction of myomas. By insufflating a large Endobag®, a virtual abdominal cavity is created, and the mass is morcellated under direct vision. The resistant bag works not only as a protection for the abdominal cavity in case of an undiagnosed malignancy, but also serves to deviate organs from the morcellator.
Laparoscopic management of bladder endometriosis
Endometriosis is an enigmatic disorder, which affects women in their reproductive age. Failure of recent clinical trials on non-surgical management of endometriosis confirms the role of surgery as a viable treatment of choice. However, recurrence after surgery is common. Recurrence rate varies according to the surgeon’s skills, instrumentation, surgical techniques, and to the postoperative intervention outcome. In patients with severe endometriosis, lesions usually involve the posterior cul-de-sac, anterior rectum, one or both pelvic sidewalls, involving the ureters, the rectosigmoid, and less commonly the anterior bladder, the appendix, and the small bowel. Ureteral retroperitoneal dissection becomes mandatory in extensive endometriosis due to pelvic anatomical distortion. It also leaves the bowel intact without injuring it as the pseudo-peritoneum is lifted along with the inflamed bowel. Consequently, in the surgical practice of benign pathologies, a proper knowledge of the retroperitoneal anatomy ensures complete clearance in cases of advanced endometriosis and frozen pelvis. Here, we present a very interesting case of bladder endometriosis associated with hematuria during menstruation. Partial cystectomy is the treatment of choice for patients with bladder endometriosis in most cases. Provided surgeons are skilled and lesions require no ureteral reimplantation, operative laparoscopy is a valid alternative to laparotomy for partial cystectomy.
D Limbachiya
Surgical intervention
3 years ago
1935 views
63 likes
0 comments
06:56
Laparoscopic management of bladder endometriosis
Endometriosis is an enigmatic disorder, which affects women in their reproductive age. Failure of recent clinical trials on non-surgical management of endometriosis confirms the role of surgery as a viable treatment of choice. However, recurrence after surgery is common. Recurrence rate varies according to the surgeon’s skills, instrumentation, surgical techniques, and to the postoperative intervention outcome. In patients with severe endometriosis, lesions usually involve the posterior cul-de-sac, anterior rectum, one or both pelvic sidewalls, involving the ureters, the rectosigmoid, and less commonly the anterior bladder, the appendix, and the small bowel. Ureteral retroperitoneal dissection becomes mandatory in extensive endometriosis due to pelvic anatomical distortion. It also leaves the bowel intact without injuring it as the pseudo-peritoneum is lifted along with the inflamed bowel. Consequently, in the surgical practice of benign pathologies, a proper knowledge of the retroperitoneal anatomy ensures complete clearance in cases of advanced endometriosis and frozen pelvis. Here, we present a very interesting case of bladder endometriosis associated with hematuria during menstruation. Partial cystectomy is the treatment of choice for patients with bladder endometriosis in most cases. Provided surgeons are skilled and lesions require no ureteral reimplantation, operative laparoscopy is a valid alternative to laparotomy for partial cystectomy.