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Monthly publications

#November 2015
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Relaxing incision for crural repair in type III paraesophageal hernia
This video shows the laparoscopic repair of a large type III paraesophageal hernia in a 55-year-old woman. After dissection of the hernia sac, partial resection is performed. Very high intramediastinal dissection of the esophagus is performed, taking special care not to injure the posterior and anterior vagal trunk. First, as the hiatal defect is very large, a right relaxing incision is performed. The crural repair is performed by interrupted Ethibond® 2/0 stitches buttressed with a polypropylene mesh. Finally, the diaphragmatic defect is covered with a non-reabsorbable mesh (Physiomesh™) and a 180-degree posterior fundoplication is performed.
P Vorwald, G Salcedo, M Posada, C Lévano Linares, ML Sánchez de Molina, R Restrepo, C Ferrero
Surgical intervention
2 years ago
1981 views
79 likes
0 comments
09:13
Relaxing incision for crural repair in type III paraesophageal hernia
This video shows the laparoscopic repair of a large type III paraesophageal hernia in a 55-year-old woman. After dissection of the hernia sac, partial resection is performed. Very high intramediastinal dissection of the esophagus is performed, taking special care not to injure the posterior and anterior vagal trunk. First, as the hiatal defect is very large, a right relaxing incision is performed. The crural repair is performed by interrupted Ethibond® 2/0 stitches buttressed with a polypropylene mesh. Finally, the diaphragmatic defect is covered with a non-reabsorbable mesh (Physiomesh™) and a 180-degree posterior fundoplication is performed.
Laparoscopic total mesorectal excision (TME) through single right iliac fossa (RIF) incision
Background: Single incision laparoscopy is worth of interest during up-to-down rectal resection because it allows to use the single site as the site of temporary ileostomy placement at the end of the procedure.
Video: This video shows an up-to-down single incision laparoscopic rectal resection in a 49-year-old woman presenting with a rectal adenocarcinoma located 12cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor. The procedure was entirely performed with curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany), inserted in the right flank. The uterus and the peritoneal sheet covering the vagina were retrieved using percutaneous sutures. A circular mechanical colorectal anastomosis was performed and a final temporary ileostomy was placed at the site of the single access.
Results: The procedure duration was 297 minutes, and peroperative bleeding was unsignificant. The final scar length was 2.5cm, and the patient was discharged on postoperative day 5. The pathological report confirmed a pT2N0M0 tumor (20 negative nodes).
Conclusions: Up-to-down single incision laparoscopic rectal resection allows to place the temporary ileostomy at the single incision site, offering oncological results comparable to conventional laparoscopy.
G Dapri, N Bachir, L Antolino, K Grozdev, D Guta, K Jottard, GB Cadière
Surgical intervention
2 years ago
2131 views
107 likes
0 comments
09:22
Laparoscopic total mesorectal excision (TME) through single right iliac fossa (RIF) incision
Background: Single incision laparoscopy is worth of interest during up-to-down rectal resection because it allows to use the single site as the site of temporary ileostomy placement at the end of the procedure.
Video: This video shows an up-to-down single incision laparoscopic rectal resection in a 49-year-old woman presenting with a rectal adenocarcinoma located 12cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor. The procedure was entirely performed with curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany), inserted in the right flank. The uterus and the peritoneal sheet covering the vagina were retrieved using percutaneous sutures. A circular mechanical colorectal anastomosis was performed and a final temporary ileostomy was placed at the site of the single access.
Results: The procedure duration was 297 minutes, and peroperative bleeding was unsignificant. The final scar length was 2.5cm, and the patient was discharged on postoperative day 5. The pathological report confirmed a pT2N0M0 tumor (20 negative nodes).
Conclusions: Up-to-down single incision laparoscopic rectal resection allows to place the temporary ileostomy at the single incision site, offering oncological results comparable to conventional laparoscopy.
Laparoscopic repair of a giant type III paraesophageal hernia with mesenteric-axial gastric volvulus
This video demonstrates a laparoscopic repair of a giant type III paraesophageal hernia with an associated mesenteric-axial gastric volvulus in a 61-year-old woman. Dissection of the hernia sac was difficult because the esophageal hiatus was not very enlarged and the overlying peritoneum was very thickened because of chronic hernia incarceration. Once the stomach was replaced into the peritoneal cavity, mediastinal mobilization of the esophagus up to the pulmonary vein was performed. After crural repair, a standard posterior fundoplication was performed, as the intra-abdominal esophageal length was adequate.
P Vorwald, M Posada, G Salcedo, R Restrepo, JR Torres
Surgical intervention
2 years ago
1533 views
52 likes
0 comments
13:44
Laparoscopic repair of a giant type III paraesophageal hernia with mesenteric-axial gastric volvulus
This video demonstrates a laparoscopic repair of a giant type III paraesophageal hernia with an associated mesenteric-axial gastric volvulus in a 61-year-old woman. Dissection of the hernia sac was difficult because the esophageal hiatus was not very enlarged and the overlying peritoneum was very thickened because of chronic hernia incarceration. Once the stomach was replaced into the peritoneal cavity, mediastinal mobilization of the esophagus up to the pulmonary vein was performed. After crural repair, a standard posterior fundoplication was performed, as the intra-abdominal esophageal length was adequate.
Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.
A Gomes, D Luis, T Carneiro, C Veiga
Surgical intervention
2 years ago
1690 views
55 likes
0 comments
06:40
Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
S Perretta, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
2 years ago
791 views
31 likes
0 comments
12:26
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
Totally laparoscopic liver resection, very low anterior resection and excision of common iliac artery lymph nodes in a patient with rectal cancer and synchronous liver metastases
This is the case of a 62-year-old lady who presented with rectal bleeding four months earlier. Rectosigmoidoscopy, contrast enhanced thoraco-abdominal CT-scan, and pelvic MRI were obtained. A T3 N2 rectal adenocarcinoma 6cm proximal to the dentate line was detected. CT-scan showed that the patient had two liver metastases: one was a 4cm mass located in liver segment II and the other one 1.5cm in liver segment V. Due to the presence of suspected common iliac artery lymph nodes as determined by CT-scan, PET-CT was also obtained, which demonstrated an 18F FDG uptake in the corresponding lymph nodes. A simultaneous resection of all malignant structures was decided upon. With the patient placed in a modified lithotomy position, five trocars were inserted in the upper quadrants to start with liver resection. Left lateral sectionectomy was performed first. After resection of the lesion situated in liver segment V, which was completed without a cholecystectomy, attention was turned towards the rectal procedure. The patient was placed in a Trendelenburg position with the left side tilted upwards. Two additional trocars were placed to facilitate handling. After IMA and IMV division, a standard total mesorectal excision procedure was completed. Common iliac artery lymph nodes were then harvested. The anastomosis was performed using a double-stapling technique. A diverting ileostomy was also fashioned.
MF Can
Surgical intervention
2 years ago
1137 views
36 likes
0 comments
16:08
Totally laparoscopic liver resection, very low anterior resection and excision of common iliac artery lymph nodes in a patient with rectal cancer and synchronous liver metastases
This is the case of a 62-year-old lady who presented with rectal bleeding four months earlier. Rectosigmoidoscopy, contrast enhanced thoraco-abdominal CT-scan, and pelvic MRI were obtained. A T3 N2 rectal adenocarcinoma 6cm proximal to the dentate line was detected. CT-scan showed that the patient had two liver metastases: one was a 4cm mass located in liver segment II and the other one 1.5cm in liver segment V. Due to the presence of suspected common iliac artery lymph nodes as determined by CT-scan, PET-CT was also obtained, which demonstrated an 18F FDG uptake in the corresponding lymph nodes. A simultaneous resection of all malignant structures was decided upon. With the patient placed in a modified lithotomy position, five trocars were inserted in the upper quadrants to start with liver resection. Left lateral sectionectomy was performed first. After resection of the lesion situated in liver segment V, which was completed without a cholecystectomy, attention was turned towards the rectal procedure. The patient was placed in a Trendelenburg position with the left side tilted upwards. Two additional trocars were placed to facilitate handling. After IMA and IMV division, a standard total mesorectal excision procedure was completed. Common iliac artery lymph nodes were then harvested. The anastomosis was performed using a double-stapling technique. A diverting ileostomy was also fashioned.
When and how to manage esophageal diverticula: surgical and endoscopic procedures
Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), mid-esophagus, or distally (epiphrenic). Most patients with diverticula are asymptomatic. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery.
Surgical treatment has changed significantly with the development of minimally invasive methods which have increasingly replaced open surgery. If certain indications persist for open surgery, Zenker’s diverticulum is mainly treated with transoral endoscopic flexible or rigid techniques. This approach, which consists of a marsupialization of the diverticulum, also treats the concomitant motor disorder. These esophageal motor disorders are also present in the vast majority of patients with mid-esophageal or epiphrenic diverticula. These diseases are also treated mainly using a minimally invasive approach which consists of a diverticulectomy associated with an esophageal myotomy, which is widely recommended.
B Dallemagne
Lecture
2 years ago
755 views
28 likes
0 comments
24:26
When and how to manage esophageal diverticula: surgical and endoscopic procedures
Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), mid-esophagus, or distally (epiphrenic). Most patients with diverticula are asymptomatic. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery.
Surgical treatment has changed significantly with the development of minimally invasive methods which have increasingly replaced open surgery. If certain indications persist for open surgery, Zenker’s diverticulum is mainly treated with transoral endoscopic flexible or rigid techniques. This approach, which consists of a marsupialization of the diverticulum, also treats the concomitant motor disorder. These esophageal motor disorders are also present in the vast majority of patients with mid-esophageal or epiphrenic diverticula. These diseases are also treated mainly using a minimally invasive approach which consists of a diverticulectomy associated with an esophageal myotomy, which is widely recommended.
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
SH Kong
Lecture
2 years ago
1813 views
113 likes
0 comments
22:10
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
Laparoscopic endoluminal resection of a Brunner’s gland hamartoma
Brunner glands are located in the proximal submucosal part of the duodenum. They secrete an alkaline mucin, which protects the mucosa from gastric acid. Hyperplasia of the Brunner glands larger than 1cm can evolve to a Brunner’s gland hamartoma. It is a hamartoma because the lesion does not have a capsule, a mix of acini, mucosal cells, adipose tissue, smooth muscle and Paneth cells, but no cell atypia. Such hamartomas are very rare and represent between 5 and 10% of benign duodenal tumors with the highest prevalence in patients aged between 40 and 60. The most common clinical presentation is bleeding or obstructive symptoms. Excision is recommended because of the risk of bleeding. Long-term outcome is good and no recurrence after complete excision has been reported.
This video presents the case of a 40-year-old patient who was admitted to our hospital with anemia (5.1g/dL), dark stools, and a past history of Hodgkin’s lymphoma with dysfunction of the spleen and of thyroid gland. Further examination using upper GI flexible endoscopy revealed a pedunculated mass in the duodenal bulb (D1). This mass migrates through the pylorus to the antrum. Additional imaging (CT-scan, MRI) confirms the localization of the mass. Biopsy is suggestive of a Brunner’s gland hamartoma. It was decided to perform a minimally invasive approach using flexible endoscopy in combination with laparoscopy. A laparoscopic endoluminal mass resection was performed using a stapling device. The finding was confirmed on the final pathological report.
S Heyman, Y Pirenne, D Vervloessem, P Willemsen
Surgical intervention
2 years ago
330 views
7 likes
0 comments
05:12
Laparoscopic endoluminal resection of a Brunner’s gland hamartoma
Brunner glands are located in the proximal submucosal part of the duodenum. They secrete an alkaline mucin, which protects the mucosa from gastric acid. Hyperplasia of the Brunner glands larger than 1cm can evolve to a Brunner’s gland hamartoma. It is a hamartoma because the lesion does not have a capsule, a mix of acini, mucosal cells, adipose tissue, smooth muscle and Paneth cells, but no cell atypia. Such hamartomas are very rare and represent between 5 and 10% of benign duodenal tumors with the highest prevalence in patients aged between 40 and 60. The most common clinical presentation is bleeding or obstructive symptoms. Excision is recommended because of the risk of bleeding. Long-term outcome is good and no recurrence after complete excision has been reported.
This video presents the case of a 40-year-old patient who was admitted to our hospital with anemia (5.1g/dL), dark stools, and a past history of Hodgkin’s lymphoma with dysfunction of the spleen and of thyroid gland. Further examination using upper GI flexible endoscopy revealed a pedunculated mass in the duodenal bulb (D1). This mass migrates through the pylorus to the antrum. Additional imaging (CT-scan, MRI) confirms the localization of the mass. Biopsy is suggestive of a Brunner’s gland hamartoma. It was decided to perform a minimally invasive approach using flexible endoscopy in combination with laparoscopy. A laparoscopic endoluminal mass resection was performed using a stapling device. The finding was confirmed on the final pathological report.
Robotic distal gastrectomy with the EndoWrist® One Vessel Sealer
The EndoWrist® One vessel sealer is a wristed, single-use instrument of the da Vinci surgical robotic system intended for bipolar coagulation and mechanical transection of vessels up to 7mm in diameter and tissue bundles. It could be a potential instrument to overcome the limitation of straight energy-based devices. Although it has the advantage of having an endowrist function which allows easy access to the surgical planes in ideal directions, it requires special caution and know-how to use the device safely and effectively, because of a relatively blunt tip and the absence of an active blade at the tip.
This video of the robotic distal gastrectomy for early gastric cancer shows how to harmonize the use of a sharp instrument with conventional bipolar electricity and of the vessel sealer device to maximize the advantages of such devices and to ensure safety. A conventional bipolar forceps is used to make entrance holes on the tissue for a safe application of the vessel sealer, and to perform fine dissections of small tissues, which are difficult to manage using a vessel sealer. Once the access hole has been made, the vessel sealer is applied in an ideal axis to the avascular tissue plane, thanks to the free wrist function. This technique combined with a sharp instrument using conventional bipolar electricity seems to be helpful for a safe and effective operation, which can use the benefit of the vessel sealer to its full potential, for instance with a high degree of freedom of the movement and secure sealing of lymphovascular structures.
HK Yang, SH Kong
Surgical intervention
2 years ago
1270 views
80 likes
0 comments
10:38
Robotic distal gastrectomy with the EndoWrist® One Vessel Sealer
The EndoWrist® One vessel sealer is a wristed, single-use instrument of the da Vinci surgical robotic system intended for bipolar coagulation and mechanical transection of vessels up to 7mm in diameter and tissue bundles. It could be a potential instrument to overcome the limitation of straight energy-based devices. Although it has the advantage of having an endowrist function which allows easy access to the surgical planes in ideal directions, it requires special caution and know-how to use the device safely and effectively, because of a relatively blunt tip and the absence of an active blade at the tip.
This video of the robotic distal gastrectomy for early gastric cancer shows how to harmonize the use of a sharp instrument with conventional bipolar electricity and of the vessel sealer device to maximize the advantages of such devices and to ensure safety. A conventional bipolar forceps is used to make entrance holes on the tissue for a safe application of the vessel sealer, and to perform fine dissections of small tissues, which are difficult to manage using a vessel sealer. Once the access hole has been made, the vessel sealer is applied in an ideal axis to the avascular tissue plane, thanks to the free wrist function. This technique combined with a sharp instrument using conventional bipolar electricity seems to be helpful for a safe and effective operation, which can use the benefit of the vessel sealer to its full potential, for instance with a high degree of freedom of the movement and secure sealing of lymphovascular structures.
Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.
HK Yang, SH Kong
Surgical intervention
2 years ago
1861 views
113 likes
0 comments
03:36
Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.