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Monthly publications

#November 2017
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Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
JL Ng, SAE Yeo
Surgical intervention
11 months ago
10135 views
1165 likes
0 comments
05:37
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
B Dallemagne, S Perretta, M Diana, D Mutter, J Marescaux
Surgical intervention
11 months ago
4493 views
435 likes
0 comments
54:47
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
AM Pereira, R Ferreira de Almeida, G Gonçalves
Surgical intervention
11 months ago
2091 views
284 likes
2 comments
09:29
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
B Dallemagne, S Perretta, D Mutter, J Marescaux
Surgical intervention
11 months ago
1082 views
111 likes
0 comments
41:44
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
D Mutter, J Marescaux
Surgical intervention
11 months ago
13498 views
1376 likes
1 comment
25:14
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
Laparoscopic anatomy of the pelvic floor involved in laparoscopic surgery for pelvic organ prolapse (POP) and urinary incontinence
In this key lecture, Professor Jean-Bernard Dubuisson delineates the laparoscopic pelvic floor anatomy involved in surgical procedures for the management of pelvic organ prolapse (POP) and urinary incontinence. Traditional anatomy considers three levels: pelvic and perineal muscles, ligaments, and the space between all fascias covering the organs. Visceral ligaments occupy an anteroposterior axis (pubovesical ligaments, bladder pillars, and uterosacral ligaments) and a transverse axis (lateral bladder ligaments, cardinal ligaments, paracervix and rectal pillars). The four attachment sites which may be used by the surgeon for fascia and pelvic organ attachment in POP surgery are discussed-- Cooper’s ligament, white line, ischial spine, and sacral promontory. Approximately 90 laparoscopic anatomy pictures are presented in this authoritative lecture. The dissection planes and the different pelvic spaces used for surgery are explained, insisting on the main vessels, nerves, plexus, ureters which are obstacles to bear in mind and to avoid.
JB Dubuisson
Lecture
11 months ago
3505 views
599 likes
0 comments
24:09
Laparoscopic anatomy of the pelvic floor involved in laparoscopic surgery for pelvic organ prolapse (POP) and urinary incontinence
In this key lecture, Professor Jean-Bernard Dubuisson delineates the laparoscopic pelvic floor anatomy involved in surgical procedures for the management of pelvic organ prolapse (POP) and urinary incontinence. Traditional anatomy considers three levels: pelvic and perineal muscles, ligaments, and the space between all fascias covering the organs. Visceral ligaments occupy an anteroposterior axis (pubovesical ligaments, bladder pillars, and uterosacral ligaments) and a transverse axis (lateral bladder ligaments, cardinal ligaments, paracervix and rectal pillars). The four attachment sites which may be used by the surgeon for fascia and pelvic organ attachment in POP surgery are discussed-- Cooper’s ligament, white line, ischial spine, and sacral promontory. Approximately 90 laparoscopic anatomy pictures are presented in this authoritative lecture. The dissection planes and the different pelvic spaces used for surgery are explained, insisting on the main vessels, nerves, plexus, ureters which are obstacles to bear in mind and to avoid.
Robotic left lateral sectionectomy in cirrhotic liver
Background: Laparoscopy for cirrhotic patients can reduce intraoperative bleeding and postoperative morbidity when compared to open surgery. Liver robotic surgery remains a work in progress and only few series reported this approach for cirrhotic patients.
Methods: This is the case of a 62-year-old man with hepatitis C virus and alcoholic cirrhosis (MELD score 10, Child-Pugh score A6) with a single lesion in liver segment III and close to its pedicle.
Results: Intraoperative ultrasound was used to confirm findings on preoperative imaging.
Parenchymal transection was made with an ultrasonic scalpel, monopolar and bipolar cautery with no Pringle’s maneuver. Linear staplers were used to control left lobe inflow and outflow. The specimen was removed through a Pfannenstiel incision. The estimated blood loss was 100mL, and the postoperative course was uneventful. Pathological findings confirmed a 2.5cm hepatocellular carcinoma, with negative margins, and a cirrhotic parenchyma.
Conclusion: Robotic left lateral sectionectomy seems to be as feasible as the conventional laparoscopic approach in selected cirrhotic patients.
R Araujo, LA de Castro, F Felippe, D Burgardt, D Wohnrath
Surgical intervention
11 months ago
1424 views
165 likes
0 comments
07:47
Robotic left lateral sectionectomy in cirrhotic liver
Background: Laparoscopy for cirrhotic patients can reduce intraoperative bleeding and postoperative morbidity when compared to open surgery. Liver robotic surgery remains a work in progress and only few series reported this approach for cirrhotic patients.
Methods: This is the case of a 62-year-old man with hepatitis C virus and alcoholic cirrhosis (MELD score 10, Child-Pugh score A6) with a single lesion in liver segment III and close to its pedicle.
Results: Intraoperative ultrasound was used to confirm findings on preoperative imaging.
Parenchymal transection was made with an ultrasonic scalpel, monopolar and bipolar cautery with no Pringle’s maneuver. Linear staplers were used to control left lobe inflow and outflow. The specimen was removed through a Pfannenstiel incision. The estimated blood loss was 100mL, and the postoperative course was uneventful. Pathological findings confirmed a 2.5cm hepatocellular carcinoma, with negative margins, and a cirrhotic parenchyma.
Conclusion: Robotic left lateral sectionectomy seems to be as feasible as the conventional laparoscopic approach in selected cirrhotic patients.
Bariatric and metabolic surgery
In this authoritative lecture, Dr. Michel Vix highlighted the indications related to metabolic and morbid obesity surgery. He presented key anatomical landmarks and operating room (OR) set-up depending on every patient. He briefly described the main principles of port placement and pneumoperitoneum, and demonstrated maneuvers, indications, and main key steps of morbid obesity procedures including LAGB, SBPD-DS, Scopinaro, RYGB, Mini Gastric Bypass, and Sleeve Gastrectomy, along with their technical aspects, mortality, morbidity, effectiveness, and results using different studies and meta-analyses. He also demonstrated the main principles and key steps of new trends and approaches in bariatric and metabolic surgery with complications and technical therapeutic aspects.
M Vix
Lecture
11 months ago
1242 views
272 likes
0 comments
04:52
Bariatric and metabolic surgery
In this authoritative lecture, Dr. Michel Vix highlighted the indications related to metabolic and morbid obesity surgery. He presented key anatomical landmarks and operating room (OR) set-up depending on every patient. He briefly described the main principles of port placement and pneumoperitoneum, and demonstrated maneuvers, indications, and main key steps of morbid obesity procedures including LAGB, SBPD-DS, Scopinaro, RYGB, Mini Gastric Bypass, and Sleeve Gastrectomy, along with their technical aspects, mortality, morbidity, effectiveness, and results using different studies and meta-analyses. He also demonstrated the main principles and key steps of new trends and approaches in bariatric and metabolic surgery with complications and technical therapeutic aspects.
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
B Dallemagne
Lecture
11 months ago
5210 views
857 likes
1 comment
39:17
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
Laparoscopic equipment and instrumentation in 2017
This two-part presentation outlines the principles and methods of functioning of the main medico-technical devices required to perform laparoscopic surgery.
The first part deals with the laparoscopic unit components including the insufflator, light sources, the evolution of cameras and screens, as well as scopes used in laparoscopic surgery. For each component, operating principles, technological developments, malfunctions and their management are discussed.
The second part presents operating modalities based on novel innovative energy technologies which are used to control tissues. Their operating modalities, specific risks and prevention means are envisaged. This relates in the first place to the evolution of the use of high frequency currents delivering monopolar and bipolar currents within tissues. New ways of management of these currents with tissue vessel-sealing processes are also discussed. Finally, the principles, use and risks of the new means of dissection and tissue sealing with ultrasonic devices are addressed.
The operating principles and the specific risks of all these systems are not well known to surgeons. In case they are not correctly used, they represent new risks and surgeons should be aware of it.
In conclusion, ergonomic choices of conventional instrumentation in minimally invasive surgery are outlined.
D Mutter
Lecture
11 months ago
2552 views
559 likes
0 comments
06:01
Laparoscopic equipment and instrumentation in 2017
This two-part presentation outlines the principles and methods of functioning of the main medico-technical devices required to perform laparoscopic surgery.
The first part deals with the laparoscopic unit components including the insufflator, light sources, the evolution of cameras and screens, as well as scopes used in laparoscopic surgery. For each component, operating principles, technological developments, malfunctions and their management are discussed.
The second part presents operating modalities based on novel innovative energy technologies which are used to control tissues. Their operating modalities, specific risks and prevention means are envisaged. This relates in the first place to the evolution of the use of high frequency currents delivering monopolar and bipolar currents within tissues. New ways of management of these currents with tissue vessel-sealing processes are also discussed. Finally, the principles, use and risks of the new means of dissection and tissue sealing with ultrasonic devices are addressed.
The operating principles and the specific risks of all these systems are not well known to surgeons. In case they are not correctly used, they represent new risks and surgeons should be aware of it.
In conclusion, ergonomic choices of conventional instrumentation in minimally invasive surgery are outlined.