Federico COSTANTINO | WebSurg, the online university of IRCAD

Laparoscopic distal pancreatectomy for mucinous cystadenoma

This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.

F Costantino, M Shahbaz, D Mutter, J Marescaux

Surgical intervention

Laparoscopic distal pancreatectomy for mucinous cystadenoma

This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.

Right hemicolectomy for appendicular mucocele

The appendicular mucocele is defined by a dilation of the appendix and an unusual accumulation of mucus within its lumen. It is a rare pathology which affects 0.25% of the population.
Its histological discovery is made during the postoperative phase in nearly 70% of cases. Appendicular mucoceles, which are secondary to a muco-secretive tumor, can potentially be a problem if they are malignant, especially in case of preoperative or intraoperative rupture, with a risk of gelatinous disease of the peritoneum.
The positive diagnosis is based on a histological study, which must be systematic, for all appendectomy specimens. Preoperatively, it is essential to recognize an appendicular mucocele, in order to properly adapt the surgical technique, and to potentially envisage a more global surgical resection technique.
We present the case of a 70-year-old man, treated in our unit for right iliac fossa abscess in which an explorative laparoscopy was decided upon after one month of medical treatment.

L Marx, F Costantino, J Marescaux

Surgical intervention

Right hemicolectomy for appendicular mucocele

The appendicular mucocele is defined by a dilation of the appendix and an unusual accumulation of mucus within its lumen. It is a rare pathology which affects 0.25% of the population.
Its histological discovery is made during the postoperative phase in nearly 70% of cases. Appendicular mucoceles, which are secondary to a muco-secretive tumor, can potentially be a problem if they are malignant, especially in case of preoperative or intraoperative rupture, with a risk of gelatinous disease of the peritoneum.
The positive diagnosis is based on a histological study, which must be systematic, for all appendectomy specimens. Preoperatively, it is essential to recognize an appendicular mucocele, in order to properly adapt the surgical technique, and to potentially envisage a more global surgical resection technique.
We present the case of a 70-year-old man, treated in our unit for right iliac fossa abscess in which an explorative laparoscopy was decided upon after one month of medical treatment.

Acute cholecystitis and CBD stone: difficult laparoscopy and ERCP

Cholecystectomy for symptomatic gallstones is one of the mostly performed laparoscopic procedures. Early laparoscopic cholecystectomy during acute cholecystitis appears to be safe and shortens the total hospital stay. This video shows a cholecystectomy for acute cholecystitis associated with an intraoperative ERCP for common biliary duct stone.

F Costantino, D Mutter, Gf Donatelli, J Marescaux

Surgical intervention

Acute cholecystitis and CBD stone: difficult laparoscopy and ERCP

Cholecystectomy for symptomatic gallstones is one of the mostly performed laparoscopic procedures. Early laparoscopic cholecystectomy during acute cholecystitis appears to be safe and shortens the total hospital stay. This video shows a cholecystectomy for acute cholecystitis associated with an intraoperative ERCP for common biliary duct stone.

Anastomotic redo after open subtotal TME for rectal cancer: laparoscopic pelvic resection with coloanal anastomosis

The objective of this film is to demonstrate how to perform a laparoscopic redo of a recurrence after carrying out a low colorectal anastomosis through open surgery to manage a cancer of the mid-upper rectum following radiochemotherapy.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Anastomotic redo after open subtotal TME for rectal cancer: laparoscopic pelvic resection with coloanal anastomosis

The objective of this film is to demonstrate how to perform a laparoscopic redo of a recurrence after carrying out a low colorectal anastomosis through open surgery to manage a cancer of the mid-upper rectum following radiochemotherapy.

Totally robot-assisted sleeve gastrectomy

This video shows how to perform a sleeve gastrectomy in a morbidly obese patient with a BMI of 46. Surgery is performed entirely using a robot-assisted approach from beginning to end. The second generation of the three-armed Da Vinci S™ robot is used. The robotic arms are orientated so as to simulate laparoscopic maneuvers.

F Costantino, J Marescaux

Surgical intervention

Totally robot-assisted sleeve gastrectomy

This video shows how to perform a sleeve gastrectomy in a morbidly obese patient with a BMI of 46. Surgery is performed entirely using a robot-assisted approach from beginning to end. The second generation of the three-armed Da Vinci S™ robot is used. The robotic arms are orientated so as to simulate laparoscopic maneuvers.

LIVE Laparoscopic total splenectomy for cystic lesions of the spleen

This the case of a 32-year-old lady who went to see her medical practitioner for a back pain and a calcification was discovered in the left upper quadrant of the abdomen. A CT-scan was performed and provided the diagnosis of a cyst of the spleen with a lot of calcifications. This cyst does not allow to perform a partial splenectomy, which is sometimes an indication if we have a cyst located at the upper or at the lower pole of the cyst. A laparoscopic live total splenectomy is presented.

D Mutter, F Costantino, L Soler, J Marescaux

Surgical intervention

LIVE Laparoscopic total splenectomy for cystic lesions of the spleen

This the case of a 32-year-old lady who went to see her medical practitioner for a back pain and a calcification was discovered in the left upper quadrant of the abdomen. A CT-scan was performed and provided the diagnosis of a cyst of the spleen with a lot of calcifications. This cyst does not allow to perform a partial splenectomy, which is sometimes an indication if we have a cyst located at the upper or at the lower pole of the cyst. A laparoscopic live total splenectomy is presented.

Laparoscopic cholecystectomy with rendez-vous technique for symptomatic cholelithiasis with occult choledocholithiasis

This video demonstrates a laparoscopic cholecystectomy with a rendez-vous technique for choledocholithiasis. This 75-year-old patient presented with pain at the level of the right hypochondrium, without jaundice. Serum chemistries show a hepatic cytolysis without cholestasis. Medical imaging demonstrated the presence of a cholelithiasis without choledocholithiasis. This was confirmed by bili-MRI and CT-scan images. A rendez-vous technique is decided upon if intraoperative cholangiography proves positive.

F Costantino, Gf Donatelli, J Marescaux

Surgical intervention

Laparoscopic cholecystectomy with rendez-vous technique for symptomatic cholelithiasis with occult choledocholithiasis

This video demonstrates a laparoscopic cholecystectomy with a rendez-vous technique for choledocholithiasis. This 75-year-old patient presented with pain at the level of the right hypochondrium, without jaundice. Serum chemistries show a hepatic cytolysis without cholestasis. Medical imaging demonstrated the presence of a cholelithiasis without choledocholithiasis. This was confirmed by bili-MRI and CT-scan images. A rendez-vous technique is decided upon if intraoperative cholangiography proves positive.

Laparoscopic treatment for intestinal occlusion following gastric bypass

Bowel obstruction after laparoscopic gastric bypass has been frequently reported. All bariatric surgeons, general surgeons, and physicians involved with postoperative management of the bariatric surgery patient should be familiar with this potentially life-threatening complication because an early diagnosis can prevent major complications. This video shows the laparoscopic treatment of bowel occlusion after gastric bypass.

F Costantino, J Marescaux

Surgical intervention

Laparoscopic treatment for intestinal occlusion following gastric bypass

Bowel obstruction after laparoscopic gastric bypass has been frequently reported. All bariatric surgeons, general surgeons, and physicians involved with postoperative management of the bariatric surgery patient should be familiar with this potentially life-threatening complication because an early diagnosis can prevent major complications. This video shows the laparoscopic treatment of bowel occlusion after gastric bypass.

Laparoscopic one-trocar cholecystectomy, vascular anomaly: interest of angled scope and liver retraction to expose Calot’s triangle

The objective of this film is to demonstrate how to perform a safe single trocar cholecystectomy in a female patient who had previously benefited from a xiphopubic laparotomy to manage several abdominal infections. This video underlines the importance of a good exposure in order to avoid dangerous lesions in case of anatomical anomalies.

F Costantino, J Leroy, J Marescaux

Surgical intervention

Laparoscopic one-trocar cholecystectomy, vascular anomaly: interest of angled scope and liver retraction to expose Calot’s triangle

The objective of this film is to demonstrate how to perform a safe single trocar cholecystectomy in a female patient who had previously benefited from a xiphopubic laparotomy to manage several abdominal infections. This video underlines the importance of a good exposure in order to avoid dangerous lesions in case of anatomical anomalies.

Laparoscopic Roux-en-Y gastric bypass after Nissen procedure for morbid obesity

Different studies have shown that revision of antireflux procedures to RYGB is safe and feasible for morbidly obese patients with weight gain or recurrent GERD symptoms. This video demonstrates a laparoscopic gastric bypass in a 56-year-old patient who had benefited from a laparoscopic Nissen fundoplication in 1999. The patient presents with a BMI of 40 and a diabetes mellitus resistant to treatment.

F Costantino, B Dallemagne, J Marescaux

Surgical intervention

Laparoscopic Roux-en-Y gastric bypass after Nissen procedure for morbid obesity

Different studies have shown that revision of antireflux procedures to RYGB is safe and feasible for morbidly obese patients with weight gain or recurrent GERD symptoms. This video demonstrates a laparoscopic gastric bypass in a 56-year-old patient who had benefited from a laparoscopic Nissen fundoplication in 1999. The patient presents with a BMI of 40 and a diabetes mellitus resistant to treatment.

Emergency Roux-en-Y jejunostomy for caustic lesion of the esophagus

This video shows a Roux-en-Y alimentary jejunostomy in a 48-year-old patient who had had symptoms of maniac and depressive psychosis and who had tried to commit suicide by drinking a cleaning product. This caused an ischemia without necrosis all along the esophagus, without reaching the stomach.

F Costantino, J Marescaux

Surgical intervention

Emergency Roux-en-Y jejunostomy for caustic lesion of the esophagus

This video shows a Roux-en-Y alimentary jejunostomy in a 48-year-old patient who had had symptoms of maniac and depressive psychosis and who had tried to commit suicide by drinking a cleaning product. This caused an ischemia without necrosis all along the esophagus, without reaching the stomach.

Laparoscopic exploration after Roux-en-Y gastric bypass following intestinal obstruction

This video demonstrates a laparoscopic exploration in a female patient who had undergone a gastric bypass in 2002. Her BMI was 58 at that time. Now it is 20. She had been operated on for an incisional hernia that occurred at the level of the former umbilical optical port site. She suffered from several episodes of proven mechanical bowel obstruction and benefited from medical treatment.
However, despite a thorough preoperative work-up, including gastroscopy, colonoscopy and repeat CT-scan studies performed over 6 months, the mechanical origin of the bowel obstruction was difficult to demonstrate. Since the patient had chronic, cramp-like abdominal pain, the exploration of the abdominal cavity using the former port entry sites is decided upon.

F Costantino, M Vix, J Marescaux

Surgical intervention

Laparoscopic exploration after Roux-en-Y gastric bypass following intestinal obstruction

This video demonstrates a laparoscopic exploration in a female patient who had undergone a gastric bypass in 2002. Her BMI was 58 at that time. Now it is 20. She had been operated on for an incisional hernia that occurred at the level of the former umbilical optical port site. She suffered from several episodes of proven mechanical bowel obstruction and benefited from medical treatment.
However, despite a thorough preoperative work-up, including gastroscopy, colonoscopy and repeat CT-scan studies performed over 6 months, the mechanical origin of the bowel obstruction was difficult to demonstrate. Since the patient had chronic, cramp-like abdominal pain, the exploration of the abdominal cavity using the former port entry sites is decided upon.

Laparoscopic partial gastrectomy for GIST

This video shows a laparoscopic partial gastrectomy of a gastrointestinal stromal tumor (GIST) with a low mitotic count located at the lesser curvature of the stomach. This low-grade tumor was found as the patient complained of chronic abdominal pain. The CT-scan evidenced the presence of a 5 by 6cm lesion at the lesser curvature between the anterior and posterior aspect of the stomach. No metastatic lesion was found during the preoperative work-up. Gastroscopy showed an extrinsic lesion at the lesser curvature of the stomach and an approximately 5 by 6cm GIST was suspected. This is why the laparoscopic approach was decided upon.

F Costantino, B Dallemagne, L Soler, J Marescaux

Surgical intervention

Laparoscopic partial gastrectomy for GIST

This video shows a laparoscopic partial gastrectomy of a gastrointestinal stromal tumor (GIST) with a low mitotic count located at the lesser curvature of the stomach. This low-grade tumor was found as the patient complained of chronic abdominal pain. The CT-scan evidenced the presence of a 5 by 6cm lesion at the lesser curvature between the anterior and posterior aspect of the stomach. No metastatic lesion was found during the preoperative work-up. Gastroscopy showed an extrinsic lesion at the lesser curvature of the stomach and an approximately 5 by 6cm GIST was suspected. This is why the laparoscopic approach was decided upon.

Laparoscopic Roux-en-Y gastric bypass after open Nissen fundoplication

Although laparoscopic revision of antireflux procedures when performing a RYGB is feasible, it presents some technical problems such as dissection of Nissen wrap and identification of anatomical landmarks. This is the case of a 50-year-old female patient who underwent a laparoscopic converted to open Nissen fundoplication 10 years ago. Her gastroesophageal reflux was healed. However, she put on weight. Her current BMI is 45. The patient asks for a bariatric procedure.

M Vix, B Dallemagne, F Costantino, J Marescaux

Surgical intervention

Laparoscopic Roux-en-Y gastric bypass after open Nissen fundoplication

Although laparoscopic revision of antireflux procedures when performing a RYGB is feasible, it presents some technical problems such as dissection of Nissen wrap and identification of anatomical landmarks. This is the case of a 50-year-old female patient who underwent a laparoscopic converted to open Nissen fundoplication 10 years ago. Her gastroesophageal reflux was healed. However, she put on weight. Her current BMI is 45. The patient asks for a bariatric procedure.

Laparoscopic treatment of a right indirect strangulated inguinal hernia: TAPP approach

Laparoscopic Trans-Abdominal PrePeritoneal (TAPP) hernia repair is a recognized procedure for inguinal hernia repair in patients undergoing elective surgery. There is a scarcity of data on TAPP repair in emergency situations such as those involving strangulated hernias. We report the laparoscopic treatment of a right indirect strangulated inguinal hernia in a young man aged 18.

F Costantino, J Leroy, J Marescaux

Surgical intervention

Laparoscopic treatment of a right indirect strangulated inguinal hernia: TAPP approach

Laparoscopic Trans-Abdominal PrePeritoneal (TAPP) hernia repair is a recognized procedure for inguinal hernia repair in patients undergoing elective surgery. There is a scarcity of data on TAPP repair in emergency situations such as those involving strangulated hernias. We report the laparoscopic treatment of a right indirect strangulated inguinal hernia in a young man aged 18.

Laparoscopic sleeve gastrectomy after gastric band removal: two different clinical cases

Sleeve gastrectomy after gastric band is a challenging procedure due to the alteration of anatomy caused by the band; the identification of anatomical landmarks is crucial. The objective of this video is to successively demonstrate two different sleeve gastrectomy cases after gastric band removal.

M Vix, F Costantino, J Marescaux

Surgical intervention

Laparoscopic sleeve gastrectomy after gastric band removal: two different clinical cases

Sleeve gastrectomy after gastric band is a challenging procedure due to the alteration of anatomy caused by the band; the identification of anatomical landmarks is crucial. The objective of this video is to successively demonstrate two different sleeve gastrectomy cases after gastric band removal.

Laparoscopic left colectomy after symptomatic constipation in a patient with previous rectopexy for rectal prolapse

The objective of this film is to demonstrate a colectomy technique after laparoscopic rectal prolapse surgery that caused increased constipation in a female patient in her fifties. Indeed, a few months earlier, an indirect rectopexy had been performed with placement of subperitoneal strips; this was combined with a partial Douglasectomy. Following the study of transit times, a laparoscopic left colectomy was decided upon.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Laparoscopic left colectomy after symptomatic constipation in a patient with previous rectopexy for rectal prolapse

The objective of this film is to demonstrate a colectomy technique after laparoscopic rectal prolapse surgery that caused increased constipation in a female patient in her fifties. Indeed, a few months earlier, an indirect rectopexy had been performed with placement of subperitoneal strips; this was combined with a partial Douglasectomy. Following the study of transit times, a laparoscopic left colectomy was decided upon.

Small bowel strangulation due to internal hernia after left colectomy

Internal small bowel herniation through a mesenteric defect is a rare but severe complication. The purpose of the video is to demonstrate the closure of a mesenteric defect following a full left colectomy. This closure is controversial, and when performed, the closure must be perfect. This is the case of a patient who underwent a left colectomy with defect closure, the latter had not been efficient and caused an obstruction syndrome postoperatively, which was well identified by the CT-scan. It identified a small bowel passage behind the lower colon. The patient is re-operated on the second postoperative day.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Small bowel strangulation due to internal hernia after left colectomy

Internal small bowel herniation through a mesenteric defect is a rare but severe complication. The purpose of the video is to demonstrate the closure of a mesenteric defect following a full left colectomy. This closure is controversial, and when performed, the closure must be perfect. This is the case of a patient who underwent a left colectomy with defect closure, the latter had not been efficient and caused an obstruction syndrome postoperatively, which was well identified by the CT-scan. It identified a small bowel passage behind the lower colon. The patient is re-operated on the second postoperative day.

Aortic injury following the first port introduction during laparoscopic cholecystectomy

Although infrequent, major complications may occur during first trocar insertion during laparoscopy. Immediate recognition and management is critical and may lead to a safe outcome. The objective of this video is to show a severe vascular complication that occurred during laparoscopic cholecystectomy performed by a novice surgeon.

F Costantino, J Leroy, Y Georg, J Marescaux

Surgical intervention

Aortic injury following the first port introduction during laparoscopic cholecystectomy

Although infrequent, major complications may occur during first trocar insertion during laparoscopy. Immediate recognition and management is critical and may lead to a safe outcome. The objective of this video is to show a severe vascular complication that occurred during laparoscopic cholecystectomy performed by a novice surgeon.

Perigastric band abscess: laparoscopic approach

Band infection after gastric banding is a relatively rare complication. In most cases, it manifests itself through abdominal pain associated with fever, and/or an abscess surrounding the access port. This is the case of a 37-year-old female patient in whom a gastric band was placed 5 years ago. The patient lost 60% of her excess weight; however, she complained that the gastric band was no longer as efficient. Imaging studies allowed to identify the existence of a 50mL supragastric pouch. A gastroscopy reveals nothing unusual.
Following this postoperative control, we decided to remove the patient’s gastric band as she was troubled by the superior gastric pouch.

M Vix, F Costantino, J Marescaux

Surgical intervention

Perigastric band abscess: laparoscopic approach

Band infection after gastric banding is a relatively rare complication. In most cases, it manifests itself through abdominal pain associated with fever, and/or an abscess surrounding the access port. This is the case of a 37-year-old female patient in whom a gastric band was placed 5 years ago. The patient lost 60% of her excess weight; however, she complained that the gastric band was no longer as efficient. Imaging studies allowed to identify the existence of a 50mL supragastric pouch. A gastroscopy reveals nothing unusual.
Following this postoperative control, we decided to remove the patient’s gastric band as she was troubled by the superior gastric pouch.

Laparoscopic TEP repair for recurrent inguinal hernia after anterior plug hernioplasty

In this video, we show the case of a patient who had undergone an anterior approach Plug treatment for an inguinal hernia. One year later, this patient presents with an obvious and painful recurrence that is well identified following a Valsalva's maneuver. We decide to perform a totally extraperitoneal laparoscopic approach.

B Dallemagne, F Costantino, J Marescaux

Surgical intervention

Laparoscopic TEP repair for recurrent inguinal hernia after anterior plug hernioplasty

In this video, we show the case of a patient who had undergone an anterior approach Plug treatment for an inguinal hernia. One year later, this patient presents with an obvious and painful recurrence that is well identified following a Valsalva's maneuver. We decide to perform a totally extraperitoneal laparoscopic approach.

One glove single port cholecystectomy: some tips and tricks

Single incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of traditional laparoscopy. The aim of this video is to show tips that are useful when performing a cholecystectomy with a single umbilical trocar while respecting the rules of biliary surgery.

J Leroy, F Costantino, J Marescaux

Surgical intervention

One glove single port cholecystectomy: some tips and tricks

Single incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of traditional laparoscopy. The aim of this video is to show tips that are useful when performing a cholecystectomy with a single umbilical trocar while respecting the rules of biliary surgery.

Internal hernia after laparoscopic Roux-en-Y gastric bypass

Internal hernia following laparoscopic RYGBP is a rare but potentially fatal complication. This is the case of a 40-year-old patient who benefited of a gastric bypass for morbid obesity. She had a BMI of 50. She presented with post-prandial pain associated with vomiting. The gastroscopy showed no abnormality. The contrast swallow and follow-through examination showed a stenosis 30cm from the gastrojejunal anastomosis with an almost complete obstruction. This finding was corroborated by the CT-scan, which identified an internal passage at the level of the alimentary loop. The laparoscopic repair of this internal hernia is presented.

F Costantino, J Marescaux

Surgical intervention

Internal hernia after laparoscopic Roux-en-Y gastric bypass

Internal hernia following laparoscopic RYGBP is a rare but potentially fatal complication. This is the case of a 40-year-old patient who benefited of a gastric bypass for morbid obesity. She had a BMI of 50. She presented with post-prandial pain associated with vomiting. The gastroscopy showed no abnormality. The contrast swallow and follow-through examination showed a stenosis 30cm from the gastrojejunal anastomosis with an almost complete obstruction. This finding was corroborated by the CT-scan, which identified an internal passage at the level of the alimentary loop. The laparoscopic repair of this internal hernia is presented.

Laparoscopic retrocaecal appendectomy and disseminated peritonitis

This video demonstrates the laparoscopic treatment of a retrocaecal appendicitis with disseminated peritonitis. This is the case of a 45-year-old patient presenting with an appendicular peritonitis. The patient, who had no previous medical history, was referred to emergencies with a pain syndrome of the right iliac fossa, fever, tachycardia and hyperleukocytosis. The CT-scan identified a retrocaecal infiltration and a voluminous appendicitis. The appendicitis, situated in a retrocaecal position, was going towards a suprahepatic position.

F Costantino, J Marescaux

Surgical intervention

Laparoscopic retrocaecal appendectomy and disseminated peritonitis

This video demonstrates the laparoscopic treatment of a retrocaecal appendicitis with disseminated peritonitis. This is the case of a 45-year-old patient presenting with an appendicular peritonitis. The patient, who had no previous medical history, was referred to emergencies with a pain syndrome of the right iliac fossa, fever, tachycardia and hyperleukocytosis. The CT-scan identified a retrocaecal infiltration and a voluminous appendicitis. The appendicitis, situated in a retrocaecal position, was going towards a suprahepatic position.

Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach

Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.

B Dallemagne, F Costantino, J Marescaux

Surgical intervention

Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach

Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.

Laparoscopic appendectomy following transparietal drainage of an abscess

Patients presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. This video shows the case of a 48-year-old female patient operated upon previously for a collection at the rectouterine (Douglas') pouch following a suspected acute appendicitis. A laparoscopic exploration was performed along with a laparoscopic drainage of the collection, but the appendix had not been identified. Fifteen days later and the patient presents with a 15cm residual collection for which we performed a puncture under CT-scan guidance. Following a 3-month interval, the patient is admitted to our Department to perform an appendectomy.

F Costantino, J Marescaux

Surgical intervention

Laparoscopic appendectomy following transparietal drainage of an abscess

Patients presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. This video shows the case of a 48-year-old female patient operated upon previously for a collection at the rectouterine (Douglas') pouch following a suspected acute appendicitis. A laparoscopic exploration was performed along with a laparoscopic drainage of the collection, but the appendix had not been identified. Fifteen days later and the patient presents with a 15cm residual collection for which we performed a puncture under CT-scan guidance. Following a 3-month interval, the patient is admitted to our Department to perform an appendectomy.

Laparoscopic partial sleeve-like gastrectomy for benign schwannoma

Schwannomas, also known as neurinomas, are generally benign, slow-growing neoplasms representing 0.2% of all gastric tumors. This is the case of a 48-year-old patient presenting with epigastralgias. A 4cm lesion is found as evidenced by the CT-scan. Gastroscopy and endoscopic ultrasonography did not show any mucosal lesion. This video shows a laparoscopic sleeve-like gastrectomy of this benign tumor.

F Costantino, B Dallemagne, J Marescaux

Surgical intervention

Laparoscopic partial sleeve-like gastrectomy for benign schwannoma

Schwannomas, also known as neurinomas, are generally benign, slow-growing neoplasms representing 0.2% of all gastric tumors. This is the case of a 48-year-old patient presenting with epigastralgias. A 4cm lesion is found as evidenced by the CT-scan. Gastroscopy and endoscopic ultrasonography did not show any mucosal lesion. This video shows a laparoscopic sleeve-like gastrectomy of this benign tumor.

Laparoscopic adrenalectomy: typical vascular anatomy and 3 major venous variations

The laparoscopic approach to adrenalectomy is based on the identification of vascular landmarks. We present a typical case of right adrenalectomy using 4 ports: one epigastric port to retract the liver, three subcostal ports to explore and dissect the adrenal fossa. This is a very interesting video in which we disclose vascular anomalies. A very good exposure of the operative field and the absence of bleeding during the procedure contribute to the perfect identification of these anatomical anomalies.

D Mutter, F Costantino, J Marescaux

Surgical intervention

Laparoscopic adrenalectomy: typical vascular anatomy and 3 major venous variations

The laparoscopic approach to adrenalectomy is based on the identification of vascular landmarks. We present a typical case of right adrenalectomy using 4 ports: one epigastric port to retract the liver, three subcostal ports to explore and dissect the adrenal fossa. This is a very interesting video in which we disclose vascular anomalies. A very good exposure of the operative field and the absence of bleeding during the procedure contribute to the perfect identification of these anatomical anomalies.

Laparoscopic approach for symptomatic benign stricture following laparoscopic sigmoid resection

Anastomotic stenosis and fistula after laparoscopic sigmoidectomy are a subject of interest in the literature. Most series reporting results on these complications are heterogeneous. In addition, the selection of patients for treatment vary considerably. The objective of this film is to show a complication, although exceptional, three months after a laparoscopic sigmoidectomy; this complication is a peri-anastomotic stenosis combined with potential rupture of the anastomosis, fistula and peri-anastomotic abscess.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Laparoscopic approach for symptomatic benign stricture following laparoscopic sigmoid resection

Anastomotic stenosis and fistula after laparoscopic sigmoidectomy are a subject of interest in the literature. Most series reporting results on these complications are heterogeneous. In addition, the selection of patients for treatment vary considerably. The objective of this film is to show a complication, although exceptional, three months after a laparoscopic sigmoidectomy; this complication is a peri-anastomotic stenosis combined with potential rupture of the anastomosis, fistula and peri-anastomotic abscess.

Laparoscopic suture of colonic perforation after colonoscopy

In this video, the laparoscopic treatment of a colonic perforation following a colonoscopic screening is presented. The procedure consisted in closure of the perforation accompanied by an omentoplasty.

F Costantino, J Marescaux

Surgical intervention

Laparoscopic suture of colonic perforation after colonoscopy

In this video, the laparoscopic treatment of a colonic perforation following a colonoscopic screening is presented. The procedure consisted in closure of the perforation accompanied by an omentoplasty.

Management of a splenic hemorrhage during mobilization of the left colon

Bleeding-related complications during the mobilization of the splenic flexure via a laparoscopic approach during left colon and rectum surgery are rare. This video shows how to manage a bleeding due to a decapsulation of the inferior pole of the spleen.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Management of a splenic hemorrhage during mobilization of the left colon

Bleeding-related complications during the mobilization of the splenic flexure via a laparoscopic approach during left colon and rectum surgery are rare. This video shows how to manage a bleeding due to a decapsulation of the inferior pole of the spleen.

Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient

Rectal prolapse is an uncommon disease mainly seen in patients of advanced age.
In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.

J Leroy, D Mutter, F Costantino, J Marescaux

Surgical intervention

Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient

Rectal prolapse is an uncommon disease mainly seen in patients of advanced age.
In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.

Laparoscopic oncologic sigmoidectomy with transanal specimen removal: a step to NOTES or single port procedure

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound-related complications, the number of the trocars and the size of the incisions in order to avoid traumatic specimen extractions at the level of the abdominal wall. This video shows the technical approach to laparoscopic oncologic sigmoidectomy in which the specimen is extracted transanally. This procedure may be considered an alternative approach to conventional minimally invasive sigmoidectomy in patients with disease of the sigmoid or left colon.

J Leroy, F Costantino, P Allemann, J Marescaux

Surgical intervention

Laparoscopic oncologic sigmoidectomy with transanal specimen removal: a step to NOTES or single port procedure

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound-related complications, the number of the trocars and the size of the incisions in order to avoid traumatic specimen extractions at the level of the abdominal wall. This video shows the technical approach to laparoscopic oncologic sigmoidectomy in which the specimen is extracted transanally. This procedure may be considered an alternative approach to conventional minimally invasive sigmoidectomy in patients with disease of the sigmoid or left colon.

Laparoscopic treatment of an incarcerated right femoral hernia in a female patient

Femoral hernia is predominantly a female disorder. Incarcerated femoral hernia is a common surgical emergency condition. Diagnosis is always obvious and straightforward by clinical examination, and open surgical repair was the mainstay of treatment. In the era of minimally invasive surgery, laparoscopic repair of femoral hernia has been shown to be feasible and safe. This video shows the laparoscopic trans-abdominal preperitoneal repair of a right femoral hernia in a female patient who has had an appendectomy and who presented to emergencies with pain in the right inguinal region associated with nausea and vomiting. This procedure was performed by a skilled surgeon fellow telementored by Prof. Leroy, a world-renowned expert in laparoscopic hernia repair surgery.

F Costantino, J Leroy, J Marescaux

Surgical intervention

Laparoscopic treatment of an incarcerated right femoral hernia in a female patient

Femoral hernia is predominantly a female disorder. Incarcerated femoral hernia is a common surgical emergency condition. Diagnosis is always obvious and straightforward by clinical examination, and open surgical repair was the mainstay of treatment. In the era of minimally invasive surgery, laparoscopic repair of femoral hernia has been shown to be feasible and safe. This video shows the laparoscopic trans-abdominal preperitoneal repair of a right femoral hernia in a female patient who has had an appendectomy and who presented to emergencies with pain in the right inguinal region associated with nausea and vomiting. This procedure was performed by a skilled surgeon fellow telementored by Prof. Leroy, a world-renowned expert in laparoscopic hernia repair surgery.

Stepwise approach for laparoscopic reversal of Hartmann's procedure

Restoration of intestinal continuity following reversal of Hartmann's procedure is an operation associated with a lengthy hospital stay, protracted convalescence, and a high morbidity rate. The advantages of minimally invasive surgery such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity are very useful in this procedure. Furthermore, laparoscopic reversal of Hartmann's has a comparable operative time with the open technique when performed by experienced surgeons like in this case. This interesting video shows each step of the procedure clearly. Three ports are used and the colon is divided intra-abdominally.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Stepwise approach for laparoscopic reversal of Hartmann's procedure

Restoration of intestinal continuity following reversal of Hartmann's procedure is an operation associated with a lengthy hospital stay, protracted convalescence, and a high morbidity rate. The advantages of minimally invasive surgery such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity are very useful in this procedure. Furthermore, laparoscopic reversal of Hartmann's has a comparable operative time with the open technique when performed by experienced surgeons like in this case. This interesting video shows each step of the procedure clearly. Three ports are used and the colon is divided intra-abdominally.

Laparoscopic Roux-en-Y gastric bypass after vertical banded gastroplasty

Patients who have undergone bariatric surgery and present with upper abdominal symptoms pose a diagnostic and management challenge.
Laparoscopic vertical banded gastroplasty (VBG) is associated with high revisional rates. In the case of failed VBG, repeat VBG seems to be a poor option and conversion to gastric bypass yields better results.
This is the case of a 35-year-old female patient who underwent a vertical banded gastroplasty by laparotomy 8 years ago and presents with dysphagia. A gastroscopy and a contrast swallow exam using radio-opaque markers do not show any fistulas, but peroperative surgical exploration discovers a gastro-gastric fistula. This video clearly shows all the technical aspects of a revisional bariatric procedure.

M Vix, F Costantino, J Marescaux

Surgical intervention

Laparoscopic Roux-en-Y gastric bypass after vertical banded gastroplasty

Patients who have undergone bariatric surgery and present with upper abdominal symptoms pose a diagnostic and management challenge.
Laparoscopic vertical banded gastroplasty (VBG) is associated with high revisional rates. In the case of failed VBG, repeat VBG seems to be a poor option and conversion to gastric bypass yields better results.
This is the case of a 35-year-old female patient who underwent a vertical banded gastroplasty by laparotomy 8 years ago and presents with dysphagia. A gastroscopy and a contrast swallow exam using radio-opaque markers do not show any fistulas, but peroperative surgical exploration discovers a gastro-gastric fistula. This video clearly shows all the technical aspects of a revisional bariatric procedure.

Benefits of laparoscopy in the management of malfunctioning peritoneal dialysis catheters: 3 clinical cases

Laparoscopic techniques for placement of peritoneal dialysis catheters are becoming increasingly popular. There may be several problems related to the functioning of peritoneal dialysis catheters. This is a report of three cases illustrating the diagnostic and often therapeutic interest of laparoscopy in patients presenting with peritoneal dialysis catheter malfunction. Case one shows laparoscopic treatment for pleural leakage, case two catheter malposition due to inflammatory and hemorrhagic adhesions with the omentum and case three a total encapsulation of the dialysis catheter by fibrin.

D Mutter, F Costantino, J D'Agostino, J Marescaux

Surgical intervention

Benefits of laparoscopy in the management of malfunctioning peritoneal dialysis catheters: 3 clinical cases

Laparoscopic techniques for placement of peritoneal dialysis catheters are becoming increasingly popular. There may be several problems related to the functioning of peritoneal dialysis catheters. This is a report of three cases illustrating the diagnostic and often therapeutic interest of laparoscopy in patients presenting with peritoneal dialysis catheter malfunction. Case one shows laparoscopic treatment for pleural leakage, case two catheter malposition due to inflammatory and hemorrhagic adhesions with the omentum and case three a total encapsulation of the dialysis catheter by fibrin.

Stepwise approach for laparoscopic treatment of retrocaecal appendicitis

The vermiform appendix has no constant position and the data on the variations in its position are limited. This video shows a stepwise approach to explore the abdominal cavity and correctly offer the treatment of a retrocaecal appendicitis.

F Costantino, J Marescaux

Surgical intervention

Stepwise approach for laparoscopic treatment of retrocaecal appendicitis

The vermiform appendix has no constant position and the data on the variations in its position are limited. This video shows a stepwise approach to explore the abdominal cavity and correctly offer the treatment of a retrocaecal appendicitis.

TME for rectal cancer: laparoscopic dissection of the Holy Plane using 3-directional (3D) retraction

This video shows how to perform laparoscopic dissection of the presacral space following the principle of 3-directional retraction as described in open surgery by Bill Heald. Monopolar cautery scissors are used. This video is very suitable for surgeons interested in rectal surgery.

J Leroy, F Costantino, J Marescaux

Surgical intervention

TME for rectal cancer: laparoscopic dissection of the Holy Plane using 3-directional (3D) retraction

This video shows how to perform laparoscopic dissection of the presacral space following the principle of 3-directional retraction as described in open surgery by Bill Heald. Monopolar cautery scissors are used. This video is very suitable for surgeons interested in rectal surgery.

Laparoscopic left colectomy for cancer in a male patient after failure of endoscopic approach

Laparoscopic colon resection is a complex endeavour since it involves a good knowledge of the anatomy, surgical skills and many times a wide specimen extraction.
This video demonstrates the technique of laparoscopic left colectomy for treatment of malignant tumor with takedown of the splenic flexure using a laparoscopic approach.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Laparoscopic left colectomy for cancer in a male patient after failure of endoscopic approach

Laparoscopic colon resection is a complex endeavour since it involves a good knowledge of the anatomy, surgical skills and many times a wide specimen extraction.
This video demonstrates the technique of laparoscopic left colectomy for treatment of malignant tumor with takedown of the splenic flexure using a laparoscopic approach.

Laparoscopic treatment of disseminated appendicular peritonitis

This video shows the case of a laparoscopic appendicectomy in a male patient with disseminated peritonitis.

F Costantino, J Marescaux

Surgical intervention

Laparoscopic treatment of disseminated appendicular peritonitis

This video shows the case of a laparoscopic appendicectomy in a male patient with disseminated peritonitis.

Retroperitoneal left pelvic migrated Kirschner pin 10 years after thoracic osteosynthesis

This video shows the case of a patient with a past medical history of a significant kyphoscoliosis, that was treated in 1999 with a surgical fixation. Nine years later, during a control exam a Kirschner pin was found in the retroperitoneum. A detailed description is made of the dissection and extraction of the foreign body localized retroperitoneally.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Retroperitoneal left pelvic migrated Kirschner pin 10 years after thoracic osteosynthesis

This video shows the case of a patient with a past medical history of a significant kyphoscoliosis, that was treated in 1999 with a surgical fixation. Nine years later, during a control exam a Kirschner pin was found in the retroperitoneum. A detailed description is made of the dissection and extraction of the foreign body localized retroperitoneally.

Laparoscopic small bowel resection for Meckel's diverticulitis

This video shows a case of laparoscopic segmental intestinal resection for Meckel's diverticulitis.

F Costantino, E Triki, J Marescaux

Surgical intervention

Laparoscopic small bowel resection for Meckel's diverticulitis

This video shows a case of laparoscopic segmental intestinal resection for Meckel's diverticulitis.

Laparoscopic ileocaecal resection for mucinous cystadenoma of the appendix

This video demonstrates a laparoscopic limited ileocecal resection for a large mucinous cystadenoma of the appendix.

J Leroy, F Costantino, J Marescaux

Surgical intervention

Laparoscopic ileocaecal resection for mucinous cystadenoma of the appendix

This video demonstrates a laparoscopic limited ileocecal resection for a large mucinous cystadenoma of the appendix.

Laparoscopic total colectomy with partial proctectomy

This video demonstrates the performance of a total colectomy performed laparoscopically that included resection of the cephalad portion of the rectum.
This approach involves resection of the proximal portion of the rectum. The authors divide the ileum near the ileocecal junction. With the ureter identified and secured, they move to dissect anterior to the fascia. The duodenum comes into view, then progressively the colon and attachments are freed. After they complete freeing the right colon, they move to the patient’s left side to carry out a left colectomy.

J Leroy, J Marescaux, F Costantino

Surgical intervention

Laparoscopic total colectomy with partial proctectomy

This video demonstrates the performance of a total colectomy performed laparoscopically that included resection of the cephalad portion of the rectum.
This approach involves resection of the proximal portion of the rectum. The authors divide the ileum near the ileocecal junction. With the ureter identified and secured, they move to dissect anterior to the fascia. The duodenum comes into view, then progressively the colon and attachments are freed. After they complete freeing the right colon, they move to the patient’s left side to carry out a left colectomy.

Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique

This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.

F Costantino, M Vix, J Marescaux

Surgical intervention

Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique

This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.

Laparoscopic treatment of acute small bowel obstruction: multiple cases of laparoscopic adhesiolysis

The video shows the laparoscopic management of three separate cases of acute small bowel obstruction secondary to adhesions. The difficulties and advantages of such an approach in this emergency scenario are discussed.
The author begins by inserting a trocar in the umbilicus. Upon exploration of the abdominal cavity, intestinal obstruction becomes clearly evident from the presence of dilated loops and flattened, collapsed loops. The author follows the collapsed loops until the transition zone is identified. The adhesions appear between the greater omentum and the mesentery. This band is divided. Further exploration leads to the finding of a second adhesion. This area shows no signs of occlusion. The author divides this adhesion. Exploration of the remainder of the small bowel continues to rule out further adhesions.

F Costantino, J Marescaux

Surgical intervention

Laparoscopic treatment of acute small bowel obstruction: multiple cases of laparoscopic adhesiolysis

The video shows the laparoscopic management of three separate cases of acute small bowel obstruction secondary to adhesions. The difficulties and advantages of such an approach in this emergency scenario are discussed.
The author begins by inserting a trocar in the umbilicus. Upon exploration of the abdominal cavity, intestinal obstruction becomes clearly evident from the presence of dilated loops and flattened, collapsed loops. The author follows the collapsed loops until the transition zone is identified. The adhesions appear between the greater omentum and the mesentery. This band is divided. Further exploration leads to the finding of a second adhesion. This area shows no signs of occlusion. The author divides this adhesion. Exploration of the remainder of the small bowel continues to rule out further adhesions.

Three trocar technique for laparoscopic left colectomy for cancer: difficult mobilization of the splenic flexure in an obese patient

This video demonstrates a three trocar technique for mobilization and resection of the left colon for malignancy despite some considerable technical difficulty due to the patient’s body habitus. It concentrates in most detail on how to obtain the exposure necessary for radical oncology resection using this technique.

C Huscher, F Costantino

Surgical intervention

Three trocar technique for laparoscopic left colectomy for cancer: difficult mobilization of the splenic flexure in an obese patient

This video demonstrates a three trocar technique for mobilization and resection of the left colon for malignancy despite some considerable technical difficulty due to the patient’s body habitus. It concentrates in most detail on how to obtain the exposure necessary for radical oncology resection using this technique.

Acute abdominal pain in a young female patient with endometrial cyst and acute appendicitis

This video is one of a series of laparoscopic appendicectomies. Evaluation of the pelvic organs in a female patient should be routinely performed to exclude any gynecological pathology.

F Costantino, J Marescaux

Surgical intervention

Acute abdominal pain in a young female patient with endometrial cyst and acute appendicitis

This video is one of a series of laparoscopic appendicectomies. Evaluation of the pelvic organs in a female patient should be routinely performed to exclude any gynecological pathology.

Benefit of laparoscopic approach in an appendicular purulent peritonitis

This video is one of a series of laparoscopic appendicectomies and shows the advantage of the videoscopic approach in accessing the entire peritoneal cavity in cases of diffuse peritonitis.
Blood tests revealed an inflammatory syndrome in a young woman with a 3-day history of diffuse abdominal pain and fever. Exploration of the abdominal cavity during emergency laparoscopy confirmed the clinical impressions. The authors performed aspiration and lavage of the peritoneal cavity. Thorough assessment revealed the omentum to be concentrated in the right iliac fossa, and gentle dissection uncovered a necrotic, perforated appendix. Dissection of the cecum and appendix was difficult because the tissues were friable and adherent. The usual tissue planes were not present, but the laparoscopic view allowed for a safe approach.

F Costantino, J Marescaux

Surgical intervention

Benefit of laparoscopic approach in an appendicular purulent peritonitis

This video is one of a series of laparoscopic appendicectomies and shows the advantage of the videoscopic approach in accessing the entire peritoneal cavity in cases of diffuse peritonitis.
Blood tests revealed an inflammatory syndrome in a young woman with a 3-day history of diffuse abdominal pain and fever. Exploration of the abdominal cavity during emergency laparoscopy confirmed the clinical impressions. The authors performed aspiration and lavage of the peritoneal cavity. Thorough assessment revealed the omentum to be concentrated in the right iliac fossa, and gentle dissection uncovered a necrotic, perforated appendix. Dissection of the cecum and appendix was difficult because the tissues were friable and adherent. The usual tissue planes were not present, but the laparoscopic view allowed for a safe approach.