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Transumbilical single access laparoscopic right adrenalectomy with 1.8mm epigastric trocarless grasping forceps
Background: Single access laparoscopic adrenalectomy has been reported in supine and prone patient positioning. The authors report the technique with the patient in supine position, with the umbilicus as access site, and with all adopted material as reusable.

Video: A 43-year-old woman was admitted to the hospital for symptomatic primary hyperaldosteronism. A right-side adrenal adenoma was diagnosed, and surgery was proposed. The patient was placed in a supine position with a mild semi-lateral left-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope, in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany). The right liver lobe was retracted using the 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz Endoskope), inserted percutaneously under the 12th right rib. The procedure started with the adhesiolysis between the hepatic surface and right Gerota’s fascia. Then, after having identified the adrenal gland, it was dissected and the inferior adrenal arteries and veins were clipped between 5mm Hem-o-lok® clips (Teleflex Medical, Research Triangle Park, NC, US). The middle adrenal vein was clipped as well using the 5mm Hem-o-lok® ligation systems. Once the specimen was completely mobilized, a plastic bag (used for suction drain) was custom-made and introduced into the abdomen through the 11mm trocar. The specimen was removed transumbilically, and the procedure finished with the closure of the access site by absorbable figure of 8 sutures.

Results: Laparoscopic time was 98 minutes, estimated blood loss was 20cc, and the final scar length was 16mm. The patient was discharged from the hospital after 2 days.

Conclusions: Transumbilical single access laparoscopic right adrenalectomy is feasible and safe. With this technique, the cost of the procedure is not increased, the final scar length is minimal, and the working triangulation is established intrabdominally as well as externally.
G Dapri, L Gerard, M Bortes, V Zulian, GB Cadière
Surgical intervention
5 years ago
1854 views
25 likes
0 comments
06:24
Transumbilical single access laparoscopic right adrenalectomy with 1.8mm epigastric trocarless grasping forceps
Background: Single access laparoscopic adrenalectomy has been reported in supine and prone patient positioning. The authors report the technique with the patient in supine position, with the umbilicus as access site, and with all adopted material as reusable.

Video: A 43-year-old woman was admitted to the hospital for symptomatic primary hyperaldosteronism. A right-side adrenal adenoma was diagnosed, and surgery was proposed. The patient was placed in a supine position with a mild semi-lateral left-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope, in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany). The right liver lobe was retracted using the 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz Endoskope), inserted percutaneously under the 12th right rib. The procedure started with the adhesiolysis between the hepatic surface and right Gerota’s fascia. Then, after having identified the adrenal gland, it was dissected and the inferior adrenal arteries and veins were clipped between 5mm Hem-o-lok® clips (Teleflex Medical, Research Triangle Park, NC, US). The middle adrenal vein was clipped as well using the 5mm Hem-o-lok® ligation systems. Once the specimen was completely mobilized, a plastic bag (used for suction drain) was custom-made and introduced into the abdomen through the 11mm trocar. The specimen was removed transumbilically, and the procedure finished with the closure of the access site by absorbable figure of 8 sutures.

Results: Laparoscopic time was 98 minutes, estimated blood loss was 20cc, and the final scar length was 16mm. The patient was discharged from the hospital after 2 days.

Conclusions: Transumbilical single access laparoscopic right adrenalectomy is feasible and safe. With this technique, the cost of the procedure is not increased, the final scar length is minimal, and the working triangulation is established intrabdominally as well as externally.
Laparoscopic resection of gastric gastrointestinal stromal tumours
We demonstrate two minimally invasive approaches for the management of gastric gastrointestinal stromal tumours (GIST). GISTs are the most common mesenchymal neoplasms of the gastroinstestinal tract. About 50% of GISTs are located in the stomach which makes it the most frequent location. GISTs can be totally intraluminal or extraluminal. In this film, we demonstrate two approaches for the removal of gastric GIST, depending upon the site of tumour. The majority of patients are diagnosed incidentally or present with vague symptoms. GISTs can also present with upper gastrointestinal bleeding as in our first case. We demonstrate that laparoscopic GIST resection is safe and effective.
SA Naqi, S Rajendran, M Arumugasamy
Surgical intervention
5 years ago
3518 views
92 likes
0 comments
13:47
Laparoscopic resection of gastric gastrointestinal stromal tumours
We demonstrate two minimally invasive approaches for the management of gastric gastrointestinal stromal tumours (GIST). GISTs are the most common mesenchymal neoplasms of the gastroinstestinal tract. About 50% of GISTs are located in the stomach which makes it the most frequent location. GISTs can be totally intraluminal or extraluminal. In this film, we demonstrate two approaches for the removal of gastric GIST, depending upon the site of tumour. The majority of patients are diagnosed incidentally or present with vague symptoms. GISTs can also present with upper gastrointestinal bleeding as in our first case. We demonstrate that laparoscopic GIST resection is safe and effective.
Peroral endoscopic myotomy of a suspected type III achalasia with a double scope control
A 59-year-old woman was referred to our unit for progressive dysphagia and chest pain associated with heartburn and chest fullness. A nutcracker esophagus was suspected at the HD manometry and the patient was scheduled for a peroral endoscopic myotomy (POEM). The procedure started with an esophagogastroduodenal series (EGDS), which showed abnormal contractions of the distal esophagus and increased resistance at the level of the esophagogastric junction (EGJ) with a high suspicion of type III achalasia. The tunnel was started 12cm above the EGJ in a 5 o’clock position. After submucosal injection, a mucosal incision was made with a new triangle-tip (TT) knife equipped with water jet facility. The access to the submucosa was gained and a submucosal longitudinal tunnel was created until the EGJ, dissecting the submucosal fibers with the TT knife. The myotomy was performed by completely dissecting the circular muscular layer muscle fibers using swift coagulation. To assess the extension of the myotomy just at the level of the EGJ, a “double scope control” was performed by inserting a pediatric scope, which confirmed the presence of the mother scope light in the esophagus. The submucosal tunnel and the myotomy were then extended together for 1 to 2cm. A second check with the pediatric scope showed the presence of the mother scope light in the correct position above the EGJ. The mucosal incision site was finally closed using multiple endoclips.
H Inoue, RA Ciurezu, M Pizzicannella, F Habersetzer
Surgical intervention
1 month ago
236 views
1 like
0 comments
25:51
Peroral endoscopic myotomy of a suspected type III achalasia with a double scope control
A 59-year-old woman was referred to our unit for progressive dysphagia and chest pain associated with heartburn and chest fullness. A nutcracker esophagus was suspected at the HD manometry and the patient was scheduled for a peroral endoscopic myotomy (POEM). The procedure started with an esophagogastroduodenal series (EGDS), which showed abnormal contractions of the distal esophagus and increased resistance at the level of the esophagogastric junction (EGJ) with a high suspicion of type III achalasia. The tunnel was started 12cm above the EGJ in a 5 o’clock position. After submucosal injection, a mucosal incision was made with a new triangle-tip (TT) knife equipped with water jet facility. The access to the submucosa was gained and a submucosal longitudinal tunnel was created until the EGJ, dissecting the submucosal fibers with the TT knife. The myotomy was performed by completely dissecting the circular muscular layer muscle fibers using swift coagulation. To assess the extension of the myotomy just at the level of the EGJ, a “double scope control” was performed by inserting a pediatric scope, which confirmed the presence of the mother scope light in the esophagus. The submucosal tunnel and the myotomy were then extended together for 1 to 2cm. A second check with the pediatric scope showed the presence of the mother scope light in the correct position above the EGJ. The mucosal incision site was finally closed using multiple endoclips.
Pancreatic duplication associated with a gastric duplication cyst: laparoscopic approach
This video shows the case of a 48-year-old male patient with a history of epigastric pain for 20 days, with the presence of nausea and vomiting but no self-reported fever. The patient was presented at the ER for examination. Computerized tomography (CT) scanning revealed a very rare case of pancreatic duplication associated with a gastric duplication cyst. He was referred to our service and then treated by laparoscopic route with partial gastrectomy and pancreatic resection (pancreas horn). On the 2nd postoperative day, the patient was discharged and allowed for free oral feeding. This is the second study in the literature reporting a case of laparoscopic resection of a gastric duplication cyst together with pancreatic resection. Of note, this is the first study in which the accessory pancreas communicates with the pancreatic head.
F Freire Lisboa Junior, R de Lima França, A de Araujo Lima Liguori, AC de Medeiros Junior, M HSMP Tavares, F Medeiros de Azevedo, D Myller Barros Lima
Surgical intervention
4 months ago
1090 views
5 likes
0 comments
14:36
Pancreatic duplication associated with a gastric duplication cyst: laparoscopic approach
This video shows the case of a 48-year-old male patient with a history of epigastric pain for 20 days, with the presence of nausea and vomiting but no self-reported fever. The patient was presented at the ER for examination. Computerized tomography (CT) scanning revealed a very rare case of pancreatic duplication associated with a gastric duplication cyst. He was referred to our service and then treated by laparoscopic route with partial gastrectomy and pancreatic resection (pancreas horn). On the 2nd postoperative day, the patient was discharged and allowed for free oral feeding. This is the second study in the literature reporting a case of laparoscopic resection of a gastric duplication cyst together with pancreatic resection. Of note, this is the first study in which the accessory pancreas communicates with the pancreatic head.
Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
D Lipski, D Garcilazo Arismendi, S Targa
Surgical intervention
1 year ago
3095 views
424 likes
0 comments
07:37
Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
S Qian, P Tejedor, M Leon, M Ortega, C Pastor
Surgical intervention
8 months ago
3783 views
5 likes
0 comments
06:45
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
A stepwise personal technique of RYGB with hand-sewn gastrojejunostomy
With more than 25 years of experience, we have created a unique laparoscopic Roux-en-Y gastric bypass technique with hand-sewn gastrojejunostomy and several additional steps which offer our patients a safe and reliable procedure.
We routinely use 5 bladeless 12mm trocars. The procedure begins with the creation of a 15-20mL gastric pouch with a tilted orientation for the first stapling (not horizontal), and staple lines are oversewn for both gastric pouch and gastric remnant. A blue dye test is always performed at this stage. The second stage of the procedure includes the creation of a 75cm biliopancreatic limb with division of the mesentery and creation of a mechanical jejunojejunostomy with a 100cm alimentary limb, and hand-sewn closure of the enterotomy. Anti-torsion stitches are mandatory at this point. Closure of mesenteric defects (intermesenteric space and Petersen's space) is accomplished with non-absorbable sutures performed in a routine manner. The third and final stage of the procedure involves the creation of the hand-sewn gastrojejunostomy with an interposed limb and 4 layers of absorbable sutures over a 28-30 French bougie.
Closure of all trocar defects is performed in every patient.
L Zorrilla-Nunez, P Zorrilla
Surgical intervention
1 year ago
1400 views
219 likes
0 comments
10:05
A stepwise personal technique of RYGB with hand-sewn gastrojejunostomy
With more than 25 years of experience, we have created a unique laparoscopic Roux-en-Y gastric bypass technique with hand-sewn gastrojejunostomy and several additional steps which offer our patients a safe and reliable procedure.
We routinely use 5 bladeless 12mm trocars. The procedure begins with the creation of a 15-20mL gastric pouch with a tilted orientation for the first stapling (not horizontal), and staple lines are oversewn for both gastric pouch and gastric remnant. A blue dye test is always performed at this stage. The second stage of the procedure includes the creation of a 75cm biliopancreatic limb with division of the mesentery and creation of a mechanical jejunojejunostomy with a 100cm alimentary limb, and hand-sewn closure of the enterotomy. Anti-torsion stitches are mandatory at this point. Closure of mesenteric defects (intermesenteric space and Petersen's space) is accomplished with non-absorbable sutures performed in a routine manner. The third and final stage of the procedure involves the creation of the hand-sewn gastrojejunostomy with an interposed limb and 4 layers of absorbable sutures over a 28-30 French bougie.
Closure of all trocar defects is performed in every patient.
PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.
A Anuwong, M Vix, HS Wu
Surgical intervention
2 years ago
4525 views
315 likes
1 comment
25:34
PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.