We use cookies to offer you an optimal experience on our website. By browsing our website, you accept the use of cookies.

Online university

The largest online video library in minimally invasive surgery.

Educational support

WebSurg is a virtual university created by surgeons for surgeons. It is an extensive source of knowledge in minimally invasive surgery. It is free and accessible to all. WebSurg promotes technological advances in the field of minimally invasive surgery, in all surgical fields, i.e. general and digestive surgery, urology, gynecology, pediatric surgery, endoscopic surgery, skull base surgery, arthroscopy and upper limb surgery. Define your educational objectives and watch the videos which correspond to your specialty.

Contributions

WeBsurg allows you to improve your surgical skills but also to share your knowledge with the largest community of surgeons worldwide. Submit the video of your surgical procedure on our website and become part of our international Faculty.

Surgical intervention
04:41
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
L Marano, A Spaziani, G Castagnoli
35 views
10 days ago
Surgical intervention
11:27
Robotic abdominoperineal resection (APR) with intraperitoneal puborectalis incision
The da Vinci™ surgical robotic system with its increased instrument stability, tridimensional view, and dexterity with 7 degrees of wristed motion offers a distinct surgical advantage over traditional laparoscopic instruments. This advantage is mainly in the deep pelvis where the limited working space and visibility makes distal rectal dissection extremely challenging. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.

An abdominoperineal resection (APR) involves the excision of the rectum with a total mesorectal excision (TME), and excision of the anus with an adequate circumferential resection margin (CRM). In a conventional open or laparoscopic approach, the rectal dissection is performed down to the level of the pelvic floor, after which the perineal approach is used to excise the anus and to cut the pelvic floor muscles circumferentially to allow for ‘en bloc’ tumor removal. However, as the pelvic floor is frequently very deep from the skin surface, dissection is technically challenging due to poor visualization, often leading to blind dissection. As a result, many APR specimens suffer from the problem of “waisting” and a positive CRM at the level of the levator ani muscle. In order to solve this problem, some units practice extralevator APR – however, in those cases, the patient ends up with a large perineal defect which frequently needs to be closed with either mesh or flap reconstruction.
With the da Vinci™ robotic system, this problem can potentially be minimized. The robotic system can be used to access deep into the pelvic cavity and make an incision in the puborectalis sling down to the ischiorectal fat. This incision, once completed, allows for easy access from the perineal approach to enter the pelvic cavity and complete the dissection, preventing any blind dissection and facilitating a CRM-clear specimen to be excised.
This video features a totally robotic approach to an abdominoperineal resection for a poorly differentiated anorectal adenocarcinoma, with intraperitoneal incision of the puborectalis sling to facilitate subsequent perineal dissection and specimen extraction.

Clinical case
A 79-year-old female patient presented with a perianal lump and discomfort. Colonoscopy revealed a 2cm mobile adenomatous polypoid lesion at the anorectal junction. Excision biopsy showed a poorly differentiated adenocarcinoma.

CT-scan of the thorax, abdomen and pelvis did not show any distant metastases, and MRI of the rectum did not show any significant locoregional disease. A robotic abdominoperineal resection was performed.

Patient set-up
The da Vinci™ Si™ robotic system was used, and a dual docking approach was chosen.
The patient was placed in a Lloyd-Davies position. Robotic ports (8mm) were placed in the epigastrium, left flank, suprapubic region, and in the right iliac fossa respectively. A 12mm trocar is inserted into the right flank for assistance and stapling.
Robotic abdominoperineal resection (APR) with intraperitoneal puborectalis incision
SAE Yeo
17 views
10 days ago
Surgical intervention
11:10
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
Background: Minimally invasive surgery (MIS) was shown to offer advantages in general and oncologic surgery (1). Over the last decade, reduced port laparoscopy (RPL) has been introduced to reduce the risks related to ports and abdominal wall trauma, with enhanced cosmetic outcomes (2). In this video, the authors report the case of a 59-year-old man with a small bowel neuroendocrine tumor, and who underwent a three-trocar right ileocolectomy.
Video: Preoperative work-up, including endoscopic ultrasound, octreoscan, PET-scan, and FDG PET-CT, showed a 15mm small bowel tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the third portion of the duodenum. The biopsy revealed a low-grade well-differentiated neuroendocrine tumor. The procedure was performed using three abdominal trocars: a 12mm one in the umbilicus, a 5mm one in the right flank, and a 5mm port in the left flank (Figure 1). Abdominal cavity exploration demonstrated the presence of a tumor located in the mesentery of the last small bowel loop, with consequent bowel retraction, dislocation of the caecum and appendix, located under the right lobe of the liver, and tumoral extension into the proximal transverse mesocolon. After mobilization of the right colon from laterally to medially, the second and third duodenal segments were exposed, showing tumor extension towards the anterior duodenal wall of these segments. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape (Figure 2), an endoscopic linear stapler was inserted through the umbilical trocar under the visual guidance of a 5mm scope in the left flank (Figure 3a), and it was fired (Figure 3b). The specimen was removed through a suprapubic access. Perioperative frozen section biopsy showed a free duodenal margin, and the procedure was subsequently completed with an ileocolic anastomosis, performed in a side-to-side handsewn intracorporeal fashion. At the end, the mesocolic defect was closed.

Results: Operative time was 4 hours. No added trocars were necessary. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Pathological findings showed a grade I well-differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration (1/20 metastatic nodes, free margins, stage: pT3N1 (8 UICC edition). A follow-up under somatostatin therapy was put forward.

Conclusions: RPL is a feasible option when performing advanced oncological surgery. Patients benefit from all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
G Dapri
887 views
1 month ago
View more  Contribute now