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This video shows a ureteroureteroplasty in a 37-year-old female patient with ureteral stricture at the level of the crossing iliac vessels due to several previous endoscopic manipulations for the treatment of ureteral/kidney stones.
The ureteroureteroplasty technique was chosen since the proximal and distal parts of the ureter near the stenosed area were healthy.
At the end of the video, preoperative MRI and 1-year follow-up CT urogram 3D reconstructions are placed side by side, demonstrating the resolution of hydronephrosis.
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.
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.
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.
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.