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Monthly publications

Whether you are looking for a surgical procedure or a contribution, WebSurg provides you an easy-to-use archiving system which will allow you to find all the videos posted since the website was launched.

Current issue   28 media

Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
L Taglietti, G Baronio, L Lussardi, R Cazzaniga, S Dester, A Zanoletti
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
S Macina, L Baldari, E Cassinotti, M Ballabio, A Spota, M de Francesco, L Boni
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