Monthly publications

Since M. Gagner published the first case of a transperitoneal laparoscopic adrenalectomy in 1992, the laparoscopic adrenalectomy has gradually become the standard operation for removing adrenal tumors. Compared to a traditional adrenalectomy, a laparoscopic adrenalectomy has a number of advantages, including less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. There are many ways to approach the adrenal gland laparoscopically, such as by a lateral transperitoneal approach, anterior transperitoneal approach, lateral retroperitoneal approach, and posterior retroperitoneal approach. This video shows a posterior left adrenalectomy using virtual reality simulation.

This video shows a fully laparoscopic right colectomy with intracorporeal anastomosis for a caecal cancer in an obese female patient with a BMI higher than 34.

In this lecture, Dr. Whiteford demonstrates the different laparoscopic approaches for right laparoscopic colectomy focusing on the top down approach.

The video "Paraesophageal hernia (PEH) in a 40-year-old patient: laparoscopic repair with reinforced cruroplasty", authored by B Dallemagne, J Marescaux, is analyzed by Dr. Nathaniel Soper, MD, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Transanal endoscopic microsurgery (TEM) provides direct endoscopic access to the rectum and peritoneal cavity. In this lecture, Dr. Sylla presents the evolution of the TEM approach from the first reports to the present-day application of laparoscopic and NOTES approaches.

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.

The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and in porcine survival models. In this lecture, Dr. Sylla presents the application of this technique in humans.

Anterior resection with total mesorectal excision (TME) has become the gold standard for the treatment of rectal cancer. In this lecture, Dr. Whiteford presents some interesting data from the literature and from important trials showing no substantial difference with the open approach.

Schwannoma occurrences in the retroperitoneal space are very rare. The procedure involves complete removal of the schwannoma. A hemorrhage is a serious intraoperative problem in cases where major vessels are situated nearby. We present a case of retroperitoneal benign schwannoma compressing the inferior vena cava (IVC) and the left renal vein (LRV) that was successfully resected using laparoscopy.

Traumatic injuries of the diaphragm are rare (0.8%-5.8% of all blunt trauma). Early diagnosis is difficult, and many reports have described delayed presentation of diaphragmatic hernia with subsequent significant morbidity and mortality.

We report a case of an acute diaphragmatic hernia in a 47-year-old male presenting 4 years after the traumatic episode (significant fall from a ladder). The patient was admitted to the emergency department with severe vomiting and dehydration. Once the patient was stabilised with fluid resuscitation and nasogastric tube aspiration, an urgent CT-scan was performed. This demonstrated a large defect within the left hemi-diaphragm, associated with herniation of both the antrum and body of the stomach, into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with herniation and rotation of the stomach was confirmed. The hernia was reduced laparoscopically, and the defect repaired with interrupted, non-absorbable polyester sutures (Ethibond 2/0, Ethicon) and a composite mesh (Proceed™, Ethicon). The patient made an uneventful recovery.
Emergency repair of the diaphragm is usually performed via a thoracotomy or/and laparotomy. In our experience, if the patient is haemodynamically stable and major organ injuries have been excluded, a laparoscopic approach can be considered safe and effective.

This video presents the case of a 29-year-old female patient presenting with abdominal pain at the epigastrium. CT-scan and magnetic resonance imaging demonstrated a septated cystic lesion at the tail of the pancreas. This lesion is about 5cm in diameter. It is incarcerated in the hilum of the spleen. Echo-endoscopy confirmed the cystic nature of the lesion and fine-needle aspiration showed mucinous fluid with a clearly pathological CEA evocative of a mucinous cystic lesion. A laparoscopic distal splenopancreatectomy is demonstrated.

This video features a 62-year-old diabetic male patient who is not undergoing any treatment. He has sufferont from vague upper abdominal pain for one month. He has a past history of acute upper abdominal pain which was managed conservatively.
Abdominal ultrasonography demonstrates cholelithiasis with signs of chronic cholecystitis. Blood examination reveals hyperglycemia with normal liver function tests.
After controlling the hyperglycemic status, the patient is subjected to a laparoscopic cholecystectomy. There is evidence of gallbladder perforation, as the gallbladder is sealed off by the omentum. The gallbladder presents a large amount of calculi which are visible through the thin wall of the gallbladder, and some calculi almost protruding out through the wall.
The laparoscopic cholecystectomy is performed successfully with caution not to soil the peritoneum.

Laparoscopy may be suggested to manage total nephrectomy in specific cases of Wilms’ tumor in children.
Minimal access surgery in pediatric oncology should remain extremely prudent. Some tumors can readily be treated laparoscopically since there is no risk of seeding. On the contrary, in case of seeding, the prognosis would be endangered during surgery for Wilms’ tumor.
Consequently, the decision as to whether or not choose laparoscopy should absolutely be discussed.
Indications for laparoscopic nephrectomy involve tumors treated according to the SIOP treatment guidelines, including primary chemotherapy.
Laparoscopy is mostly decided upon in the presence of a stage I tumor, more rarely in the presence of a stage II tumor without distant metastasis and without tumor thrombus of the renal vein and/or of the vena cava.
Patients with a bilateral tumor are excluded from such therapeutic strategy. Therefore, they will be offered an open nephron-sparing surgery.
Contraindications to laparoscopy include massive post-chemotherapy residual tumor sizes and tumors located proximal to the hilum, since the risk of injuring the tumor during the primary vascular dissection is high.

We present the case of a 28-year-old woman with primary infertility and severe pelvic pain. MRI shows an endometriotic nodule at the level of the torus uterinus that affects the left ureter extrinsically and that is attached to the anterior wall of the rectosigmoid junction. Double-J catheters are correctly placed. Rectovaginal exam reveals an endometriotic nodule under the uterine cervix. This video demonstrates how important surgical strategy is to perform this challenging surgery safely.

We present the case of a 25-year-old nulligravida woman with a history of severe pelvic pain, and pelvic surgery during which her left uterosacral ligament was partially resected. Pain recurred progressively after the surgery. MRI shows no specific alterations, apart from a retroverted uterus. A bimanual vaginal exam was consistent with a retroflexed uterus and a small hard and painful zone in the posterior cul-de-sac. This video demonstrates how to perform this surgery routinely and safely.

Endoscopic submucosal dissection is an endoscopic procedure that is widely performed for many gastrointestinal lesions. Dr. Yahagi presents a detailed lecture on this subject.

Endoscopic mucosal resection (EMR) has become the standard of care for removal of flat and sessile neoplastic lesions of the GI tract. Recently, endoscopic submucosal dissection (ESD) has been introduced in Japan as an alternative technique allowing for an en bloc resection of large lesions. The applications of EMR, ESD and surgery are discussed in this lecture by Dr. Yahagi.

This video shows the case of a 56-year-old man with a T2N2M1 sigmoid cancer managed under radiochemotherapy referred for bowel obstruction without gas and without faeces for four days, with a dilated abdomen. An abdominal CT-scan confirmed the colonic obstruction caused by an obstructing lesion at the rectosigmoid junction, 18cm away from the anal verge. An endoscopic colonic stenting is demonstrated.

In this lecture, Dr. Van Loveren discusses many different cases of FTOZ.

In this lecture, Dr. Van Loveren discusses the treatment strategy for petroclival meningiomas.

This lecture reviews the endoscopic anatomy of the skull base beginning at the frontal, ethmoid, and sphenoid sinuses and extending across the sella and down the clivus to the foramen magnum. The anatomy of the area is reviewed from both above and below with a focus on the endoscopic anatomy of the transnasal approaches to the anterior fossa, sella, clivus, cavernous sinus, and medial part of the CP angle.

In this lecture, Dr. Regli discusses the different techniques for bypass surgery.

This lecture reviews the microsurgical anatomy of the craniocervical junction and foramen magnum with a focus on the following surgical approaches: far lateral approach and its transcondylar, supracondylar, and paracondylar modifications. It also reviews the extreme lateral approach and the anatomy of the cranial junction as viewed through the transnasal endoscopic approach.

This lecture reviews the anatomy of the temporal bone including the microsurgical anatomy of the approaches directed through the middle fossa including the middle fossa approach to the internal acoustic meatus and the anterior petrosectomy approaches; the retrosigmoid approach to the CP angle and the internal acoustic meatus; and the lateral approaches directed through the mastoid including the retrolabyrinthine, translabyrinthine, and transcochlear approaches including the combined supra-infratentorial presigmoid variants of these approaches.

The ulnocarpal conflict is not a rare condition and should be taken into account in the event of ulnocarpal pain. The conflict is created by too narrow a space of the ulnar head and the ulnar edge of the lunate and the triquetrum. During loading and ulnar deviation of the wrist, a direct contact between these bones is produced. This leads to degenerative changes on the cartilage and produces pain. The origin may be a congenital positive ulnar situation, or a trauma impairing the natural leveling of the forearm bones. We distinguish a fresh traumatic condition (ulnar impaction syndrome) from a chronic condition (ulnar impingement syndrome). The midcarpal bones may also suffer from a similar condition, which is the hamate tip syndrome.
Diagnosis is made by clinical examination including the ulnocarpal stress test, standard X-rays, MRI enhanced with endovenous contrast and subsequent wrist arthroscopy.

Therapeutic options include the ulnar shortening osteotomy and the resection of the distal head of the ulna. Decision can be made depending on the state of the TFCC, the age of the patient and the collateral changes in the wrist. If the lesion occurs in young patients without any concomitant lesion, a shortening osteotomy is more often chosen.

In all other conditions, the less invasive choice for the minimal resection of the distal ulnar head is made by arthroscopic and open surgery. The camera is introduced through the 3-4 portal and the burr through the 6R portal. At the beginning, a 3.5 burr —in more trained hands a 4.2 burr— is used to resect about 2-3 mm of the distal ulnar head during supination and pronation movements. Care is taken not to resect the foveal area or the DRUJ.

After the operation, a comfort splint can be adapted for 3-4 days, and immediate physiotherapy is initiated.

In this key lecture, Dr. Caroline Leclercq goes over the complications of wrist arthroscopy with an extensive survey of 10,107 cases.

Intrinsic (and extrinsic) lesions of the wrist ligaments are common, and their treatment is still controversial. Indeed, conventional open surgery sutures often allow the lesions to stabilize, but may cause stiffness, most often preventing a return to previous physical activities, particularly in athletic patients. The advent of arthroscopy has deeply changed the understanding and the treatment of such lesions. This video presents a severe chronic double lesion of the triangular and scapholunate ligaments, as well as a demonstration of how to suture them using arthroscopic techniques.

Both the dorsal and the volar portion of the scapholunate interosseous ligaments are the major stabilizers of the scapholunate joint. Most conventional methods to restore scapholunate stability do not address the volar constraints and frequently fail to reduce the SL gapping. Wrist arthroscopy allows for a complete evaluation of the SL interval, accompanying ligament status and associated SLAC wrist changes. It enables simultaneous reconstruction of the dorsal and palmar scapholunate ligaments anatomically with the use of the palmaris longus tendon as a tendon graft in a box-like structure.

With the assistance of arthroscopy, a combined limited dorsal and volar incision can expose the dorsal and palmar scapholunate interval, where bone tunnels can be made by a cannulated drill under image control on the proximal scaphoid and lunate. The palmaris longus tendon graft is then used to reduce and connect the two bones in a box-like fashion. Once joint diastasis has been reduced and DISI malrotation has been corrected, the tendon graft can be knotted under maximal tension on the dorsal surface of the scapholunate joint in a shoe-lacing manner. Correction and control of the DISI deformity can be achieved by placing drill holes at different levels, more proximally over the lunate and distally over the scaphoid to counter-rotate the deformity. Either the scapholunate or the scaphocapitate joint is then transfixed using K-wires for temporary protection of the reconstruction.

From October 2002 to June 2009, the treatment method was applied in 8 patients suffering from chronic SL instability with an average duration of 7.4 months (3-9 months). There were 6 male and 2 female patients. The average age for this group was 45.4 years (34-60 years). Six of the injured wrists were right wrist injuries. There were two Geissler grade 3 and six grade 4 instability cases. The average pre-operative SL interval was 4.7mm (3-9mm). Concomitant procedures were performed in 4 patients. The average follow-up was 34.9 months (10-66 months).

Symptoms in all patients —except in one— either improved or completely disappeared. The functional wrist score improved from 23.1 to 34.4 on a 40-point scale. Pain score decreased from 12 to 4.4 on a 20-point scale. There was no pain in 5 patients and exertion pain in 3. The injured/uninjured grip power ratio improved from 73.9% to 89%. The average SL interval at final follow-up was 3.6mm (2-7mm). An ischemic change of the proximal scaphoid was noted in one case without symptoms or progression. There were no major complications. All patients —except one— were satisfied with the procedure and the treatment outcome.

Scapholunate ligament injuries remain serious. It is a challenge for all surgeons to treat them. There are two options: either the scapholunate space is stabilized but the wrist is stiff, or the mobility is kept, but the stabilization of the space may sometimes be defective. This paper presents an overview of past and current techniques, lessons learned, and how we apply this knowledge. Thanks to wrist arthroscopy and to EWAS members, we have made a step forward in the understanding of lesions and achieved a proper way to stabilize the scapholunate space. Consequently arthroscopic treatment seems highly promising.

Caroline Leclercq submits a particularly difficult clinical case to a group of international experts in wrist surgery. This is the case of a 17-year-old girl who presented with midcarpal instability secondary to the treatment of a fractured scaphoid, with intact scapholunate ligament. The experts' feedback demonstrate how intricate this kind of situation can be.

The objective of this presentation is not to perform an exhaustive review of the surgical treatment of scaphoid fractures but to try to justify our choice to systematically associate an arthroscopic control in with a percutaneous fixation using a cannulated screw in all non- or minimally displaced scaphoid fractures. Scaphoid fractures are frequent but present unique challenges because of the particular geometry of the bone and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures may lead to non-unions that can progress to carpal collapse and degenerative arthritis of the wrist.
Improvements in diagnosis, surgical treatment and implant materials have encouraged a trend towards early internal fixation even for non-displaced scaphoid fractures that could potentially be treated non-operatively. In our experience, wrist arthroscopy is a useful tool in the management of these fractures not only to assess the quality of reduction but also not to overlook severe carpal ligament injuries, which would be untreated and may lead to chronic and symptomatic carpal instability.

The interest of wrist arthroscopy for the treatment of intra-articular fractures of the distal radius has been demonstrated in the literature for several years. This surgical technique requires specific instrumentation,
like a tower traction, small size optics and small tools. Once the stabilization of the wrist has been performed (using K-wires or plates), an arthroscopic control allows to appreciate the reduction of the fracture, and to diagnose and treat ligamentous injuries. Reduction of the fracture is
sometimes not sufficient and can be carried out under arthroscopic control using K-wires as a joystick. This surgical technique needs a learning curve to be able to treat difficult articular fractures of the distal radius. Using arthroscopy, the follow-up of operated articular fractures of the distal radius is easier for the surgeon and the patient.