Monthly publications : April 2012 | WebSurg, the online university of IRCAD

Laparoscopic rectal promontopexy for prolapse in a 15-year-old boy

Surgical indications for total rectal prolapse in children are rare. Surgery is decided upon after full clinical work-up, including a sweat test to rule out the possibility of cystic fibrosis, a malformation work-up of the caudal region as well as a medullary MRI.
This video demonstrates the laparoscopic rectal promontopexy for prolapse in a 15-year-old boy.

F Becmeur, C Gomes Ferreira

Surgical intervention

Laparoscopic rectal promontopexy for prolapse in a 15-year-old boy

Surgical indications for total rectal prolapse in children are rare. Surgery is decided upon after full clinical work-up, including a sweat test to rule out the possibility of cystic fibrosis, a malformation work-up of the caudal region as well as a medullary MRI.
This video demonstrates the laparoscopic rectal promontopexy for prolapse in a 15-year-old boy.

Technical aspects of the dissection of the anterior parametrium

The parametrium is defined by the tissues that surround the uterine artery between the uterine corpus and the pelvic sidewall cranial to the ureter.
It has two portions, the medial portion corresponding to the vesicouterine ligament, and the lateral portion corresponding to the lateral ligament of the bladder.
It is a very complex area and its dissection is commonly performed in laparoscopic radical hysterectomy. It requires a perfect knowledge of the specific anatomy as this site is a known risk area for major complications such as bleeding and functional disorders.
Concerning functional disorders of bladder, rectum and genital organs, three main sites should be identified in order to avoid damaging the nerves: the external leaf of the uterosacral ligament (inferior hypogastric plexus), the inferior third of the parametrium (pelvic splanchnic root nerves), and the posterior leaf of the lateral ligament of the bladder.

Technical aspects of the dissection of the anterior parametrium

The parametrium is defined by the tissues that surround the uterine artery between the uterine corpus and the pelvic sidewall cranial to the ureter.
It has two portions, the medial portion corresponding to the vesicouterine ligament, and the lateral portion corresponding to the lateral ligament of the bladder.
It is a very complex area and its dissection is commonly performed in laparoscopic radical hysterectomy. It requires a perfect knowledge of the specific anatomy as this site is a known risk area for major complications such as bleeding and functional disorders.
Concerning functional disorders of bladder, rectum and genital organs, three main sites should be identified in order to avoid damaging the nerves: the external leaf of the uterosacral ligament (inferior hypogastric plexus), the inferior third of the parametrium (pelvic splanchnic root nerves), and the posterior leaf of the lateral ligament of the bladder.

Radical excision or bowel resection for deep endometriosis

In this key lecture, the author focuses on bowel endometriosis. This disease is often multifocal and there are 8% of resection margins which are not free despite segmental resection. Although bowel resection is widely performed, indications are poorly documented regarding nodule size or localization. Segmental resection at the level of the rectum is associated with bowel, bladder, and sexual complications as found in other conditions (such as cancer). The author insists on the need to first perform a discoid resection except if the size of the lesion takes up more than 50% of the wall area and exceeds 2-3cm. For this procedure, it is recommended that the operation be carried out by pelvic surgeons with perfect expertise in endometriosis.

Radical excision or bowel resection for deep endometriosis

In this key lecture, the author focuses on bowel endometriosis. This disease is often multifocal and there are 8% of resection margins which are not free despite segmental resection. Although bowel resection is widely performed, indications are poorly documented regarding nodule size or localization. Segmental resection at the level of the rectum is associated with bowel, bladder, and sexual complications as found in other conditions (such as cancer). The author insists on the need to first perform a discoid resection except if the size of the lesion takes up more than 50% of the wall area and exceeds 2-3cm. For this procedure, it is recommended that the operation be carried out by pelvic surgeons with perfect expertise in endometriosis.

Robotic right tumorectomy for schwannoma mimicking adrenal tumor

This video presents the case of a patient presenting with a 7cm tumor that was diagnosed as a non-secreting adrenal tumor. An adrenalectomy was proposed after the CT-scan analysis. A robotic approach was performed. It allowed for the resection of a tumor located between the kidney and the adrenal gland. The adrenal gland was preserved. Pathological findings helped to evidence a schwannoma.

D Mutter, M Vix, L Soler, J Marescaux

Surgical intervention

Robotic right tumorectomy for schwannoma mimicking adrenal tumor

This video presents the case of a patient presenting with a 7cm tumor that was diagnosed as a non-secreting adrenal tumor. An adrenalectomy was proposed after the CT-scan analysis. A robotic approach was performed. It allowed for the resection of a tumor located between the kidney and the adrenal gland. The adrenal gland was preserved. Pathological findings helped to evidence a schwannoma.

Gasless transaxillary robotic thyroidectomy

Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.

Gasless transaxillary robotic thyroidectomy

Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.

Spacelift robotic thyroidectomy

The influence of minimally invasive options has led to the application of new evolving techniques in thyroid surgery to eliminate visible neck scars. In this lecture, Dr. Piccoli presents her first experience with robotic thyroidectomy.

Spacelift robotic thyroidectomy

The influence of minimally invasive options has led to the application of new evolving techniques in thyroid surgery to eliminate visible neck scars. In this lecture, Dr. Piccoli presents her first experience with robotic thyroidectomy.

Hand-assisted vs. laparoscopic colectomy: when and how?

Laparoscopic colectomy has significant patient benefits but is technically challenging. Hand-assisted laparoscopic surgery (HALS) allows for tactile feedback because the surgeon's hand assists in retraction and dissection. This may decrease the technical difficulty. In this lecture, Dr. Whelan presents the different aspects of the two procedures.

Hand-assisted vs. laparoscopic colectomy: when and how?

Laparoscopic colectomy has significant patient benefits but is technically challenging. Hand-assisted laparoscopic surgery (HALS) allows for tactile feedback because the surgeon's hand assists in retraction and dissection. This may decrease the technical difficulty. In this lecture, Dr. Whelan presents the different aspects of the two procedures.

Single port colorectal surgery: the Cleveland Clinic experience

The first single port colorectal procedure was described in 2008. It is feasible but only in selected cases. In this lecture, Dr. Costedio presents the Cleveland Clinic experience.

Single port colorectal surgery: the Cleveland Clinic experience

The first single port colorectal procedure was described in 2008. It is feasible but only in selected cases. In this lecture, Dr. Costedio presents the Cleveland Clinic experience.

Bariatric surgery: results

Obesity is a major risk factor for many diseases and is associated with significant morbidity and mortality. It has reached an epidemic proportion in the Western society. Bariatric surgery is currently the only modality that provides a significant and sustained weight loss for the patient who is morbidly obese. In this lecture, Dr. Michel Vix presents the current results of the different procedures performed worldwide.

M Vix

Bariatric surgery: results

Obesity is a major risk factor for many diseases and is associated with significant morbidity and mortality. It has reached an epidemic proportion in the Western society. Bariatric surgery is currently the only modality that provides a significant and sustained weight loss for the patient who is morbidly obese. In this lecture, Dr. Michel Vix presents the current results of the different procedures performed worldwide.

Which bariatric procedure for which patient?

This lecture presents a discussion between bariatric surgery experts held during a laparoscopic obesity surgery course at the IRCAD, moderated by Dr. Michele Diana. A real-time quiz-based presentation of 4 challenging virtual cases, each one presenting very specific characteristics, assessed the variability among the attending audience concerning the best possible surgical procedure for each case. In case of considerable divergence of opinion within the audience, the results were more deeply discussed.

M Diana

Which bariatric procedure for which patient?

This lecture presents a discussion between bariatric surgery experts held during a laparoscopic obesity surgery course at the IRCAD, moderated by Dr. Michele Diana. A real-time quiz-based presentation of 4 challenging virtual cases, each one presenting very specific characteristics, assessed the variability among the attending audience concerning the best possible surgical procedure for each case. In case of considerable divergence of opinion within the audience, the results were more deeply discussed.

Rapid Tissue Ablation with a Small Diameter –

19 Fr. Intrauterine BIGATTI Shaver (IBS®) with HYSTEROMAT E.A.S.I.®

Rapid Tissue Ablation with a Small Diameter –

19 Fr. Intrauterine BIGATTI Shaver (IBS®) with HYSTEROMAT E.A.S.I.®

instrument

Hand-sewn retrogastric retrocolic gastric bypass

Nowadays, the Roux-en-Y gastric bypass has become a gold standard in bariatric surgery. In this procedure, the stomach is divided into a small gastric pouch and a Y-shaped section of the intestine is then fashioned and joined to the gastric pouch. A jejunojejunal anastomosis allows for a restoration of the duodenal continuity. This video demonstrates several technical options for these two anastomoses. Dr. Higa has an outstanding experience in the field and has subsequently been able to ergonomically improve every operative step, which is being shown in detail in the video. Authoritative interaction of the expert with the operating room staff is ideal to promote clear and stepwise explanations throughout the procedure. Antecolic or retrocolic approaches, the necessity to look for a hiatal hernia as well as which type of gastrojejunal anastomosis is required are being discussed. This intervention allows for a true teaching lesson in the field of morbid obesity surgery.

KD Higa, M Vix, J Marescaux

Surgical intervention

Hand-sewn retrogastric retrocolic gastric bypass

Nowadays, the Roux-en-Y gastric bypass has become a gold standard in bariatric surgery. In this procedure, the stomach is divided into a small gastric pouch and a Y-shaped section of the intestine is then fashioned and joined to the gastric pouch. A jejunojejunal anastomosis allows for a restoration of the duodenal continuity. This video demonstrates several technical options for these two anastomoses. Dr. Higa has an outstanding experience in the field and has subsequently been able to ergonomically improve every operative step, which is being shown in detail in the video. Authoritative interaction of the expert with the operating room staff is ideal to promote clear and stepwise explanations throughout the procedure. Antecolic or retrocolic approaches, the necessity to look for a hiatal hernia as well as which type of gastrojejunal anastomosis is required are being discussed. This intervention allows for a true teaching lesson in the field of morbid obesity surgery.

Laparoscopic partial gastrectomy for stromal tumor

In this video, a young woman presenting with abdominal pain was investigated. The diagnosis of an 8cm GIST tumor was established through imaging studies and endoscopic biopsy. A laparoscopic partial gastrectomy was carried out preserving the antrum. The resection involved 3 staplers and allowed to keep a 2cm safety margin. The postoperative course was uneventful. Pathological findings confirmed a high-grade GIST tumor.

D Mutter, L Soler, J Marescaux

Surgical intervention

Laparoscopic partial gastrectomy for stromal tumor

In this video, a young woman presenting with abdominal pain was investigated. The diagnosis of an 8cm GIST tumor was established through imaging studies and endoscopic biopsy. A laparoscopic partial gastrectomy was carried out preserving the antrum. The resection involved 3 staplers and allowed to keep a 2cm safety margin. The postoperative course was uneventful. Pathological findings confirmed a high-grade GIST tumor.

Management of left hepatic artery injury during laparoscopic redo sleeve gastrectomy

The video entitled "Management of left hepatic artery injury during laparoscopic redo sleeve gastrectomy", authored by M Vix and J Marescaux, is analyzed by Dr. Jacques Himpens, MD, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

J Himpens

Surgical intervention

Management of left hepatic artery injury during laparoscopic redo sleeve gastrectomy

The video entitled "Management of left hepatic artery injury during laparoscopic redo sleeve gastrectomy", authored by M Vix and J Marescaux, is analyzed by Dr. Jacques Himpens, MD, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Laparoscopic enucleation of a solitary insulinoma located in the isthmus of the pancreas

The majority of insulinomas are benign, solitary, and are located within the pancreatic parenchyma. Because of the characteristic clinical presentation of hypoglycemia, they are usually diagnosed when they are still small (

B Dallemagne, J D'Agostino, L Marx, J Marescaux

Surgical intervention

Laparoscopic enucleation of a solitary insulinoma located in the isthmus of the pancreas

The majority of insulinomas are benign, solitary, and are located within the pancreatic parenchyma. Because of the characteristic clinical presentation of hypoglycemia, they are usually diagnosed when they are still small (

Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure

This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.

B Dallemagne, S Perretta, Gf Donatelli, J Marescaux

Surgical intervention

Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure

This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.

Appendicular mucocele: laparoscopic management

Appendicular mucocele is a rare, yet typical tumor of the appendix. Its potentially malignant nature, the risk of pseudomyxoma peritonei (PMP) in case of rupture mandates a surgical resection without damage. In this case, diagnosis was suspected during colonoscopy performed because of right iliac fossa pain. The exam revealed an appendicular protrusion. CT-scan demonstrated the presence of an appendicular mucocele. A laparoscopic approach was decided upon. Parietal adhesions were identified. A primary vascular approach is then carried out. Once the ileocolic division has been achieved, a medial approach allows to complete the dissection within the wall keeping away from the lesion. Following the complete specimen resection, an ileocolic anastomosis is performed laparoscopically. At the end of the intervention, a small bowel exploration helps to identify a Meckel’s diverticulum that will be resected.

M Vix, D Mutter, J Leroy, J Marescaux

Surgical intervention

Appendicular mucocele: laparoscopic management

Appendicular mucocele is a rare, yet typical tumor of the appendix. Its potentially malignant nature, the risk of pseudomyxoma peritonei (PMP) in case of rupture mandates a surgical resection without damage. In this case, diagnosis was suspected during colonoscopy performed because of right iliac fossa pain. The exam revealed an appendicular protrusion. CT-scan demonstrated the presence of an appendicular mucocele. A laparoscopic approach was decided upon. Parietal adhesions were identified. A primary vascular approach is then carried out. Once the ileocolic division has been achieved, a medial approach allows to complete the dissection within the wall keeping away from the lesion. Following the complete specimen resection, an ileocolic anastomosis is performed laparoscopically. At the end of the intervention, a small bowel exploration helps to identify a Meckel’s diverticulum that will be resected.

Sentinel node technique in uterine cancers

Standard full pelvic lymph node dissection is a simple operation but with potential complications, such as lymphedema, which can be very disturbing for the patient. Additionally, even full pelvic dissection may miss the so-called “ectopic nodes”. Moreover, if a large number of nodes are sent for pathological exam, the pathologist is unable to perform serial sections and immunohistochemistry (IHC) to all nodes. For that reason, the pathologist could well miss positive nodes.
On the other hand, the sentinel node technique is able to detect the nodes that are not included in standard pelvic node dissection. It is also able to diagnose micro-metastasis on serial sections.
This technique, which is performed laparoscopically, uses blue dye combined with radio-isotopic identification and mapping, potentially associated with planar lymphoscintigraphy and SPECT-CT. In this way, it is possible to also detect “hot” nodes that are not colored by blue dye. The injection is performed in each quadrant of the cervix, approximately 2mm deep in the stroma.
In the near future, the sentinel node will probably have become the only one to be removed in early cervical cancer as well as in low and intermediate risk endometrial cancer.

Sentinel node technique in uterine cancers

Standard full pelvic lymph node dissection is a simple operation but with potential complications, such as lymphedema, which can be very disturbing for the patient. Additionally, even full pelvic dissection may miss the so-called “ectopic nodes”. Moreover, if a large number of nodes are sent for pathological exam, the pathologist is unable to perform serial sections and immunohistochemistry (IHC) to all nodes. For that reason, the pathologist could well miss positive nodes.
On the other hand, the sentinel node technique is able to detect the nodes that are not included in standard pelvic node dissection. It is also able to diagnose micro-metastasis on serial sections.
This technique, which is performed laparoscopically, uses blue dye combined with radio-isotopic identification and mapping, potentially associated with planar lymphoscintigraphy and SPECT-CT. In this way, it is possible to also detect “hot” nodes that are not colored by blue dye. The injection is performed in each quadrant of the cervix, approximately 2mm deep in the stroma.
In the near future, the sentinel node will probably have become the only one to be removed in early cervical cancer as well as in low and intermediate risk endometrial cancer.

Breast endoscopic single-site surgery for nipple-sparing mastectomy in oncological patient

Minimally invasive breast surgery has recently been proposed although the optimal technique still has not been determined. We report for the first time the new technique of video-assisted nipple-sparing mastectomy (V-NSM) performed through an axillary single port access with gas flow for breast cancer. The technique was named BESS: breast endoscopic single site surgery. A 3cm skin incision in the axilla was used for all surgical procedures. If indicated, axillary operative steps (sentinel lymph node biopsy, full dissection) were performed under direct vision as well as the preparation of the breast tail. A single port device that can hold up to 3 instruments was then inserted into the axillary incision. Trocars were used for the placement of a 30-degree, 5mm scope and 2 operative instruments. The use of carbon dioxide gas flow allowed for an optimal operative field to easily separate the mammary gland from the superficial skin layer along the stretched Cooper’s ligaments, by using Ultracision 5-plus during the whole endoscopic time.

A Ferrari, A Sgarella, S Zonta, P Dionigi

Surgical intervention

Breast endoscopic single-site surgery for nipple-sparing mastectomy in oncological patient

Minimally invasive breast surgery has recently been proposed although the optimal technique still has not been determined. We report for the first time the new technique of video-assisted nipple-sparing mastectomy (V-NSM) performed through an axillary single port access with gas flow for breast cancer. The technique was named BESS: breast endoscopic single site surgery. A 3cm skin incision in the axilla was used for all surgical procedures. If indicated, axillary operative steps (sentinel lymph node biopsy, full dissection) were performed under direct vision as well as the preparation of the breast tail. A single port device that can hold up to 3 instruments was then inserted into the axillary incision. Trocars were used for the placement of a 30-degree, 5mm scope and 2 operative instruments. The use of carbon dioxide gas flow allowed for an optimal operative field to easily separate the mammary gland from the superficial skin layer along the stretched Cooper’s ligaments, by using Ultracision 5-plus during the whole endoscopic time.

Laparoscopic repair of vesicocervical fistula post Laparoscopic Supracervical Hysterectomy (LSH)

Two weeks after a Laparoscopic Supracervical Hysterectomy (LSH), the patient presented a fistula between the bladder and the cervical canal. The surgery consists of defining the fistula, closing the fistula and extirpating the cervix. The patient had a Foley catheter for 4 weeks. No leakage was observed with a 6-month follow-up. The video shows the laparoscopic approach for the management of this rare complication.

A Langebrekke, J Kisic-Tropé

Surgical intervention

Laparoscopic repair of vesicocervical fistula post Laparoscopic Supracervical Hysterectomy (LSH)

Two weeks after a Laparoscopic Supracervical Hysterectomy (LSH), the patient presented a fistula between the bladder and the cervical canal. The surgery consists of defining the fistula, closing the fistula and extirpating the cervix. The patient had a Foley catheter for 4 weeks. No leakage was observed with a 6-month follow-up. The video shows the laparoscopic approach for the management of this rare complication.

Robotic-assisted right partial nephrectomy with multiple arterial clamping

Robotic-assisted partial nephrectomy (RAPN) has become increasingly important in the field of minimally invasive surgery of the kidney and the prostate. This technique presents many advantages and helps with the exposure of all anatomical details (vessels included). It allows surgeons to make a very easy and precise dissection of the hilum, and provides an excellent view of renal masses. This allows to precisely cut off masses and differentiate them from normal renal parenchyma. The use of the robot is time-saving and allows for an easy exposure, suture, and closure of the kidney.

T Piéchaud, VE Corona Montes

Surgical intervention

Robotic-assisted right partial nephrectomy with multiple arterial clamping

Robotic-assisted partial nephrectomy (RAPN) has become increasingly important in the field of minimally invasive surgery of the kidney and the prostate. This technique presents many advantages and helps with the exposure of all anatomical details (vessels included). It allows surgeons to make a very easy and precise dissection of the hilum, and provides an excellent view of renal masses. This allows to precisely cut off masses and differentiate them from normal renal parenchyma. The use of the robot is time-saving and allows for an easy exposure, suture, and closure of the kidney.

VERSAONE™ BLADELESS TROCAR

Instrument

Endoscopic removal of migrated plastic biliary stent

Biliary plastic stenting is routinely used by pancreatobiliary endoscopists to manage bile duct pathologies. Proximal or distal migration of plastic biliary stents is uncommon and occurs in about 5 to 7% of patients. Different techniques have been described to manage these complications under endo-fluoroscopy control: balloon counter traction, snaring, rat-tooth forceps, cholangioscopy, among other techniques. The endoscopic management of this complication is technically challenging. This video demonstrates the management of a proximal migrated plastic stent using an extraction catheter balloon.

Gf Donatelli, L Marx, J Marescaux

Surgical intervention

Endoscopic removal of migrated plastic biliary stent

Biliary plastic stenting is routinely used by pancreatobiliary endoscopists to manage bile duct pathologies. Proximal or distal migration of plastic biliary stents is uncommon and occurs in about 5 to 7% of patients. Different techniques have been described to manage these complications under endo-fluoroscopy control: balloon counter traction, snaring, rat-tooth forceps, cholangioscopy, among other techniques. The endoscopic management of this complication is technically challenging. This video demonstrates the management of a proximal migrated plastic stent using an extraction catheter balloon.

Indication of skull base approach for aneurysm surgery, the zygomatic tubercle

In this key lecture, Professor Khaled Aziz, MD, PhD, focuses on the indication of the skull base approach for aneurysm surgery, the zygomatic tubercle.

KM Aziz

Indication of skull base approach for aneurysm surgery, the zygomatic tubercle

In this key lecture, Professor Khaled Aziz, MD, PhD, focuses on the indication of the skull base approach for aneurysm surgery, the zygomatic tubercle.

The central skull base: neuro-anatomical perspectives and surgical considerations

In this key lecture, Professor Jeffrey Thomas Keller, MD, PhD, presents the central skull base, its neuro-anatomical perspectives and surgical considerations.

The central skull base: neuro-anatomical perspectives and surgical considerations

In this key lecture, Professor Jeffrey Thomas Keller, MD, PhD, presents the central skull base, its neuro-anatomical perspectives and surgical considerations.

Minimally invasive transpalpebral eyelid approach to the anterior cranial base: 65 cases

In this key lecture, Professor Khaled Aziz, MD, PhD, focuses on the minimally invasive transpalpebral eyelid approach to the anterior cranial base, with a review of 65 cases.

KM Aziz

Minimally invasive transpalpebral eyelid approach to the anterior cranial base: 65 cases

In this key lecture, Professor Khaled Aziz, MD, PhD, focuses on the minimally invasive transpalpebral eyelid approach to the anterior cranial base, with a review of 65 cases.

Lateral suboccipital retrosigmoid approach

In this key lecture, Professor Khaled Aziz, MD, PhD, presents the lateral suboccipital retrosigmoid approach.

KM Aziz

Lateral suboccipital retrosigmoid approach

In this key lecture, Professor Khaled Aziz, MD, PhD, presents the lateral suboccipital retrosigmoid approach.

Drilling of the internal auditory canal in acoustic neuroma surgery by retrosigmoid approach

In this key lecture, Dr. Arnaud Bazin presents the drilling of the internal auditory canal in acoustic neuroma surgery using a retrosigmoid approach.

A Bazin

Drilling of the internal auditory canal in acoustic neuroma surgery by retrosigmoid approach

In this key lecture, Dr. Arnaud Bazin presents the drilling of the internal auditory canal in acoustic neuroma surgery using a retrosigmoid approach.

Arthroscopic four bone fusion

In this key lecture, Dr. Cohen focuses on arthroscopic four bone fusion.

G Cohen

Arthroscopic four bone fusion

In this key lecture, Dr. Cohen focuses on arthroscopic four bone fusion.

Technique of arthroscopic-assisted foveal repair for TFCC 1B lesion

Three classes of TFCC peripheral 1B tears are recognized in a treatment-orientated algorithm based on arthroscopic findings. Distal tear (class 1), associated with minimal instability of the DRUJ, requires ligament to capsule suture. Complete (class 2) and proximal tears (class 3) are associated with major DRUJ instability and require foveal re-attachment of the TFCC. A new arthroscopic-assisted technique to repair the foveal attachment of the TFCC by using a suture anchor is described. It is indicated for class 2 and 3 TFCC peripheral tears, instead of an open repair. The technique requires a dedicated working portal called Direct Foveal (DF) to approach the ulnar fovea. This DF portal is used to prepare the ligament and bone and to drill and insert a suture anchor loaded with a pair of sutures. Under arthroscopic vision, a suture is passed through each limb of the ligament and tied using a small knot-pusher or a simple mosquito forceps. This arthroscopic technique restores original TFCC anatomy and adequate DRUJ stability with less morbidity and easier rehabilitation as compared to open repair.

R Luchetti, A Atzei

Surgical intervention

Technique of arthroscopic-assisted foveal repair for TFCC 1B lesion

Three classes of TFCC peripheral 1B tears are recognized in a treatment-orientated algorithm based on arthroscopic findings. Distal tear (class 1), associated with minimal instability of the DRUJ, requires ligament to capsule suture. Complete (class 2) and proximal tears (class 3) are associated with major DRUJ instability and require foveal re-attachment of the TFCC. A new arthroscopic-assisted technique to repair the foveal attachment of the TFCC by using a suture anchor is described. It is indicated for class 2 and 3 TFCC peripheral tears, instead of an open repair. The technique requires a dedicated working portal called Direct Foveal (DF) to approach the ulnar fovea. This DF portal is used to prepare the ligament and bone and to drill and insert a suture anchor loaded with a pair of sutures. Under arthroscopic vision, a suture is passed through each limb of the ligament and tied using a small knot-pusher or a simple mosquito forceps. This arthroscopic technique restores original TFCC anatomy and adequate DRUJ stability with less morbidity and easier rehabilitation as compared to open repair.

Management of scapholunate tears: open versus arthroscopic treatment

The understanding of scapholunate ligament lesions has made great strides in recent years, largely thanks to the work undertaken by the two wrist surgery "heavyweights" who are Dr. Marc Garcia-Elias and Dr. Christophe Mathoulin.
Although they do not use the same approach to treat scapholunate ligament lesions (Marc Garcia-Elias opens the wrist and Christopher Mathoulin tries to process them arthroscopically), they have both reached the same conclusion:
- the scapholunate ligament is more than just an interosseous ligament but rather a real scapholunate ligament complex with intrinsic and extrinsic components;
- proprioception is involved in the stability of scapholunate space;
- and early diagnosis and treatment seem essential to obtain good results.
This peer-to-peer conversation between these two friends is not a battle, but rather an extremely modern development on a long debated topic... have fun!
Moderator: Riccardo Luchetti, MD

M Garcia-Elias, C Mathoulin, R Luchetti

Management of scapholunate tears: open versus arthroscopic treatment

The understanding of scapholunate ligament lesions has made great strides in recent years, largely thanks to the work undertaken by the two wrist surgery "heavyweights" who are Dr. Marc Garcia-Elias and Dr. Christophe Mathoulin.
Although they do not use the same approach to treat scapholunate ligament lesions (Marc Garcia-Elias opens the wrist and Christopher Mathoulin tries to process them arthroscopically), they have both reached the same conclusion:
- the scapholunate ligament is more than just an interosseous ligament but rather a real scapholunate ligament complex with intrinsic and extrinsic components;
- proprioception is involved in the stability of scapholunate space;
- and early diagnosis and treatment seem essential to obtain good results.
This peer-to-peer conversation between these two friends is not a battle, but rather an extremely modern development on a long debated topic... have fun!
Moderator: Riccardo Luchetti, MD

Distal radius fractures - principles to make complications rare

In this authoritative lecture, Dr. Krimmer focuses on distal radius fractures and looks into the principles to make complications rare.

Distal radius fractures - principles to make complications rare

In this authoritative lecture, Dr. Krimmer focuses on distal radius fractures and looks into the principles to make complications rare.

EndoCAMeleon® Telescope with Variable Direction of View

instrument

Trigger finger thumb

The trigger finger is a common pathology in which the course of the flexor tendon is diminished or stopped because the A1 pulley became too small. The release of the pulley is a classical surgical treatment used when the medical treatment has failed. This video was captured using the VITOM system from KARL STORZ.

C Mathoulin

Surgical intervention

Trigger finger thumb

The trigger finger is a common pathology in which the course of the flexor tendon is diminished or stopped because the A1 pulley became too small. The release of the pulley is a classical surgical treatment used when the medical treatment has failed. This video was captured using the VITOM system from KARL STORZ.

Endoscopic carpal tunnel release (2 portals)

Carpal tunnel syndrome (median nerve entrapment) is one of the most frequent nerve compressions. Endoscopic release is probably a great advance in the way the median nerve is released. This video was captured using the VITOM system from KARL STORZ.

C Mathoulin

Surgical intervention

Endoscopic carpal tunnel release (2 portals)

Carpal tunnel syndrome (median nerve entrapment) is one of the most frequent nerve compressions. Endoscopic release is probably a great advance in the way the median nerve is released. This video was captured using the VITOM system from KARL STORZ.

Reintervention for anastomotic colorectal stenosis after laparoscopic reversal of Hartmann's procedure

The objective of this film is to demonstrate the different steps to resect a stenotic colorectal anastomosis following a Hartmann's reversal procedure and to perform a new anastomosis.
The author outlines tips and tricks that allow for pelvic access which is often the seat of abundant adhesions. In addition, prior to undoing the new anastomosis, it is mandatory to check if it is possible to free the rectal stump. The author also shows the principles of a completely laparoscopic technique.

J Leroy, J Marescaux

Surgical intervention

Reintervention for anastomotic colorectal stenosis after laparoscopic reversal of Hartmann's procedure

The objective of this film is to demonstrate the different steps to resect a stenotic colorectal anastomosis following a Hartmann's reversal procedure and to perform a new anastomosis.
The author outlines tips and tricks that allow for pelvic access which is often the seat of abundant adhesions. In addition, prior to undoing the new anastomosis, it is mandatory to check if it is possible to free the rectal stump. The author also shows the principles of a completely laparoscopic technique.