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Monthly publications

#March 2014
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Single port laparoscopic-assisted ileocolic resection for recurrent Crohn's disease
Background: Here we demonstrate a single port laparoscopic ileocolic resection technique in a patient with Crohn’s disease and recurrent anastomotic stricturing despite prior ileocaecal resection and medication.
Procedure: The procedure is begun with a 3cm transumbilical incision. After safe peritoneal entry, a wound protector-retractor was placed into the wound and then sealed for laparoscopy with a surgical glove port. Thereafter, the operation proceeded using a 30-degree high definition laparoscope with sterile in-line cabling (EndoEYE™, Olympus Corporation) along with other standard, rigid instrumentation (primarily an atraumatic grasper and a LigaSure™ sealer-cutter, Covidien). The strictured anastomotic segment was cleared of an omental adhesion and mobilized laterally. The proximal colon was fully mobilized and the duodenum as well as right gonadal vessels and ureter were clearly preserved. After medialization of the diseased segment, the glove port was removed and the specimen extracted (without further fascial extension) via the single port access site. A side-to-side stapled anastomosis was performed in the usual fashion and re-laparoscopy done after return of the bowel into the peritoneum.
Comment: Single port laparoscopic-assisted surgery is applicable to the re-operative setting in selected patients. Its advantages particularly apply to young patients who value body image and reduced scarring.
F Narouz, R Cahill
Surgical intervention
4 years ago
2257 views
44 likes
0 comments
12:34
Single port laparoscopic-assisted ileocolic resection for recurrent Crohn's disease
Background: Here we demonstrate a single port laparoscopic ileocolic resection technique in a patient with Crohn’s disease and recurrent anastomotic stricturing despite prior ileocaecal resection and medication.
Procedure: The procedure is begun with a 3cm transumbilical incision. After safe peritoneal entry, a wound protector-retractor was placed into the wound and then sealed for laparoscopy with a surgical glove port. Thereafter, the operation proceeded using a 30-degree high definition laparoscope with sterile in-line cabling (EndoEYE™, Olympus Corporation) along with other standard, rigid instrumentation (primarily an atraumatic grasper and a LigaSure™ sealer-cutter, Covidien). The strictured anastomotic segment was cleared of an omental adhesion and mobilized laterally. The proximal colon was fully mobilized and the duodenum as well as right gonadal vessels and ureter were clearly preserved. After medialization of the diseased segment, the glove port was removed and the specimen extracted (without further fascial extension) via the single port access site. A side-to-side stapled anastomosis was performed in the usual fashion and re-laparoscopy done after return of the bowel into the peritoneum.
Comment: Single port laparoscopic-assisted surgery is applicable to the re-operative setting in selected patients. Its advantages particularly apply to young patients who value body image and reduced scarring.
Tubal surgery - neosalpingostomy
The functionality of the uterine (Fallopian) tube depends on the patency of the tubal lumen and on the integrity of the tubal mucosa. The tubal mucosa consists of 3 to 5 major folds and several minor folds with secondary folds on the top. Ciliated cells cover the folds. The tubal transport of gametes and embryos is a result of the ciliary beating activity and of the contractility of the tube through its muscular structure. The tubal mucosa is fragile and is very sensitive to infections such as Chlamydia, gonorrhea. In the most severe cases, the distal tubal end will be blocked with the formation of a hydrosalpinx.
In case of hydrosalpinx, tubal surgery should always be performed. Depending upon the remaining quality of the tubal mucosa, a decision has to be made favoring either salpingostomy or salpingectomy.
S Gordts
Lecture
4 years ago
1279 views
38 likes
0 comments
18:47
Tubal surgery - neosalpingostomy
The functionality of the uterine (Fallopian) tube depends on the patency of the tubal lumen and on the integrity of the tubal mucosa. The tubal mucosa consists of 3 to 5 major folds and several minor folds with secondary folds on the top. Ciliated cells cover the folds. The tubal transport of gametes and embryos is a result of the ciliary beating activity and of the contractility of the tube through its muscular structure. The tubal mucosa is fragile and is very sensitive to infections such as Chlamydia, gonorrhea. In the most severe cases, the distal tubal end will be blocked with the formation of a hydrosalpinx.
In case of hydrosalpinx, tubal surgery should always be performed. Depending upon the remaining quality of the tubal mucosa, a decision has to be made favoring either salpingostomy or salpingectomy.
Transvaginal laparoscopy: subtle lesions and infertility
Transvaginal laparoscopy is performed as a simple needle puncture technique of the pouch of Douglas in patients without an obvious pelvic pathology. An obliterated pouch of Douglas and acute situations such as bleeding and infections are contraindications. As a distension medium, a watery solution such as Ringer lactate is used. This keeps organs afloat. Without extra manipulation, ovaries and tubes can be inspected in their natural position. In absence of a high intra-abdominal pressure as in standard laparoscopy, subtle lesions are not masked but become clearly visible due to the watery distension medium. The transvaginal approach also provides easy access to perform a salpingoscopy and allows the detection of subtle tubal mucosal lesions. The technique allows early detection of peritoneal and ovarian endometriosis with the possibility of early treatment.
S Gordts
Lecture
4 years ago
743 views
25 likes
0 comments
23:35
Transvaginal laparoscopy: subtle lesions and infertility
Transvaginal laparoscopy is performed as a simple needle puncture technique of the pouch of Douglas in patients without an obvious pelvic pathology. An obliterated pouch of Douglas and acute situations such as bleeding and infections are contraindications. As a distension medium, a watery solution such as Ringer lactate is used. This keeps organs afloat. Without extra manipulation, ovaries and tubes can be inspected in their natural position. In absence of a high intra-abdominal pressure as in standard laparoscopy, subtle lesions are not masked but become clearly visible due to the watery distension medium. The transvaginal approach also provides easy access to perform a salpingoscopy and allows the detection of subtle tubal mucosal lesions. The technique allows early detection of peritoneal and ovarian endometriosis with the possibility of early treatment.
Tubal reversal
In several countries, tubal sterilization is frequently used as a definitive form of anti-conception. However, 2 to 13% of women come to express regret and 1 to 3% will have a reversal. Regret is frequently due to change of partner, dead of infant or for psychological reasons. As for laparotomy and also laparoscopy, tubal reversal should always be performed using the principles of microsurgery and gentle tissue handling.
Depending upon the place of tubal ligation, tubal anastomosis can be isthmo-isthmic, isthmo-ampullary, ampullo-ampullary, ampullo-cornual, and isthmo-cornual.
Mean pregnancy rate after tubal reversal is reported to be between 60 and 85%. Additionally, in patients older than 39, an intrauterine pregnancy rate of 40 to 50% can be achieved.
S Gordts
Lecture
4 years ago
886 views
28 likes
0 comments
17:55
Tubal reversal
In several countries, tubal sterilization is frequently used as a definitive form of anti-conception. However, 2 to 13% of women come to express regret and 1 to 3% will have a reversal. Regret is frequently due to change of partner, dead of infant or for psychological reasons. As for laparotomy and also laparoscopy, tubal reversal should always be performed using the principles of microsurgery and gentle tissue handling.
Depending upon the place of tubal ligation, tubal anastomosis can be isthmo-isthmic, isthmo-ampullary, ampullo-ampullary, ampullo-cornual, and isthmo-cornual.
Mean pregnancy rate after tubal reversal is reported to be between 60 and 85%. Additionally, in patients older than 39, an intrauterine pregnancy rate of 40 to 50% can be achieved.
Hysteroscopic treatment option of hydrosalpinx to improve pregnancy rate
Hydrosalpinges adversely affect fertility and IVF outcomes. The toxic environment affects the endometrium and embryo implantation. Prospective randomized multicentric trials of salpingectomy prior to IVF clearly demonstrate a 2-fold increase in IVF success rates and should be recommended to all women with hydrosalpinges planning IVF. However, salpingectomy impairs regional vascular network, compromising ovarian function and induction of ovulation. In cases with severe pelvic adhesions, this risk and other operative complications increase during salpingectomy or tubal ligation. Micro-insert proximal end occlusion by hysteroscopy is another option to occlude and treat salpingectomy in an office set-up. Seven studies published on the topic have demonstrated generally positive results and success rates of pregnancies comprised between 36% and 64%. Proximal tubal occlusion using micro-inserts seem to be effective, fast, “low risk” in the management of severe forms of hydrosalpinges.
V Tanos
Lecture
4 years ago
903 views
32 likes
0 comments
13:28
Hysteroscopic treatment option of hydrosalpinx to improve pregnancy rate
Hydrosalpinges adversely affect fertility and IVF outcomes. The toxic environment affects the endometrium and embryo implantation. Prospective randomized multicentric trials of salpingectomy prior to IVF clearly demonstrate a 2-fold increase in IVF success rates and should be recommended to all women with hydrosalpinges planning IVF. However, salpingectomy impairs regional vascular network, compromising ovarian function and induction of ovulation. In cases with severe pelvic adhesions, this risk and other operative complications increase during salpingectomy or tubal ligation. Micro-insert proximal end occlusion by hysteroscopy is another option to occlude and treat salpingectomy in an office set-up. Seven studies published on the topic have demonstrated generally positive results and success rates of pregnancies comprised between 36% and 64%. Proximal tubal occlusion using micro-inserts seem to be effective, fast, “low risk” in the management of severe forms of hydrosalpinges.
Hysteroscopic polypectomy
Chronic endometrial inflammation, endometrial erosion and vascular dilatation are usually prominent characteristics in cases with polyp(s). Abnormal bleeding is a frequent symptom due to vascular fragility and surface erosion. Tubocornual polyps interfere with oocyte/embryo transport and implantation. Trials have shown the effectiveness of hysteroscopic polypectomy in enhancing fertility. Using appropriate instruments and techniques, further to a suitable training, hysteroscopic polypectomy can be performed in the office setting without limitations of size, location, histological structure, and number of polyps. The surgical removal of big polyps by shavers and morcellators can reduce learning curve and increase patient safety.
V Tanos
Lecture
4 years ago
1564 views
42 likes
0 comments
12:51
Hysteroscopic polypectomy
Chronic endometrial inflammation, endometrial erosion and vascular dilatation are usually prominent characteristics in cases with polyp(s). Abnormal bleeding is a frequent symptom due to vascular fragility and surface erosion. Tubocornual polyps interfere with oocyte/embryo transport and implantation. Trials have shown the effectiveness of hysteroscopic polypectomy in enhancing fertility. Using appropriate instruments and techniques, further to a suitable training, hysteroscopic polypectomy can be performed in the office setting without limitations of size, location, histological structure, and number of polyps. The surgical removal of big polyps by shavers and morcellators can reduce learning curve and increase patient safety.
Nerve tumor excision with robots
Chronic peripheral nerve lesion surgery should not only limit recurrence after excision, but it could also limit sensory and motor sequelae. The aim of this work was to study the interest of telemicrosurgery to improve this result.
Our series included 7 patients with peripheral nerve neuroma and tumors including two cases of hereditary neurofibromatosis. A da Vinci S® robot with microsurgical instruments was used for intraneural dissection. One case was performed using a minimally invasive approach.
At the last follow-up, pain ranged from 6/10 preoperatively to 3/10 postoperatively. The sensory deficit was stable except in 2 patients whose sensory function was improved. No recurrence was noted.
Telemicrosurgery seems to have two interests in the treatment of chronic peripheral nerve lesions: it reduces the size of incisions and increases surgery accuracy. These preliminary results suggest that surgical robots could play an essential role in microsurgery.
P Liverneaux
Lecture
4 years ago
89 views
1 like
0 comments
10:17
Nerve tumor excision with robots
Chronic peripheral nerve lesion surgery should not only limit recurrence after excision, but it could also limit sensory and motor sequelae. The aim of this work was to study the interest of telemicrosurgery to improve this result.
Our series included 7 patients with peripheral nerve neuroma and tumors including two cases of hereditary neurofibromatosis. A da Vinci S® robot with microsurgical instruments was used for intraneural dissection. One case was performed using a minimally invasive approach.
At the last follow-up, pain ranged from 6/10 preoperatively to 3/10 postoperatively. The sensory deficit was stable except in 2 patients whose sensory function was improved. No recurrence was noted.
Telemicrosurgery seems to have two interests in the treatment of chronic peripheral nerve lesions: it reduces the size of incisions and increases surgery accuracy. These preliminary results suggest that surgical robots could play an essential role in microsurgery.
Robotic technology in wound healing osteomyelitis
Introduction:
We initiated the use of robotic instrumentation in the surgical management of complex, recurrent non-healing wounds due to osteomyelitis in July 2012. The primary objective is to demonstrate the benefit of the visual superiority and more precise tissue dissection offered by robotic technology.

Material and methods:
After obtaining approval for the use of the da Vinci® robotic surgical system (Intuitive Surgical®) as an “exoscopic” approach at our institution, three patients were enrolled in the protocol wound debridement/osteomyelitis/da Vinci®.
We will be presenting the clinical manifestations and imaging diagnosis of osteomyelitis, as well as outlining the surgical procedure and the use of the robotic system for soft tissue and bone debridement. The complimentary application of bioengineering tissue enhancement material was used in one patient (Cryopreserved amniotic membrane Amniox®), and in two patients (Apligraf Organogenesis, Inc). Comprehensive postoperative wound management will be discussed.

Results:
Two patients had completely healed wounds at 130 and 230 days respectively, without functional joint deficit. Although the third patient had only 3 weeks of follow-up, they appear to be progressing as expected.

Conclusions:
The basic capability of robotic technology (visual and manual control) appears to facilitate the surgical management of osteomyelitis, particularly in restricted anatomical spaces and in proximity to joints. We propose further clinical research and outcome healing measurements with this subgroup of patients that might otherwise require amputation.
B Martinez
Lecture
4 years ago
89 views
3 likes
0 comments
09:44
Robotic technology in wound healing osteomyelitis
Introduction:
We initiated the use of robotic instrumentation in the surgical management of complex, recurrent non-healing wounds due to osteomyelitis in July 2012. The primary objective is to demonstrate the benefit of the visual superiority and more precise tissue dissection offered by robotic technology.

Material and methods:
After obtaining approval for the use of the da Vinci® robotic surgical system (Intuitive Surgical®) as an “exoscopic” approach at our institution, three patients were enrolled in the protocol wound debridement/osteomyelitis/da Vinci®.
We will be presenting the clinical manifestations and imaging diagnosis of osteomyelitis, as well as outlining the surgical procedure and the use of the robotic system for soft tissue and bone debridement. The complimentary application of bioengineering tissue enhancement material was used in one patient (Cryopreserved amniotic membrane Amniox®), and in two patients (Apligraf Organogenesis, Inc). Comprehensive postoperative wound management will be discussed.

Results:
Two patients had completely healed wounds at 130 and 230 days respectively, without functional joint deficit. Although the third patient had only 3 weeks of follow-up, they appear to be progressing as expected.

Conclusions:
The basic capability of robotic technology (visual and manual control) appears to facilitate the surgical management of osteomyelitis, particularly in restricted anatomical spaces and in proximity to joints. We propose further clinical research and outcome healing measurements with this subgroup of patients that might otherwise require amputation.
Neurotisation to the axillary nerve by the nerve to the triceps
Nerve transfer to the deltoid muscle using the nerve of the long head of the triceps is a reliable method for deltoid function restoration. The aim of this retrospective study was to report the results of the nerve transfer procedure to the deltoid muscle using the nerve of the long head of the triceps by means of a robot.
Our series included six patients (mean age: 36.3 years) with total deltoid muscle paralysis. A da Vinci S® robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, then robotically sutured with two 10/0 Nylon stitches. In 2 cases, an endoscopic procedure was attempted under carbon dioxide insufflation.
In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No elbow extension weakness was observed. In 2 cases with the endoscopic technique, vision was blurred and conversion to the open technique was performed.
The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremors. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without sensory feedback. The robot-assisted nerve transfer to the deltoid muscle using the nerve of the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury.
H Miyamoto
Lecture
4 years ago
65 views
2 likes
0 comments
07:07
Neurotisation to the axillary nerve by the nerve to the triceps
Nerve transfer to the deltoid muscle using the nerve of the long head of the triceps is a reliable method for deltoid function restoration. The aim of this retrospective study was to report the results of the nerve transfer procedure to the deltoid muscle using the nerve of the long head of the triceps by means of a robot.
Our series included six patients (mean age: 36.3 years) with total deltoid muscle paralysis. A da Vinci S® robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, then robotically sutured with two 10/0 Nylon stitches. In 2 cases, an endoscopic procedure was attempted under carbon dioxide insufflation.
In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No elbow extension weakness was observed. In 2 cases with the endoscopic technique, vision was blurred and conversion to the open technique was performed.
The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremors. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without sensory feedback. The robot-assisted nerve transfer to the deltoid muscle using the nerve of the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury.
Oberlin's procedure for restoration of elbow flexion with a da Vinci® robot
Robotics allow visual magnification up to 40 times, and a 10 time-magnification of the surgeon’s movements, as well as the elimination of physiological tremors. These properties should allow for the development of minimally invasive limb surgery, especially brachial plexus surgery. The purpose of this work was to test the feasibility of elbow flexion restoration according to the technique of Oberlin using a da Vinci® robot. Our series included 4 patients (mean age: 31 years) presenting with elbow flexion paralysis. They were operated on 8 months after injury using a da Vinci S® robot. In three patients, the open technique (technique 1) was used, and the minimally invasive approach (technique 2) was used for the last one. Strength of elbow flexion was measured. After 1 year of follow-up, all patients recovered elbow flexion. No sensory nor motor deficit was found in the ulnar nerve territory. There was no difficulty with technique 1; technique 2, however, required a conversion to technique 1 due to the difficulty in visualizing the operative field. The results of our series show the feasibility of the robot-assisted technique for the Oberlin procedure. The lack of sensory feedback was not an issue. The development of specific retractors and instruments should improve the minimally invasive technique.
K Naito
Lecture
4 years ago
104 views
2 likes
0 comments
07:00
Oberlin's procedure for restoration of elbow flexion with a da Vinci® robot
Robotics allow visual magnification up to 40 times, and a 10 time-magnification of the surgeon’s movements, as well as the elimination of physiological tremors. These properties should allow for the development of minimally invasive limb surgery, especially brachial plexus surgery. The purpose of this work was to test the feasibility of elbow flexion restoration according to the technique of Oberlin using a da Vinci® robot. Our series included 4 patients (mean age: 31 years) presenting with elbow flexion paralysis. They were operated on 8 months after injury using a da Vinci S® robot. In three patients, the open technique (technique 1) was used, and the minimally invasive approach (technique 2) was used for the last one. Strength of elbow flexion was measured. After 1 year of follow-up, all patients recovered elbow flexion. No sensory nor motor deficit was found in the ulnar nerve territory. There was no difficulty with technique 1; technique 2, however, required a conversion to technique 1 due to the difficulty in visualizing the operative field. The results of our series show the feasibility of the robot-assisted technique for the Oberlin procedure. The lack of sensory feedback was not an issue. The development of specific retractors and instruments should improve the minimally invasive technique.
Small vessels endoscopic anastomosis: feasibility study
The size of incisions for free muscle flaps is often very large, and a source of deep adhesions and unesthetic scars but it is justified by performing the microsurgical step comfortably. In the hope of shortening the size of incisions, the objective of this work was to study the feasibility of vascular micro-anastomoses using an endoscopic approach. The material consisted of 2 cadavers, a tele-manipulator, and a vascular clamp. The antebrachial skin was detached, then distended by gas insufflations. Four incisions, one centimeter each, allowed for the set-up of 4 trocars connected to the tele-manipulator. The artery was dissected (radial or ulnar) and the vascular clamp was introduced under the skin through one of the trocars, and then positioned on the dissected artery. The vascular anastomosis was performed with the use of a 10/0 Nylon suture. The anastomosis lasted 2 hours under insufflation with no leaks. The 2 arteries were identified, then dissected without difficulty. The anastomosis was performed in adequate conditions. The mounting and demounting of the clamp were time-consuming. The main difficulties were caused by a long suture and a very fragile needle. Our results demonstrate the feasibility of vascular micro-anastomosis using an endoscopic approach. The next step is to perform the first clinical case (e.g., on a latissimus dorsi free muscle flap).
E Robert
Lecture
4 years ago
136 views
3 likes
0 comments
08:37
Small vessels endoscopic anastomosis: feasibility study
The size of incisions for free muscle flaps is often very large, and a source of deep adhesions and unesthetic scars but it is justified by performing the microsurgical step comfortably. In the hope of shortening the size of incisions, the objective of this work was to study the feasibility of vascular micro-anastomoses using an endoscopic approach. The material consisted of 2 cadavers, a tele-manipulator, and a vascular clamp. The antebrachial skin was detached, then distended by gas insufflations. Four incisions, one centimeter each, allowed for the set-up of 4 trocars connected to the tele-manipulator. The artery was dissected (radial or ulnar) and the vascular clamp was introduced under the skin through one of the trocars, and then positioned on the dissected artery. The vascular anastomosis was performed with the use of a 10/0 Nylon suture. The anastomosis lasted 2 hours under insufflation with no leaks. The 2 arteries were identified, then dissected without difficulty. The anastomosis was performed in adequate conditions. The mounting and demounting of the clamp were time-consuming. The main difficulties were caused by a long suture and a very fragile needle. Our results demonstrate the feasibility of vascular micro-anastomosis using an endoscopic approach. The next step is to perform the first clinical case (e.g., on a latissimus dorsi free muscle flap).