We use cookies to offer you an optimal experience on our website. By browsing our website, you accept the use of cookies.

Monthly publications

#July 2014
Filter by
Clear filter Specialty
View more

Clear filter Media type
View more
Clear filter Category
View more
Laparoscopic resection of extra-adrenal paraganglioma
Introduction
Paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells. These tumors arise from dispersed paraganglia that tend to be symmetrically distributed in close relation to the aorta and to the sympathetic nervous system. Paragangliomas have a higher malignancy potential than adrenal pheochromocytomas.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Laparoscopic resections of such tumors have been described in isolated cases.

Material and methods
We present the case of a 16-year-old female patient who presents with repeated urinary tract infection. An ultrasound demonstrates the presence of a retropancreatic mass. The study was completed by abdominal CT-scan and PET-scan (123-MIBG) where a solid mass of 4.5cm in diameter, homogeneous, encapsulated, without calcifications, located between the third duodenal portion (which is displaced anteriorly) and the inferior vena cava from the level of the right renal vein to the level of the right renal lower pole, is found. The patient presents MIBG (metaiodobenzylguanidine) tracer uptake in the Iodine-123-MIBG scintigraphy, suggesting the diagnosis of adrenal medullary tumor. The hormonal study shows a significant increase in plasmatic normetanephrine (25 times the normal upper limit). A genetic study has found no mutation of the most frequent responsible genes.
Given radiological and hormonal findings, laparoscopic surgery is decided upon with suspected diagnosis of extra-adrenal paraganglioma.

Discussion
In this video, we present a laparoscopic approach to this mass, using an 11mm optical trocar and four 5mm working trocars. As can be appreciated, a very careful dissection is carried out to separate the mass from adjacent structures, dissecting small vessels that drain directly into the inferior vena cava.
Final pathology reports a 5cm retroperitoneal paraganglioma, with vascular invasion. In the immunohistochemical study, cells are positive for Synaptophysin and Chromogranin A. The postoperative course was uneventful, and the patient was discharged on postoperative day 4.
The laparoscopic excision of paraganglioma is safe and feasible, reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
As a general conclusion, it is essential to diagnose, localize, and treat paragangliomas, because of the potential cure of symptoms associated with functional tumors, prevention of a lethal hypertensive paroxysm, and early diagnosis of malignant tumors.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Tumors located between major vessels rarely invade these vessels, but careful and meticulous dissection of the surrounding small vessels is necessary.
The laparoscopic excision of paraganglioma reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
C Rodríguez-Otero Luppi, M Rodríguez Blanco, V Artigas Raventós, M Trías Folch
Surgical intervention
4 years ago
978 views
34 likes
0 comments
12:04
Laparoscopic resection of extra-adrenal paraganglioma
Introduction
Paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells. These tumors arise from dispersed paraganglia that tend to be symmetrically distributed in close relation to the aorta and to the sympathetic nervous system. Paragangliomas have a higher malignancy potential than adrenal pheochromocytomas.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Laparoscopic resections of such tumors have been described in isolated cases.

Material and methods
We present the case of a 16-year-old female patient who presents with repeated urinary tract infection. An ultrasound demonstrates the presence of a retropancreatic mass. The study was completed by abdominal CT-scan and PET-scan (123-MIBG) where a solid mass of 4.5cm in diameter, homogeneous, encapsulated, without calcifications, located between the third duodenal portion (which is displaced anteriorly) and the inferior vena cava from the level of the right renal vein to the level of the right renal lower pole, is found. The patient presents MIBG (metaiodobenzylguanidine) tracer uptake in the Iodine-123-MIBG scintigraphy, suggesting the diagnosis of adrenal medullary tumor. The hormonal study shows a significant increase in plasmatic normetanephrine (25 times the normal upper limit). A genetic study has found no mutation of the most frequent responsible genes.
Given radiological and hormonal findings, laparoscopic surgery is decided upon with suspected diagnosis of extra-adrenal paraganglioma.

Discussion
In this video, we present a laparoscopic approach to this mass, using an 11mm optical trocar and four 5mm working trocars. As can be appreciated, a very careful dissection is carried out to separate the mass from adjacent structures, dissecting small vessels that drain directly into the inferior vena cava.
Final pathology reports a 5cm retroperitoneal paraganglioma, with vascular invasion. In the immunohistochemical study, cells are positive for Synaptophysin and Chromogranin A. The postoperative course was uneventful, and the patient was discharged on postoperative day 4.
The laparoscopic excision of paraganglioma is safe and feasible, reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
As a general conclusion, it is essential to diagnose, localize, and treat paragangliomas, because of the potential cure of symptoms associated with functional tumors, prevention of a lethal hypertensive paroxysm, and early diagnosis of malignant tumors.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Tumors located between major vessels rarely invade these vessels, but careful and meticulous dissection of the surrounding small vessels is necessary.
The laparoscopic excision of paraganglioma reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
Laparoscopic resection and radiofrequency thermal ablation for colorectal liver metastasis
We report a case of laparoscopic hepatic resection combined with radiofrequency thermoablation for colonic liver metastases. A 55-year old female patient underwent a laparoscopic right colectomy for a pT2N0 right colon adenocarcinoma and she presented 18 months after liver metastases. The procedure begins with the exploration of the entire peritoneal cavity and an intraoperative ultrasonography was performed. At the left liver lobe, the lesion situated at the upper part of segment 2 is identified, allowing for the placement of a 3cm radiofrequency needle within the lesion treated for 20 minutes. A clamping of the hepatic pedicle is then performed. An atypical resection of the liver’s 5th segment is decided upon. No drainage was used and the patient was discharged on postoperative day 5. The postoperative CT-scan confirmed the correct thermoablation of the lesion in segment 2 of the liver.
P Pessaux, D Ntourakis, S Varatharajah, D Mutter, J Marescaux
Surgical intervention
4 years ago
2074 views
7 likes
0 comments
06:29
Laparoscopic resection and radiofrequency thermal ablation for colorectal liver metastasis
We report a case of laparoscopic hepatic resection combined with radiofrequency thermoablation for colonic liver metastases. A 55-year old female patient underwent a laparoscopic right colectomy for a pT2N0 right colon adenocarcinoma and she presented 18 months after liver metastases. The procedure begins with the exploration of the entire peritoneal cavity and an intraoperative ultrasonography was performed. At the left liver lobe, the lesion situated at the upper part of segment 2 is identified, allowing for the placement of a 3cm radiofrequency needle within the lesion treated for 20 minutes. A clamping of the hepatic pedicle is then performed. An atypical resection of the liver’s 5th segment is decided upon. No drainage was used and the patient was discharged on postoperative day 5. The postoperative CT-scan confirmed the correct thermoablation of the lesion in segment 2 of the liver.
Subtotal laparoscopic cholecystectomy for Mirizzi syndrome type IA
This video shows a case of Mirizzi syndrome type IA (according to the classification of Csendes and Nagakava). This 36-year-old female patient was admitted for an elective laparoscopic cholecystectomy due to a chronic calculous cholecystitis. Preoperative examination did not reveal any peculiarities. Patient set-up and trocar placement were conventional and unremarkable. During the operation, anatomical abnormalities of Calot’s triangle were observed -- namely common bile duct and other elements of the neck of gallbladder were not differentiated. The common bile duct was firstly adopted as the cystic duct, giving the impression that it falls into the gallbladder. In addition, it was impossible to visualize the proximal part of the common bile duct. After several long attempts at dissection, the cystic duct failed to show. We then opened the lumen of the gallbladder accidentally, which revealed the inner opening of the cystic duct. We used it as a landmark to dissect the stump of the cystic duct. Three Endoclips were applied onto the stump of the duct. The free wall of the gallbladder was excised. The remaining mucosa of the gallbladder was carefully coagulated.
In relation to such changes, the diagnosis of chronic calculous cholecystitis, Mirizzi syndrome type IA was established.
A Sazhin, S Mosin
Surgical intervention
4 years ago
4558 views
127 likes
2 comments
14:44
Subtotal laparoscopic cholecystectomy for Mirizzi syndrome type IA
This video shows a case of Mirizzi syndrome type IA (according to the classification of Csendes and Nagakava). This 36-year-old female patient was admitted for an elective laparoscopic cholecystectomy due to a chronic calculous cholecystitis. Preoperative examination did not reveal any peculiarities. Patient set-up and trocar placement were conventional and unremarkable. During the operation, anatomical abnormalities of Calot’s triangle were observed -- namely common bile duct and other elements of the neck of gallbladder were not differentiated. The common bile duct was firstly adopted as the cystic duct, giving the impression that it falls into the gallbladder. In addition, it was impossible to visualize the proximal part of the common bile duct. After several long attempts at dissection, the cystic duct failed to show. We then opened the lumen of the gallbladder accidentally, which revealed the inner opening of the cystic duct. We used it as a landmark to dissect the stump of the cystic duct. Three Endoclips were applied onto the stump of the duct. The free wall of the gallbladder was excised. The remaining mucosa of the gallbladder was carefully coagulated.
In relation to such changes, the diagnosis of chronic calculous cholecystitis, Mirizzi syndrome type IA was established.
Robot-assisted vasectomy reversal
Robot-assisted surgery developed faster and earlier in urology as compared to other fields of surgery. As some microsurgical procedures are applicable to this field, the evolution towards robot-assisted microsurgery was a logical extension. We started our vasectomy reversal program as early as 2003 and completely left the traditional microscope aside.
Microsurgical techniques must be mastered first. The lack of haptic feedback must then be compensated with the robot by means of optical vision of the tension applied on the thread. In addition, the force applied on the manipulators must be controlled with gentle pressure in order to prevent mashing and cutting of the threads or bending of the needles. The pressure of the jaws of the forceps is less intense at the tip, and only that part of the instrument should be used.
Our results on 19 robot-assisted vasectomy reversal (RAVV) procedures demonstrate a 92% patency rate.
We present two videos. The first video describes a two-plane vasectomy reversal with 11/0 and 10/0 sutures. The second one presents a modified two-plane vasectomy reversal with 10/0 and 9/0 sutures. We use two black diamond micro-forceps and Potts scissors. The use of the fourth arm shortens the procedure, precluding the need to change instruments or the help of an assistant.
Robotic microsurgery offers a better outcome with a more stable operative field, more precise movements without tremor and better ergonomics for the surgeon, hence reducing the operative time.
GA de Boccard
Lecture
4 years ago
169 views
6 likes
0 comments
16:26
Robot-assisted vasectomy reversal
Robot-assisted surgery developed faster and earlier in urology as compared to other fields of surgery. As some microsurgical procedures are applicable to this field, the evolution towards robot-assisted microsurgery was a logical extension. We started our vasectomy reversal program as early as 2003 and completely left the traditional microscope aside.
Microsurgical techniques must be mastered first. The lack of haptic feedback must then be compensated with the robot by means of optical vision of the tension applied on the thread. In addition, the force applied on the manipulators must be controlled with gentle pressure in order to prevent mashing and cutting of the threads or bending of the needles. The pressure of the jaws of the forceps is less intense at the tip, and only that part of the instrument should be used.
Our results on 19 robot-assisted vasectomy reversal (RAVV) procedures demonstrate a 92% patency rate.
We present two videos. The first video describes a two-plane vasectomy reversal with 11/0 and 10/0 sutures. The second one presents a modified two-plane vasectomy reversal with 10/0 and 9/0 sutures. We use two black diamond micro-forceps and Potts scissors. The use of the fourth arm shortens the procedure, precluding the need to change instruments or the help of an assistant.
Robotic microsurgery offers a better outcome with a more stable operative field, more precise movements without tremor and better ergonomics for the surgeon, hence reducing the operative time.
Transoral supraglottic and tongue base surgery: da Vinci® robot versus CO2 laser surgery
Introduction
To date, the gold standard for transoral tongue base and supraglottic surgery is the CO2 laser. The Da Vinci robot has been tested for transoral surgery since 2006. Is the Da Vinci robot an alternative or will it replace the CO2 laser for these surgical procedures?

Methods
The advantages and drawbacks of all approaches (i.e. external approach, transoral approach) with the CO2 laser and the Da Vinci robot are reviewed.

Results
The external approach still has an interest for massive pre-epiglottic space invasion. For small tumors, the CO2 laser presents an advantage as compared to the Da Vinci robot as it causes less thermal damage. For large tumors, the quality of exposure provided by the Da Vinci robot as compared to the scope of the CO2 laser improves quality and makes tumor resection easier.

Conclusion
The Da Vinci robot has been largely developed over these last years and therefore will replace the CO2 laser for some surgical procedures.
P Schultz
Lecture
4 years ago
127 views
5 likes
0 comments
14:18
Transoral supraglottic and tongue base surgery: da Vinci® robot versus CO2 laser surgery
Introduction
To date, the gold standard for transoral tongue base and supraglottic surgery is the CO2 laser. The Da Vinci robot has been tested for transoral surgery since 2006. Is the Da Vinci robot an alternative or will it replace the CO2 laser for these surgical procedures?

Methods
The advantages and drawbacks of all approaches (i.e. external approach, transoral approach) with the CO2 laser and the Da Vinci robot are reviewed.

Results
The external approach still has an interest for massive pre-epiglottic space invasion. For small tumors, the CO2 laser presents an advantage as compared to the Da Vinci robot as it causes less thermal damage. For large tumors, the quality of exposure provided by the Da Vinci robot as compared to the scope of the CO2 laser improves quality and makes tumor resection easier.

Conclusion
The Da Vinci robot has been largely developed over these last years and therefore will replace the CO2 laser for some surgical procedures.
Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
J Selber
Lecture
4 years ago
376 views
10 likes
0 comments
14:26
Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.
J Selber
Lecture
4 years ago
154 views
4 likes
0 comments
17:18
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.
Transoral robotic surgery
Access to oropharyngeal tumors has traditionally been using a transmandibular, translabial approach. Unfortunately, mandibulotomies and large pharyngotomies can result in significant postoperative morbidity and functional compromise. Because of the morbidity involved in some of these more aggressive resections, and the proven efficacy of chemoradiation in the treatment of some oropharyngeal cancers, there has been a paradigm shift away from ablative surgery. As long-term follow-up on these “organ-sparing” protocols have begun to take shape, however, significant morbidity and mortality has emerged with these therapies as well. Trans-oral robotic resections and reconstructions can provide the benefits of locoregional control without the morbidity of wide pharyngeal access or high-dose radiation. It can also prevent the use of external facial incisions and morbidity related to division of the mandible including hardware complications such as fistula. In addition, it can reduce and occasionally eliminate the need for radiation and its associated problems such as osteoradionecrosis and a functionless larynx. Transoral robotic tumor resection provides a challenge to the plastic surgeon because the cylinder of the oropharynx remains closed, making access to the oropharyngeal anatomy very difficult, particularly between the uvula and the epiglottis. The surgical robot, when positioned transorally, can allow the reconstructive surgeon to inset a variety of free and local flaps to perform complex reconstructions in challenging areas and meet the reconstructive demands of transoral resections.
J Selber
Lecture
4 years ago
214 views
9 likes
0 comments
17:18
Transoral robotic surgery
Access to oropharyngeal tumors has traditionally been using a transmandibular, translabial approach. Unfortunately, mandibulotomies and large pharyngotomies can result in significant postoperative morbidity and functional compromise. Because of the morbidity involved in some of these more aggressive resections, and the proven efficacy of chemoradiation in the treatment of some oropharyngeal cancers, there has been a paradigm shift away from ablative surgery. As long-term follow-up on these “organ-sparing” protocols have begun to take shape, however, significant morbidity and mortality has emerged with these therapies as well. Trans-oral robotic resections and reconstructions can provide the benefits of locoregional control without the morbidity of wide pharyngeal access or high-dose radiation. It can also prevent the use of external facial incisions and morbidity related to division of the mandible including hardware complications such as fistula. In addition, it can reduce and occasionally eliminate the need for radiation and its associated problems such as osteoradionecrosis and a functionless larynx. Transoral robotic tumor resection provides a challenge to the plastic surgeon because the cylinder of the oropharynx remains closed, making access to the oropharyngeal anatomy very difficult, particularly between the uvula and the epiglottis. The surgical robot, when positioned transorally, can allow the reconstructive surgeon to inset a variety of free and local flaps to perform complex reconstructions in challenging areas and meet the reconstructive demands of transoral resections.