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#September 2014
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Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea)
The video entitled "Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition", authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea) is analyzed by Dr. Michel Vix, MD (Nouvel Hôpital Civil, Strasbourg, France), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Reply from Dr. Ji Yeon Park to the reviewer:
The South Korean surgeon in the current case, who originally was a gastric cancer surgeon, was extremely inexperienced in bariatric surgery at the time of the primary surgery in this patient. He applied “uncut” Roux-en-Y reconstruction for gastric cancer surgery to RYGB in this patient; it is a simple modification of Billroth II with Braun anastomosis with additional occlusion of the jejunogastric pathway with a non-bladed linear stapler. Consequently, sufficient distance between the gastrojejunostomy and the jejunojejunostomy was preserved in order to prevent bile reflux into the remnant stomach when staple-line recanalization occurs. However, intraoperative findings at reversal showed that the previously uncut staple line was found split apart, far from being recanalized. This consequently resulted in a long “true” blind loop at the distal end of the biliopancreatic limb. At reversal, we established a new jejunojejunal anastomosis between the distal end of the blind loop and the cut end of the proximal alimentary limb, and left the old jejunojejunostomy in situ. The operative procedure per se became much simpler by not dismantling the old jejunojejunostomy; as a result, the number of new anastomoses and the operating time could be reduced.
JY Park, YJ Kim, M Vix
Surgical intervention
4 years ago
1247 views
20 likes
0 comments
17:41
Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea)
The video entitled "Successful laparoscopic reversal of Roux-en-Y gastric bypass in a patient suffering from malnutrition", authored by JY Park and YJ Kim (Soonchunhyang University Seoul Hospital, Seoul, South Korea) is analyzed by Dr. Michel Vix, MD (Nouvel Hôpital Civil, Strasbourg, France), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Reply from Dr. Ji Yeon Park to the reviewer:
The South Korean surgeon in the current case, who originally was a gastric cancer surgeon, was extremely inexperienced in bariatric surgery at the time of the primary surgery in this patient. He applied “uncut” Roux-en-Y reconstruction for gastric cancer surgery to RYGB in this patient; it is a simple modification of Billroth II with Braun anastomosis with additional occlusion of the jejunogastric pathway with a non-bladed linear stapler. Consequently, sufficient distance between the gastrojejunostomy and the jejunojejunostomy was preserved in order to prevent bile reflux into the remnant stomach when staple-line recanalization occurs. However, intraoperative findings at reversal showed that the previously uncut staple line was found split apart, far from being recanalized. This consequently resulted in a long “true” blind loop at the distal end of the biliopancreatic limb. At reversal, we established a new jejunojejunal anastomosis between the distal end of the blind loop and the cut end of the proximal alimentary limb, and left the old jejunojejunostomy in situ. The operative procedure per se became much simpler by not dismantling the old jejunojejunostomy; as a result, the number of new anastomoses and the operating time could be reduced.
SILS (single access) transhiatal esophagectomy for cancer
An 82-year-old man was referred to our department for a 3cm long esophageal cancer.
He was smoking 40 cigarettes a day and drinking 1.5L of wine a day. He had a BMI of 21 and he was ASA 2.
A CT-scan showed a 3cm tumor not entering the muscle layer and no nodes were found in the mediastinum.
No liver metastases were visible on CT-scan and ultrasonography (US).
During GI endoscopy, a biopsy showed an esophageal adenocarcinoma.
Ejection fraction (EF) during cardiac ultrasound was 55%.
After 15 days of gym workouts in our department (15 minutes of exercise bike in the morning and 20 minutes in the afternoon, and inflating 30 balloons in the morning, 30 at lunchtime and 30 before nighttime), the patient was operated on.
A laparoscopic transhiatal single port esophagectomy was performed according to Orringer’s technique.
Procedure time was 195 minutes. Estimated blood loss was nihil. Time in ICU was 24 hours and hospital stay was 7 days.
This was our 11th case using this technique.
C Huscher
Surgical intervention
4 years ago
2519 views
105 likes
0 comments
08:29
SILS (single access) transhiatal esophagectomy for cancer
An 82-year-old man was referred to our department for a 3cm long esophageal cancer.
He was smoking 40 cigarettes a day and drinking 1.5L of wine a day. He had a BMI of 21 and he was ASA 2.
A CT-scan showed a 3cm tumor not entering the muscle layer and no nodes were found in the mediastinum.
No liver metastases were visible on CT-scan and ultrasonography (US).
During GI endoscopy, a biopsy showed an esophageal adenocarcinoma.
Ejection fraction (EF) during cardiac ultrasound was 55%.
After 15 days of gym workouts in our department (15 minutes of exercise bike in the morning and 20 minutes in the afternoon, and inflating 30 balloons in the morning, 30 at lunchtime and 30 before nighttime), the patient was operated on.
A laparoscopic transhiatal single port esophagectomy was performed according to Orringer’s technique.
Procedure time was 195 minutes. Estimated blood loss was nihil. Time in ICU was 24 hours and hospital stay was 7 days.
This was our 11th case using this technique.
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
S Perretta, D Ntourakis, J Marescaux
Surgical intervention
4 years ago
1808 views
54 likes
0 comments
06:43
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
Laparoscopic central pancreatectomy for insulinoma
We report the case of a 43-year-old male patient who was diagnosed with insulinoma and had a robotic enucleation of an isthmic pancreatic tumor in November 2012. However, the patient presents with clinical recurrences of hypoglycemia 18 months later. Re-evaluation studies demonstrated a local recurrence. A laparoscopic central pancreatectomy was indicated. The procedure started with the opening of the lesser sac. The splenic vessels were dissected and controlled. A retropancreatic passage along the venous mesenterico-portal axis was performed. Ultrasonography was carried out to assess the pancreatic recurrence area. The pancreas isthmus was transected. A pancreaticogastric anastomosis was performed at the posterior aspect of the stomach. The resected specimen confirms the recurrence of an insulinoma, which has been entirely removed.
P Pessaux, J Teyssedou, D Ntourakis, M Vix, J Marescaux
Surgical intervention
4 years ago
1234 views
30 likes
0 comments
09:21
Laparoscopic central pancreatectomy for insulinoma
We report the case of a 43-year-old male patient who was diagnosed with insulinoma and had a robotic enucleation of an isthmic pancreatic tumor in November 2012. However, the patient presents with clinical recurrences of hypoglycemia 18 months later. Re-evaluation studies demonstrated a local recurrence. A laparoscopic central pancreatectomy was indicated. The procedure started with the opening of the lesser sac. The splenic vessels were dissected and controlled. A retropancreatic passage along the venous mesenterico-portal axis was performed. Ultrasonography was carried out to assess the pancreatic recurrence area. The pancreas isthmus was transected. A pancreaticogastric anastomosis was performed at the posterior aspect of the stomach. The resected specimen confirms the recurrence of an insulinoma, which has been entirely removed.
Laparoscopic spleen-preserving distal pancreatectomy for mucinous cystadenoma (Warshaw’s technique)
The video presents the case of a surgical procedure performed in a 58-year old woman presenting with mucinous cystadenoma in the left pancreas. The patient complained of early satiety and her CT-scan demonstrated the existence of a huge cystic tumor replacing her pancreatic body and tail. The tumor involved the splenic vein and artery, resulting in a left segmental portal hypertension. Preoperative CT-scan showed that collaterals from the short gastric vessels maintained splenic vascularization.
A spleen-preserving distal pancreatectomy, sacrificing splenic vessels, according to Warshaw’s technique was decided upon.
Fa Madureira, Fe Madureira, D Madureira
Surgical intervention
4 years ago
2993 views
52 likes
0 comments
10:43
Laparoscopic spleen-preserving distal pancreatectomy for mucinous cystadenoma (Warshaw’s technique)
The video presents the case of a surgical procedure performed in a 58-year old woman presenting with mucinous cystadenoma in the left pancreas. The patient complained of early satiety and her CT-scan demonstrated the existence of a huge cystic tumor replacing her pancreatic body and tail. The tumor involved the splenic vein and artery, resulting in a left segmental portal hypertension. Preoperative CT-scan showed that collaterals from the short gastric vessels maintained splenic vascularization.
A spleen-preserving distal pancreatectomy, sacrificing splenic vessels, according to Warshaw’s technique was decided upon.
Single port laparoscopic assisted anorectal pull-through in anorectal malformation
This is the case of a 21-month-old male infant, referred from another center, with anorectal malformation and rectourethral fistula. The patient underwent a colostomy two months earlier and weighed 10Kg. On physical examination, the intergluteal cleft is evident, the infant has a good anal fovea, and his coccyx is palpable. In the distal colostogram, the distance between the rectum and the anus is approximately 2.7cm. The patient underwent single port laparoscopic anorectal pull-through, using the GelPOINT® Mini advanced access platform at umbilical level and a 3mm accessory port was placed at left upper quadrant level. Dissection of the distal part and division of the fistula by a white cartridge 45mm and 10mm ECHELON™ Hem-o-Lok® to remove the fistula at the level of the membranous urethra. A 5mm trocar was placed at the level of the fovea anal and rectum is lowered. The length of the procedure was approximately 3 hours and the patient was discharged on postoperative day 3, and progressed satisfactorily. One advantage of the use of the GelPOINT® Mini advanced access platform is that it allows the introduction of a larger number of instruments of different diameters (3 to 15mm) through the GelSeal® cap without placing other working ports. The single port laparoscopic anorectal pull-through procedure seems to be an efficient method that allows for adequate visualization and tissue manipulation in these patients.
A Parilli, J Mejías, W Salcedo, G Contreras
Surgical intervention
4 years ago
1316 views
22 likes
0 comments
09:55
Single port laparoscopic assisted anorectal pull-through in anorectal malformation
This is the case of a 21-month-old male infant, referred from another center, with anorectal malformation and rectourethral fistula. The patient underwent a colostomy two months earlier and weighed 10Kg. On physical examination, the intergluteal cleft is evident, the infant has a good anal fovea, and his coccyx is palpable. In the distal colostogram, the distance between the rectum and the anus is approximately 2.7cm. The patient underwent single port laparoscopic anorectal pull-through, using the GelPOINT® Mini advanced access platform at umbilical level and a 3mm accessory port was placed at left upper quadrant level. Dissection of the distal part and division of the fistula by a white cartridge 45mm and 10mm ECHELON™ Hem-o-Lok® to remove the fistula at the level of the membranous urethra. A 5mm trocar was placed at the level of the fovea anal and rectum is lowered. The length of the procedure was approximately 3 hours and the patient was discharged on postoperative day 3, and progressed satisfactorily. One advantage of the use of the GelPOINT® Mini advanced access platform is that it allows the introduction of a larger number of instruments of different diameters (3 to 15mm) through the GelSeal® cap without placing other working ports. The single port laparoscopic anorectal pull-through procedure seems to be an efficient method that allows for adequate visualization and tissue manipulation in these patients.
Video-assisted thoracoscopic surgery (VATS): Right middle lobectomy and complete mediastinal lymphadenectomy
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is actually preferred over a thoracotomy in experienced centers.
Potential advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital length of stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 63-year-old woman with clinical cT2 cN0 lung adenocarcinoma of the middle lobe. The patient underwent right middle lobectomy with complete mediastinal lymph node dissection using an anterior three-port thoracoscopic approach.
M Gonzalez, T Krueger, JY Perentes
Surgical intervention
4 years ago
1674 views
41 likes
0 comments
10:42
Video-assisted thoracoscopic surgery (VATS): Right middle lobectomy and complete mediastinal lymphadenectomy
The surgical management of non-small cell lung cancer (NSCLC) involves anatomical lung resection and systematic mediastinal lymph node dissection.
Video-assisted thoracic surgery (VATS) lobectomy for early NSCLC is actually preferred over a thoracotomy in experienced centers.
Potential advantages described of VATS lobectomy are decreased postoperative pain, less blood loss, shortened hospital length of stay, fewer overall complications, diminished immunologic suppression, as well as an increased ability to deliver adjuvant therapy. Oncological results are at least equivalent as thoracotomy in terms of long-term recurrence and survival rates.
We present the case of a 63-year-old woman with clinical cT2 cN0 lung adenocarcinoma of the middle lobe. The patient underwent right middle lobectomy with complete mediastinal lymph node dissection using an anterior three-port thoracoscopic approach.
Management of a severe bleeding during laparoscopy for recurrent rectovaginal endometriosis
This case demonstrates the potential danger of a repetitive surgery after an incomplete resection of rectovaginal endometriosis. A severe bleeding occurred during the dissection of the recurrent nodule. It was managed through multiple coagulations, which could only be performed safely and effectively because important landmarks had been identified and retracted prior to resecting the nodule. A key point in the surgery was also circumventing the nodule in order to pass in sano as the bleeding came from vessels entrapped in fibrosis and scarring tissue which could not be effectively coagulated.
A Wattiez, R Murtada, G Centini, R Fernandes, K Afors, C Meza Paul, J Castellano
Surgical intervention
4 years ago
3074 views
59 likes
0 comments
08:06
Management of a severe bleeding during laparoscopy for recurrent rectovaginal endometriosis
This case demonstrates the potential danger of a repetitive surgery after an incomplete resection of rectovaginal endometriosis. A severe bleeding occurred during the dissection of the recurrent nodule. It was managed through multiple coagulations, which could only be performed safely and effectively because important landmarks had been identified and retracted prior to resecting the nodule. A key point in the surgery was also circumventing the nodule in order to pass in sano as the bleeding came from vessels entrapped in fibrosis and scarring tissue which could not be effectively coagulated.
Laparoscopic management of a cavitated non-communicating rudimentary uterine horn of a unicornuate uterus: a case report
Introduction: A unicornuate uterus with a cavitated non-communicating rudimentary uterine horn is one of the most uncommon uterine anomalies of the female genital tract. It has an estimated frequency of 1 in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.
Case: This video describes the laparoscopic diagnosis and management of a unicornuate uterus with a left cavitated non-communicating rudimentary uterine horn in a 27-year old woman who presented with lower abdominal pain and severe dysmenorrhea. She was submitted to a preoperative imaging study with a MRI, a uro-CT and a CT-scan of the vertebral column. There were no concomitant urinary anomalies and the sagittal CT-scan revealed abnormalities in the development of the terminal portion of the column. A laparoscopic removal of this cavitated non-communicating uterine horn was performed without any complication in the postoperative period.
Conclusion: Operative laparoscopy proved to be a successful approach in the treatment of this congenital Müllerian anomaly.
H Ferreira Carvalho
Surgical intervention
4 years ago
1708 views
55 likes
0 comments
05:13
Laparoscopic management of a cavitated non-communicating rudimentary uterine horn of a unicornuate uterus: a case report
Introduction: A unicornuate uterus with a cavitated non-communicating rudimentary uterine horn is one of the most uncommon uterine anomalies of the female genital tract. It has an estimated frequency of 1 in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.
Case: This video describes the laparoscopic diagnosis and management of a unicornuate uterus with a left cavitated non-communicating rudimentary uterine horn in a 27-year old woman who presented with lower abdominal pain and severe dysmenorrhea. She was submitted to a preoperative imaging study with a MRI, a uro-CT and a CT-scan of the vertebral column. There were no concomitant urinary anomalies and the sagittal CT-scan revealed abnormalities in the development of the terminal portion of the column. A laparoscopic removal of this cavitated non-communicating uterine horn was performed without any complication in the postoperative period.
Conclusion: Operative laparoscopy proved to be a successful approach in the treatment of this congenital Müllerian anomaly.
Video endoscopic inguinal lymphadenectomy (VEIL) for penile cancer
This video reports the endoscopic technique used for the dissection of inguinal lymph nodes as complementary treatment for penile cancer.
Laparoscopic surgery has been used in iliac and retroperitoneal lymph nodes approaches, as well as for inguinal nodes dissection (video endoscopic) with fewer sequels and faster recuperation, according to conventional surgery indications.
This technique is indicated in patients presenting with penile cancer, in the following situations:
- after local treatment;
- when there is a lymph node mass less than 4cm;
- when mobile palpable lymph nodes appear in the postoperative follow-up;
- when there are risk factors for the development of inguinal metastasis (clinical stage > T1 or information regarding the initial biopsy such as histological grade > 1, lymphatic or vascular invasion).
This operation is performed bilaterally once.
This technique duplicates the conventional technique principles, promoting a radical resection of inguinal lymph nodes, regarding the reduction of surgical morbidity.
The video demonstrates that this procedure is feasible and safe with encouraging results.
References:

1. Bevan-Thomas R, Slaton JW, Pettaway CA: Contemporary morbidity from lymphadenectomy for penile squamous cell carcinoma: the M.D. Anderson Cancer Center Experience. J Urol 2002;167:1638-42.

2. Barnholtz-Sloan JS, Maldonado JL, Pow-Sang J, Giuliano AR. Incidence trends in primary malignant penile cancer. Urol Oncol 2007;25:361-7.

3. Bishoff JA, Lackland AF, Basler JW, Teichman JM, Thompson IM: Endoscopy subcutaneous modified inguinal lymph node dissection (ESMIL) for squamous cell carcinoma of the penis. J Urol 2003:169;Suppl 4:78.

4. Dardour JC, Ktorza T: Endoscopic deep periorbital lifting: study and results based on 50 consecutive cases. Aesthetic Plast Surg 2000;24:292-8.

5. D’Ancona CA, de Lucena RG, Querne FA, Martins MH, Denardi F, Netto NR Jr: Long-term follow-up of penile carcinoma treated with penectomy and bilateral modified inguinal lymphadenectomy. J Urol 2004;172:498-501;discussion 501.

6. Folliguet TA, Le Bret E, Moneta A, Musumeci S, Laborde F: Endoscopic saphenous vein harvesting versus ‘open’ technique. A prospective study. Eur J Cardiothorac Surg 1998;13:662-6.

7. Horenblas S. Lymphadenectomy for squamous cell carcinoma of the penis. Part 2: the role and technique of lymph node dissection. BJU Int 2001;88:473-83.

8. Hungerhuber E, Schlenken B, Karl A, et al. Risk stratification in penile carcinoma: 25-year experience with surgical inguinal lymph node staging. Urology 2006;68:621-5.

9. Leijte JA, Kroon BK, Valdés Olmos RA, Nieweg OE, Horenblas S. Reliability and safety of current dynamic sentinel node biopsy for penile carcinoma. Eur Urol 2007;52:170-7.

10. Machado MT, Tavares A, Molina Jr WR, Zambon JP, Forsetto Jr P, Juliano RV, Wroclawski ER: Comparative study between videoendoscopic radical inguinal lymphadenectomy (VEIL) and standard open lymphadenectomy for penile cancer: preliminary surgical and oncological results. J Urol 2005;173:226, Abst 834.

11. Ornellas AA, Seixas AL, Marota A, Wisnescky A, Campos F, de Moraes JR. Surgical treatment of invasive squamous cell carcinoma of the penis: retrospective analysis of 350 cases. J Urol 1994;151:1244-9.

12. Hegarty PK, Dinney CP, Pettaway CA. Controversies in Ilioinguinal lymphadenectomy. Urol Clin North Am 2010;37:421-34.

13. Protzel C, Alcaraz A, Horenblas S, Pizzocaro G, Zlotta A, Hakenberg OW. Lymphadenectomy in the surgical management of penile cancer. Eur Urol 2009;55:1075-88.

14. Sotelo R, Sánchez-Salas R, Carmona O, Garcia A, Mariano M, Neiva G, Trujillo G, Novoa J, Cornejo F, Finelli A. Endoscopic lymphadenectomy for penile carcinoma. J Endourol 2007;21:364-7;discussion 367.

15. Tobias-Machado M, Tavares A, Ornellas AA, Molina WR Jr, Juliano RV, Wroclawski ER. Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure for radical management of inguinal nodes in patients with penile squamous cell carcinoma. J Urol 2007;177:953-7;discussion 958.

16. Velasquez EF, Melamed J, Barreto JE, Aguero F, Cubilla AL. Sarcomatoid carcinoma of the penis. A clinicopathologic study of 15 cases. Am J Surg Pathol 2005;29:1152-8.

17. Master V, Ogan K, Kooby D, Hsiao W, Delman K. Leg endoscopic groin lymphadenectomy (LEG procedure): step-by-step approach to a straightforward technique. Eur Urol 2009;56:821-8.
VE Corona Montes, T Machado, C Fraga, T Piéchaud
Surgical intervention
4 years ago
2604 views
76 likes
0 comments
11:31
Video endoscopic inguinal lymphadenectomy (VEIL) for penile cancer
This video reports the endoscopic technique used for the dissection of inguinal lymph nodes as complementary treatment for penile cancer.
Laparoscopic surgery has been used in iliac and retroperitoneal lymph nodes approaches, as well as for inguinal nodes dissection (video endoscopic) with fewer sequels and faster recuperation, according to conventional surgery indications.
This technique is indicated in patients presenting with penile cancer, in the following situations:
- after local treatment;
- when there is a lymph node mass less than 4cm;
- when mobile palpable lymph nodes appear in the postoperative follow-up;
- when there are risk factors for the development of inguinal metastasis (clinical stage > T1 or information regarding the initial biopsy such as histological grade > 1, lymphatic or vascular invasion).
This operation is performed bilaterally once.
This technique duplicates the conventional technique principles, promoting a radical resection of inguinal lymph nodes, regarding the reduction of surgical morbidity.
The video demonstrates that this procedure is feasible and safe with encouraging results.
References:

1. Bevan-Thomas R, Slaton JW, Pettaway CA: Contemporary morbidity from lymphadenectomy for penile squamous cell carcinoma: the M.D. Anderson Cancer Center Experience. J Urol 2002;167:1638-42.

2. Barnholtz-Sloan JS, Maldonado JL, Pow-Sang J, Giuliano AR. Incidence trends in primary malignant penile cancer. Urol Oncol 2007;25:361-7.

3. Bishoff JA, Lackland AF, Basler JW, Teichman JM, Thompson IM: Endoscopy subcutaneous modified inguinal lymph node dissection (ESMIL) for squamous cell carcinoma of the penis. J Urol 2003:169;Suppl 4:78.

4. Dardour JC, Ktorza T: Endoscopic deep periorbital lifting: study and results based on 50 consecutive cases. Aesthetic Plast Surg 2000;24:292-8.

5. D’Ancona CA, de Lucena RG, Querne FA, Martins MH, Denardi F, Netto NR Jr: Long-term follow-up of penile carcinoma treated with penectomy and bilateral modified inguinal lymphadenectomy. J Urol 2004;172:498-501;discussion 501.

6. Folliguet TA, Le Bret E, Moneta A, Musumeci S, Laborde F: Endoscopic saphenous vein harvesting versus ‘open’ technique. A prospective study. Eur J Cardiothorac Surg 1998;13:662-6.

7. Horenblas S. Lymphadenectomy for squamous cell carcinoma of the penis. Part 2: the role and technique of lymph node dissection. BJU Int 2001;88:473-83.

8. Hungerhuber E, Schlenken B, Karl A, et al. Risk stratification in penile carcinoma: 25-year experience with surgical inguinal lymph node staging. Urology 2006;68:621-5.

9. Leijte JA, Kroon BK, Valdés Olmos RA, Nieweg OE, Horenblas S. Reliability and safety of current dynamic sentinel node biopsy for penile carcinoma. Eur Urol 2007;52:170-7.

10. Machado MT, Tavares A, Molina Jr WR, Zambon JP, Forsetto Jr P, Juliano RV, Wroclawski ER: Comparative study between videoendoscopic radical inguinal lymphadenectomy (VEIL) and standard open lymphadenectomy for penile cancer: preliminary surgical and oncological results. J Urol 2005;173:226, Abst 834.

11. Ornellas AA, Seixas AL, Marota A, Wisnescky A, Campos F, de Moraes JR. Surgical treatment of invasive squamous cell carcinoma of the penis: retrospective analysis of 350 cases. J Urol 1994;151:1244-9.

12. Hegarty PK, Dinney CP, Pettaway CA. Controversies in Ilioinguinal lymphadenectomy. Urol Clin North Am 2010;37:421-34.

13. Protzel C, Alcaraz A, Horenblas S, Pizzocaro G, Zlotta A, Hakenberg OW. Lymphadenectomy in the surgical management of penile cancer. Eur Urol 2009;55:1075-88.

14. Sotelo R, Sánchez-Salas R, Carmona O, Garcia A, Mariano M, Neiva G, Trujillo G, Novoa J, Cornejo F, Finelli A. Endoscopic lymphadenectomy for penile carcinoma. J Endourol 2007;21:364-7;discussion 367.

15. Tobias-Machado M, Tavares A, Ornellas AA, Molina WR Jr, Juliano RV, Wroclawski ER. Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure for radical management of inguinal nodes in patients with penile squamous cell carcinoma. J Urol 2007;177:953-7;discussion 958.

16. Velasquez EF, Melamed J, Barreto JE, Aguero F, Cubilla AL. Sarcomatoid carcinoma of the penis. A clinicopathologic study of 15 cases. Am J Surg Pathol 2005;29:1152-8.

17. Master V, Ogan K, Kooby D, Hsiao W, Delman K. Leg endoscopic groin lymphadenectomy (LEG procedure): step-by-step approach to a straightforward technique. Eur Urol 2009;56:821-8.
Robotic assistance to flexible endoscopy by physiological motion tracking
New techniques are currently under development for minimally invasive surgery with the objective to perform surgery without visible scars. Single port access surgery is one of the approaches, natural orifice endoluminal or transluminal surgery is the other one.

The latter is based on the use of flexible endoscopes and instruments which are introduced inside the patient through natural orifices such as the mouth or the anus. This type of surgery is quite complex. It relies on the use of flexible instruments which allow the surgeon or the endoscopist to control the orientation of the endoscope's head as well as the instruments inside the channels.

Two surgeons are often required to work simultaneously. The ICube laboratory and the IRCAD institute have developed a robotic platform for endoluminal and transluminal surgery with a flexible endoscope and two flexible instruments that can be efficiently telemanipulated by one surgeon.

Physiological motions of organs are difficult to compensate in manual procedures while controlling flexible instruments. By using automatic visual tracking of the anatomical target, the robotized flexible endoscope can follow the moving organ at a constant distance. This feature provides the surgeons the perception of a non-mobile surgical environment while the organ is moving. This feature has been tested and validated in vivo using porcine models.
M de Mathelin
Lecture
4 years ago
114 views
4 likes
0 comments
15:09
Robotic assistance to flexible endoscopy by physiological motion tracking
New techniques are currently under development for minimally invasive surgery with the objective to perform surgery without visible scars. Single port access surgery is one of the approaches, natural orifice endoluminal or transluminal surgery is the other one.

The latter is based on the use of flexible endoscopes and instruments which are introduced inside the patient through natural orifices such as the mouth or the anus. This type of surgery is quite complex. It relies on the use of flexible instruments which allow the surgeon or the endoscopist to control the orientation of the endoscope's head as well as the instruments inside the channels.

Two surgeons are often required to work simultaneously. The ICube laboratory and the IRCAD institute have developed a robotic platform for endoluminal and transluminal surgery with a flexible endoscope and two flexible instruments that can be efficiently telemanipulated by one surgeon.

Physiological motions of organs are difficult to compensate in manual procedures while controlling flexible instruments. By using automatic visual tracking of the anatomical target, the robotized flexible endoscope can follow the moving organ at a constant distance. This feature provides the surgeons the perception of a non-mobile surgical environment while the organ is moving. This feature has been tested and validated in vivo using porcine models.
State-of-the-art: anesthetic management for robotic surgery: the MD Anderson Cancer Center Experience
Background:
Robotic-assisted surgery has evolved over the past decade and has paved the way for the future surgical approach in multiple subspecialty disciplines. Technological advancements present potential advantages for our oncologic patients as well as new challenges for anesthesia and surgery teams. Robotic head and neck, plastic and thoracic surgery carry specific associated risks that require a precise anesthetic perioperative management plan in order to prevent catastrophic events such as airway fire, life-threatening hemodynamic instability and flap failure, from happening. The main goals are to estimate and minimize the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Description:
The three most important anesthetic considerations during TransOral Robotic Surgery (TORS) are: airway management, facial trauma prevention and fire prevention strategies. The surgical bed is usually rotated 180 degrees away from the anesthesiologist and securing the airway becomes pivotal in order to prevent accidental disconnection or extubation caused by the patient-robot conflict. Facial trauma, and specifically ocular trauma including retinal detachment, is prevented by the routine use of surgical goggles. The risk of fire is high during TORS and specific strategies must be put in place in order to prevent such a catastrophic event from occurring. Strategies include: a fire checklist including precise knowledge of oxygen shutoff location outside the OR and fire extinguisher location inside the OR, as well as decreasing oxygen concentration to less than 35% as tolerated by oxygen saturation.
During robotic reconstructive plastic surgery fluid management must be precise because very conservative fluid administration can lead to hypotension and hypoperfusion of the flap due to a decrease in oxygen delivery and potential ischemia. Over-administration of fluids can lead to interstitial edema putting flap integrity at risk, due to an increase in the distance oxygen molecules travel from the endothelium to the cells, to contribute with adequate tissue oxygenation and aerobic metabolism. Excessive fluid administration leads to dilution anemia increasing the need for blood transfusions, which negatively impact immunomodulation in cancer patients as demonstrated by several meta-analyses.
We currently have new minimally invasive hemodynamic monitoring technology such as Flo Trac, Vigileo and LiDCO at our fingertips, which allows to monitor beat-to-beat precise fluid administration to maintain a perfect state of euvolemia.
Minimally invasive thoracic surgery such as Da Vinci® assisted robotic surgery and Video-assisted thoracoscopic surgery (VATS) are routine procedures at our institution. Enhanced Recovery After Surgery (ERAS) and specifically Enhanced Recovery After Thoracic Surgery (ERATS) strategies are currently used as part of our thoracic surgical protocols in order to decrease morbidity, length of stay (LOS), opioid consumption and costs to the healthcare system and institution.

These strategies are the result of scientifically and evidence-based data from RCT’s and multiple meta-analyses. The role of multimodal analgesia for perioperative pain management with pharmacological opioid sparing strategies using Lyrica (Pregabalin), Tramadol ER (Ultram), Celebrex (Celecoxib), IV Acetaminophen (Ofirmev) and Ketorolac IV (Toradol) have clearly shown to decrease the use of opioids by more than 50%. Opioids are clearly known to lead to side effects such as ileus, urinary retention, respiratory depression and immunomodulation which are all associated with increased LOS, morbidity and costs.

Total Intravenous Anesthesia (TIVA) using continuous intraoperative infusions of propofol, dexmedetomidine (Precedex) and lidocaine are part of the ERATS strategies to decrease opioid use and to avoid the side effects of inhaled volatile agents.

Surgical strategies such as intercostal block with Exparel (Liposomal Encapsulated Bupivacaine) and incisional port injection with Exparel as well as early chest tube removal (24-48 hours) allow early patient mobilization and discharge while maintaining the same outcomes and increasing patient satisfaction.


Discussion:
Team work between surgeons and anesthesiologists as well as constant communication and a thorough understanding of the physiological, hemodynamic, oncologic and analgesic implications minimizes the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Anesthesiologists must have in-depth knowledge of specific anesthetic considerations and implications associated with TORS such as airway fire and fire prevention strategies. Precise fluid administration and Enhanced Recovery After Surgery (ERAS) strategies during plastic robotic surgery as well as thoracic robotic surgery are pivotal in the perioperative period and for accelerated recovery while maintaining same quality of care and patient satisfaction.
As surgical approaches change with robotic surgery, it is necessary to understand the impacts these changes have on perioperative care to optimize surgical success, safety, patient satisfaction, decreased LOS, opioid usage and Institutional costs.

References:
1. Campos JH. An update on robotic thoracic surgery and anesthesia. Curr Opin Anaesthesiol 2010;23:1-6.
2. Steenwyk B, Lyerly R 3rd. Adavancements in robotic-assisted thoracic surgery. Anesthesiol Clin 2012;30:699-708.
3. Selber JC. Discussion: Reconstructive techniques in transoral robotic surgery for head and neck cancer: A North American survey. Plast Reconstr Surg 2013;131:188e-197e.
4. Hassanein AH, Mailey BA, Dobke MK. Robotic-assisted plastic surgery. Clin Plast Surg 2012 12;5:232-8.
5. Selber JC, Baumann DP, Holsinger CF. Robotic Harvest of the latissimus dorsi muscle: laboratory and clinical experience. J Reconstr Microsurg 2012;20:457-64.
6. Chi JJ, Mandel JE, Weinstein GS, O’Malley BW Jr. Anesthetic considerations for transoral robotic surgery. Anesthesiol Clin 2010;28:411-22.
7. Song JB, Vemana G, Mobley JM, Bhayani SB. The second “time-out”: a surgical safety checklist for lengthy robotic surgeries. Patient Saf Surg 2013;3:19.
8. Ahmed K, Khan N, Khan MS, Dasgupta P. Development and content validation of surgical safety checklist for operating theaters that use robotic technology. BJU Int 2013;111:1161-74.
GE Mena
Lecture
4 years ago
72 views
2 likes
0 comments
14:22
State-of-the-art: anesthetic management for robotic surgery: the MD Anderson Cancer Center Experience
Background:
Robotic-assisted surgery has evolved over the past decade and has paved the way for the future surgical approach in multiple subspecialty disciplines. Technological advancements present potential advantages for our oncologic patients as well as new challenges for anesthesia and surgery teams. Robotic head and neck, plastic and thoracic surgery carry specific associated risks that require a precise anesthetic perioperative management plan in order to prevent catastrophic events such as airway fire, life-threatening hemodynamic instability and flap failure, from happening. The main goals are to estimate and minimize the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Description:
The three most important anesthetic considerations during TransOral Robotic Surgery (TORS) are: airway management, facial trauma prevention and fire prevention strategies. The surgical bed is usually rotated 180 degrees away from the anesthesiologist and securing the airway becomes pivotal in order to prevent accidental disconnection or extubation caused by the patient-robot conflict. Facial trauma, and specifically ocular trauma including retinal detachment, is prevented by the routine use of surgical goggles. The risk of fire is high during TORS and specific strategies must be put in place in order to prevent such a catastrophic event from occurring. Strategies include: a fire checklist including precise knowledge of oxygen shutoff location outside the OR and fire extinguisher location inside the OR, as well as decreasing oxygen concentration to less than 35% as tolerated by oxygen saturation.
During robotic reconstructive plastic surgery fluid management must be precise because very conservative fluid administration can lead to hypotension and hypoperfusion of the flap due to a decrease in oxygen delivery and potential ischemia. Over-administration of fluids can lead to interstitial edema putting flap integrity at risk, due to an increase in the distance oxygen molecules travel from the endothelium to the cells, to contribute with adequate tissue oxygenation and aerobic metabolism. Excessive fluid administration leads to dilution anemia increasing the need for blood transfusions, which negatively impact immunomodulation in cancer patients as demonstrated by several meta-analyses.
We currently have new minimally invasive hemodynamic monitoring technology such as Flo Trac, Vigileo and LiDCO at our fingertips, which allows to monitor beat-to-beat precise fluid administration to maintain a perfect state of euvolemia.
Minimally invasive thoracic surgery such as Da Vinci® assisted robotic surgery and Video-assisted thoracoscopic surgery (VATS) are routine procedures at our institution. Enhanced Recovery After Surgery (ERAS) and specifically Enhanced Recovery After Thoracic Surgery (ERATS) strategies are currently used as part of our thoracic surgical protocols in order to decrease morbidity, length of stay (LOS), opioid consumption and costs to the healthcare system and institution.

These strategies are the result of scientifically and evidence-based data from RCT’s and multiple meta-analyses. The role of multimodal analgesia for perioperative pain management with pharmacological opioid sparing strategies using Lyrica (Pregabalin), Tramadol ER (Ultram), Celebrex (Celecoxib), IV Acetaminophen (Ofirmev) and Ketorolac IV (Toradol) have clearly shown to decrease the use of opioids by more than 50%. Opioids are clearly known to lead to side effects such as ileus, urinary retention, respiratory depression and immunomodulation which are all associated with increased LOS, morbidity and costs.

Total Intravenous Anesthesia (TIVA) using continuous intraoperative infusions of propofol, dexmedetomidine (Precedex) and lidocaine are part of the ERATS strategies to decrease opioid use and to avoid the side effects of inhaled volatile agents.

Surgical strategies such as intercostal block with Exparel (Liposomal Encapsulated Bupivacaine) and incisional port injection with Exparel as well as early chest tube removal (24-48 hours) allow early patient mobilization and discharge while maintaining the same outcomes and increasing patient satisfaction.


Discussion:
Team work between surgeons and anesthesiologists as well as constant communication and a thorough understanding of the physiological, hemodynamic, oncologic and analgesic implications minimizes the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Anesthesiologists must have in-depth knowledge of specific anesthetic considerations and implications associated with TORS such as airway fire and fire prevention strategies. Precise fluid administration and Enhanced Recovery After Surgery (ERAS) strategies during plastic robotic surgery as well as thoracic robotic surgery are pivotal in the perioperative period and for accelerated recovery while maintaining same quality of care and patient satisfaction.
As surgical approaches change with robotic surgery, it is necessary to understand the impacts these changes have on perioperative care to optimize surgical success, safety, patient satisfaction, decreased LOS, opioid usage and Institutional costs.

References:
1. Campos JH. An update on robotic thoracic surgery and anesthesia. Curr Opin Anaesthesiol 2010;23:1-6.
2. Steenwyk B, Lyerly R 3rd. Adavancements in robotic-assisted thoracic surgery. Anesthesiol Clin 2012;30:699-708.
3. Selber JC. Discussion: Reconstructive techniques in transoral robotic surgery for head and neck cancer: A North American survey. Plast Reconstr Surg 2013;131:188e-197e.
4. Hassanein AH, Mailey BA, Dobke MK. Robotic-assisted plastic surgery. Clin Plast Surg 2012 12;5:232-8.
5. Selber JC, Baumann DP, Holsinger CF. Robotic Harvest of the latissimus dorsi muscle: laboratory and clinical experience. J Reconstr Microsurg 2012;20:457-64.
6. Chi JJ, Mandel JE, Weinstein GS, O’Malley BW Jr. Anesthetic considerations for transoral robotic surgery. Anesthesiol Clin 2010;28:411-22.
7. Song JB, Vemana G, Mobley JM, Bhayani SB. The second “time-out”: a surgical safety checklist for lengthy robotic surgeries. Patient Saf Surg 2013;3:19.
8. Ahmed K, Khan N, Khan MS, Dasgupta P. Development and content validation of surgical safety checklist for operating theaters that use robotic technology. BJU Int 2013;111:1161-74.
Health in space: surgery in the context of manned space exploration
The European Space Agency (ESA) foresees the exploration of the solar system, which implies as a long-term objective the prospect of Mars’s exploration by human beings. Ensuring the crew’s well-being and operational performance will not only depend on the ability to prevent health issues, but also to make a fast and accurate diagnosis and therefore to quickly provide reliable and adequate treatment. Building the required knowledge and understanding the aspects specifically related to crewed exploration will be performed on a long timescale. It is therefore of high interest to also develop short-term and medium-term technologies, especially by resorting to the use of analog environments such as the Concordia station to validate these technological concepts for future space activities.
While the ESA has carried out several activities in the field of prevention and countermeasures, monitoring, and diagnosis, only a very limited number of projects have been dealing with treatment techniques. Consequently, the ESA recently decided to explore this rather untapped field and has started working on assisted surgery as a potential treatment possibility for future space exploration missions. During a manned Lunar or Martian mission, emergency surgical care for life-threatening pathologies (e.g. major trauma) may have to be carried out inside the spacecraft or habitat since an evacuation to a specialized surgical facility may not be immediately possible. The crew would therefore need some support, in order 1) to overcome the lack of surgical expertise and sufficiently skilled staff on the site where the patient is located (e.g. spacecraft, geographically isolated place), 2) to overcome the lack of training (no daily practice) and preserve medical skills (including surgical procedures) of the crew’s medical officer, if any.
The presentation given in November 2013 at the 3rd RAMSES symposium aims at providing a first overview about surgery-related activities at the European Space Agency, including achievements and future perspectives.
A Runge
Lecture
4 years ago
165 views
6 likes
0 comments
13:11
Health in space: surgery in the context of manned space exploration
The European Space Agency (ESA) foresees the exploration of the solar system, which implies as a long-term objective the prospect of Mars’s exploration by human beings. Ensuring the crew’s well-being and operational performance will not only depend on the ability to prevent health issues, but also to make a fast and accurate diagnosis and therefore to quickly provide reliable and adequate treatment. Building the required knowledge and understanding the aspects specifically related to crewed exploration will be performed on a long timescale. It is therefore of high interest to also develop short-term and medium-term technologies, especially by resorting to the use of analog environments such as the Concordia station to validate these technological concepts for future space activities.
While the ESA has carried out several activities in the field of prevention and countermeasures, monitoring, and diagnosis, only a very limited number of projects have been dealing with treatment techniques. Consequently, the ESA recently decided to explore this rather untapped field and has started working on assisted surgery as a potential treatment possibility for future space exploration missions. During a manned Lunar or Martian mission, emergency surgical care for life-threatening pathologies (e.g. major trauma) may have to be carried out inside the spacecraft or habitat since an evacuation to a specialized surgical facility may not be immediately possible. The crew would therefore need some support, in order 1) to overcome the lack of surgical expertise and sufficiently skilled staff on the site where the patient is located (e.g. spacecraft, geographically isolated place), 2) to overcome the lack of training (no daily practice) and preserve medical skills (including surgical procedures) of the crew’s medical officer, if any.
The presentation given in November 2013 at the 3rd RAMSES symposium aims at providing a first overview about surgery-related activities at the European Space Agency, including achievements and future perspectives.