Monthly publications

In this live interactive video, authors present a demonstration of a right partial colectomy with ileo ascending anastomosis in a patient with a sessile polyp in the ileocaecal junction not endoscopically resectable. A vascular 3D reconstruction is also included at the beginning of the video.

This is the case of a 58-year-old woman who presented with polyposis coli and a colonic carcinoma at the level of the hepatic flexure. A proctocolectomy was performed laparoscopically. This video demonstrates the vascular approach to the middle colic artery as it is also performed during an extended right hemicolectomy.

In this live surgery, Dr. Francesco Corcione presents the case of a subocclusive caecal tumor associated with a large polyp in an obese patient (BMI of 30) with a past surgical history of open cholecystectomy. 3D reconstruction of the preoperative imaging showed a pronounced lymphadenopathy and the absence of a right colic artery. The operative technique shown includes an oncological ‘en bloc’ resection and intracorporeal anastomosis.

In this live surgery, Dr. Barry Salky presents a case of sigmoid diverticular disease with multiple recurrent episodes of sigmoiditis, complicated by a sigmoid stricture. The operative technique shown includes transection of the sigmoid mesentery close to the bowel wall, preserving the superior rectal artery. Mobilization of the splenic flexure is not performed as a first step, but is adapted to the remaining colon length.

The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of a 66-year-old woman with a sigmoid-rectal junction early stage cancer submitted to laparoscopic resection. Before surgery, the patient was submitted to endoscopy with the objective to mark the distal margin of the neoplasia, and 2mL of ICG were injected into the mucosa of the rectum, 2cm distal to the inferior border of the tumor.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588 camera system), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
It was possible to verify the good perfusion of the proximal stump of the anastomosis before the Knight-Griffen anastomosis was performed, thanks to an intravenous injection of ICG.
This technique could allow for a more precise and radical nodal dissection, a safer work respecting vascular and nerve structures, and could be related with a lower risk of anastomotic fistula, controlling the adequate perfusion of the stump.

Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.

This is the case of two adult patients who presented with a low rectal carcinoma. A low anterior resection was performed laparoscopically. In both cases, the procedure was begun with a mobilization of the splenic flexure to ensure sufficient length on the proximal colonic segment to facilitate a tension-free low colorectal anastomosis. In the first case, a small aberrant artery, and during the second case, an aberrant artery of greater caliber can be appreciated. Anatomical studies report an extra central arterial connection between the superior and inferior mesenteric arterial systems in addition to the marginal artery of Drummond in 10 to 30% of cases. In such cases, there is an extra connection from the ascending branch of the left colic artery to the middle colic artery or the marginal artery of Drummond. Different names have been given to these connections, such as for example the meandering mesenteric artery, the artery of Moskovitch and Riolan’s arch.

In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.

In this key lecture, Dr. Barry Salky highlights laparoscopic right colectomy and describes intracorporeal vs. extracorporeal anastomosis.

In this key lecture and video session, Dr. Kim Seon-Hahn (MD, PhD, FACS) outlines the vascular anatomy for D3 CME extended right hemicolectomy.

In this key lecture, Dr. Patricia Sylla highlights the TES toolkit, stressing preparation and technical steps.

In this key lecture, Dr. Eric Rullier focuses on sphincter-saving approaches during laparoscopic TME.

In this key lecture, Professor Eric Rullier focuses on TaTME, to demonstrate its real advantages.

In this key lecture, Professor RJ Heald highlights skeletons in the cupboard, stressing when bad things occur to good surgeons.

In this key lecture, Dr. Patricia Sylla focuses on the management of chronic anastomotic leaks, fistulas and sinuses.

In this key lecture, Professor Eric Rullier focuses on ways to prevent pelvic nerve injury during laparoscopic total mesorectal excision (TME).