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Epublication, Sep 2016;16(09). URL: http://websurg.com/doi/fc01en1
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Robotic adrenalectomy for left adrenal Conn’s adenoma: live broadcast
According to recent studies, robotic adrenalectomy has proven to be superior to laparoscopic adrenalectomy, with a reduction of blood loss during procedure and a reduced operative time.
The robotic system provides an intraoperative stability to the surgeon, allowing for a perfect handling of sensitive functional adrenal tumors. The main advantage of robotics lies in the ease of dissection, aided by improved visualization, the EndoWrist®, articulated instruments, and reduction of tremors, allowing for more accurate movements.

Indications: hormone-secreting tumors, adrenal masses >5cm, smaller lesions suspicious for malignancy, and lesions increasing in size on serial imaging.
Contraindications: infiltrative adrenal masses and tumors of extremely large size, because the size of adrenal lesions correlates with the potential for adrenal carcinoma.
The da Vinci Robotic Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) and the following robotic instruments are used:30-degree scope, ProGrasp™ forceps, Hot Shears (monopolar curved scissors or a hook), and a Robotic Clip Applier. A monopolar cautery hook and Harmonic ACE® curved shears can also be used when deemed helpful by the surgeon.
Laparoscopic instruments that can be handled by the bedside assistant, a clip applier and a suction device are also used.
CN Tang
Surgical intervention
2 years ago
1728 views
132 likes
0 comments
24:47
Robotic adrenalectomy for left adrenal Conn’s adenoma: live broadcast
According to recent studies, robotic adrenalectomy has proven to be superior to laparoscopic adrenalectomy, with a reduction of blood loss during procedure and a reduced operative time.
The robotic system provides an intraoperative stability to the surgeon, allowing for a perfect handling of sensitive functional adrenal tumors. The main advantage of robotics lies in the ease of dissection, aided by improved visualization, the EndoWrist®, articulated instruments, and reduction of tremors, allowing for more accurate movements.

Indications: hormone-secreting tumors, adrenal masses >5cm, smaller lesions suspicious for malignancy, and lesions increasing in size on serial imaging.
Contraindications: infiltrative adrenal masses and tumors of extremely large size, because the size of adrenal lesions correlates with the potential for adrenal carcinoma.
The da Vinci Robotic Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) and the following robotic instruments are used:30-degree scope, ProGrasp™ forceps, Hot Shears (monopolar curved scissors or a hook), and a Robotic Clip Applier. A monopolar cautery hook and Harmonic ACE® curved shears can also be used when deemed helpful by the surgeon.
Laparoscopic instruments that can be handled by the bedside assistant, a clip applier and a suction device are also used.
Mixed robotic laparoscopic synchronous left colectomy and left renal tumor enucleation
A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.
M Lotti, RLJ Naspro, L Rocchini, L Campanati, L Da Pozzo, L Ansaloni
Surgical intervention
2 years ago
1203 views
42 likes
0 comments
16:25
Mixed robotic laparoscopic synchronous left colectomy and left renal tumor enucleation
A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.
Laparoscopic anterior resection for locally advanced sigmoid cancer with 'en bloc' excision of bladder cuff
We present an operative video of a 61-year-old Chinese gentleman with locally advanced sigmoid carcinoma. Preoperative histology from endoscopy revealed an adenocarcinoma. The patient underwent laparoscopic anterior resection. Intraoperatively, the sigmoid tumor was adherent to the bladder with surrounding inflammation and edema. The colectomy had to be performed with an ‘en bloc’ excision of a bladder cuff. The bladder defect was repaired laparoscopically in two layers. Operative time was 4 hours 15 minutes and total blood loss was less than 100mL. The patient was discharged in good health conditions, four days after the operation with an outpatient cystogram performed before subsequent successful removal of the indwelling catheter. Final histology was pT4bN0 (0/31 lymph nodes) with clear margins. This case demonstrates that laparoscopic colectomy with ‘en bloc’ bladder cuff excision and subsequent laparoscopic repair of bladder defect are both feasible and safe.
S Mantoo, E Yong
Surgical intervention
2 years ago
3126 views
139 likes
0 comments
07:26
Laparoscopic anterior resection for locally advanced sigmoid cancer with 'en bloc' excision of bladder cuff
We present an operative video of a 61-year-old Chinese gentleman with locally advanced sigmoid carcinoma. Preoperative histology from endoscopy revealed an adenocarcinoma. The patient underwent laparoscopic anterior resection. Intraoperatively, the sigmoid tumor was adherent to the bladder with surrounding inflammation and edema. The colectomy had to be performed with an ‘en bloc’ excision of a bladder cuff. The bladder defect was repaired laparoscopically in two layers. Operative time was 4 hours 15 minutes and total blood loss was less than 100mL. The patient was discharged in good health conditions, four days after the operation with an outpatient cystogram performed before subsequent successful removal of the indwelling catheter. Final histology was pT4bN0 (0/31 lymph nodes) with clear margins. This case demonstrates that laparoscopic colectomy with ‘en bloc’ bladder cuff excision and subsequent laparoscopic repair of bladder defect are both feasible and safe.
Laparoscopic extraction of gastric denture
A 49-year-old generally fit man presented with abdominal pain following accidental swallowing of his denture 2 weeks previously. He looked well and his abdomen was soft and non-tender. A CT-scan showed a denture in the pyloric antrum of the stomach.
Gastroenterologists thought that it would be too large to be removed endoscopically. Laparoscopy was performed and the denture could be easily felt with a laparoscopic forceps. The denture was extracted in an Albert bag via the umbilical port after longitudinal gastrotomy. The gastrotomy was closed with 2/0 Vicryl continuous suture in 2 layers intracorporeally as shown on the video.
The patient was discharged on postoperative day 2 and remains well at 6 weeks of follow-up. Laparoscopic extraction of the gastric foreign body has the advantage of quicker recovery and better cosmesis as compared to the open technique.
K Aryal
Surgical intervention
2 years ago
1063 views
14 likes
0 comments
06:18
Laparoscopic extraction of gastric denture
A 49-year-old generally fit man presented with abdominal pain following accidental swallowing of his denture 2 weeks previously. He looked well and his abdomen was soft and non-tender. A CT-scan showed a denture in the pyloric antrum of the stomach.
Gastroenterologists thought that it would be too large to be removed endoscopically. Laparoscopy was performed and the denture could be easily felt with a laparoscopic forceps. The denture was extracted in an Albert bag via the umbilical port after longitudinal gastrotomy. The gastrotomy was closed with 2/0 Vicryl continuous suture in 2 layers intracorporeally as shown on the video.
The patient was discharged on postoperative day 2 and remains well at 6 weeks of follow-up. Laparoscopic extraction of the gastric foreign body has the advantage of quicker recovery and better cosmesis as compared to the open technique.
Single incision laparoscopic peritoneal hole repair during right TEP procedure
Background: Laparoscopic inguinal hernia repair offers various advantages both to the patient and the surgeon. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs represent the two laparoscopic options. A personal technique of single incision laparoscopic TEP has already been published on WebSurg (Link: http://www.websurg.com/MEDIA/?noheader=1&doi=vd01en4054).
Video: This video demonstrates the single incision laparoscopic treatment of a peritoneal hole, which occurred accidentally during a right TEP procedure.
Results: The TEP procedure lasted 41 minutes and the peritoneal repair 8 minutes. The final umbilical scar length was 10mm and the patient was discharged within 24 hours.
Conclusions: Peroperative complications can occur during single incision laparoscopy, as well as during conventional laparoscopy and open surgery. The procedure can be performed without conversion or additional trocars, depending on the complications which occurred.
G Dapri
Surgical intervention
2 years ago
2095 views
148 likes
0 comments
04:03
Single incision laparoscopic peritoneal hole repair during right TEP procedure
Background: Laparoscopic inguinal hernia repair offers various advantages both to the patient and the surgeon. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs represent the two laparoscopic options. A personal technique of single incision laparoscopic TEP has already been published on WebSurg (Link: http://www.websurg.com/MEDIA/?noheader=1&doi=vd01en4054).
Video: This video demonstrates the single incision laparoscopic treatment of a peritoneal hole, which occurred accidentally during a right TEP procedure.
Results: The TEP procedure lasted 41 minutes and the peritoneal repair 8 minutes. The final umbilical scar length was 10mm and the patient was discharged within 24 hours.
Conclusions: Peroperative complications can occur during single incision laparoscopy, as well as during conventional laparoscopy and open surgery. The procedure can be performed without conversion or additional trocars, depending on the complications which occurred.
Laparoscopic subtotal cholecystectomy
Laparoscopic cholecystectomy is a hazardous operation when the anatomy of Calot’s triangle is distorted by acute inflammation or any other factor (in our case, adhesions due to the recent surgery, and especially due to radiotherapy). In these difficult situations, the intraoperative decision to use a protective surgical technique as subtotal cholecystectomy is made with the purpose to prevent any injury to the biliary tree.
This video demonstrates the case of a 69-year-old woman with morbid obesity (BMI of 55) and diagnosed with acute cholecystitis. Her past medical history is relevant for right nephrectomy for renal carcinoma using a right subcostal laparotomy followed by radiochemotherapy completed 3 months earlier.
Subtotal cholecystectomy is a procedure which aims to remove portions of the gallbladder when structures of Calot’s triangle cannot be safely identified in "difficult gallbladders". The conversion rate to open surgery was higher among this category of patients. We describe our experience with a technical change, namely, a tactical laparoscopic subtotal cholecystectomy which almost always prevents conversion at the end of the procedures, and prevents both the risk of injury to the common bile duct and the risk of hemorrhage. In such cases, there is a need for rigor and prudence in order to return to the traditional technique in real time, if necessary.
Laparoscopic subtotal cholecystectomy can be considered a safe and feasible alternative to conversion to open surgery. Subtotal cholecystectomy is an essential technique to be used in difficult gallbladders. It achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases.
A Cotirlet, M Nedelcu
Surgical intervention
2 years ago
4328 views
284 likes
0 comments
20:31
Laparoscopic subtotal cholecystectomy
Laparoscopic cholecystectomy is a hazardous operation when the anatomy of Calot’s triangle is distorted by acute inflammation or any other factor (in our case, adhesions due to the recent surgery, and especially due to radiotherapy). In these difficult situations, the intraoperative decision to use a protective surgical technique as subtotal cholecystectomy is made with the purpose to prevent any injury to the biliary tree.
This video demonstrates the case of a 69-year-old woman with morbid obesity (BMI of 55) and diagnosed with acute cholecystitis. Her past medical history is relevant for right nephrectomy for renal carcinoma using a right subcostal laparotomy followed by radiochemotherapy completed 3 months earlier.
Subtotal cholecystectomy is a procedure which aims to remove portions of the gallbladder when structures of Calot’s triangle cannot be safely identified in "difficult gallbladders". The conversion rate to open surgery was higher among this category of patients. We describe our experience with a technical change, namely, a tactical laparoscopic subtotal cholecystectomy which almost always prevents conversion at the end of the procedures, and prevents both the risk of injury to the common bile duct and the risk of hemorrhage. In such cases, there is a need for rigor and prudence in order to return to the traditional technique in real time, if necessary.
Laparoscopic subtotal cholecystectomy can be considered a safe and feasible alternative to conversion to open surgery. Subtotal cholecystectomy is an essential technique to be used in difficult gallbladders. It achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases.
Sutures transfixing bladder as a complication of laparoscopic burch colposuspension
Laparoscopic Burch colposuspension may be difficult in cases of stress urinary incontinence (SUI) associated with large lateral cystocele. In these cases, complications may occur. However, they are rare.
This video shows the cystoscopic treatment of intravesical adhesions, secondary to sutures transfixing the bladder during the Burch laparoscopic procedure and lateral suspension, without perioperative use of control cystoscopy. An office cystoscopy was performed after the operation, nine months later, because of gradual onset of entirely isolated pelvic pain at the end of urination. It showed intravesical synechia as bilateral pillars. The different steps of the operation are the following:
1) Diagnostic laparoscopy with a good status of the lateral suspension without mesh migration.
2) Operative laparoscopy with opening of Retzius’s space, dissection, adhesiolysis, and division of the non-absorbable sutures of the past colposuspension in order to mobilize the bladder, followed by reperitonization of Retzius’s space.
3) Diagnostic cystoscopy confirming adhesions as bilateral pillars, laterally to the trigone with normal ejaculation of both ureteral ostia.
4) Operative cystoscopy after catheterization of both ureters: division of the pillars with the monopolar electrode without visualization of the Burch sutures, as they probably migrated upward in the first postoperative months.
In the postoperative period, ureteral catheters are removed 48 hours after surgery. Pain resolves completely during urination. Normal kidneys and ureters are observed at ultrasound.
This video clearly demonstrates the advantages related to the routine use of cystoscopy at the end of the laparoscopic Burch procedure, especially in cases of large lateral cystocele.
JB Dubuisson, J Dubuisson, JM Wenger, A Caviezel
Surgical intervention
2 years ago
2204 views
94 likes
0 comments
07:41
Sutures transfixing bladder as a complication of laparoscopic burch colposuspension
Laparoscopic Burch colposuspension may be difficult in cases of stress urinary incontinence (SUI) associated with large lateral cystocele. In these cases, complications may occur. However, they are rare.
This video shows the cystoscopic treatment of intravesical adhesions, secondary to sutures transfixing the bladder during the Burch laparoscopic procedure and lateral suspension, without perioperative use of control cystoscopy. An office cystoscopy was performed after the operation, nine months later, because of gradual onset of entirely isolated pelvic pain at the end of urination. It showed intravesical synechia as bilateral pillars. The different steps of the operation are the following:
1) Diagnostic laparoscopy with a good status of the lateral suspension without mesh migration.
2) Operative laparoscopy with opening of Retzius’s space, dissection, adhesiolysis, and division of the non-absorbable sutures of the past colposuspension in order to mobilize the bladder, followed by reperitonization of Retzius’s space.
3) Diagnostic cystoscopy confirming adhesions as bilateral pillars, laterally to the trigone with normal ejaculation of both ureteral ostia.
4) Operative cystoscopy after catheterization of both ureters: division of the pillars with the monopolar electrode without visualization of the Burch sutures, as they probably migrated upward in the first postoperative months.
In the postoperative period, ureteral catheters are removed 48 hours after surgery. Pain resolves completely during urination. Normal kidneys and ureters are observed at ultrasound.
This video clearly demonstrates the advantages related to the routine use of cystoscopy at the end of the laparoscopic Burch procedure, especially in cases of large lateral cystocele.
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
HK Yang, SH Kong
Surgical intervention
2 years ago
1532 views
73 likes
0 comments
15:56
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
Laparoscopic excision of a gastric duplication cyst
Duplication cysts are rare benign congenital anomalies, located predominantly at the proximal small intestine, emerging in the stomach in about 2 to 4% of all cases. Usually diagnosed in the pediatric age, they are commonly asymptomatic in adulthood and found incidentally on endoscopic or radiological exams. The therapeutic management of asymptomatic cysts is usually expectant. However, a surgical resection is recommended based on the potential risk of complications, such as malignant transformation.
Clinical case: This is the case of a 44-year-old woman, who had an incidental diagnosis of an intra-abdominal cyst on ultrasound examination. CT-scan and MRI revealed the presence of a 6x4cm cystic mass located between the posterior wall of the stomach and the anterior wall of the pancreas, assuming the differential diagnosis of enteric duplication cyst or pancreatic cystic lesion. A laparoscopic exploration is decided upon. She underwent a laparoscopic excision of cystic lesion of the gastric wall, without complications. The patient was discharged home on the third postoperative day. The pathological examination confirmed the diagnosis of enteric duplication cyst. Histology showed a cystic lesion composed of smooth muscle tissue and partially covered by gastric antral-type mucosa.
C Branco, C Viana, H Cristino, S Vilaça, J Falcão
Surgical intervention
2 years ago
820 views
32 likes
0 comments
06:07
Laparoscopic excision of a gastric duplication cyst
Duplication cysts are rare benign congenital anomalies, located predominantly at the proximal small intestine, emerging in the stomach in about 2 to 4% of all cases. Usually diagnosed in the pediatric age, they are commonly asymptomatic in adulthood and found incidentally on endoscopic or radiological exams. The therapeutic management of asymptomatic cysts is usually expectant. However, a surgical resection is recommended based on the potential risk of complications, such as malignant transformation.
Clinical case: This is the case of a 44-year-old woman, who had an incidental diagnosis of an intra-abdominal cyst on ultrasound examination. CT-scan and MRI revealed the presence of a 6x4cm cystic mass located between the posterior wall of the stomach and the anterior wall of the pancreas, assuming the differential diagnosis of enteric duplication cyst or pancreatic cystic lesion. A laparoscopic exploration is decided upon. She underwent a laparoscopic excision of cystic lesion of the gastric wall, without complications. The patient was discharged home on the third postoperative day. The pathological examination confirmed the diagnosis of enteric duplication cyst. Histology showed a cystic lesion composed of smooth muscle tissue and partially covered by gastric antral-type mucosa.