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Focus on Laparoscopic General Surgery

Epublication, Nov 2017;17(11). URL: http://websurg.com/doi/fc01en31
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LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
B Dallemagne, S Perretta, M Diana, F Longo, D Mutter, J Marescaux
Surgical intervention
1 year ago
4804 views
435 likes
0 comments
54:47
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
B Dallemagne, S Perretta, D Mutter, J Marescaux
Surgical intervention
1 year ago
1137 views
111 likes
0 comments
41:44
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
D Mutter, J Marescaux
Surgical intervention
1 year ago
14981 views
1379 likes
1 comment
25:14
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
Bariatric and metabolic surgery
In this authoritative lecture, Dr. Michel Vix highlighted the indications related to metabolic and morbid obesity surgery. He presented key anatomical landmarks and operating room (OR) set-up depending on every patient. He briefly described the main principles of port placement and pneumoperitoneum, and demonstrated maneuvers, indications, and main key steps of morbid obesity procedures including LAGB, SBPD-DS, Scopinaro, RYGB, Mini Gastric Bypass, and Sleeve Gastrectomy, along with their technical aspects, mortality, morbidity, effectiveness, and results using different studies and meta-analyses. He also demonstrated the main principles and key steps of new trends and approaches in bariatric and metabolic surgery with complications and technical therapeutic aspects.
M Vix
Lecture
1 year ago
1298 views
272 likes
0 comments
04:52
Bariatric and metabolic surgery
In this authoritative lecture, Dr. Michel Vix highlighted the indications related to metabolic and morbid obesity surgery. He presented key anatomical landmarks and operating room (OR) set-up depending on every patient. He briefly described the main principles of port placement and pneumoperitoneum, and demonstrated maneuvers, indications, and main key steps of morbid obesity procedures including LAGB, SBPD-DS, Scopinaro, RYGB, Mini Gastric Bypass, and Sleeve Gastrectomy, along with their technical aspects, mortality, morbidity, effectiveness, and results using different studies and meta-analyses. He also demonstrated the main principles and key steps of new trends and approaches in bariatric and metabolic surgery with complications and technical therapeutic aspects.
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
B Dallemagne
Lecture
1 year ago
5733 views
858 likes
1 comment
39:17
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
Laparoscopic equipment and instrumentation in 2017
This two-part presentation outlines the principles and methods of functioning of the main medico-technical devices required to perform laparoscopic surgery.
The first part deals with the laparoscopic unit components including the insufflator, light sources, the evolution of cameras and screens, as well as scopes used in laparoscopic surgery. For each component, operating principles, technological developments, malfunctions and their management are discussed.
The second part presents operating modalities based on novel innovative energy technologies which are used to control tissues. Their operating modalities, specific risks and prevention means are envisaged. This relates in the first place to the evolution of the use of high frequency currents delivering monopolar and bipolar currents within tissues. New ways of management of these currents with tissue vessel-sealing processes are also discussed. Finally, the principles, use and risks of the new means of dissection and tissue sealing with ultrasonic devices are addressed.
The operating principles and the specific risks of all these systems are not well known to surgeons. In case they are not correctly used, they represent new risks and surgeons should be aware of it.
In conclusion, ergonomic choices of conventional instrumentation in minimally invasive surgery are outlined.
D Mutter
Lecture
1 year ago
2762 views
560 likes
0 comments
06:01
Laparoscopic equipment and instrumentation in 2017
This two-part presentation outlines the principles and methods of functioning of the main medico-technical devices required to perform laparoscopic surgery.
The first part deals with the laparoscopic unit components including the insufflator, light sources, the evolution of cameras and screens, as well as scopes used in laparoscopic surgery. For each component, operating principles, technological developments, malfunctions and their management are discussed.
The second part presents operating modalities based on novel innovative energy technologies which are used to control tissues. Their operating modalities, specific risks and prevention means are envisaged. This relates in the first place to the evolution of the use of high frequency currents delivering monopolar and bipolar currents within tissues. New ways of management of these currents with tissue vessel-sealing processes are also discussed. Finally, the principles, use and risks of the new means of dissection and tissue sealing with ultrasonic devices are addressed.
The operating principles and the specific risks of all these systems are not well known to surgeons. In case they are not correctly used, they represent new risks and surgeons should be aware of it.
In conclusion, ergonomic choices of conventional instrumentation in minimally invasive surgery are outlined.