experience using stereoscopic 3D volume rendered images coupled with the robotic system during abdominal surgery. Methods: Volume rendered images were obtained from standard computed tomography datasets using the OsiriX DICOM workstation. Regions of interest were highlighted and the relationship with patient’s vital anatomical structures established. A custom plugin allowed for stereoscopic volume rendered reconstruction within the da Vinci surgeon’s console, using TilePro™ multi-input display. The upper part of the screen showed the endoscopic operative view while the bottom showed the previously prepared reconstructed stereoscopic volumes. Images manipulated within OsiriX using a 3D mouse (3DConnexion Inc., Silicon Valley, CA, USA) installed on the console bar, are updated in real time in the Surgeon’s Console. Results: During cholecystectomy, the surgeon switched several times to the mixed reality view, comparing the endoscopic and virtual images that appear in his field of vision, looking for the spatial location of the gallbladder. Its relationship with the common hepatic duct and the common bile duct was easily established. Finally, the absence of aberrant biliary duct was confirmed. During robotic colectomy, tumor position, vascular supply, spatial location and relationships between organs appeared directly within the surgeon’s field of view. This allowed for a safer procedure; sight diversions out of the surgical field of view were no longer necessary. Depth perception was subjectively perceived as profitable. Conclusion: Total immersion in the operative field may give the surgeon greater control over the surgical procedure, which partially replaces the lack of tactile feedback specific to robotic intervention. Surgical teaching will also benefit from these technological progresses facilitating transmission of knowledge and skill to young surgeons. This innovative tool is another step towards augmented reality robot-assisted surgery.
8.2 Laparoscopic extralevator abdominoperineal resection (APR) for very low rectal cancer L. Marti1,2, S. Bischofberger1, C. Maurus1, B. Schmied1, M. Thurnheer1 (1St. Gallen, 2Mannheim/DE) Objective: Many studies showed an inferior oncological outcome after standard abdominoperineal resection (APR) compared to low anterior resection for rectal cancer. This was attributed to the technique of standard APR, which creates a waist at the level of the tumor-bearing segment. Hence T. Holm and other surgeons developed a new procedure with resection of the levator ani near its origin. This extralevator APR allows for a more cylindrical resected specimen. As a consequence less involvement of the circumferential margin, less intraoperative bowel perforations, and lately less local recurrences have been shown. Methods: In our video we demonstrate the extralevator APR in a female patient with a sphincter involving rectal cancer. After stages in Leeds and Stockholm the procedure was introduced and standardized. A laparoscopic abdominal phase is combined with the prone resection followed by a reconstruction of the pelvic floor using a biological mesh. Results: The procedure is started in a Lloyd-Davis position after introducing two 12mm and two 5mm trocars. The inferior mesenteric vessels are divided centrally. The mesorectum is mobilized posteriorly down to coccyx, and anteriorly to the cranial third of the vagina. Consecutively the mesentery and the descending colon are divided. A terminal stoma is formed at the planed location. The patient is brought in a prone-jackknife position. The anus is closed with a purse-string suture, the skin incised and the perianal fat dissected down to the levator ani. The presacral space is entered by division of the coccyx. The levator ani is divided at its origin on both sides. This permits to bring down the mobilized rectosigmoid. Finally the resection is completed anteriorly at the posterior vaginal wall. A Permacol^TM mesh is sutured into the big defect in the pelvic floor and the perineal wound is closed in layers. Conclusion: The extralevator APR enables for dissection in safer distance to a sphincter infiltrating rectal cancer and if done in prone position gives a better view for the dissection of the posterior aspect of the vagina or the prostate. Closure of the pelvic floor using a porcine collagen mesh makes this safer by preclusion of perineal hernias and lessening the impact of the common wound problems. Combined with a laparoscopic approach, the procedure has also the potential to improve postoperative recovery.
8.3 How do we apply the video assisted retroperitoneal necrosectomy with minimal access? A. S. Wenning, A. Lechleiter, E. Angst, B. Gloor, D. Candinas (Bern) Objective: The conservative treatment of acute necrotizing pancreatitis has much improved, due to broad antibiotic treatment and improved organ support in intensive care units. Nevertheless infected necrosis or persistent multi-organ dysfunction are predictors of poor outcome. Therefore we still need to perform necrosectomy in these patients. Open surgery results in extensive operative trauma and is associated with high morbidity and mortality. Therefore, several minimally invasive techniques have been developed in the last years. Retroperitoneal necrosectomy has been shown to be safe and to reduce morbidity and mortality compared to the open procedure. Results: In an instructive video we show the technique of video assisted retroperitoneal necrosectomy with minimal access, including the preoperative percutaneous drain and several methods to approach the necrosis. We will show a typical case and discuss the indication for retroperitoneal necrosectomy as well as the optimal time point of the intervention. Conclusion: In the management of acute necrotizing pancreatitis the team-approach is crucial. The initial treatment by the intensive care unit should be extended to surgery in case of infected necrosis or persistent multi-organ dysfunction. We show here the neat solution with the placement of a percutaneous drain followed by video assisted retroperitoneal necrosectomy.
8.4 Partial splenectomy using laparoscopic-open technique G. Hässig, P. Villiger (Chur) Objective: Non-parasitic splenic cysts are very rare. They are classified as primary (true) cysts with epithelial lining or secondary cysts (pseudocyst) without epithelial lining. Due to the risk of rupture and abdominal disorders large cysts require operative surgical therapy. The first open splenectomy was described in 1549. The first laparoscopic splenectomy was performed in 1992 and is the preferred treatment for elective procedures with better intraoperative visualisation and benefits for the patient with lesser pain reduced hospital stay. During the last years, laparoscopic spleen preserving treatment of cysts was described in several studies and case-reports as a treatment opportunity to preserve splenic function. We present a video of a partial splenectomy using a combined laparoscopic/open technique. Methods: A 37-year-old woman was admitted with acute abdominal pain. The CT scan showed a rupture of a splenic cyst. Initially, a conservative approach was performed. A recurrence of the cyst (7x8x11cm) was detected with ultrasound five weeks later. Due to the increased risk of rupture, surgical treatment was indicated. After placement of four ports in the left hemiabdomen the spleen is completely freed. Through a leftsided subcostal incision of 7cm the spleen was exteriorized. The dissection of the polar vessels supplying the superior lobe was preformed extra- corporally. The resection of the superior pole including the cyst using UltraCision was undertaken following the line of demarcation. After applying FlowSeal and TaboTamp on the resection surface the spleen was frapped in a Vicryl-Mesh. Finally the intraabdominal situs was controlled laparoscopically. Results: Intra- and postoperative course was uneventful. The patient was discharged on postoperative day 5. The histologic work-up confirmed a unilocular cyst lined by an epithelial layer. Duplex ultrasound taken 6 weeks later showed a homogeneous perfusion without areas of hypoperfusion. The patient was completely free of discomfort. While preserving splenic function there is no need of vaccination (Meningococcus, Pneumococcus) to reduce the risk of an overwhelming postsplenectomy sepsis. Conclusion: The combined laparoscopic/open surgical approach for partial splenectomy is a safe and successful technique for the treatment of non-parasitic cysts.
8.5 Single port laparoscopic assisted transvaginal puncture of pericolic abscess (SAT – Procedure) P. Folie, N. Kalak, F. Marra, K. Ukegjini, S. Bock, A. Kachel, D. Gallay, C. Maurus, W. Brunner (Rorschach) Objective: The first therapy choice for covered perforation of the sigmoid colon with local abscess is usually ultrasound or CT scan guided drainage. In case of failure laparoscopic or sometimes blind transvaginal approach is considered. Due to the fact that transvaginal Hybrid -NOTES (natural orifice transluminal endoscopic surgery) and Single Port Surgery is practiced regularly at our institution we are skilled in performing transvaginal access. We propose SAT – Procedure (Single port Abdominal – Transluminal) for these combination of Single Port and Hybrid Notes Surgery. Methods: We report about a 62-year-old woman who presented on our emergency ward with left abdominal pain and local peritonismus in the left lower quadrant. Six weeks before the patient underwent routine colonoscopy, which revealed diverticulosis of the sigmoid colon. Emergency abdominal CT scan revealed now diverticulitis of the sigmoid colon with a covered local perforation and an abscess graded Hinchey II, Hanson Stock IIb. CT-guided puncture failed because of the abscess’ special location hidden in the small pelvis with proximity to the vagina. For well-directed drainage we decided to do diagnostic Single Port laparoscopy combined with transvaginal puncture. This method allowed for a safe approach with the possibility of puncturing transvaginally under direct vision and installation of drainage by insertion of an indwelling catheter transvaginally in the abscess. Additionally i.v.-antibiotics were administered to the patient in the usual fashion. The catheter was left in place until normalization of the initially elevated CRP and then easily could be removed by unblocking and pulling. Results: Our patient could be discharged after 10 days and is planned for sigmoid resection in an elective setting after six weeks. Conclusion: In this case we showed that Single Port laparoscopic assisted transvaginal abscesspuncture in patients with complicated diverticulitis is feasible and safe, if ultrasound- or ct- guided drainage fails. Combination of single port approach and NOTES is proposed to be named SAT – Single Port Abdominal – transluminal procedure.
8.6 Is transumbilical single port laparoscopic transabdominal preperitoneal repair for acutely incarcerated inguinal hernia feasible? F. Marra, N. Kalak, P. Folie, S. Bock, C. Ukegjini, A. Kachel, D. Gallay, C. Maurus, W. Brunner (St.Gallen) Objective: Approximately 5% of men and 17% of women suffering from inguinal hernia undergo emergency surgery because of incarceration. Laparoscopic treatment is a common practice nowadays. We evaluate the feasibility of transumbilical single port laparoscopic transabdominal preperitoneal repair for acutely incarcerated inguinal hernia. Results: A 53-year-old man presented to emergency with the last 4 hours suddenly occurring severe pain in the left inguina. Six years ago he was operated on for a combined inguinal hernia using an open Lichtenstein technique. A 4cm wide visible and painful palpable bulge in the groin was present in the sense of an incarcerated hernia. By an transumbilical incision, a diagnostic laparoscopy revealed an incarcerated, combined recurrent inguinal hernia with abdominal fat as content of the herniation. A single port transabdominal preperitoneal repair was performed without complications. The postoperative
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