Internal hemorrhoids and loose rectal mucosa may block the exposure during the purse string suturing in stapled hemorrhooidopexy, and this may cause some complications. To retract the prolapsing rectal mucosa we modified the purse string anoscope of the PPH01 kit (Ethicon-Endosurgery, Cincinnati, O...H, USA) and produced a special anoscope. The open part of the purse string suture anoscope is covered by transparent acrylic (Orthoacryl�, Dentaurum, Pforzheim, Germany). The covering material had complete cylindrical outer and inner surfaces and was thin enough to let the anoscope easily rotate in the anal dilator and to let the 26 mm curved, round bodied needle of the 2/0 polypropilene suture move in the anoscope. A window, 3 cm long and 3-4 mm wide, was opened at the angled part of the anoscope 2 cm to the tip of the anoscope. This special anoscope was used for the purse string suture during stapled hemorrhoidopexy procedure in five patients. No postoperative complications, early or late, were encountered, and we propose that stapled hemorrhoidopexy procedure can be applied more easily by using this special anoscope.

The colonoscope is slowly withdrawn during this screening colonoscopy down from the transverse colon, back around the splenic flexure, and down the descending colon, and reveals this finding a colonic diverticula. Diverticulosis is a common, acquired, age-related occurrence affecting over 50% of the... western adult population over the age of 50. It is seen rarely in Africa and Asia where the dietary fiber content is traditionally higher. Thus most investigators feel that low fiber diets are related to the development of this condition. Ironically, colonic diverticula are not true diverticula but rather pseudodiverticula in that the sac includes layers of the mucosa and submucosa that push through rather than include the outer muscular layer. As with the small bowel the colon has an inner circular muscular layer, but the outer longitudinal layer is composed of three bands of muscle that run the length of the colon known as teniae. Diverticula occur in rows between the mesenteric and two antimesenteric teniae where the colonic wall is further weakened by the defect caused by the perforating vasa recti artery which supplies the colonic mucosa. Occasionally, the anatomic propensity of diverticula to form in rows is quite apparent as seen when this clip is replayed in slow motion. Most often, however, the arrangement of the diverticula appears random due to the angulation of the bowel and thickening of the semi lunar folds. The conditions that cause these pulsion diverticula are not know with certainty but may include high intrahaustral pressures, muscular hypertrophy, and age related alterations in collagen cross linking. Diverticula can bleed or can abscess and perforate. The incidence of diverticulitis or diverticular bleeding is in the range of 1:1,000 patients with diverticulosis.

Liver Metastasis Resection. A Technique That Makes It Easier. Authors: de Santibañes E, Sánchez Clariá R, Palavecino M, Beskow A, Pekolj J. Background: Liver resection is the only therapeutic option that achieves long-term survival for patients with hepatic metastases. We propose a tech...nique that causes traction and counter traction on the resection area, thus easily exposing the structures to be ligated. Since the parenchyma protrudes like a cork from a bottle we named this procedure “Corkscrew Technique”. Objective: To describe an original surgical technique to resect liver metastases. Technique: We delimite the resection area at 2 cm from the tumor. We place separated stitches, in a radiate way. The needle diameter must allow passing far from the deepest margin of the tumor. The stitches must be tractioned all together to separate the tumor from the normal parenchyma. Material and Methods: Between years 1983 and 2006, we perform 1270 liver resection. We used the corkscrew technique like only procedure in 612 patients whereas in 129 patients we associated it to an anatomic resection. Results: Mortality was 1%. Morbidity was 16% with a reoperation rate of 3%. Conclusions: The Corkscrew Technique is simple and safe, it spares surgical time, avoids blood loss, ensures free tumor margins and it is easy to perform.

Natural Orifice Endoscopic Transgastric Distal Pancreatectomy, A Prospective Randomized Controlled Trial. Natural orifice surgery may represent a paradigm shift in the area of minimally invasive surgery and therapeutic endoscopy. However, studies to date have been limited primarily to small ca...se series with small sample sizes. There has been no large rigorous randomized controlled trial of natural orifice surgery to date. Early work on procedures such as peritoneoscopy, oophorectomy and tubal ligation, while pioneering, have reproduced laparoscopic procedures with minimal morbidity and mortality. In contrast, distal pancreatectomy has a post-operative morbidity of more than 50% even in high volume tertiary care centers. As a highly morbid surgery, the post-operative event rate would allow for a significant difference to be seen in a trial of conventional versus NOTES distal pancreatectomy. We have recently completed a prospective randomized controlled trial of NOTES versus laparoscopic distal pancreatectomy in a swine model which builds on our earlier non-survival work. This video focuses on the endoscopic technique.

Maintaining sufficient blood flow to the gastric tube after a subtotal esophagectomy for esophageal cancer is crucial for decreasing the esophagogastric anastomotic leakage. After subtotal esophagectomy for esophageal cancer, to additionally revascularize the gastric tube using the splenic artery a...nd vein, external carotid artery, and internal jugular vein, the supercharge technique was performed in esophageal reconstruction patients. Operative results of these patients (supercharge group) were retrospectively compared with those of patients not receiving the technique (control group). Both operation time and operative blood loss in the supercharge group were significantly longer and larger than those of the control group. However, the incidence of anastomotic leakage was significantly lower in the supercharge group than in the control group, and a 30-day reduction in the mean postoperative hospital stay was achieved with the supercharge group. This practical supercharge technique could be a breakthrough less to reduce leakage during esophageal anastomosis.

Robotic surgery was developed to facilitate endoscopic surgery and overcome its disadvantage. Thus, we performed robotic Total Mesorectal Excison (TME) in patient with rectal cancer by using the Intuitive Surgical® da Vinci surgicalTM system (Intuitive Surgical®, Sunnyvale, CA). To our knowledge, ...this is the first robotic low anterior resection base on standard TME principle with pelvic autonomic preservation. In conclusion, Robotic system is the best operative instrument for performing the standard TME procedure in rectal cancer patients.

Loop duodenal switch is an end-to-side proximal duodeno-ileal bypass with a sleeve gastrectomy. The proximal duodenal stump is anastomosed to an ileal loop, 200 cm from the ileocecal valve. The procedure is a malabsorptive operation with some theoretical advantages: only one anastomosis is performed..., and so the operative time is shorter, and there is no mesenteric opening. It is not a mini-gastric bypass, as the gastric antrum, the pylorus and the first centimeters of the duodenum are preserved. The short term outcome shows a very good weight loss curve with no metabolic disturbances.

Can bile duct injuries be prevented? A new technique in laparoscopic cholecystectomy

Over the last decade, laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis. However, the incidence of bile duct injury in laparoscopic cholecystectomy is still two times greater ...compared to classic open surgery. The development of bile duct injury may result in biliary cirrhosis and increase in mortality rates. The mostly blamed causitive factor is the misidentification of the anatomy, especially by a surgeon who is at the beginning of his learning curve. Biliary tree injuries may be decreased by direct coloration of the cystic duct, ductus choledochus and even the gall bladder. Methods gall bladder fundus was punctured by Veress needle and all the bile was aspirated. The same amount of fifty percent methylene blue diluted by saline solution was injected into the gall bladder for coloration of biliary tree. The dissection of Calot triangle was much more safely performed after obtention of coloration of the gall bladder, cystic duct and choledocus. Results Between October 2003 and December 2004, overall 46 patients (of which 9 males) with a mean age of 47 (between 24 and 74) underwent laparoscopic cholecystectomy with methylene blue injection technique. The diagnosis of chronic cholecystitis (the thickness of the gall bladder wall was normal) confirmed by pre-operative abdominal ultrasonography in all patients. The diameters of the stones were greater than 1 centimeter in 32 patients and calcula of various sizes being smaller than 1 cm. were documented in 13 cases. One patient was operated for gall bladder polyp (our first case). Successful coloration of the gall bladder, cystic duct and ductus choledochus was possible in 43 patients, whereas only the gall bladder and proximal cystic duct were visualised in 3 cases. In these cases, ductus choledochus visibility was not possible. None of the patients developed bile duct injury. Conclusion The number of bile duct injuries related to anatomic misidentification can be decreased and even vanished by using intraoperative methylene blue injection technique into the gall bladder fundus intraoperatively.

Removal of adrenal gland

This 81 year old man with severe CAD and CHF was referred for VCE following a negative endoscopic workup for chronic guaiac positive stools. Seen on only three frames, this sequence reveals a single mid small bowel telangectasia, a possible source for his chronic GI blood loss. He has been managed c...onservatively and continues to require intermittent transfusions despite oral iron therapy.

Transoral Access in Endoscopic Thyroid Surgery Background: The number of patients demanding endoscopic neck surgery is rising. The access trauma of the axillary, breast and chest approaches is bigger than in open or video assisted surgery. We tested the feasibility of he sublingual transoral access which is in our opinion the only real minimally...-invasive extracollar endoscopic access to the thyroid gland Methods: We performed an experimental investigation in a porcine model. In 10 pigs we made 10 endoscopic transoral thyroidectomys with a modified axilloscope with the help of ultrasonic scissors and a neuro-monitoring system for identification of the recurrent laryngeal nerve. Results: The average operation time from the introduction to the removal of the obturator just above the larynx was 57 seconds. The mean operation time was 43 minutes. With the help of the neuro-monitoring system we proved in all cases the function of the recurrent laryngeal nerve on both sides. The pigs were observed for another two hours after operation. During and after the operation no complications appeared. Conclusions: We could show that the endoscopic transoral thyroid resection in pigs is possible and save. Our results might be useful for using this access for endoscopic thyroid resection in humans.

Background: The number of patients demanding endoscopic neck surgery is rising. The access trauma of the axillary, breast and chest approaches is bigger than in open or video assisted surgery. We tested the feasibility of he sublingual transoral access which is in our opinion the only real minimally...-invasive extracollar endoscopic access to the thyroid gland Methods: We performed an experimental investigation in a porcine model. In 10 pigs we made 10 endoscopic transoral thyroidectomys with a modified axilloscope with the help of ultrasonic scissors and a neuro-monitoring system for identification of the recurrent laryngeal nerve. Results: The average operation time from the introduction to the removal of the obturator just above the larynx was 57 seconds. The mean operation time was 43 minutes. With the help of the neuro-monitoring system we proved in all cases the function of the recurrent laryngeal nerve on both sides. The pigs were observed for another two hours after operation. During and after the operation no complications appeared. Conclusions: We could show that the endoscopic transoral thyroid resection in pigs is possible and save. Our results might be useful for using this access for endoscopic thyroid resection in humans.

Biliary and Pancreatic Sphincterotomies for Sphincter of Oddi Dysfunction

This 43 year old woman has severe recurrent RUQ pain post cholecystectomy. Liver and pancreatic chemistries and duct size are normal, but pancreatic manometry is abnormal. The plan is to perform dual biliary and pancreatic sphincterotomy. The pancreatic duct is cannulated with a 3.9 French tip tr...iple lumen papillotome loaded with a 0.025 inch Jagwire. Contrast is injected to outline the course of the duct. The wire is passed to the tail. Notice the knuckling of the wire into the tail. This provides a safety loop, but is only safe in a small duct with use of a smaller caliber wire. Then with the wire securely in PD, papillotome is used to cannulate the bile duct. Placement of the wire in PD guarantees access for pancreatic stent placement, which is mandatory in these patients to reduce risk, it also facilitates difficult biliary cannulation. Here is the fluoroscopic view as the papillotome is passed deep into bile duct. This shows wires in the CBD and PD. Now a biliary sphincterotomy is performed, with the pancreatic guidewire in place beside the papillotome. The scope is pushed into a longer position to orient up the middle of the papilla. The sphincterotomy is done in very careful stepwise fashion to avoid perforation. Now the biliary wire is removed and the papillotome passed over the pancreatic wire for pancreatic sphincterotomy. The incision is aimed back up towards the biliary sphincterotomy to ensure the septum only is cut. Note the large pancreatic orifice. Last, a 4 French 9cm unflanged soft material pancreatic stent is placed. We always use single pigtail design to avoid inward migration of the stent. The long unflanged design allows spontaneous passage within a few weeks.

Animated video about Cardiac Arrhythmia

Avideo showing suturing of the uterus and abdominal wall after c-section

Scleral Buckling: Slinging Muscles & Marking Breaks VR1 Basic Techniques

Off-Pump CABG in Dextrocardia; A New Challenge for a New Era

Axillary Cannulation: Antegrade Flow and Brain Protection

Repair of Anomalous Left Coronary Artery from the Pulmonary Artery (AlCAPA) in an Adult

Aortic Valve-Sparing Operation in a Patient with Aortic Root Aneurysm using a new Prosthesis for Anatomical Reconstruction of the Sinuses of Valsalva