Video Article Research Articles

Leyomiomatosis peritonealis disseminata associated with ovarian endometriosis in a patient submitted to hysteroscopic myomectomy

To describe laparoscopic management of a case of leyomiomatosis peritonealis disseminata associated with ovarian endometriosis. Surgical video article. Academic hospital. We present a case of a 30-year-old woman referred to our clinic for abdominal and pelvic pain and dyspareunia. A hysteroscopic myomectomy was reported as previous surgical history. At ultrasound examination, a left ovarian cyst of 4cm suspected for typical endometrioma and a mild hydroureteronephrosis of left kidney were revealed. The patient was scheduled for laparoscopic surgery. During laparoscopy, multiple nodules were found simulating widespread metastases involving colon, small bowel, omentum, right diaphragmatic dome, gastric surface, vesico-uterine area and abdominal peritoneum. Several biopsies and a peritoneal washing were performed, suspecting a peritoneal carcinomatosis. The histological frozen section examination revealed a possible benign disease, requiring further immunohistochemical study that diagnosed leiomyomatosis peritonealis. A second laparoscopy was then performed after one month. Enucleation of the left ovarian endometriotic cyst with classic stripping technique was performed. The left ureter was compressed by a fibrotic nodule of 5cm that was isolated and removed. Operating time was 80minutes. The postoperative course was uneventful and the patient was discharged on postoperative day2. Description of a case of leiomyomatosis peritonealis disseminata in a patient with no previous history of intra-abdominal morcellation. The removal of the left ovarian endometriotic cyst and the periureteral nodule was successfully performed. The patient reported good health conditions without hydroureteronephrosis at six months follow up visit. Leiomyomatosis peritonealis disseminata is a rare clinical disorder characterized by proliferation of nodules, consisted by smooth muscle cells. The association of this condition with endometriosis has been described in other studies. Despite several medical therapies have been proposed (chemotherapy, aromatase inhibitor, gonadotropin-releasing hormone agonist), surgical excision remains a good option, frequently performed for symptoms palliation. Laparoscopic approach might be considered the procedure of choice in case of symptomatic women with leiomyomatosis peritonealis disseminata.

Intracerebral Delivery in Complex 3D Arrays: The Intracerebral Microinjection Instrument

This video article describes and illustrates the function and application of the intracerebral microinjection instrument (IMI). This newly developed technology allows delivery of therapeutic agents within the human brain in complex 3-dimensional arrays using a single pass or minimal overlying penetrations through brain tissue. The IMI uses a delivery microcannula with a reduced diameter that minimizes local trauma and is capable of delivering precise volumes of therapeutic agents to discrete brain substructures. The IMI also permits simultaneous recording of neural activity during the delivery procedure, enabling extreme precision using electrophysiologic mapping. Surgical planning software designed specifically for the IMI enables strategic placement of multiple injections. This technology platform is presently being used successfully to deliver therapeutic stem cells to restore function in stroke patients. Additional applications of the IMI include delivery of viral vectors for gene therapy, infusion of neurotrophic factors, targeted delivery of chemotherapeutic agents, and delivery of antiretroviral medications.

Laparoscopic Resection of Diaphragmatic Endometriosis in 10 Steps

Laparoscopic resection of diaphragmatic endometriosis has the advantages of a minimally invasive approach [1]. The standardization and description of the technique are the main objectives of this video. We described the procedure in 10 steps to make it easier and safer. A step-by-step video demonstration of the technique (Video 1). A French university tertiary care hospital. Patients with diaphragmatic endometriosis confirmed by magnetic resonance imaging [2]. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. There are no guidelines on the surgical treatment of diaphragmatic endometriosis [3]. We propose a laparoscopic approach using a right lateral access with the patient in the left lateral decubitus position [4]. This video presents the procedure divided into the following 10 steps: step 1, set up; step 2, patient position; step 3, installation of the trocars; step 4, releasing the liver; step 5, exposure of the diaphragmatic endometriosis; step 6, making a diaphragmatic defect; step 7, exploring the thoracic cavity; step 8, resection of diaphragmatic endometriosis; step 9, inserting the suction catheter; and step 10, closing the diaphragmatic defect. Standardization of laparoscopic resection of diaphragmatic endometriosis could make this procedure easier and safer to perform. The left lateral decubitus position helps to have complete exposure of the right diaphragmatic muscle and endometriosis. We presented 10 steps to help perform each part of the surgery in logical sequence, making the procedure ergonomic and easier to adopt and learn [5]. Standardization of laparoscopic techniques could help to reduce the learning curve.

Extraperitoneal radical trachelectomy with pelvic lymphadenectomy.

Radical trachelectomy combined with pelvic lymphadenectomy has been used to treat patients with early-stage cervical cancer who wish to preserve their fertility. Vaginal, abdominal, laparoscopic, and robotic approaches have been employed during this procedure, but all cause peritoneal damage, which could result in periadnexal adhesion. As periadnexal adhesion can lead to female infertility due to restricted sweeping of the fimbria over the ovary, it is important to minimize peritoneal damage during the fertility-preserving surgery. Aiming to minimize peritoneal damage, we recently developed a new surgical approach. The techniques used are similar to those used for type III radical hysterectomy; however, all procedures are performed via the extraperitoneal approach.In this video article, we describe a step-by-step technique of this new fertility-preserving surgical procedure. Surgical procedures are as follows: (1) extraperitoneal pelvic lymphadenectomy, (2) excision of the vesicohypogastric fascia and median umbilical ligament, (3) bladder dissection from the peritoneum and identification of uterine cervix, (4) transection of the cardinal ligaments and vesicouterine ligaments, (5) transection of the vagina, (6) excision of the rectovaginal and uterosacral ligaments, (7) transection of the uterine cervix, (8) cervical cerclage and placement of a Foley catheter, (9) anastomosis of the uterine cervix, (10) suture of the median umbilical ligament and vesicohypogastric fascia. During these procedures, the uterine arteries, inferior hypogastric nerve, and pelvic splanchnic nerve were preserved. The advantages of this new surgical approach are first, peritoneal injuries can be completely avoided as the procedure is performed extraperitoneally, and second, it can be carried out using conventional low-cost instruments. In view of these features, we consider that this technique could be an ideal treatment option for selected women with early-stage cervical cancer. The oncological and reproductive outcomes of this new surgical approach need to be evaluated in future clinical studies.

Mini-invasive transvaginal repair of isthmocele: a video case report

To describe our technique for transvaginal treatment of isthmocele. Surgical video article. Local Institutional Review Board approval for the video reproduction was obtained. A scientific institute. A 26-year-old patient complaining of abnormal uterine bleeding and pelvic pain was referred to our gynecological clinic for secondary infertility. At transvaginal ultrasound examination, a cesarean scar defect of 22 × 11mm was identified, with a residual myometrial thickness over the defect of 2mm. Isthmocele excision and myometrial repair was performed transvaginal, under regional anesthesia. Before surgery, a hysteroscopy was performed to identify the dehiscence of the cesarean scar on the anterior wall of the uterus and to confirm the presence of the isthmocele and its distance from the external os. Then an incision was made at the anterior cervicovaginal junction and the bladder was dissected away until the anterior peritoneal reflection was identified. Hysteroscopic guidance by transillumination was used to identify the exact position and the limits of the isthmocele. The fibrotic tissue was then removed, and the myometrial defect was closed with interrupted sutures by using 2-0 Vicryl, engulfing the myometrial fibers that would tend to slide laterally. The vaginal mucosa was then sutured with interrupted Vicryl 2-0 sutures. At the end of the procedure, a hysteroscopy was performed to visualize the correction of the defect and to prove the continuity of the cervical canal with the uterine cavity. Repair of isthmocele and relief of symptoms. The postoperative course was uneventful, and the patient was discharged the day after surgery. At 1-month follow-up pelvic ultrasound showed complete anatomic repair of the uterine defect. The patient was asymptomatic with no more postmenstrual bleeding. She is satisfied with the treatment and is still trying for pregnancy. Symptomatic isthmocele can be treated surgically via a hysteroscopic, laparoscopic, or vaginal approach, depending on the clinical findings and the skill set and comfort level of the surgeon. Unfortunately, there is no consensus about the ideal surgical approach. The hysteroscopic approach has been demonstrated to be effective for the treatment of abnormal uterine bleeding; however, it does not strengthen the uterine wall and it has a risk of bladder injury. The laparoscopic approach provides good anatomic results, but it requires general anesthesia and may be associated with bladder injury. The transvaginal approach appears to be a feasible, effective, and safe modality to repair the uterine defect and to restore the original thickness of the myometrium. It is a minimally invasive, scarless, and low-cost procedure. It ensures quick recovery and a relatively pain-free postoperative course with early return to normal function.

Laparoscopic ovarian tissue harvesting and orthotopic ovarian cortex grafting for fertility preservation: less is more

To describe our surgical techniques for laparoscopic ovarian tissue harvesting and orthotopic ovarian cortex grafting (LOOCG). This video article uses surgical cases to demonstrate the detailed surgical techniques. Institutional Review Board approval was not required for this video presentation. University hospital. Patients presenting with indication for fertility preservation by means of ovarian tissue harvesting and orthotopic ovarian cortex grafting (in case of setting up a high risk of gonadotoxicity treatment or patients presenting with a pathology with risk of premature ovarian failure). Ovarian tissue harvesting: The entire ovary is harvested by placing an EndoGIA stapler to ensure the control of infundibulopelvic ligament and then, after reloading, the section of the mesovarium. LOOCG one-step procedure: A large and superficial incision of the peritoneum is performed to create a peritoneal pocket. The fragments of ovarian cortex are secured with the use of nonresorbable surgical wire (Prolene 5.0) and introduced into the peritoneal pocket. The peritoneum is not closed after placing the graft. Value and feasibility of LOOCG. Restoration of endocrine function and fertility results. Thirty-four patients were included from November 2011 to October 2017. LOOCG restored ovarian endocrine activity in 88.2% of cases. Ten patients had become pregnant (29.4%), and the same number gave birth to at least one child. Our surgical approach is simple, safe, and reproducible and seems to be as effective as previously described techniques. It deserves to be proposed to patients eligible for ovarian cortex grafting.

Laparoscopic Myomectomy in 10 Steps

Laparoscopic myomectomy has the advantages of a minimally invasive approach for the surgical treatment of myomas. The standardization and description of the technique are the main objectives of this video. We described laparoscopic myomectomy in 10 steps, which could help make this procedure easier and safer [1]. A French university tertiary care hospital. Patients with indication for laparoscopic myomectomy. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. Standardized laparoscopic myomectomies were recorded to realize the video. This video presents a systematic approach to myomectomy clearly divided into 10 steps: (1) prepare your surgery, make selection and prehabilitation of patient [2], provide a good cartography of the myoma(s), and plan the surgery [3,4]; (2) ergonomy and material; (3) preventive hemostasis: triple occlusion; (4) hysterotomy; (5) enucleation by fast dissection and traction; (6) bipolar hemostasis; (7) check for missing myomas; (8) suture; (9) extraction/morcellation; and (10) prevent adhesions [5]. Standardization of laparoscopic myomectomy could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of surgery in logical sequence making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Arthroscopic Anterior Talofibular Ligament Repair with Use of a 2-Portal Technique.

Ankle sprains are common musculoskeletal injuries, with approximately 27,000 occurring every day in the U.S. alone. The anterior talofibular ligament (ATFL) is the most commonly injured ligament. Although most acute lateral ankle sprains can be treated conservatively, up to 20% of these injuries result in chronic lateral ankle instability and may require surgical stabilization. Recently, an arthroscopic lateral ankle ligament repair technique has become increasingly popular. This minimally invasive procedure is expected to reduce postoperative pain and promote faster recovery. The current article presents an ATFL repair using a 2-portal, non-distraction arthroscopic technique. Chronic lateral ankle instability refractory to physical therapy for 3 to 6 months is the main indication for surgical treatment, and sufficient quality of ligament tissue remnant is required for arthroscopic repair. Compared with an open procedure, equivalent clinical results and earlier recovery following arthroscopic ATFL repair have been reported. The major steps of the procedure, demonstrated in this video article, are (1) placement of portals for the arthroscopic procedure, (2) suture anchor insertion into the distal aspect of the fibula, (3) needle insertion into the ATFL remnant, (4) a lasso-loop stitch using a suture relay technique, (5) reattachment of the ATFL remnant, and (6) postoperative protocol. Complications are rare, and earlier return to daily activities compared with a standard open technique can be achieved.

Retroperitoneoscopic lower pole heminephrectomy

Retroperitoneoscopic heminephrectomy is a challenging procedure but with advantages over open and transperitoneal laparoscopic approaches. Lower pole heminephrectomy is less commonly undertaken compared with the upper pole.s OBJECTIVE: This VideoBank article aims to aid the surgeon in reducing the associated risks by demonstrating key steps including patient positioning, access and demonstrating key critical views. This is a video article with audio commentary of a pediatric patient undergoing a retroperitoneoscopic lower pole heminephrectomy. Lower pole heminephrectomy can be safely undertaken via a retroperitoneoscopic approach.

Surgical Management and Prevention of Ovarian Remnant

Study ObjectiveTo provide surgeons with surgical techniques necessary for management and prevention of ovarian remnant syndrome. DesignInstructional video (Canadian Task Force classification III). SettingAcademic medical center. InterventionSurgical dissection and retroperitoneal anatomy. Measurements and Main ResultsOvarian remnant syndrome occurs when residual ovarian tissue inadvertently remains in situ after salpingo-oophorectomy [1–4]. It can result in pelvic pain and pelvic mass [1–4]. Risk factors include endometriosis, adhesive disease, pelvic inflammatory disease, and prior pelvic surgery [1–4]. Ovarian remnant can also occur as a result of ovarian stroma extending up to 1.4 cm into the infundibulopelvic ligament beyond the visible margin [5]. Medical management and radiotherapy are treatment options but do not provide the definitive management that surgery affords [1–4]. Surgery also avoids missing a potential malignancy within the remnant tissue [1–4]. This video demonstrates the surgical techniques necessary to treat and prevent this condition, including key retroperitoneal anatomy. Mayo Clinic Institutional Review Board approval was not required for this video article. ConclusionBoth treatment and prevention of ovarian remnant syndrome follow the same basic surgical principles, including high ligation of the infundibulopelvic ligament, retroperitoneal dissection, and excision of all peritoneum and tissue adherent to the ovary.

Laparoscopic uterine fixation to spare fertility before pelvic radiation therapy

To describe a surgical technique for laparoscopic uterine fixation (LUF) to decrease uterine radiation therapy side effects in case of rectal or anal cancer. This video article uses a surgical case to demonstrate the detailed technique. Institutional Review Board approval was not required for this video presentation. University hospital. A 26-year-old nulliparous female patient diagnosed with rectal adenocarcinoma and liver metastases. After the completion of right hepatectomy and neoadjuvant chemotherapy with the use of the FOLFOX regimen, pelvic radiation therapy was applied before tumor excision. The patient underwent laparoscopic ovarian transposition. During the same intervention, we fixed the uterus with three late resorbable sutures into the fascia of the anterior abdominal wall as cranial as possible to remove the uterus away from the radiation field. Value and feasibility of LUF. LUF was feasible and effective. Estimated isodoses demonstrated that this intervention may decrease uterine consequences of pelvic radiotherapy. The patient did not report any specific pain or complication in the postoperative period. Three months after the completion of pelvic concurrent chemoradiation therapy, the patient had normal menstrual periods. Hormonal blood tests were satisfactory. Ultrasound showed persistent ovarian function. Considering its simplicity of realization, LUF should be discussed for reproductive-age patients before undergoing pelvic radiotherapy for anal or rectal cancer. A close collaboration is required between surgeons and radiation oncologists to optimize the treatment and to decrease side-effects of radiotherapy. Intensity-modulated radiation therapy may contribute to enhance a multimodal fertility-sparing strategy in global management of young patients.

Techniques for Preemptive Analgesia in Gynecologic Surgery

To provide surgeons with techniques for preemptive analgesia during minimally invasive gynecologic surgery. Postoperative pain management is an important component of patient care after gynecologic surgery. There have been numerous advances in pain management, including studies that show that preoperative administration of analgesics decreases postoperative pain scores and narcotic medication requirements [1-3]. However, there is limited information on the techniques for preemptive analgesia [4,5]. An instructional video showing a variety of preemptive analgesia techniques and the corresponding neuroanatomy (Canadian Task Force classification III). Mayo Clinic Institutional Review Board approval was not required for this video article. Academic Medical Center INTERVENTIONS: Relevant abdominopelvic neuroanatomy is reviewed. This is followed by a demonstration of the preemptive analgesia techniques based on neuroanatomy principles. Techniques for preemptive analgesia are simple and effective. These tools can be used for patients undergoing gynecologic surgeries via a vaginal or abdominal approach and can help optimize postoperative pain and narcotic usage.

Individualized alignment in total knee arthroplasty using image-based robotic assistance : Video article.

IntroductionOver the past decades many innovations were introduced in total knee arthroplasty (TKA) focusing on implant longevity and higher procedural precision; however, there are still a high number of dissatisfied patients. It was reported that better anatomical alignment may result in improved patient outcome; however, current technologies have limitations to achieve this. The aim of this video article is to describe the technique of individualized alignment in TKA with the use of image-based robotic assistance.MethodsThe technology is based on an individual patient knee model computed from segmented computed tomography (CT) scans. A preoperative planning of prosthesis position is conducted following the principle of kinematic alignment. Intraoperatively the soft tissue envelope is recorded and the computer predicts the gap balance based on the virtual planning. The prosthesis position is then adapted to achieve balanced gaps and to avoid soft tissue release. This technique is shown in a cadaver operation and clinical examples of two patients are described.ResultsWith the combination of anatomically oriented prosthesis positioning and minor adaptations with respect to the soft tissue, an individualized alignment is achieved with reduced need of soft tissue release. The robotic-assisted surgery guarantees a precise implementation of the planning. The initial experience showed a promising outcome in short-term follow-up.Video onlineThe online version of this article (10.1007/s00132-018-3637-1) contains a video on patient individualized alignment in total knee arthroplasty. The article and video are available in the electronic full text archive at SpringerMedizin.de under http://www.springermedizin.de/der-orthopaede. The video can be found at the end of the article as supplementary material.

Central Neck Dissection: The Five Key Steps

Abstract In this video article, we present an interesting clinical case as a vehicle for discussing the indications for a central neck dissection and the important technical points, including the f...

Invasive Hemodynamic Characterization of the Portal-hypertensive Syndrome in Cirrhotic Rats.

This is a detailed protocol describing invasive hemodynamic measurements in cirrhotic rats for the characterization of portal hypertensive syndrome. Portal hypertension (PHT) due to cirrhosis is responsible for the most severe complications in patients with liver disease. The full picture of the portal hypertensive syndrome is characterized by increased portal pressure (PP) due to the increased intrahepatic vascular resistance (IHVR), hyperdynamic circulation, and increased splanchnic blood flow. Progressive splanchnic arterial vasodilation and increased cardiac output with elevated heart rate (HR) but low arterial pressure characterizes the portal hypertensive syndrome. Novel therapies are currently being developed that aim to decrease PP by either targeting IHVR or increased splanchnic blood flow - but side effects on systemic hemodynamics may occur. Thus, a detailed characterization of portal venous, splanchnic, and systemic hemodynamic parameters, including measurement of PP, portal venous blood flow (PVBF), mesenteric arterial blood flow, mean arterial pressure (MAP), and HR is needed for preclinical evaluation of the efficacy of novel treatments for PHT. Our video article provides the reader with a structured protocol for performing invasive hemodynamic measurements in cirrhotic rats. In particular, we describe the catheterization of the femoral artery and the portal vein via an ileocolic vein and the measurement of portal venous and splanchnic blood flow via perivascular Doppler-ultrasound flow probes. Representative results of different rat models of PHT are shown.

The Shore Revisited

This video article is based on a recorded return, in 2018, to the site of a performance for camera repeated weekly on Harakka Island in Helsinki during the year of the goat (2003–2004) as well as for a day and night during Easter that year. The video installations made fourteen years earlier are inserted in miniature format within the recent recording, complemented by journal entries from the day and night. The voice-over text discusses concerns relevant at the time of recording the performances and displaying the installations for the first time, such as the question what is repeated, what stays the same. It uses these works to exemplify one possible understanding of Karen Barad’s notion agential cut.

Can we improve the results of venous grafts in CABG?

Saphenous Vein as a conduit in coronary artery bypass surgery (CABG) has a high attrition rate. Yet because of free availability and technical ease of use, it accounts for 80% of all grafts in CABG. The reasons for its failure and the ways to improve its patency have been discussed in this video article with special emphasis on post harvest storage of the vein grafts.

The minimally invasive AMIS technique for total hip replacement : Video article

Minimally-invasive implantation of atotal hip arthroplasty without damage to or incision of muscles. Osteoarthritis, femoral neck fracture, general indications for total hip arthroplasty. Contraindications for hip arthroplasty. The surgical technique is demonstrated in detail with the help of avideo of the surgical procedure, which is available online: positioning on afracture table with a special leg holder, anterior approach between tensor fasciae latae and rectus femoris muscle, incision of hip capsule and capsular protection, osteotomy of femoral neck in situ, removal of femoral head and acetabular reaming, minimally invasive implantation of acetabular cup, release of pubofemoral ligament and-if necessary-ischiofemoral ligament, external rotation and hyperextension in leg holder with elevation of the proximal femur by ahypomochlion, femoral preparation and implantation of femoral implant, reposition, capsular suture, wound closure. Weight-bearing as tolerated, free movement without limitation of range of motion. Randomized trials and systematic reviews report faster rehabilitation with early mobilization, within the first 3months after surgery; less postoperative pain, less muscle damage and shorter hospital stay; older patients benefit from reduced morbidity and mortality.

Uterus transplantation: organ procurement in a deceased donor model

To demonstrate our technique of uterine procurement from a deceased donor. This video uses live action footage from surgery and detailed illustrations to review the steps and techniques involved in deceased donor procurement surgery. Academic medical center. A deceased multiorgan donor. Trial organ procurement of a viable uterus from a deceased donor. Procurement time and associated features of suitability of dissected specimen. This video article describes the advantages of a deceased donor model over a live donor model, including eliminating the risk of surgical complications to a living donor, avoidance of ethical issues inherent in live donation, easier access to generous vascular pedicles for anastomosis, and faster procurement time. This video also outlines the key steps to a successful uterine procurement using illustrations and live action footage from a trial organ procurement. Uterine transplantation is an emerging surgical treatment for patients with absolute uterine factor infertility. Continued practice is essential in preparing for a deceased donor uterine procurement. The process continues to be refined and adapted as new information becomes available toward the goal of safe, efficient, ethical, and effective surgical treatment of absolute uterine factor infertility.

VIDEO: Ultrasound Evaluation of External Shoulder Impingement.

The purpose of this video article is to show sonographic anatomy at the shoulder joint relevant to impingement and to describe the diagnostic techniques that can be used to diagnose this condition. The article contains several video clips depicting both the normal and pathologic appearances of the bursa during dynamic assessment. The technique for guided injection at this location with sonographic guidance will be covered as well as pitfalls for reporting impingement. Dynamic ultrasound assessment of the shoulder is a useful adjunct to clinical assessment in the evaluation and diagnosis of impingement.