AIS CHANNEL

Left Colectomy for Cancer and Vaginal Extraction

Laparoscopic left colectomy is a standardized procedure and a cornerstone of ERAS management. Nonetheless, in France in 2014, 45% of left colectomy was still performed by laparotomy. And yet the benefits of laparoscopic approach have been established for a long time: low mortality, low morbidity and reduction of hospital stay. With the use of the ERAS program all these benefits have been increased. In our institution we routinely perform ambulatory colectomy (>171 procedures) (B. Gignoux & al Annals of Surgery 2018). Our technique is a three-port surgery requiring only one assistant and the surgeon. The use of new energy devices simplifies surgery and reduces operating time. In this case we show how to use the Ligasure Hook (Medtronic) and the Signia Stapling (Medtronic) devices. Specimen extraction is carried out through the anterior vaginal wall.

Laparoscopic TME with colonic J Pouch

Laparoscopic total mesorectal excision with restorative proctectomy with colonic J-pouch coloanal anastomosis and loop ileostomy including indocyanine green fluorescence angiography

The Role of ICG in Breast Reconstruction with DIEP FLAP: from Quality Assessment to Quantification

Dr. Joan Fontdevila and Dr. Jordi Descàrrega present "The Role of ICG in Breast Reconstruction with DIEP FLAP: from Quality Assessment to Quantification".

TaTME with Cecil Approach

Dr. Antonio M. Lacy performs a TaTME with Cecil Approach surgery to a 76 years old male, an ADK 6cm from anal verge, clinical staging T3N0 and is submitted to LAR with taTME, with protective ileostomy.

TME by Transanal approach (TaTME) performed by Dr. Lacy

A live surgery with special interest for surgeons starting their experience with the TaTME. The procedure focuses on the key points for transanal dissection.

Sleeve Gastrectomy by Antonio M. Lacy and his Team

The most popular surgical procedure for treatment of morbid obese patients was performed live. The annual meeting of the Spanish Society of Bariatric Surgery and Metabolic Diseases - SECO was held from May 27 to May 29, 2015. A number of live surgical procedures were performed during the meeting. Dr Antonio M. Lacy and Dr Raquel Bravo from the Hospital Clinic of Barcelona performed a Sleeve Gastrectomy by laparoscopic approach. Learn the essential steps and the tips and tricks of the operation directly from the experts.

Step by step for a Gastric Bypass by Antonio M. Lacy

The gold standard for the surgical treatment of morbid obese patients performed and commented by Dr. Antonio M Lacy and Dr. Dulce Momblán. The Roux-n-Y gastric bypass has proven to be safe with good long terms outcomes for the treatment of morbid obese patients, it is feasible and safe to perform it by laparoscopic approach. The incidence of Roux-n-Y has decreased due to its technical difficulties when compared to the sleeve gastrectomy. Learn the essential steps, the tips and the tricks of the operation directly from the experts!

Roux-en-Y Gastric Bypass for GERD after a sleeve gastrectomy by Antonio M. Lacy

Conversion of a sleeve gastrectomy into a Roux-en-Y Gastric Bypass for the treatment of GERD in morbid obese patients It is mandatory to assess GERD in morbid patients before undergoing a bariatric surgical procedure. Surgical repair of the crura must be considered for patients with hiatal hernia who are unsuitable for a Roux-en-Y gastric Bypass. Sleeve gastrectomy patients with GERD may experience insufficient weight loss, esophagitis and a decreased quality of life. Surgical revision is the definitive treatment for these issues. Conversion of the sleeve gastrectomy into Roux-en-Y gastric bypass is the gold standard. In some cases this revisional bariatric surgery may pose a technical challenge. Dr. Antonio M Lacy and Dr. Ricard Corcelles dealt with these issues live from the operating room.

Proctology procedure: THD & THD Gatekeeper by S. Biondo

Modern treatments for fecal incontinence and internal hemorrhoids Fecal incontinence and hemorrhoids are common problems that have an impact on up to 50% of the population over 45 - 50. Clinical manifestations such as low rectal bleeding, soiling and pain decrease patients’ quality of life. There are several treatments, ranging from medical therapies to various surgical procedures, with different success rates. There are currently modern techniques to treat these pathologies delivering the lowest aggression rate to selected patients. Dr. Sebastiano Biondo performed a THD and THD Gatekeeper live and explaining his tips and tricks.

Proctocolectomy by Transanal & Transabdominal Approach (Cecil Approach)

Minimal invasive surgery has been accepted by the colorectal surgical community. In most patients it makes it possible to reproduce the surgical dissection performed using an open approach. Advantages such as faster recovery, less pain, and fewer complications are evident. Complex colorectal procedures can also be performed by laparoscopic surgery after an adequate learning curve. The transanal approach combined with the transabdominal laparoscopic dissection (The Cecil Approach) enhances patients benefits in terms of quality of dissection and surgical time. Antonio M. Lacy, Maria Fernandez-Hevia and Raquel Bravo exhibited all the benefits of the Cecil Approach during a total proctocolectomy.

Rectal Cancer, Transanal TME – Cecil Approach

Performed by Antonio M. Lacy, Salvadora Delgado & María F. Hevia. Described by Joep Knol and Patricia Sylla in the Operating Room. Co-discussants: Richard J. Heald, Steven D. Wexner & H. Jaap Bonjer. Live connection during the surgery with Philip Quirke, Mariana Berho and Míriam Cuatrecasas for the pathology examination of the specimen.

Hernioplasty by Laparoscopic Approach (Sugarbaker Technique)

The least aggressive and most successful treatment for parastomal hernias: One of the most frequent complications after stoma formation is parastomal hernia. Symptomatic patients require surgical treatment. Simple repair is associated with high risk morbidity and relapse of up to 100%. Relocating the stoma also has a high rate of recurrence (76%) plus the probability of incisional hernia at the previous stoma site. The laparoscopic hernioplasty (Sugarbaker technique) provides a solution to these issues as it offers patients the benefits of minimal invasive surgery and superior repair success. Juan José Espert and Ricard Corcelles from the Hospital Clinic of Barcelona performed this technique for the entire AIS Community.

Robotic Sigmoidectomy

Technical benefits of robot-assisted surgery for colorectal resection: Robotic techniques and robotic colorectal surgery constitute an emerging field that has helped surgeons to overcome some technical difficulties in the conventional laparoscopic approach. However, the balance between costs and benefits, as well as some specific indications, remain controversial. The combination of 3D visualization, a stable camera and articulated instruments that simulate the movements of the human wrist are the features that seem to provide greater surgical precision. Antonio M. Lacy, Raquel Bravo and Amelia Hessheimer demonstrated live all these benefits for the AIS Channel Community during a sigmoid resection.

New tools to perform the ideal Sleeve Gastrectomy

The ideal sleeve gastrectomy for a patient with a high risk of hypoglycemia. RYGBP is not suitable for all morbid obese patients. The sleeve gastrectomy is a valid option that should be performed properly to avoid complications and ensure the best long-term result for our patients. Antonio M. Lacy, Ricard Corcelles and Maria F Hevia used new tools to perform the ideal sleeve gastrectomy.

Novel therapies for different Anal Fistulas

Novel proctological procedures: Novel therapies for different Anal Fistulas. There are many surgical techniques for treatment of anal fistulas, each of which has a main indication and success rate. Sometimes surgical treatment may lead to complications, relapses and re-operation. Novel techniques have appeared as less aggressive alternatives for these patients. On May 3, Eloy Espín, from Hospital Vall d'Hebron, performed some of these techniques live for the entire AIS Channel community.

Sleeved Gastric Bypass

Emergent surgical treatment for morbid obese patients: Several modifications have been proposed to the standard surgical treatment of morbid obese patients. The goal is to achieve improvement of surgical outcomes and provide better results for the patients. Rui Ribeiro from Curry Cabral Hospital (Centro Hospitalar de Lisboa Central) performed a Sleeved Gastric Bypass for the entire AIS Community.

Surgical treatment of T2DM

There is enough data to support surgery as the best treatment of morbid obese patients with type 2 diabetes mellitus (T2DM). The Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold standard surgical procedure. However, the sleeve gastrectomy is also being considered among the bariatric community. On June 21th, the 18th National Congress of the Spanish Society of Surgery of Morbid Obesity and its Metabolic Diseases (SECO) was held in Barcelona. On its first day Camilo Boza (Chile), Luigi Angrisani (Italy) and Antonio M. Lacy (Spain) performed 3 simultaneous live surgical procedures for the treatment of T2DM for the entire AIS Community: LRYGB, sleeve gastrectomy and conversion of a sleeve gastrectomy into LRYGB.

Hartmann reversal by transanal approach (Cecil Approach)

Minimal invasive approaches after previous abdominal surgeries may be challenging, particularly in cases where patients had emergency surgical procedures or anastomotic leaks that required temporary colostomies. Combining minimal invasive dissection transabdominally and transanally (Cecil Approach) provides several advantages, especially the identification of unclear planes and hostiles pelvises.

Proctoring for young surgeons: Laparoscopic Roux-en-Y Gastric Bypass

AIS Channel maintains its commitment to surgical education: so far we have broadcast several colorectal and bariatric procedures focusing on the training of surgical residents and young surgeons. It's time for a new live surgery in this area! On September 14th at 12:30pm (UTC+02), Antonio M. Lacy and Ricard Corcelles from the Hospital Clinic of Barcelona guided Ana Otero in the performance of a Laparoscopic Roux-en-Y Gastric Bypass.

Robotic Banded Bypass

The Roux-en-Y Gastric Bypass is the surgical technique with the best balance between long term results and low morbidity. However, some authors report 10-20% of failed weight loss in the long term. Several surgical strategies have been described to deal with this issue. On September 29 Carlos Vaz from Hospital CUF Infante Santo in Lisboa (Portugal) performed a banded gastric bypass on a morbid obese patient in order to prevent pouch distention and weight regain. In addition, he was assisted by a surgical robot.

Transanal TME

Transabdominal-transanal surgery (the Cecil approach) has increasingly become the technique of choice for rectal cancer for many surgeons. Ever since the first cases were published in 2009, the transanal approach has proven to be an excellent technique when faced with a narrow male pelvis or bulky tumours, where transabdominal dissection can pose a challenge, even for experienced surgeons. Moreover, the transanal approach is not only limited to rectal cancer, but can also be used in inflammatory bowel disease and other benign processes. During this live streaming surgery session, which will be broadcast on October 29 at 8am (UTC+8) from China Medical University Hospital in Taichung (Taiwan), Dr. Wexner and Dr. Lacy will be respectively leading the transabdominal and transanal teams in a combined approach to rectal cancer. These expert surgeons will be guiding viewers through the steps of the surgery, discussing the difficulties of the technique and answering the questions from the live chat users.

Ileosigmoidal fistula complicating diverticular disease

Complications secondary to diverticular disease can still pose a surgical challenge regarding surgery timinig, the selected approach, or the indicated technique. Antonio M. Lacy and Ana Otero, from the Optimus ISE OR in Hospital Clinic Barcelona, were broadcast live in an ileosigmoidal fistula secondary to diverticular disease treatment. In addition, our team worked with 4K technology on a 85" monitor (courtesy of SONY), which optimized the endoscopic view of minimally invasive procedures.

Cecil Approach in Proctectomy for Ulcerative Colitis

Patients with Ulcerative Colitis and lack of response to medical treatments require surgical intervention. This is usually performed in three stages (Total Colectomy, Proctectomy plus J Pouch, and finally bowel transit restorance) and can be fully performed by minimally invasive surgery. Technological improvements and current experience in TaTME make it possible to extend the indications of the transanal approach to the IBD field. Antonio M. Lacy and Dulce Momblan from Hospital Clinic Barcelona, demonstrated the advantages of the Cecil Approach to perform a Proctectomy in a case of Ulcerative Colitis.

Rectosigmoid Cancer by Transanal Approach (Cecil)

Transanal approach for rectal cancer can be helpful not only on a mid and low rectal cancer, but also on a high rectum neoplasias. A precise distal margin from the tumor will ensure an adequate oncologic resection leaving the anastomosis at a height of 8 to 10 cm from the anal verge. From the Hospital Clinic in Barcelona, a TaTME by Cecil Approach by Dr. Antonio M. Lacy for neoplasia at the level of the peritoneal reflexion, was broadcasted, 14 cm from the anal verge, demonstrating the results of a high rectal anastomosis from a transanal approach.

Revisional surgery after POSE technique

Several endoscopic procedures are proposed as an alternative to formal surgical treatment for morbid obesity. Some advantages are that it less aggressive and can be performed under sedation. Some data shows good outcomes in the short term. However, in daily practice there is an increasing number of patients who require conversion into surgical treatment. Antonio M. Lacy and Ricard Corcelles performed from the Hospital Clinic in Barcelona, a revisional bariatric surgery with 3D technology on a morbid obese patient with a failure after a POSE procedure.

TaTME and Robotic LAR

The surgical community continues to debate on the best technique for rectal cancer. We presented two cases of the most frequently used approaches to rectum cancer: the robotic transabdominal approach versus the transanal approach. As these two simultaneous live surgeries were broadcast live on AIS Channel, the AIS Community across the world was able to view them and interact with the surgeons in real time!

Low Anterior Resection

Rectal cancer accounts for approximately one third of all colorectal cancers. Since the early 1990s, total mesorectal excision (TME) has remained the gold standard surgical treatment for rectal cancer, following Prof. Heald’s detailed description of the technique in 1986. In this era of the multidisciplinary approach, the quality of TME has been shown to be a significant prognostic factor for cancer-specific survival. The TME technique has evolved from traditional ‘open’ to minimal access approaches, such as laparoscopic, robotic and more recently, transanal techniques. However, acceptance of one option as better than or even equivalent to the others remains a matter of debate.

TaTME CECIL Approach

The transanal approach for rectal cancer (TaTME) and combined dissection by a transabdominal and transanal team (Cecil approach) has emerged as the next step in rectal cancer surgery. TaTME (the Cecil approach) aims to solve some problems that occurred in the previous TME, such as exposure of the peripheral mid-lower rectal space, judging the distal cutting margin, carrying out a completely minimal invasive operation, overcoming the lack of visibility in the small pelvis, and theoretically improving the rate of radical resections

Sleeve Gastrectomy: Not as easy as it seems

During the 13th AIS World Live Congress, the live surgery session involved 3 simultaneous cases operated simultaneously in separate theaters from Barcelona (Dr. Lacy), Montreal (Dr. Gagner) and Bruges (Dr. Dillemans): primary Sleeve Gastrectomy, and 2 revisions after Sleeve Gastrectomy.

TaTME Updates

Rectal cancer surgery has had a tremendous evolution over the last few years. Since the landmark set by Dr Bill Heald with Total Mesorectal Excision, later advances have turned open proctectomies and abdominoperineal resections into transanal minimally invasive approaches with sphincter-saving procedures. Our 15th AIS Live Congress (April 12, 2017) showcased and discussed the current status of Transanal Total Mesorectal Excision (TaTME). Our global audience across the entire world were able to watch presentations by world-leading experts followed by live TaTME surgery

New tools to perform the ideal Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy was performed by Dr. Antonio M. Lacy and Dr. Ricard Corcelles from the Hospital Clinic Barcelona. During the live surgery, new technologies were used in front of the entire AIS World Community. Laparoscopic Sleeve Gastrectomy (LSG) has become the most commonly performed bariatric operation in recent years. LSG has increased in popularity as a primary procedure due to its simplicity, relative safety, and effectiveness to achieve sustained weight loss over time compared to gastric bypass. We have recently witnessed a surge in new technologies whose purpose is to increase the safety and efficiency of surgical interventions. The aim of these advanced tools is to facilitate the surgeon's work by decreasing the number of perioperative complications. However, new tools must be validated to gain universal acceptance. The field of bariatric surgery is constantly evolving. In LSG procedures, several new devices have appeared and may play a crucial role in the near future. Some of these new tools will be introduced during the live surgery, such as new retractors, ICG for vascularization of gastric remnant and new stapling devices combining Tri-Staple technology with real time feedback.

TaTME Cecil Approach 2

The gold standard approach for rectal cancer is still under debate. Transabdominal-Transanal surgery (the Cecil Approach) is in the spotlight as it helps overcome technical difficulties in rectal cancer surgery, particularly in mid and low rectal cancer, but also in high rectal cancer. Once the mesorectal excision has been completed, a hand-swen or stapled anastomosis is created at the tumor level. For mid-rectal cancers, a stapled anastomosis may be fashioned either transabdominally or transanally. During the live surgery, the Cecil Approach for mid rectal cancer and stapled anastomosis were demonstrated by Dr. Antonio Lacy and his team from Hospital Clinic in Barcelona. The different steps of the technique were discussed, as well as tips and tricks.

Nissen Fundoplication

The management of paraesophageal hernia is one of the most discussed topics in surgical forums. Most surgeons currently take a laparoscopic approach with the excision of the sac and the addition of an anti-reflux procedure to treat coexistent reflux. A total fundoplication (Nissen Fundoplication) is the preferred approach to patients with gastroesophageal reflux as it provides better control of the reflux compared to partial fundoplications. Whether placement of a mesh is necessary or not is still under debate.

Total Colectomy with Transanal Retrieval

Prophylactic surgery for cancer prevention of familial adenomatous polyposis yields good short-term surgical outcomes, with low morbidity rates, good functional outcomes, and excellent overall survival rates. Rectal preservation is the surgical choice when the rectal lesions are endoscopically addressable. Furthermore, transanal retrieval of the specimen may prevent additional abdominal incisions and their associated complications. On June 8th 2017 at 3:30pm (Barcelona Time), Dr. Antonio Lacy and his team from Hospital Clinic in Barcelona performed a live total colectomy with rectal preservation for a familial adenomatous polyposis. Join us and discover the tips and tricks for this technique step by step!

Training for Residents in Ileostomy closure

Temporary loop ileostomies are frequently used in colorectal surgery to protect high risk anastomosis, such as low colorectal anastomosis or ileal pouch ileoanal anastomosis. With the advent of the new surgical techniques, procedures involving higher risk anastomosis, such as transanal total mesorectal excision, are performed more often. Thus, as the rate of derivative ileostomies increases, a revision of the surgical ileostomy closure technique becomes necessary, particularly focusing on our younger trainees.

Proctectomy & Ileal Pouch by Transanal Approach

In selected cases of ulcerative colitis (UC), restorative proctocolectomy with a J-pouch and ileo-anal anastomosis (IPAA) is the treatment of choice. Total mesorectal excision has been preferred when performing the proctectomy, although a close rectal dissection (CRD), without following the "holy plane", has also been described. The transanal approach has evolved, and it is no longer limited to local excision of rectal neoplasms, with total mesorectal excision having currently become one of its main indications. Furthermore, this approach can also be used in cases of UC requiring surgery. Hybrid transanal CRD appears to be the next step in the evolution of minimally invasive transanal surgery.

Sigmoidectomy: Robotic vs. Laparoscopic

Minimally invasive colorectal surgery is a challenging procedure. Surgical practice has changed since the introduction of robotic techniques, and robotic colorectal surgery is an emerging field. Robotic surgery for colorectal cancer has several advantages over conventional laparoscopic surgery when performing precise dissection and was proved to be safe and effective in previous studies. The combination of 3D visualization, a stable camera and articulated instruments that simulate the movements of the human wrist are the features that seem to provide greater surgical precision. However, the comparison between laparoscopic and robotic colorectal resection has yielded contradictory results. The balance between costs and benefits, as well as some specific indications, remain controversial. Two consecutive procedures, a laparoscopic and a robotic sigmoidectomy, were performed LIVE, showing our search for excellence in terms of surgical techniques and new technologies such as laparoscopy and robotics to treat colorectal cancer. On August 23rd 2017, Dr. Antonio Lacy and Dr. Raquel Bravo demonstrated, from Hospital Clinic Barcelona, all these benefits and controversies for the AIS Community during consecutive laparoscopic and robotic sigmoid resections.

Robotic vs. Lap RY Gastric Bypass

Robotic bariatric surgery is still an emerging field, with slow but consistent growth. In the last few months, various bariatric centers in Europe have started their practice. With the entry of new robotic devices in the market, prices will definitely drop and new relevant features will be made available to surgeons. Current possible advantages are: 1. Steady-surgeon controlled image 2. Tremor filtration 3. Wristed instruments with intuitive motion 4. More precise dissection 5. Easier and safer suturing These can translate into safer anastomosis and better performance during complex revision surgery, and could enable more surgeons to perform single-incision bariatric surgery in a wider range of procedures.

Winter Event 2017

During the AIS Winter Event 2017, AIS Channel broadcasted LIVE the following surgeries: ESD colon/rectal by A. Haji / P. Bhandari, Lap Right Hemicolectomy (4K Surgery) by AM Lacy / B. De Lacy and Robotic Right Hemicolectomy by V. Obias / C. Johnson

Reconversion to Normal Anatomy for Hypoglycemia

The laparoscopic Roux-en-Y gastric bypass (RYGB) is currently one of the most common bariatric procedures. However, RYGB can cause specific undesired side effects related to the bypassing of a large part of the stomach, duodenum, and the proximal jejunum. These side effects include early dumping syndrome, hypoglycemia, malnutrition, severe diarrhea and excessive nausea, and vomiting. Although these conditions can usually be managed conservatively, occasionally a surgical reintervention may be required. Hence different reversal techniques, including endoscopic approaches, have been described. In extreme cases surgical options include reversal to normal anatomy (NA) or into sleeve gastrectomy or sleeve-like resection (NASG) to address undesired side effects. This procedure usually requires dismantling both the gastrojejunostomy and the jejunojejunostomy, reanastomosing the gastric pouch into a gastric remnant, and the proximal alimentary limb end into a distal biliary limb end. Eventually, concomitant hiatal hernia repair may be required.

Transanal Proctectomy and J pouch

Ulcerative colitis (UC) usually involves the rectum and may extend proximally to the rest of the colon. In an emergency setting, total colectomy with a terminal ileostomy is usually performed. In selected cases, the emergency surgery is followed by further completion of the proctectomy with a J-pouch and an ileal pouch-anal anastomosis (IPAA). Total mesorectal excision has been the preferred way to perform the proctectomy, although a close rectal dissection (CRD), without following the holy plane, has also been described and has the potential to better preserve the autonomic function. The transanal approach has evolved and is no longer limited to oncological indications, but can also be used in cases of UC requiring surgery. Hybrid transanal CRD seems to be a valid alternative for proctectomy.

New tricks in TaTME

Minimal invasive surgery for locally advanced rectal cancer is challenging and requires advanced technological assistance to make the procedure feasible and safe. The Transanal Total Mesorectal Excision is an innovative approach for rectal cancer. It provides several advantages compared to the fully laparoscopic technique. Issues such as transection of the distal margin and difficult cases may have found a solution with this procedure. You have been able to see this procedure many times on AIS Channel. This time we want to show you transanal surgery from another point of view. This surgery will focus on the main steps for the combined transanal and transabdominal approach (Cecil approach) for rectal cancer, highlighting the most frequent mistakes and how to prevent them.

Argentina: Is TaTME the easiest technique?

Innovation comes at a cost - it creates a conflict between the supporters of the tradition and those that embrace the new ideas. Total mesorectal excision, described by Dr. Heald, was one of these innovative ideas that changed the course of colorectal surgery. Several years later, the advent of minimally invasive surgery was another important step in the evolution of surgery. Laparoscopic surgery is now accepted as an approach that minimizes pain and accelerates recovery after surgery. The next step in rectal cancer treatment was the transanal approach (TaTME). This approach overcomes the difficulties of laparoscopic surgery in special situations: obese and male patients, those with a narrow pelvis and bulky tumors, and these difficulties are specially true for the distal margin section. Furthermore, the use of two simultaneous teams - the Cecil Approach - has reduced procedure time.

Retroperitoneoscopic Adrenalectomy

Two Retroperitoneoscopic Adrenalectomies performed by Dr. Martin K. Walz and Dr. Pier F. Alesina at the Kiliniken Essen-Mitte (Germany) were broadcasted on May 11th. During the live surgery this wonderful procedure was described in detail to the entire AIS World Community. The Retroperitoneoscopic Adrenalectomy combines the advantages of minimally invasive surgery with a direct approach to the adrenal glands. Having the patient in the prone position makes a fast and extremely safe operation possible. As the whole procedure is extraperitoneal, patient morbidity is far lower than in transperitoneal techniques. Thus, the retroperitoneoscopic adrenalectomy is the ideal option. Having performed more than 2,000 procedures, Martin Walz and his team presented two cases. One patient suffering from a right-sided Conn adenoma. The second patient has a left-sided adrenal metastasis after a contralateral nephrectomy and adrenalectomy for renal cell cancer.