Videoscopy™

Treatment for primary hyperparathyroidism in the appropriately selected symptomatic or asymptomatic patient includes surgical removal of the hypercellular parathyroid gland(s). Up to 20% of abnormal parathyroid glands causing primary or secondary hyperparathyroidism are located ectopically. Depending on location, mediastinal parathyroid adenomas may be successfully extirpated via a traditional cervical surgical approach. However, if unable to access via this approach, alternative methods originally included sternotomy or thoracotomy. The recent rise in minimally invasive techniques have been shown to reduce morbidity and improve postoperative recovery. We demonstrate a mediastinal parathyroidectomy via video-assisted thoracoscopic surgery (VATS) approach while utilizing intraoperative parathyroid hormone guidance and frozen-section pathologic analysis.

The patient is a 13-year-old female with a biochemical diagnosis of primary hyperparathyroidism and a past history significant for nephrolithiasis. Four months prior, the patient underwent a cervical exploration with the removal of two left-sided parathyroid glands and a right cervical thymic remnant with parathyroid tissue; however, this failed to resolve her parathyroid disease. Chest computed tomography and a nuclear medicine parathyroid scan did demonstrate a paraaortic, thymic nodule consistent with parathyroid tissue. A right VATS thymectomy was recommended.

After accessing the right chest by VATS approach, the thymus was identified and dissected free from the pericardium, phrenic nerve, superior vena cava, and aortic arch. Intraoperative parathyroid hormone guidance confirmed an appropriate reduction after thymectomy was complete. She was discharged from hospital on postoperative day two with calcium supplementation and Calcitriol.

Ectopic mediastinal parathyroid adenomas are an uncommon cause of primary hyperparathyroidism. VATS thymectomy provides a safe and effective approach for resection.

No competing financial interests exist.

Runtime of video: 4 mins 15 secs

The source of the study is the Division of Pediatric Surgery at Penn State Milton S. Hershey Medical Center.

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Robotic surgery has grown exponentially over the past several years and has expanded across several surgical specialties. ¹ With the rapid rise in robotic surgery, an effective, standardized, and validated robotic surgery training curriculum for general surgery residents is required. ^2,3 The aim of this video is to demonstrate the feasibility of a curriculum to provide a standardized training program in robotic surgery for the new generation of surgeons.

This is a 2-week robotic training curriculum instituted by the University of Chicago General Surgery Residency Program. The robotic training rotation was offered to every postgraduate year 3 general surgery resident. The curriculum involved training on virtual reality simulations that included 23 exercises using The da Vinci ^® Skills Simulator (DVSS) and SimNow^®, inanimate drills including inguinal and ventral hernia repair, suturing, biotissue exercises including interrupted hepaticojejunostomy, running hepaticojejunostomy, gastrojejunostomy, and pancreaticojejunostomy, operating room (OR) observations, and mentored sessions with surgical faculty highly trained on the robot. All drills were recorded and timed, and residents' performances were graded using the Objective Structured Assessment Technical Skills (OSATS). After the completion of the curriculum, residents received clearance to use the robot in the OR and completed a robotic case under supervision as console surgeon, usually performing a cholecystectomy.

Twenty-three residents completed the curriculum. Residents improved both their time and performance (OSATS score) when comparing the first attempt with their fourth attempt. After completion of the curriculum, all residents were effective in performing a robotic cholecystectomy under supervision without any eventful complications.

Residents' robotic skills, as demonstrated by time and performance, improved upon completion of the curriculum. Patient safety is paramount, and this curriculum ensures adequate robotic surgical experience before utilizing the console in the OR. This video ultimately provides one example of the effectiveness and feasibility that this curriculum can offer to general surgery resident training.

All authors contributed to the concept and approved the submitted version.

No consent form was needed.

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9 mins 35 secs

Intestinal duplication cysts are rare congenital malformations, mainly found in the midgut that generate nonspecific symptoms. The clinical presentation is mainly with abdominal pain, intestinal obstruction, and digestive bleeding. The open surgical approach is usually performed. We present a case of a 7-year-old patient in whom an effective laparoscopic management was implemented.

A 7-year-old patient was admitted because of weight loss and frequent emesis. A mass in the mesogastrium was palpated upon physical examination. Imaging studies showed a lesion with cystic content in the first duodenal portion measuring 4.7 × 4.4 × 5.6 cm, suggestive of duodenal duplication cyst causing obstruction of the gastric outlet tract. Nutritional support was performed with total parenteral nutrition for a week and laparoscopic resection was programmed. Using an open technique, insertion of a 5-mm umbilical port and two other ports of equal size in the right iliac fossa and epigastrium was performed. Upon entry into the abdominal cavity, a dilated duodenal bulb and collapsed second and third portions of the duodenum were seen. Pyloroduodenotomy was performed, and dissection of the muscle fibers showed a cystic lesion in the first portion of the duodenum, located between the muscle layer and the mucosa, which was subsequently completely resected and referred to pathology analysis. The procedure was completed without complications, and the postoperative evolution was adequate, with discharge on the fourth postoperative day.

There are few reports of management with minimally invasive techniques for intestinal duplications, Galazka et al. performed a retrospective analysis of patients presented with congenital abdominal cystic lesions between 2011 and 2019. Of the 39 cases analyzed, 6 were found to have intestinal duplications, 4 of these underwent surgical management by laparoscopy without reporting complications, but did not report the exact location of the cysts. ¹ In the case of duodenal duplication, there is a case report of an 8-month-old patient with a prenatal diagnosis who underwent laparoscopic resection dependent on the medial wall of the second duodenal portion, without postoperative complications. ²

The accumulation of secretions within the intestinal duplication cyst leads to progressive growth, with compression of adjacent structures producing pain and obstruction. They are rare malformations with nonspecific symptoms that require surgical management to avoid associated complications; enucleation or resection of the lesion are the pillars of treatment. Despite few reports in the literature, it is possible to perform a laparoscopic approach in this type of pathology analysis. This approach allows short recovery times, early initiation of oral intake, and better cosmetic results.

No competing financial interests exist.

All attempts have been exhausted in trying to contact the patient, next of kin, and/or parent/guardian for informed consent to publish their information, but consent could not be obtained.

Runtime of video: 2 mins 58 secs

The video was presented at “XXIV Congreso Colombiano de Cirugía Pediátrica,” March 2023, Rionegro, Colombia.

The video was presented at “48th Congreso Semana Quirúrgica Nacional,” November 2022, Cartagena, Colombia.

Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed worldwide. ¹ Postoperative bile leaks caused by bile duct injuries (BDIs) are serious complications after LC, resulting in a prolonged length of hospital stay, increased costs, morbidity, and mortality rates. ² Incidence of BDIs during LC is ∼0.4%–1.5%. ¹ Intraoperative fluorescent cholangiography using indocyanine green fluorescence (ICG-C) is a safe method to observe the biliary tree and may be useful to prevent postoperative bile leaks after LC and hepatic surgery. ^1,2 However, detection of bile leaks using the ICG-C during LC has limited evidence in international literature. ^{3 –8} This video illustrates how to use ICG-C to identify and treat a bile leak after an urgent LC.

A 54-year-old man with a history of hypertension, diabetes mellitus, cholelithiasis, and hepatic abscesses was admitted with right upper quadrant pain and fever. An urgent CT scan of the abdomen showed acute cholecystitis associated with a large pericholecystic abscess. A percutaneous cholecystostomy (PC) was placed and nonoperative management with intravenous antibiotic was started. On the seventh postprocedural day, the PC was accidentally removed, and a second CT scan of the abdomen showed a reduction of the pericholecystic abscess size, and a subhepatic fluid collection. An urgent LC was performed, and two surgical drains were placed (one subhepatic and one suprahepatic). On the first postoperative day, a low-flow biliary output (250 mL/day) from the subhepatic drainage was associated with a gradual deterioration of the patient's clinical condition. Considering the low flow rate of the biliary fistula, nonoperative management was carried out; on the second post-operative day the patient presented hypotension, oliguria, fever (temperature 38.2°C), and worsening right upper abdominal pain with signs of diffuse peritonitis. The hematologic investigations showed a WBC 17,560/mL, Hb 10.7 g/dL, C-Reactive Protein 17.66 mg/dL, normal liver function tests, and normal bilirubin levels. Owing to signs of septic shock and diffuse signs of peritonitis, an urgent surgical exploration was performed. After the induction of anesthesia, 2.5 mg of Indocyanine Green was intravenously injected. Eight minutes later, the ICG-C demonstrated exactly and in real-time the biliary leak on the liver surface, coming from a subvesical bile duct. Two laparoscopic Roeder's knots were placed to repair the injury. Two surgical drains were placed.

The postoperative period was uneventful, with a progressive improvement of the patient's performance status, vital parameters, and laboratory tests. The surgical drains were serosanguinous with low output and both were removed on postoperative day 9. The patient was discharged on day 10 in good clinical condition.

One of the most common causes of LC-associated biliary leaks are injuries to the subvesical bile ducts. ICG-C clearly identifies these bile spots on the liver surface during surgery, allowing them to be repaired immediately and prevent biliary fistulas. ICG-C is a safe, easy, repeatable, and noninvasive method to identify bile leaks during surgery. ICG-C may be useful to prevent and treat bile leaks after LC, especially in complicated cholecystitis. ^5,6

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

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Running time of video: 8 mins 27 secs

Bronchogenic cysts result from a congenital anomalous budding of the tracheobronchial tree. They should be excised, regardless of symptoms, due to the risk of infection, mass effect on adjacent structures, and malignant transformation. Mediastinal bronchogenic cysts present a unique challenge due to their proximity to vital structures. We present a video of two cases of technically challenging mediastinal bronchogenic cysts successfully excised thoracoscopically.

Two patients who underwent mediastinal bronchogenic cyst excision in 2022 were identified. Patient demographics were assessed, including age at diagnosis, presenting symptoms, imaging workup, and cyst characteristics. Operative approach, complications, and surgical pathology were reported. Intraoperative thoracoscopic videos were reviewed, highlighting unique challenges and technical maneuvers that were utilized.

Case 1 is a previously healthy 37-month-old female with a mediastinal cystic mass initially diagnosed on screening echocardiogram due to a parental history of connective tissue disorder. CT confirms a 2.4-cm lobulated mediastinal mass with compression of the left main stem bronchus and abutment of the aorta, pulmonary artery, and esophagus. The mass is initially believed to be a lymphatic malformation, so the patient undergoes sclerotherapy. Follow-up MRI demonstrates a persistent subcarinal mass that appears more consistent with a bronchogenic cyst. Case 2 is a 30-month-old female with recurrent pneumonia and upper respiratory tract infections. CT demonstrates a 3.9 cm posterior mediastinal cystic mass resulting in deviation of adjacent mediastinal structures and compression of the left main stem bronchus consistent with a bronchogenic cyst vs foregut duplication cyst. Both patients undergo thoracoscopic resection. Excision was technically challenging in both cases due to the location of the cyst deep within the mediastinum. Case 1 was particularly challenging given its adherence to the right pulmonary artery and proximity to the aorta, azygous vein, and trachea. Case 2 demonstrated signs of chronic inflammation. The accompanying video illustrates right and left thoracoscopic resection of a central adherent bronchogenic cyst, including port placement, energy device use, and exposure strategy. Techniques specifically highlighted include retraction of surrounding vital structures without grasping, working within different windows inferior and posterior to the bronchus, and cyst aspiration for optimal visualization of the cyst wall. Both cases were successfully managed thoracoscopically with complete cyst wall excision and no observed complications. Both patients were discharged on postoperative day 1.

Thoracoscopy is a safe and effective procedure for mediastinal bronchogenic cyst excision in children. Certain technical maneuvers are highlighted that may facilitate resection.

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

No competing financial interests exist.

Runtime of video: 4 mins 33 secs

Transanal and transvaginal natural orifice specimen extraction (NOSE) are viable alternatives to transabdominal specimen retrieval after laparoscopic colorectal surgery in selected patients without increasing morbidity or compromising oncologic outcomes. ¹ Conventional laparoscopic colorectal surgery is performed using one camera port, two operator ports, and one or two assistant ports. Three-port surgery is feasible ² and complementary to NOSE for laparoscopic colorectal cancer surgery to reduce surgical trauma to the abdominal wall. ³

Transanal NOSE avoids an additional vaginal incision, however, the transvaginal route is preferable for larger tumors because of the elasticity of the vagina. ³ Although dyspareunia and rectovaginal fistulae are theoretical concerns following transvaginal NOSE, these fears are thus far unfounded. ^1,3 Placement of a transvaginal wound protector protects against the risk of tumor seeding.

Transvaginal NOSE following three-port laparoscopic D3 right hemicolectomy ⁴ and three-port laparoscopic anterior resection ⁵ have been previously demonstrated. Compared with other locations within the large bowel, cancers of the splenic flexure are relatively uncommon. ⁶ Splenic flexure colectomy preserves bowel and is safe and oncologically comparable with a subtotal colectomy or formal left hemicolectomy. ^7,8 However, segmental resection and anastomosis for tumors in this area can be technically challenging.

A 69-year-old patient with a descending colon cancer and body mass index of 29.2 kg/m ² presented for resection. Preoperative bowel preparation with 2 L polyethylene glycol was administered. A 12-mm transumbilical camera port was used, with a 12- and 5-mm right iliac fossa and right flank working ports, respectively. The splenic flexure was mobilized from medial to lateral. The inferior mesenteric artery was identified, and the left colic artery was ligated at its origin, with adequate distal mesenteric division to ensure satisfactory lymph node harvest. Proximal and distal bowel transection were performed intracorporeally with a linear stapler. An isoperistaltic side-to-side colocolic anastomosis was fashioned, with a two-layer closure of the colonic defect. The uterus was hitched to the anterior abdominal wall with a transabdominal suture. The vagina was cleansed before a posterior vaginotomy was created with the help of a transvaginal sizer. A double ring wound protector was inserted transvaginally with one ring completely within the abdominal cavity and the other ring opened against the perineum to shorten the channel for specimen delivery. The wound protector was removed and the vaginotomy was closed using a barbed suture.

Operative time was 3 hours 15 minutes, with 20 mL intraoperative blood loss. There was minimal postoperative pain with return of gastrointestinal function on the first postoperative day. The patient was discharged uneventfully on postoperative day 2. Histology was pT4N1 and 27 lymph nodes were harvested. Adjuvant chemotherapy was administered, with no evidence of disease recurrence at 6 months follow-up.

The reduced port technique is feasible and synergistic with NOSE for splenic flexure colectomy in selected patients, augmenting the minimally invasive nature of laparoscopy.

No competing financial interests exist.

Runtime of video: 5 mins 49 secs

The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Colonic intussusception is a rare form of bowel obstruction in which a segment of the colon telescopes into the adjacent distal portion of the bowel. ¹ This condition may resolve and recur, or it may lead to a complete obstruction, necrosis of the bowel, and additional complications if untreated. Causes of colonic intussusception in adults include benign polyps, lipomas, lymphoid hyperplasia, or malignant tumors. ² This video depicts a colonic intussusception and a robotic resection entailing a right hemicolectomy to treat the underlying etiology.

A 42-year-old woman presented with an episode of constipation and crampy abdominal pain. A computed tomography scan revealed right-sided colonic intussusception that spontaneously reduced after initial presentation. Imaging did not reveal any other pathology or evidence of metastatic malignant disease. Subsequent evaluation included a diagnostic colonoscopy, which revealed a large polypoid mass in her ascending colon. Superficial biopsies revealed adenoma but no invasive malignancy. Based on her presentation, lesion size, and concern for cancer, she was encouraged to undergo surgical resection. Shortly after her expedited work-up, a robotic right colectomy with intracorporeal anastomosis was performed. The key steps in the operation are highlighted, including division of the ileocolic pedicle, medial-to-lateral dissection, transection of the bowel, and an intracorporeal isoperistaltic anastomosis.

The patient recovered well and uneventfully after surgery, and was discharged home on postoperative day three. Final pathology analysis revealed a 4 cm colonic adenocarcinoma invading the submucosa (T1 lesion) with negative margins and 28 lymph nodes, all negative for metastatic disease (AJCC stage I).

Colonic intussusception is concerning for cancer when this condition presents in adult patients and may be treated using a robotic approach to provide a shorter postoperative length of stay and greater lymph node harvest as compared with a traditional laparoscopic right colectomy. ³ As the video demonstrates, this condition can be treated safely using a minimally invasive robotic surgical approach.

No competing financial interests exist.

Runtime of video: 8 mins 37 secs

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

The recurrence rate of tracheoesophageal fistulas (TEFs) has been quoted at 5%–10%. Recurrent TEFs are traditionally treated with thoracotomy, which carries significant potential morbidity, especially in a previously operated field. Endoscopic techniques have been proposed as an alternative to open repair, which include electrocautery, laser, and wire brushing, applications of tissue adhesives, and clips to close mucosal defects endoscopically. ¹ A review of literature shows only case reports and case series of such techniques being utilized. ^2,3 In this video case report, we present the use of endoscopic therapy for definitive management of a persistent TEF in a pediatric patient.

This is a 17-month-old female with a complex medical history who was status post-tracheoesophageal repair complicated by anastomotic leak requiring redo thoracotomy with an intercostal muscle flap and has since required serial endoscopic dilatations. She developed a recurrent TEF that was symptomatic with oral intake. A plan for staged endoscopic intervention was developed. In the operating room, flexible bronchoscopy was used to identify the fistula opening and an associated cavity filled with old food debris. A GIF-XP pediatric gastroscope was used to find two defects in the right lateral esophageal wall, above the normal nonstrictured esophageal anastomosis, that connected to the old leak cavity. A septum separated the esophageal lumen proper from the leak cavity, which spanned the gap between the two separate defects. A septotomy was performed to decompress the false lumen back into the true lumen to allow better drainage and the mucosa was closed using several through-the-scope (TTS) clips. Owing to the location of the leak cavity and fistula, definitive fistula management was deferred to a subsequent operation to allow the septotomy to heal. Two months later, she underwent a second operation to close the TEF. The bronchial side of the fistula tract was ablated with electrocautery, taking care to decrease the oxygen concentration during this time to reduce the risk of airway fire. The esophageal side of the fistula was ablated with circumferential argon plasma coagulation (APC) followed by a TTS clip to close the esophageal opening. Three months later, she underwent a third operation and was found to have bronchoscopic evidence of a patent TEF <2 mm in size. The esophageal side of the fistula was then again ablated with circumferential APC and closed with three TTS clips.

The patient recovered without incident and her symptoms completely resolved. Postoperative water-soluble esophagram showed a small irregular outpouching of contrast that was contained, did not enlarge with progressive contrast distension, and did not obviously communicate into the trachea. At 9 months postoperatively from her index case, the patient has no symptoms to suggest a recurrent TEF.

Endoscopic therapy for recurrent TEFs is technically feasible and avoids the morbidity of a repeat thoracotomy. To date, no other similar procedures have been performed by our department in other patients. Further study is necessary to establish the safety of this procedure before its implementation as standard practice in the pediatric population.

A.H., A.N.K., and D.P. have no financial disclosures. E.M.P. is a speaker for Becton Dickinson, Medtronic, Ovesco, and Boston Scientific. E.M.P. is a consultant for Boston Scientific Corp., Actuated Biomedical, Inc., Baxter, Wells Fargo, Cook Biotech, Neptune MEdical, Surgimatrix, CMR Surgical, Boehringer Laboratories, Allergan, and Noah Medical.

The source of the study is the Department of Minimally-Invasive Surgery at Penn State Milton S. Hershey Medical Center.

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Runtime of video: 382 mins

This video was presented as a video presentation at the 2022 American College of Surgeons annual meeting on October 16–20, 2022, in San Diego, CA.

Patients with chronic pancreatitis may suffer from debilitating pain, rendering them dependent on narcotics. ¹ In a single-institution review of 219 patients, 51% had opioid prescriptions with an average of 78 morphine milligram equivalents (MME) daily. ² Surgery is often considered after more conservative approaches fail, but randomized controlled trials show improved long-term outcomes with earlier surgical intervention ^{3 –5} and surgery for appropriate candidates may be offered based on multidisciplinary discussion. Minimally invasive surgery may be especially beneficial in these patients by reducing postoperative pain and expediting recovery. A robotic lateral pancreaticojejunostomy (modified Puestow) for chronic pancreatitis is presented in this video.

The patient is a 39-year-old female with a history of alcohol-related pancreatitis and tobacco abuse, with abdominal pain requiring up to 92 MME daily. Imaging revealed dilation of the pancreatic duct to 11 mm, intraductal stones, and disease limited to the pancreatic body and tail. The patient had no evidence of exocrine insufficiency preoperatively. She underwent initial evaluation for endoscopic management by gastroenterology and was referred for surgical management after multidisciplinary discussion. Given the dilation of the duct predominantly throughout the body and tail, the consensus was that surgery would likely yield optimal long-term benefits. The patient successfully abstained from alcohol and tobacco prior to proceeding with surgery. The procedure began by mobilizing the pancreas and using intraoperative ultrasound to localize and create a longitudinal ductotomy. Stones and debris were extracted, and the ductotomy was extended to encompass the extent of the dilated duct. Reconstruction was performed with a retrocolic Roux limb. The jejunojejunostomy was created in a stapled fashion and the pancreaticojejunostomy was created using self-retaining barbed sutures. The inferior portion of the anastomosis was created in two layers consisting of an outer layer securing pancreatic parenchyma to seromuscular jejunum and an inner duct-to-mucosa layer. The superior aspect was created similarly but in a Connell fashion.

The patient did well postoperatively and was discharged on hospital day 5. At her 2-week follow-up visit, she was noted to have decreased narcotic use to 15 MME per day. She continued to do well on her reduced pain medication dose at 16 months postoperatively and has had one episode of recurrent pancreatitis. Radiologic improvement was observed as well in terms of resolution of ductal dilatation and reduction in pancreatic head calcifications.

This video highlights the benefits of a robotic surgical approach for chronic pancreatitis. The stereoscopic visualization assists with the difficult dissection in the setting of prior pancreatitis and the wristed instruments provide improved dexterity to create the pancreaticojejunostomy. Additionally, the minimally invasive approach allows for excellent postoperative recovery for the patient and can contribute to decreased opioid use. Due to the uncommon use of the Puestow procedure and even fewer cases being performed minimally invasively, case series are limited.

All authors report no commercial associations during the last 3 years that may create a conflict of interested in connection with the video.

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Runtime of video: 9 mins 59 secs

This abstract was presented at the 15th World Congress of the International Hepato-Pancreato-Biliary Association March 30–April 2, 2022.

Transoral endoscopic thyroidectomy through vestibular approach (TOETVA) is a new technique that has become more popular worldwide because of its many advantages. ^{1 –4} However, this novel approach for thyroid cancer treatment in children is highly challenging, even for high-volume surgeons. ^5,6 In our study, we report a video of TOETVA for a pediatric patient with thyroid cancer.

A 14-year-old female was found to have cT1aN0M0 papillary thyroid carcinoma (PTC) with 7 and 5 mm tumor size. The patient's weight was 35 kg. The patient underwent right hemithyroidectomy with isthmusectomy and ipsilateral central neck dissection through the transoral endoscopic approach.

The operative time was 85 minutes. The pathologic results were PTC. The number of harvested lymph nodes was five with one positive lymph node. The stage was pT1aN1aM0. The patient was discharged 3 days after surgery without any complications such as bleeding, infection, mental nerve damage, permanent hoarseness, or hypoparathyroidism. The patient was completely satisfied with the cosmetic result. However, this technique was more challenging in children than in adults because the body size was smaller in children than in adults. It could lead to difficulty in insertion of trocars. Moreover, the chance of instrument collision may be higher.

TOETVA may be a new, feasible, and safe approach for selected pediatric patients with PTC. To the best of our knowledge, this is the first TOETVA video in children. We highly recommend that only high-volume thyroid surgeons with experience of TOETVA should perform TOETVA on the pediatric population.

No competing financial interests exist.

The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Runtime of video: 09 mins 01 secs

Children with esophageal atresia (EA) often have concomitant airway pathology, including tracheoesophageal fistula (TEF), tracheobronchomalacia (TBM), and tracheal diverticulum (TD). ^1,2 TD is rare and the incidence is estimated to be <1%. The hypothesized pathophysiology is because of a weakening in the tracheal lining resulting in an outpouching. Although largely asymptomatic, presence of a TD poses a risk for secretion accumulation with recurrent infection burden, and dangerous accidental intubation of the TD. Although some advocate for routine airway evaluation in all patients with EA, others perform it selectively, particularly in cases of long-gap EA (LGEA) thought to not have a TEF. ³ We aim to highlight the importance of a thorough preoperative airway evaluation in all cases of EA, as other entities besides TEF/TBM can exist altering LGEA management.

A 2-month-old male term infant with history notable for vertebral, anal, cardiac, tracheoesophageal fistula, renal, and/or limb defects anomalies, including unrepaired LGEA (Type A), underwent preoperative aerodigestive evaluation before LGEA management. Clinically, he had intermittent desaturations/tachypnea, requiring supplemental oxygen through nasal cannula. He underwent a three-phase rigid dynamic tracheobronchoscopy, flexible esophagoscopy, gapogram, and CT of the chest. Video of the bronchoscopy is provided.

CT imaging noted a lobulated 4 mm soft tissue density projecting from the posterior tracheal wall of the upper thoracic trachea thought to be a focal mucus accumulation. Bronchoscopy identified a mid-tracheal soft tissue “mass” creating significant airway obstruction (80%–90%). With positive pressure ventilation, the “mass” self-everted to showcase its true nature: a TD that would invaginate into the trachea on exhalation and returning to diverticular shape with positive pressure. This was confirmed on operative exploration where a true congenital diverticulum, entirely separate from the upper esophageal pouch, was identified and removed with a transverse tracheoplasty-type closure followed by posterior tracheopexy. Depending on the location of the TD, this can be done through a neck or thoracic approach. We chose to perform a right-sided thoracic approach. This can be completed thoracoscopically given the correct anatomical circumstances. We advocate for tracheopexy for several reasons: (1) to stabilize the tracheal suture line and help it heal; (2) given that we will be performing an esophageal anastomosis to treat the patient's EA, this prevents the risk for acquired TEF if the suture lines are in proximity; and (3) many of these children also have TBM and this aids in stabilization of the tracheal membrane. Alternative methods of management can involve plication of the TD without resection or endoscopic approaches with irritant/abrasive substances, yet this can lead to recurrence as the inner mucosa is not removed.

This video highlights the importance of thorough preoperative airway evaluations in all EA cases, as not only are TEFs important to identify, but also other significant airway pathology often coexists requiring treatment with the EA repair. Rigid ventilating bronchoscopy provides the ability to evaluate airway anomalies that may be missed or misdiagnosed without the ability to deliver positive pressure ventilation.

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Patient consent is within the medical record.

No competing financial interests exist.

Runtime of video: 1 min 56 secs

To be presented as a video presentation at the upcoming IPEG/ESPES Conference, July 2023.

Sialolithiasis is major cause of the obstructive salivary gland disease, accounting for ∼60% of all cases. Other etiologies include strictures, mucoid debris, anatomic ductal abnormalities, and scar tissue. ¹ About 80% to 95% of sialolithiasis cases occur in the submandibular gland, 5% to 20% in the parotid gland, and only 1% to 2% in the remaining glands. The treatment of the obstructive salivary gland has evolved in the past 25 years with the introduction of thin semiflexible endoscopes and microinstruments such as forceps, baskets, wires, lasers, and balloons. These advancements allow for sialendoscopy and other intraductal manipulations including stone removal, dilatation of strictures, and cleansing of mucus plugs. ² In addition, these procedures can be used in combination with minimally invasive external approaches. ³ Sialendoscopy is the main option for effectively treating these obstructive conditions, leading to improvements in overall quality of life. ⁴ The objective of the surgical video is to clarify the basic steps involved in effectively removing intraductal sialolithiasis.

A 36-year-old man presented with complaints of pain, swelling, and difficulty swallowing during meals, in the right submandibular salivary gland area. The symptoms had been present for the past 2 years and had worsened progressively, with no improvements with analgesics. The patient had a history of drinking less water during the past 10 years, but otherwise had no remarkable medical history. During the neck clinical examination, the right submandibular gland was found to be smaller than the contralateral gland, and no atypical lymph nodes were detected. Intraoral examination revealed a palpable 8 mm sialolith in the right floor of the mouth, which caused a discharge of milky saliva on manipulation. The remaining mucosa appeared normal. A CT scan revealed a 9 mm elliptical sialolith in the middle third of the right submandibular duct, consistent with the clinical examination and suspicion of obstructive sialolithiasis. Laboratory tests were normal. As treatment, sialendoscopy was indicated. The procedure was conducted following the standards set by Marchal et al. ⁵ The intervention was performed for both diagnostic and therapeutic interventions, using a semirigid modular sialendoscope (Karl Storz, Tuttlingen, Germany) with a diameter of 1.7 mm, along with working channel, salivary probes, conic dilatators, bougies, baskets for stones, dilatator balloons, and silastic stents to the main duct to maintain papilla patency. ⁶ The sialolith was completely removed without any adverse events.

The patient recovered uneventfully postoperatively and was discharged the next day.

Our findings support the use of sialendoscopy for obstructive sialolithiasis. Patients usually obtain a complete resolution of their clinical symptoms and the technology has a high success rate when performed by an experienced team.

The patient who agreed to participate in the study has written and signed the informed consent statement.

No competing financial interests exist.

No funding was received for this article.

Runtime of video: 4 mins 49 secs

Intestinal malrotation is one of the rare causes of intestinal obstruction secondary to failure of normal embryologic 270° anticlockwise rotation around the superior mesenteric vessels. Adult intestinal malrotation prevalence is unknown; however, computed tomography screening has revealed 0.17% prevalence. ¹ Surgical treatment may be required and entails widening the mesenteric pedicle to prevent future volvulus and obstruction rather than correcting the malrotation. The Ladd's procedure is the standard corrective measure for intestinal malrotation. Seymour and Anderson documented seven adult patients with malrotation who underwent a laparoscopic Ladd's procedure. These patients were discharged on postoperative day (POD) one through three with substantial improvement in six patients and slight improvement in one patient. ² Frasier et al reported a significant difference in hospital length of stay that favored the laparoscopic approach over an open approach. ^3,4 This video presents an adult intestinal malrotation treated laparoscopically for chronic abdominal pain and subacute intestinal obstruction.

An 18-year-old girl presented with abdominal pain and vomiting for 2 days. As per the history she had been having similar episodes three to four times per year since childhood causing nutritional impairment with a body mass index of 15. The current episode was resolved nonoperatively and computed tomography revealed intestinal malrotation. The patient was taken for a laparoscopic Ladd's procedure. The patient was positioned supine and the abdomen was entered through a 12-mm infraumbilical port and two 5-mm working ports. An adhesiolysis was performed with division of the Ladd's bands and intermesenteric bands. The duodenum was kocherized and straightened followed by widening of the base of the mesentery, an appendectomy, placement of bowel in nonrotation.

Total operative time was 40 minutes with an estimated blood loss of 10 mL. There were no complications, and the patient was advanced to a diet on POD 1 and discharged on POD 2. At the patient's 5-month follow-up, she was tolerating diet without pain and a weight gain of 12 kg.

The laparoscopic Ladd's procedure can be done safely in adults with adequate satisfaction, minimal postoperative pain and early hospital discharge. The laparoscopic method requires long-term follow-up to document its efficacy.

No competing financial interests exist.

S.K. wrote the first draft of the article, collected data, and managed the literature searches. A.K. was the operating surgeon and scientific advisor. N.G. and A.K.G. read and approved the final article. All the authors mentioned in the title page have read and gone through the article and attest the legitimacy and validity of the data, and approved it.

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

This procedure and video do not contain any resources that may cause plagiarism and patent-related issues in future.

Authors did not have any commercial associations during the past 3 years that might create a conflict of interest in connection with the video.

The preoperative work-up, operative procedure, and postoperative follow-ups were carried out in a government/public-run tertiary care hospital. There were no special fundings or financial assistances from third parties.

Runtime of video: 9 mins 44 secs

Optical imaging using near-infrared (NIR) fluorescence is now actively used to observe structures during real-time surgery. The advantages of NIR fluorescent light (700–900 nm) include high tissue penetration and low autofluorescence, which enable sufficient contrast. ¹ Lymph node dissection along the suprapancreatic area (e.g., nodes 7, 8a, 9, 11p, and 12a) during laparoscopic gastrectomy remains challenging even for an experienced surgeon. Fluorescent lymphography may be useful for performing a complete lymphadenectomy by assessing the adequacy of lymphadenectomy in real time. ² To facilitate this procedure, a sophisticated articulation device was used with NIR fluorescence imaging guidance. ³

A 54-year-old man was found to have gastric adenocarcinoma located at the midbody along the lesser curvature of the stomach. An abdominal computed tomography scan revealed clinical stage T2N1M0. No metastatic lesions were found on preoperative testing. Laparoscopic distal gastrectomy was performed with a D2 lymph node dissection. The laparoscopic articulating instrument with a multijointed structure that synchronized with the surgeon's hand, wrist, and finger movements was used to facilitate the lymph node dissection. Of note, indocyanine green was injected submucosally at four sites around the cancerous tissues during intraoperative endoscopy before the lymph node dissection.

The operating time was 150 minutes, and the estimated blood loss was 30 mL. The patient recovered well, and he was started on a liquid diet on postoperative day 3. He was discharged on postoperative day 6 without any complications. The final pathologic report revealed that 45 lymph nodes had been retrieved and 2 were metastatic. He received adjuvant therapy and is alive at 1.6 years follow-up without recurrence.

The suprapancreatic lymph node dissection procedure can be accomplished by using a novel multijointed articulating instrument and simultaneous NIR imaging in a patient with gastric cancer.

No competing financial interests exist.

Runtime of video: 7 mins 41 secs

A renal mass with a concurrent stone is a complex challenge. The challenge is to tackle both pathologies using a single anesthetic without compromising the oncologic or renal functional outcomes. This video demonstrates two cases using robot-assisted nephron-sparing surgery (RA-NSS) and provides tips for effective management to maintain the oncologic and functional safety.

Simultaneous RA-NSS with stone retrieval was performed with DaVinci SiHD system using three robotic arms in two cases after obtaining due consent as per our previously described technique. ¹ Case 1 was a 66-year-old man, whereas the second case was a 56-year-old woman. In Case 1, during resection of the tumor the renal stone was identified through the opening in the pelvicaliceal system (PCS), which was further extended and three stones were retrieved intact. For Case 2, after dissecting the hilum, the renal pelvic dissection was performed followed by a pyelotomy to retrieve the stones. This mimics a previous published technique by Garisto et al. ² The PCS was closed with 3-0 polygalactin sutures over a Double-J stent (DJS), in both cases.

The warm ischemia time (WIT) was 27 minutes in Case 1 and the renal hilum was not clamped in Case 2. The estimated blood loss was 800 and 200 mL and the length of hospital stay was 7 and 5 days for Cases 1 and 2, respectively. The histopathology report in both the cases was clear cell with negative margins. The DJS were removed at 4 weeks. No adjuvant treatment was offered in both the cases. Both the patients were recurrence free with normal renal function at a follow-up of >5 years.

During RA-NSS the focus is to limit WIT and maintain the oncologic margins. In a situation where a renal stone is large and the tumor is close to PCS (index Case 1), the NSS is performed initially followed by an incision further into pelvis for stone extraction. However, when the stone is in the pelvis and the tumor is in the periphery (index Case 2), pyelolithotomy should be performed first followed by NSS to decrease or avert the WIT.

Both the patients of this video submission gave full consent for recording the surgical procedure and its use for publication.

The authors have received and archived patient consent for video recording/publication

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8 mins 10 secs

Advanced robotic technology enhances a total mesorectal excision for rectal cancer and may overcome challenges associated with difficult pelvic anatomy. ^1,2 Moreover, minimally invasive approach may be used to address several common complications of solid organ malignancies. ^3,4 This video shows a patient with rectal cancer who underwent neoadjuvant therapy with a new finding of a primary pancreatic cancer at postneoadjuvant re-evaluation. The patient underwent a palliative robotic anterior rectal resection for a bleeding adenocarcinoma of the rectum.

A 70-year-old patient presented to the outpatient clinic with diarrhea and rectal bleeding. Diagnostic work-up included a colonoscopy that showed an adenocarcinoma of the rectum at 8–9 cm from the anal verge. A CT scan revealed no pulmonary disease and no carcinosis, and a pelvic MRI confirmed a substenotic, full thickness infiltrating tumor of the rectum. Multidisciplinary tumor board recommended neoadjuvant treatment based on capecitabine and RT (total dose 55 Gy/25 fractions). Postneoadjuvant re-evaluation included a pelvic MRI that showed a partial response of the rectal tumor. A CT scan identified a new finding of a neoplasm at the level of the pancreatic body. Endoscopic ultrasonography showed a mesopancreatic tumor with splenic vessel involvement. Histologic examination documented an adenocarcinoma and magnetic resonance cholangiopancreatography confirmed the tumor. Multidisciplinary tumor board recommended gemcitabine but it was halted for rectal bleeding after 1 week. A rectoscopy confirmed the bleeding from the rectal lesion. Palliative rectal surgery was recommended, and the patient underwent an anterior rectal resection with S3 metastasectomy and partial pelvic peritonectomy for carcinosis with an end-to-end colorectal anastomosis according to the Knight & Griffen technique and a diverting ileostomy (S3 metastasis and carcinosis were intraoperative findings).

The patient was discharged on postoperative day 6. The postoperative course was uneventful and afterward systemic treatment with gemcitabine and paclitaxel was resumed. At re-evaluation by CT and MRI, no pelvic recurrence was diagnosed, whereas the volume of the pancreatic lesion was reduced. A stereotactic ablation was performed on the pancreatic lesion. The patient underwent ileostomy closure, but after 1 year from the primary surgery, the patient referred was admitted with an intestinal obstruction. An explorative laparoscopy revealed diffuse carcinosis from the pancreatic lesion. The patient died a few months later.

Robotic technique is a safe and an efficacious tool for palliative surgery. In complex cases, a robotic technique provides a fast recovery and a quick reprise for further oncologic treatments. Palliative surgery, however, must be delivered as part of an interdisciplinary team and should be attempted through a minimally invasive approach to reduce pain and adverse effects of surgical intervention. ⁵

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Runtime of video: 10 mins

In patients with liver metastases, robotic liver resection was reported to be safe and feasible. ^1,2 Some researchers suggested that Indocyanine green (ICG) fluorescence imaging allowed to detect occult small-sized lesions which were not diagnosed preoperatively and was effective in real-time assessment of surgical margins by evaluating the integrity of the fluorescent rim around the tumour. ^3,4 Here, we report a 70-year-old man with liver metastasis in segment VIII from sigmoid cancer who received robotic nonanatomical hepatectomy guided by ICG fluorescence.

One day before operation, we gave the patient ICG 25 mg intravenously to guide the surgeon to perform robotic resection of liver metastasis in firefly mode. The operation was performed in supine position under general anesthesia. We inserted the robot trocars into the right axillary front line 3 cm away from the costal arch, the right clavicle midline 3 cm away from the costal arch, the right upper umbilicus, and the lower xiphoid process, respectively, and inserted a 12 mm trocar into the left upper umbilicus as an auxiliary port. After that, the position was adjusted to reverse Trendelenburg and left tilt. We explored the abdominal cavity and revealed the tumor in segment VIII of the liver. After converting to the firefly mode, in green fluorescent signals, we further confirmed the tumor, with a diameter of about 3 cm and showed suspicious small superficial lesions, not diagnosed preoperatively. We incised the falciform ligament and the ligamentum teres hepatis was ligated and cut routinely. In firefly mode, we marked the resection line and resected suspicious small superficial lesions. Before we performed nonanatomical hepatectomy in segment VIII, hepatic hilar occlusion was performed with a bulldog clamp. During the resection, the vessels were ligated and cut. In firefly mode, no fluorescence signal produced by the liver wound bed and we confirmed there should be no residual tumor. After resection, we removed the bulldog clamp. The hepatic inflow occlusion time was 20 minutes. Finally, meticulous hemostasis was performed. Two drainage tubes were placed, and the specimen was removed through the incision.

In this case, no intraoperative or postoperative complications were observed. The total operation time was 200 minutes and blood loss was 50 mL. Postoperative pathology showed the metastatic adenocarcinoma, and all margins were negative. The patient underwent an uneventful recovery and was discharged on postoperative day 7. The aspartate transaminase and alanine transaminase showed temporary abnormalities and recovered on postoperative day 4. Carcinoembryonic antigen and carbohydrate antigen 19-9 decreased obviously 1 month after operation.

Robotic resection of liver metastases guided by ICG fluorescence was feasible in selected cases. Intravenous injection of ICG before surgery could help accurately locate tumor and detect occult small-sized lesions during the operation. In firefly mode, ICG fluorescence imaging could be adopted as a real-time guide to assessing surgical margins to obtain a margin-free resection.

H.Z. had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: H.Z. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: All authors. Critical revision of the manuscript for important intellectual content: All authors. Supervision: H.Z.

This study was approved by the Ethics Committee of Changzheng Hospital.

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

No competing financial interests exist.

Runtime of video: 5 mins 9 secs

Endoluminal vacuum therapy (EVT) is a standard endoscopic treatment option in esophageal anastomotic leakages in adults. This technique involves combining a polyurethane sponge with a nasoenteral tube, through which an external vacuum is applied. Benefits of EVT include wound decontamination through active drainage and the ability to debride and lavage the wound cavity endoscopically at each endoluminal vacuum exchange. The main disadvantage is the treatment burden on the endoscopist and patient, as the EV must be changed at least twice a week until the leak cavity has closed and the anastomosis has healed through secondary intention, which may take several or more weeks. Although well described in adult literature, there is a paucity of studies on EVT in the pediatric population, with only case reports and case series. ^{1 –3} In this video case report, we describe our technique for effective management of an esophageal anastomotic leak in an infant using EVT.

This is a 4-month-old male child with congenital isolated esophageal atresia who underwent primary repair at the age of 3 months after a procedure to lengthen his esophagus. Thirteen days postoperatively, a swallow study demonstrated contrast extravasation into the right pleural space through a sizable defect along the right lateral aspect of the mid esophagus. The decision was made to proceed with endoscopic management of the leak to avoid the morbidity of a repeat surgical operation. In the operating room, the area of the anastomotic disruption was identified, with an ∼1.5 to 2 cm gap on the right side occupying 50% to 60% of the anastomosis. The EV was made with an 8F nasogastric feeding tube with black GranuFoam secured with 3-0 Prolene sutures proximal and distal. The distal suture acted as a handle for the bronchoscopy grasper to drag it into position in a standard manner under direct endoscopic observation. The vacuum pressure was set to 75 mm Hg. After the initial EV placement, the patient subsequently underwent exchange of his endoluminal vacuum in the operating room twice a week for a period of 2 months. Foreign objects such as suture material from the patient's primary repair and chest tubes were removed during this period as well. Over time, the cavity appeared clean, contained, and was self-draining. When his esophageal anastomotic leak had healed by secondary intention, EVT was terminated.

Two months postoperatively, he underwent planned endoscopic re-evaluation and was found to have an asymptomatic short segment esophageal stricture on endoscopy that had required serial endoscopic dilatations. During this time, he received all feedings through his jejunal feeding tube while undergoing small volume per oral trials under the guidance of his speech therapists. He now only requires dilatations on an as-needed basis.

EVT for esophageal anastomotic leaks is technically feasible and appears safe in the pediatric population. To date, no other similar procedures have been performed by our department in other patients. Further study is necessary to establish the safety of this procedure before its implementation as standard practice in infants.

Author Disclosure Statement: A.H., S.D.S., A.N.K., A.Y.T., M.C.S., and D.V.R. have no financial disclosures. J.S.W. is a consultant for Boston Scientific Co. and Bard. E.M.P. is a speaker for Becton Dickinson, Medtronic, Ovesco, and Boston Scientific. E.M.P. is a consultant for Boston Scientific Corp., Actuated Biomedical, Inc., Baxter, Wells Fargo, Cook Biotech, Neptune MEdical, Surgimatrix, CMR Surgical, Boehringer Laboratories, Allergan, and Noah Medical.

Runtime of video: 5 mins 58 secs

Acknowledgments: The source of the study is the Department of Minimally-Invasive Surgery at Penn State Milton S. Hershey Medical Center. This video was presented as a video presentation at the 2023 Society of Gastrointestinal and Endoscopic Surgery on March 29 to April 1, 2023.

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

A right-side colon cancer combined with a lumbar hernia is an unusual clinical presentation. A laparoscopic approach for both pathologies provides a faster recovery while enhancing the exact anatomical borders of the lumbar hernia defect. ¹ In addition, an intracorporeal laparoscopic anastomosis reduces mesenteric traction, decreases the risk of twisting the ileal mesentery, and accelerates postoperative recovery. ² This video illustrates the case of a 79-year-old man with an ascending colon cancer with a lumbar hernia who received a laparoscopic right colectomy and concurrent lumbar hernia repair.

The patient was placed in the supine position with legs apart. Three 5-mm trocars, one 10-mm trocar, and one 12-mm trocar were used. The right colon was mobilized using a caudal-to-cranial approach. The dissection was performed along the avascular plane between Toldt's and Gerota's fascia. After mobilization of the ascending colon, the D3 lymphadenectomy was performed through a central approach. Then, the gastrocolic ligament was divided, followed by mobilization of the hepatic flexure. After the mesocolic excision was completed, the transverse colon was transected 10 cm distal to the tumor, and the terminal ileum was transected 15 cm proximal to the ileocecal valve using linear staplers. A side-to-side anastomosis was performed in an isoperistaltic manner using a 60 mm linear stapler. ³ The enterostomy was closed using a linear stapler. Then, the lumbar hernia defect was closed with a 3-0 V-Loc™ suture in a single layer. Subsequently, a DynaMesh^®-IPOM was secured using a laparoscopic ProTack™. Finally, a 4-cm longitudinal incision was made for specimen extraction.

The operation time was 2 hours 35 minutes. The estimated blood loss was 40 mL. The patient was discharged on postoperative day 6. The final pathology confirmed a moderately differentiated adenocarcinoma with mesenteric lymph nodes metastases (pT3N2aM0). All surgical margins were negative. The patient will receive eight cycles of XELOX. Since the time of surgery, the patient has undergone one cycle of XELOX. The follow-up CEA level (7.24 μg/L, 1 month after operation) decreased compared to the preoperative value (14.49 μg/L). There was no evidence of a recurrent hernia or mesh infection at 1 month follow-up in clinic. The radiologic assessment will be performed at 3, 6, and 12 months.

Laparoscopic right colectomy with a concurrent lumbar hernia repair with mesh may be performed safely without the risk of infection or recurrence and excellent oncologic outcomes.

H.Z. had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: H.Z. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: All authors. Critical revision of the manuscript for important intellectual content: All authors. Supervision: H.Z.

This study was approved by the Ethics Committee of Changzheng Hospital.

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Runtime of video: 6 mins 25 secs

Robot-assisted hernia repairs provide equal clinical outcomes versus laparoscopic and open surgery. ^1,2 The Versius system, developed by Cambridge Medical Robotics Surgical, first obtained European Conformity (CE) mark approval in March 2019 and was subsequently used initially in India and then the United Kingdom in the autumn of 2019. ³ The chief advantages include a lower cost that may play an important role in resource-poor countries. The Versius system provides an open console, is portable, and has flexible port placements. In addition, the Versius system may utilize existing laparoscopic equipment. This video documents the technique of the Versius system for robotic hernia repairs.

Two robotic hernia repairs using the transabdominal preperitoneal repair technique were performed in male patients, age 27 and 45 years. Both the patients presented with lump in the groin associated with dull pain. Ultrasonography of the abdomen confirmed the diagnosis. Intraoperatively, a peritoneal flap was raised, and the dissection was carried out into the space of bogros and retzius. The sac was separated from cord structures and inverted into the peritoneal cavity. The pubic tubercle was observed and a 10 × 15 cm Prolene mesh was placed and covered the entire myopectineal orifice. The second patient had a direct hernia and the pseudosac was reduced and fixed with a tacker before mesh placement.

Both patients recovered without complications. Operatively, the procedure was slightly longer than usual. Similar results have been noted in a study performed on 32 patients using this system. ⁴

Robotic hernia repairs are a feasible alternative for inguinal hernia repairs. Studies with larger cohorts are needed to assess and compare all robotic systems.

No competing financial interests exist.

Runtime of video: 7 mins 16 secs

The Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Colocutaneous fistulas are severe complications that traditionally are repaired surgically with resection of the fistula followed by end-to-end anastomosis of the bowel. Given the high morbidity of surgery, an alternative approach to consider is endoscopic fistula closure with clips, which is a minimally invasive approach and is safe with high success rates. ^{1 –5} Currently, there are no reports in the literature describing endoscopic closure of the appendiceal orifice. This video case report describes a technique for placement of an over the endoscope clip at the appendiceal orifice to effectively close a colocutaneous fistula.

The patient was a 69-year-old male with Marfan's syndrome who was 5 months status post primary repair of a duodenal perforation with feculent peritonitis. His early postoperative course was complicated by a persistent leak from an unknown source. One month postoperatively, imaging showed a large retroperitoneal abscess that required percutaneous drain placement. At that time, surgical endoscopy was consulted for duodenal evaluation and found no clear evidence of a leak from the duodenum. A percutaneous endoscopic gastrostomy tube with a jejunal feeding extension was placed. Four months after his index operation, he presented to the clinic with a change in drain output character that was suspicious for an enterocutaneous fistula. Fistulogram with contrast injected into the patient's percutaneous drainage catheter demonstrated continuity with the colon in the right lower quadrant. He was taken for a colonoscopy and fluoroscopy for further evaluation of the colocutaneous fistula. After injection of saline at the drain site, saline was seen trickling into the cecum from the appendiceal orifice. The decision was made to close the orifice with a 12/6T over-the-endoscope clip. The percutaneous retroperitoneal drain was removed 5 days postoperatively and he was discharged home 7 days postoperatively on a low residue diet.

At 1 month follow-up, the patient was doing well on a regular diet with no abdominal pain or fevers. A routine imaging scan performed 7 weeks postoperatively showed no recurrent retroperitoneal fluid collection. His gastrojejunal feeding tube was removed.

Over-the-endoscope clipping of the appendiceal orifice to repair a colocutaneous fistula is technically feasible and appears safe. Endoscopic therapy spared this patient from a potential ileocecectomy. To date, no other similar procedures have been performed by our department in other patients. Further study is necessary to establish the safety of this procedure before its implementation as standard practice.

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Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Runtime of video: 5 mins 20 secs

This video was accepted as a video presentation at the 2023 Society of Gastrointestinal and Endoscopic Surgery on March 29 to April 1, 2023.

Blunt trauma may cause small occult diaphragmatic injuries that increase in size over the course of decades. The gradual increase is secondary to the pressure disparity between the abdominal and thoracic cavities. Over time, visceral contents may traverse the defect and become incarcerated within the thoracic cavity. ¹ Typically, the defect occurs on the left side with gastric herniation. Rarely, the defect occurs on the RIGHT side since the large right lobe of the liver may preclude herniation through a right-sided diaphragmatic defect. ^2,3 This video presents a repair of a symptomatic right-sided diaphragmatic hernia that occurred decades after blunt trauma.

A 58-year-old man was admitted to the emergency department with a 2-day history of acute abdominal pain that was sharp and diffuse. He had vomited several times and denied flatus for 24 hours. He had a history of three prior motor vehicle accidents in the 1980s. He had a history of oropharyngeal cancer that was treated with radiation then a neck dissection 2 years before presentation. He had no history of abdominal or thoracic surgery but had a significant tobacco history for 40 years. His blood work was normal. A CT scan of the abdomen showed a right-sided diaphragmatic hernia defect that contained small intestine and colon. There was no dilated bowel or evidence of a pneumoperitoneum or free fluid. There was air in the rectum. A well-healed old nondisplaced pubic rami fracture was evident also on the scan. Surgical intervention included a laparoscopic possible thoracoscopic diaphragmatic repair. Operatively, he was placed in a semilateral position at 30°. A Veress needle was used to enter the abdomen and three 5 mm ports were placed along the subcostal border. One of the 5 mm ports was upsized to a 10 mm port. Diagnostic laparoscopy delineated the diaphragmatic defect containing bowel. Several adhesions were divided and the colon and small intestine were reduced from the defect. There was no hernia sac and the thoracic cavity was pristine. Once the bowel was reduced, the defect was measured at ∼5 cm by 3 cm. The defect was closed with interrupted 0-silk sutures. The suture line was then buttressed with a 15 cm by 10 cm mesh. The mesh was secured with absorbable tacks. A 28F chest tube was placed.

The operative time was 90 minutes. The patient was started on a clear liquid diet on postoperative day 1 and advanced to a regular diet on postoperative day 2. Because of social issues, he was discharged on postoperative day 4. A chest CT at ∼6 months postoperatively showed no evidence of a recurrent diaphragmatic defect.

Minimally invasive techniques are well suited for diaphragmatic defects. If a right-sided symptomatic diaphragmatic hernia is diagnosed, a minimally invasive approach through the abdomen may be performed without a thoracic approach. Adhesions may warrant thoracic access to reduce the abdominal contents, so double lumen intubation is prudent. A durable repair may be obtained by suturing the defect and adding a mesh buttress.

Authors have received and archived patient consent for video recording/publication of the procedure.

There are no conflict of interests associated with this video in terms of commercial or financial interests.

Runtime of video: 5 mins 42 secs

Pediatric laparoscopic inguinal hernia repair is safe and effective, but the learning curve can be steep. Preperitoneal hydrodissection with saline or local anesthetic is a well-described adjunct to facilitate safe and accurate placement of the deep ring-closing suture. ¹ One issue encountered frequently is that the area of hydrodissection can rapidly dissipate while passing the closing suture and prevent smooth needle dissection through the preperitoneal space and away from the cord structures. ² We aim to adapt this technique to combine hydrodissection with the suture passage to improve the safety profile and flatten the learning curve of these repairs.

A novel adjunct to this technique was developed utilizing materials already available in the operating room. We conducted proof of concept testing with this novel configuration on an animal model to assess ease of use and refine the technique. Through iterative testing, we determined that a connector device used in vascular surgery applications to accommodate both guidewire passage and catheter lumen flushing easily facilitates simultaneous hydro dissection during introduction of the suture. We observed that the instillation of saline during needle advancement made the dissection very smooth and that the addition of the connector and syringe did not significantly alter the maneuverability of the needle through the tissue. An assistant provided the manual installation of the saline at the direction of the operative surgeon to free the primary operator to manipulate the placement of the suture passing needle.

We utilized this configuration on five pediatric patients with inguinal hernias. Using the same set up as shown in the animal model, the spinal needle attached to the Tuohy–Borst was used to hydro dissect from 12 o'clock to 6 o'clock, and the suture loop was then introduced into the peritoneal cavity. The spinal needle was withdrawn and then reintroduced in a similar fashion on the opposite side of the deep ring to complete the encirclement of the ring in the preperitoneal space taking care to avoid the vas deferens and the vessels. This simultaneous hydrodissection anecdotally reduced operative time and ensured a greater margin of safety by lifting the peritoneum off the cord structures in real time.

In summary, this modification is a successful adaptation to a classic technique that we hope will allow for increased safety and efficiency in the operating room. This novel configuration can also accommodate variations in the actual technique of deep ring encirclement and addresses the problem of rapid dissipation of fluid in the peritoneal space, increasing the safety profile for a procedure that has a steep learning curve. Additional studies to capture quantifiable metrics of efficiency and efficacy for trainees in the advanced pediatric surgery learning environment are planned.

No competing financial interests exist.

Runtime of video: 2 mins 42 secs

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Uterine fibroids and ovarian endometriosis are the most frequent gynecological pathologies. ^1,2 The gold standard treatment for both is laparoscopy which almost always involves hospitalization with overnight accommodation, high costs, and surgical skills. This surgery sometimes results in long recovery times and harmful effects for patients wishing to conceive. ^3,4 The goal of this video is to show the possibility and effectiveness of radiofrequency (RF) ablation to treat a patient affected by uterine fibroid and ovarian endometrioma with a single minimally invasive intervention. ^5,6

A 42-year-old woman affected by menorrhagia and pelvic pain caused by a 3 cm diameter posterior uterine fibroid and a 3 cm diameter right ovarian endometriotic cyst. With a view to conservative and minimally invasive surgery, RF ablation of the uterine myoma and ovarian endometrioma was performed transvaginally (TV). The ultrasound-guided biopsy of the myoma was performed with an 18 Gauge × 25 cm disposable core biopsy instrument (Bard^® Max-Core^®). ⁷ A single lumen 17G × 250 mm (Cook^® Medical) and a 35 cm long 17G internally cooled electrode with an exposed tip of 10 mm (RF STAR-Fixed—STARmed) were used, respectively, for puncture and cyst ablation. The five surgical steps described in the video are (1) myoma biopsy (histology); (2) myoma RF ablation; (3) cyst aspiration (cytology); (4) washing of the cyst; and (5) RF ablation of the cystic walls.

MRI follow-up at 6 months and clinical follow-up at 12 months documented reduction of the uterine fibroid volume by 70%, absence of ovarian cyst recurrence, and patient satisfaction with the procedure.

To our knowledge, this is the first report in the literature of a combined and simultaneous treatment of a uterine fibroid and an endometriotic ovarian cyst through transvaginal ultrasound-guided RF ablations.

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I certify that during the last 3 years I have had no association with any commercial organization that might create a conflict of interest in connection with the video.

Runtime of video: 10 mins 10 secs

Mucinous cystic neoplasms are rare premalignant tumors of the pancreas and account for 1–2% of all pancreatic tumors. Surgical removal before invasive malignancy offers the best long-term outcome. ¹ Distal pancreatectomy with or without spleen preservation remains the standard procedure. Although an open technique is still the most commonly used approach, laparoscopy is associated with less pain, less blood loss, less morbidity, similar clinical outcomes, and an early return to activities. ^2,3 This video presents a laparoscopic distal pancreaticosplenectomy (LDPS) performed for a mucinous cystic neoplasm in the body of pancreas.

A 30-year-old lady presented with a 2-year history of recurrent epigastric pain that had increased in severity over the past 2 months and required admission. Her physical examination was normal. A contrast-enhanced computed tomogram revealed a 3 × 3 cm well-defined cystic lesion in the tail of the pancreas adherent to the splenic vein. An endoscopic ultrasonography with fine needle aspirate revealed a complex cystic mucinous cystic neoplasm measuring 2.8 × 2.5 cm in the body of the pancreas. Owing to its premalignant potential and recurrent symptoms, an LDPS was performed for the mucinous cystic neoplasm of the body of pancreas. Vaccinations covering Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae were administered 2 weeks before surgery. The patient was placed in a French position with ports as shown in the video. Spleen preservation was not attempted because of the splenic vein involvement. The pancreas was divided using a stapler and the vessels were divided using sequential clips. The pancreas was separated from the spleen as it was a nonmalignant lesion and enabled easy removal from the port site without enlarging the incision or morcellation.

The operative time was 90 minutes with <10 mL of blood loss. The perioperative course was uneventful, and her diet was resumed on postoperative day 1. The drain was removed on postoperative day 3 after an insignificant drain amylase. The patient was discharged on postoperative day 4. Final histopathology report revealed a low-grade mucinous cystic neoplasm of the pancreas. The patient is asymptomatic at 3 months follow-up.

LDPS is a safe and feasible approach for mucinous cystic neoplasms of pancreas. It provides less pain, lower blood loss, and early return to work to the patient while providing similar outcomes.

The authors have no commercial associations resulting in conflict of interest with respect to the submitted video.

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Runtime of video: 9 mins 57 secs

This video was presented and awarded third best video presentation at SURGICON 2022 (Annual conference of Association of Surgeons of India—Delhi Chapter) on November 13, 2022.

Atypical hernias include suprapubic, iliac, and lumbar hernias, and they are almost always incisional in nature. ^{1 –3} Laparoscopic management of these hernias is technically challenging due to close proximity to bone and other neurovascular structures. ^{2 –4} This technical challenge may be overcome by raising the peritoneal flap in the lower half as it would be very difficult and ergonomically challenging to suture the peritoneal flap in the proximal location. This video evaluates the results of laparoscopic transabdominal partially extraperitoneal (TAPE) mesh repair for atypical hernias.

This study comprised five patients with atypical incisional hernias. All patients were managed laparoscopically by TAPE repair at AIIMS, New Delhi, with a follow-up at least 6 months. The inclusion criteria were small and medium (<10 cm) hernias located over the iliac, suprapubic, or lumbar regions. Hernias with defect size >10 cm or features of strangulation were excluded. In TAPE plus repair, an extraperitoneal pocket was created by starting the dissection just above the superior margin of defect horizontally and extending the dissection up to 2 cm below Cooper's ligament inferiorly and laterally along the psoas muscle. The hernia defect was closed with barbed suture, incorporating the overlying abdominal wall to obliterate the cavity. A macroporous, tissue-separating mesh of adequate size was paced partially inside the pocket. Four corner transfascial suturing was used with Polypropylene 1-0 via an epidural needle. Tacks were placed at Cooper's ligament, the superior margin of the dissected peritoneum, and the edges of the mesh.

Five patients (M:F::1:4) with mean age of 43 years (range 30–59 years) and mean body mass index of 28.6 kg/m² (range 26.7–31.4 kg/m²) were included. Two patients were postabdominal hysterectomy, one post-lower segment cesarean section, one postappendectomy, and one post left nephrectomy. The average operative time was 104 minutes (range 85–130 minutes). All patients were discharged on postoperative day 1. There were no bowel or bladder injury, surgical site infection, seroma, or recurrence noted over 6 months of follow-up.

TAPE repair is a safe and feasible option for incisional hernias located at atypical locations including iliac, suprapubic, and lumbar regions.

Corresponding author have received and archived patient consent for video recording/publication of the video without exhibiting patient demographic details in advance.

This is an original work carried out in a tertiary care public hospital, and there are no conflicts of interest or obligations resulting from it to any of the authors.

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Runtime of video: 8 mins 18 secs

Choledochal cysts are rare congenital anomalies of the bile ducts, characterized by dilations of the intrahepatic and extrahepatic biliary ducts. Approximately 80% are diagnosed in childhood, with a higher incidence in Asian countries. ¹ Imaging studies are essential for the diagnosis, including magnetic resonance cholangiopancreatography as the method of choice. ² Patients with types I, II, or IV cysts usually undergo surgical resection of the cysts because of the significant risk of malignancy. The treatment of choice of type I bile duct cysts in adults is total cystectomy and hepaticojejunostomy in a Roux-en-Y manner. ² The advantages of this procedure include a reduced incidence of anastomotic strictures, stone formation, cholangitis, and intracystic malignancy. ² This video shows the surgical steps, tips, and tricks of minimally invasive resection of the choledochal cyst and continuity with a bilioenteric anastomosis.

A 48-year-old woman with previous laparoscopic cholecystectomy presented with a history of right subcostal pain and jaundice. After magnetic resonance cholangiopancreatography, a type I Todani choledochal cyst was diagnosed with a width of the proximal bile duct of 12 mm. She underwent minimally invasive resection of the bile duct and a terminolateral hepaticojejunostomy in a Roux-en-Y manner. Operatively, an 11 mm trocar was placed at the umbilicus. Three 5 mm trocars were placed in the epigastrium, right hypochondrium, and right flank. An 11 mm trocar was placed in the left flank. A type I choledochal cyst was confirmed with cystic duct dilation. The right hepatic artery, proximal bile duct, and portal vein were identified. The main bile duct was completely dissected, and two clips were placed in the intrapancreatic portion. The distal part of the bile duct was sectioned above the clips. The proximal bile duct was divided 1 cm from the hilar plate and the specimen was completely removed. The jejunal loop was identified and a terminolateral hepaticojejunal anastomosis was performed using barbed suture (V-locTM 4/0, Covidien). Then, a laterolateral jejunojejunal anastomosis was performed using a stapler. The common loop between the two anastomosis was sectioned with another stapler that completed the Roux-en-Y. Finally, a subhepatic suction drain was left.

The drain was removed 72 hours after the procedure and the patient was discharged on postoperative day 6 without complications. The pathology report confirmed a choledochal cyst without malignancy. A follow-up was done at 1 and 6 months. The patient was asymptomatic and blood workup and cholangiography were normal.

Different publications with high level of evidence document that minimally invasive surgical treatment on Todani I choledochal cysts reduces hospital stay and postoperative pain compared with an open approach. ³ It is a demanding technique with a long learning curve that decreases with the use of barbed sutures without increasing complications.

No competing financial interests exist.

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