Harmonic Scalpel

Laparoscopic right hemicolectomy

Laparoscopic right hemicolectomy.
D-r Puchkov D.K. (CMS) is performing an operation (2018).

• In this video the technique of laparoscopic right hemicolectomy is presented. A 53 year-old female patient was operated with diagnosis: Cancer of the hepatic flexure of the colon fT3N0M0, G2. During preoperation investigation of the abdominal cavity according to RCT, was found extensive formation about 5.5 cm in diameter and multiple increased lymphatic nodes along the artery ileocolica, without symptoms of their metastatic lesion. The first stage of operation: a 10 mm troacar was placed above the umbilicus, 10 mm optic was introduced. Then a 5 mm troacar was introduced in epigastrium along the midline of abdomen under the guidance of optic, 5 mm troacars were introduced into the right and left iliac areas. During revision of the abdominal cavity where was not found any sings of metastases in liver. The tumour was found in the cecum, movable, firm, does not involve the serous layer. Increased lymphatic nodes of the first priority were visualized. Intraoperatively surgeons decided to perform a right hemicolectomy with the high ligating of artery and vein ileocolica. Artery and vein were visualized, skeletonized, transected near the area of its origin with 5 mm LigaSure (“Medtronic Covidien”) device. The right part of the large colon was mobilized from “downwards-to- upwards” within the boundaries of Toldt’s fascia with Harmonic (“Ethicon”) scalpel, the descending part of duodenum was visualized, the head of pancreas, infrapyloric lymphatic nodes are intact. The abdomen of the right lateral canal was transected, resection of gastrocolic ligament up to the level of middle one-third of the transverse colon was done. Mesentery of the colic colon was mobilized up to the level of middle one-third of the transverse colic colon. Mesentery of the iliac colon was transected at the distance of 15 cm proximally to Bauhin’s (ileocecal) valve. Middle minilaparotomy was performed. Latex ring “Dextrus” was placed into the wound to restrict tissues of the anterior abdominal wall from the colon with tumour, the colon is exteriorized into the wound, resection of the right parts of the colon and iliac colon was done. Bistapler ileotransversoanastomosis “side –by-side” was performed. Edges of anastomosis were additionally stitched by “Vicryl” 3-0 thread. The abdominal cavity was drained via troacar incision in the right iliac area. Minilaparotomic and troacar wounds were stitched layer by layer. Aceptic bandage was applied. Operation duration is 80 minutes.

Laparoscopic anterior resection of rectum

Laparoscopic anterior resection of rectum
D-r Puchkov D.K. (CMS) is performing an operation (2018).

In this video the technique of performing the anterior rectal resection for chronic diverticular disease of the sigmoid colon is presented. A 58 year-old female patient was treated, having the diagnosis: Diverticular disease of the sigmoid colon, relapsing diverticular without complications. Within the last 5 months a patient thrice was hospitalized for acute complications of diverticular disease. During preoperation investigation according to fibrocolonoscopy, had found multiple diverticula with the symptoms of inflammation in the sigmoid colon, and in rectum on the border of middle ampullar and upper ampullar parts and proximally thickening and rigidity of rectal wall had been found out. RCT of abdominal cavity had shown multiple diverticula in the sigmoid colon, some indirect symptoms of presence of “chronic” abscess in Douglas cul-de-sac.
“Classical” scheme of positioning of troacars had been used: in the right iliac area, the right and left mesogastric area. The operation was started from rectum, identification of interfascial layer with help of Harmonic scalpel (”Ethicon”) device. In case, if it is not possible clearly visualize the layer between Toldt’s fascia and fascia Gerotae distally to the inferior mesenteric artery, the layer could be visualized under the inferior mesenteric vein. Transection of the inferior mesenteric artery was done near at the origin with LigaSure instrument (“Medtronic”). The next stage was exposure of the inferior mesenteric vein, identification of embryologic layer of the large colon, we use from media-to-lateral direction towards splenic flexure. For safe mobilization of the splenic flexure of the colon was dissected in inframesocolic way. Preliminarily dissection of pancreas should be done, then opening of omentum sac, after that the abdomen of the left lateral canal was incised, then mobilization of the descending part of colon and of splenic flexure of the colon took place. Then exposure of rectum along the posterior wall with the identification of the left ureter took place. Exposure of rectum is up to the infiltrate level along the posterior wall, then – along the right and left half - curcumference, and only after at the end-along the anterior wall. Transection of the large colon in the distal part was done with EcheloFlex-60 (a blue cassette) device (“Ethicon”). Then minilaparotomy was performed (about 5 cm), a latex ring “Dextrus” was placed in the wound to restrict tissues of the anterior abdominal wall from the colon. The colon was exteriorized, resection of specimen was done, the head of CDH-29 device (“Ethicon”) was inserted into the proximal end, it was fixed by purse-string suture, “Vicryl” 2-0 thread was used, then, it was immersed into the abdominal cavity. CDH-29 device was introduced transanally, created an anastomosis. Operation was finished by draining the small pelvis. The duration of operation was 130 minutes.

Laparoscopic D3 lymphadenectomy for right-sided colon cancer

Laparoscopic D3 lymphadenectomy for right-sided colon cancer.
D-r Puchkov D.K. (CMS) is performing an operation (2018).

In this film the technique of performing D-3 lymphadenectomy (operation stage) for right-sided colon cancer is presented. A 50 year-old male patient was treated with diagnosis: Cancer of hepatic flexure of colon fT3N1M0, G2. During preoperation investigation, on RCT research a few findings was detected: a big formation in the transverse colon, closer to the hepatic flexure about 5 cm in diameter, there were multiple increased lymphatic nodes in the mesentery of the ascending colon, without sings of metastatic lesion. There is no RCT information about local spreading of tumour. The first stage of operation: a 10 mm troacar was placed above the umbilicus and then 10 mm optic was introduced. Then a 5 mm troacar was introduced into epigastrium along the midline of abdomen under the guidance of optic and then 5 mm troacars were introduced into the right and left iliac area. During the revision of the abdominal cavity where was no evidence for liver metastases. The tumour was located in the proximal one-third of the transverse colon, is movable, firm, does not invade the serous layer, increased paracolic lymphatic nodes. Taking into consideration the intraoperation situation of the patient, we decided to perform a right hemicolectomy with D3 lymphadenectomy, high ligation of main arteries and veins. V.ileocolica was visualized, skeletonized and transected at the origin into the superior mesenteric vein with a 5 mm LigaSure (“Medtronic Covidien”) device, a. ileocolica is ligated in the origin of the superior mesenteric artery. Then the right part of the colon was mobilized from “downwards-to upwards” within the Toldt’s fascia by Harmonic Scalpel (“Ethicon”) device, a descending part of duodenum is visualized. The head of pancreas, infrapyloric lymphatic nodes were intact. Lymphatic nodes along the superior mesenteric artery and vein were removed. The operation is continued. Mesocolonectomy has been performed. The duration of this stage was 50 minutes.

Laparoscopic correction of direct inguinal hernia in a female

Laparoscopic correction of direct inguinal hernia in a female.
Professor Puchkov K.V. is performing an operation (2017).

In this film the technique of laparoscopic correction of direct right inguinal hernia in a female is presented. Mobilization of hernial sac, lipoma and dissection of the round ligament is done with the help of a 5 mm Harmonic Scalpel Ethicon instrument. The exposure of the inguinal ligament, of connected tendineous aponeurosis, internal inferior epigastral artery, pubic tubercle and round uterine ligament is demonstrated. Plasty of hernial ports is done by means of Bard 3d Max LIGHT Mesh, that is the facilitated analogue of 3DMaxmesh, it has 50% lesser weight, provides bigger scope of vision of the surgical site without losing firmness of the implant. The unique 3D design of this prosthesis has been elaborated specially for laparoscopic hernioplasty. The material of mesh implant is non-covered polypropylene. The shape and contours of the implant completely correspond to this anatomic area, that provides maximum close-fitting and minimizes the probability of shifting of the prosthesis. Fixation of the prosthesis is done by a herniostapler ProTack MEDTRONIC COVIDIEN. Peritonization of abdomen is done by ‘Monocril” thread. Operation duration is 24 minutes.

You can read about this technique in detail on the personal cite of Professor Puchkov Konstantin Viktorovich. To go to the link.

Laparoscopic right resection of kidney with wound stitching

Laparoscopic right resection of kidney with wound stitching.
Professor Puchkov K.V. is performing an operation (2017).

In this film the laparoscopic resection of the right kidney for malignant tumour (4.5 cm), located in the area of the upper pole, is demonstrated. Mobilization of kidney and dissection of the renal artery and vein are done with the help of a 5 mm Harmonic Scalpel Ethicon instrument, as well as LigaSure (MEDTRONIC COVIDIEN) instrument. De Bekey vascular forceps are temporarily applied onto the renal artery. Kidney resection is performed by a 5 mm Harmonic Scalpel Ethicon instrument within the limits of healthy tissues. Hemostasis in the area of bed is done by a bipolar instrument of Karl Storz Company. An atraumatic interrupted suture is placed on the kidney wound, using “Vicryl” thread. For the sake of additional hemostasis the wound is stitched by hemostatic PerClot (Italy). Then the forceps are removed from the renal artery, and blood circulation is restored in the kidney. The time of ischemia is 32 minutes. The tumour is placed in a special container MEDTRONIC COVIDIEN and is removed through the umbilical access. Operation time is 1 hour 20 minutes.

You can read about this technique in detail on the personal cite of Professor Puchkov Konstantin Viktorovich. To go to the link.

Laparoscopic radical right nephrectomy with aortocaval lymphadenectomy

Laparoscopic radical right nephrectomy with aortocaval lymphadenectomy.
Professor Puchkov K.V. is performing an operation (2017).

In this film the technique of laparoscopic right nephrectomy for malignant tumour (7 cm) is presented. Before operation MSCT with water-soluble contrast agent has been done. And in the aortocaval space the increased lymphatic nodes up to 4 cm have been found out. Access to hilum of kidney is done by means of bringing down the hepatic angle of the large colon and tissue dissection between Toldt’s fascia and fascia Gerotae by means of a 5 mm LigaSure (MEDTRONIC COVIDIEN) instrument and Karl Storz Company instruments. Then mobilization of duodenum according to Kocher is performed, with exposure of the inferior vena cava and gonad vein. At the next stage aoptocaval lymphadenectomy is performed, using a 5 mm Harmonic Scalpel Ethicon instrument. Ureter is transected at the level of the common iliac artery. Then the renal artery is exposed and clipped. The renal vein is stitched and transected by a 45 mm Endo GIA MEDTRONIC COVIDIEN apparatus with vascular casette. The preparation and removed lymphatic nodes are placed into a special plastic container MEDTRONIC COVIDIEN, that is removed through the umbilical access. Operation time is 1 hour 20 minutes.

You can read about this technique in detail on the personal cite of Professor Puchkov Konstantin Viktorovich. To go to the link.

Laparoscopic nephropexy, using mesh implant

Laparoscopic nephropexy, using mesh implant.
Professor Puchkov K.V. is performing an operation (2017).

In this film the technique of laparoscopic nephropexy for nephroptosis, degree 3, is presented. Mobilization of the anterior surface of kidney and periosteum of the 12-th rib is performed by a 5 mm Harmonic Scalpel Ethicon instrument and Karl Storz Company instruments. Tissue dissection is performed fast and without blood loss. Only the anterior surface of kidney is exposed for fixation of mesh implant. It is done for the sake of prophilaxis to prevent nephrosclerosis formation after operation. Prolene mesh implant is fixed to the periosteum of the 12-th rib. Then it is fixed to the capsule of the kidney by placing an atraumatic interrupted suture, with extracorporeal knots, using monofilament thread. Stitching of fascia Gerotae is done, using continuous suture and ‘Monocril” thread. Operation duration is 30 minutes.

You can read about this technique in detail on the personal cite of Professor Puchkov Konstantin Viktorovich. To go to the link.