Selected publications from PubMed
Fresh cadaver, an old surgical model in current general surgery.
Vidal Ó, Ginestà C, Espert JJ, Valentini M, García-Valdecasas JC
Cir Esp. 2016 Mar;94(3):201-2 doi: 10.1016/j.ciresp.2014.12.005.
Suprapubic single-incision laparoscopic appendectomy: a nonvisible-scar surgical option.
Vidal O, Ginestà C, Valentini M, Martí J, Benarroch G, García-Valdecasas JC
Surg Endosc. 2011 Apr;25(4):1019-23 doi: 10.1007/s00464-010-1307-4.
Laparoendoscopic single-site surgery appendectomy.
Vidal O, Valentini M, Ginestà C, Martí J, Espert JJ, Benarroch G, García-Valdecasas JC
Surg Endosc. 2010 Mar;24(3):686-91 doi: 10.1007/s00464-009-0661-6.
Laparoendoscopic single-site cholecystectomy: a safe and reproducible alternative.
Vidal O, Valentini M, Espert JJ, Ginesta C, Jimeno J, Martinez A, Benarroch G, Garcia-Valdecasas JC
J Laparoendosc Adv Surg Tech A. 2009 Oct;19(5):599-602 doi: 10.1089/lap.2009.0205.
Indocyanine green (ICG) is a fluorescent dye that has been widely employed in different fields: for confirming the patency of vascular reconstruction surgery, anastomosis of the gastrointestinal tract, brain aneurysms, identification of sentinel lymph node, and it also plays an important role in fluorescence imaging during hepatobiliary surgery, in both malignant and benign pathologies. ICG characteristics In the early 1970s, fluorescence imaging systems using ICG were introduced as an intra-operative method for retinal angiography. Since then, as mentioned before, its usage has been extended. When ICG is injected intravenously is selectively taken up by the liver, and then secreted into the bile. The catabolism and fluorescence properties of ICG permit a wide range of visualization methods in hepatobiliary surgery. ICG emits fluorescence when excited by infrared light. Light penetration depth is no larger than 10 mm (tissue optical window), which sometimes makes difficult to observe the fluorescence in obese patients or inflammatory situations. ICG binds to plasma proteins and lipoproteins to form aggregated dye molecules in physiological environments. Binding of ICG to plasma proteins does not alter protein structure, therefore intravenous administration of ICG is not toxic. The side effects reported with the use of ICG are seen in less than 1 out of 40,000 patients. ICG fluorescence imaging in hepatobiliary surgery. – Liver mapping: During resection, all the liver segments should be clearly defined. For this purpose, intra-operative contrast-enhanced ultrasound remains the gold standard. However, portal hypertension caused by liver cirrhosis might obstruct conventional liver mapping by ultrasonography. Fluorescence imaging is a safe and sensitive method for identifying liver segments during liver resection, even in the case of liver cirrhosis. – Partial liver transplantation: ICG has been employed to visualize flow turbulence in reconstructed vessels and to evaluate patency, kinking, and stenosis of vascular anastomoses following partial liver transplantation. – Intra-operative fluorescence cholangiography: ICG cholangiography is an alternative to conventional cholangiography. It does not involve radiation. With intravenous ICG administration, the cystic duct can be identified without dissection of Calot’s triangle. It can be administered directly into the gallbladder as well, to identify the biliary tree anatomy. ICG cholangiography during laparoscopic cholecystectomy. Laparoscopic cholecystectomy (LC) is one of the most common operations in the surgical field. Bile duct injury is rare, with an incidence of 0.3% to 0.7% but it can lead to serious consequences. Surgery for cholecystitis tends to be difficult, even for high-volume surgeons. An intraoperative cholangiography technique during laparoscopic cholecystectomy, involving the excretion of fluorescent ICG in the bile after intravenous injection has been used to determine the bile duct anatomy. ICG cholangiography during laparoscopic cholecystectomy. One of the most significant drawbacks of cholangiography following systemic ICG injection lies in the very high background signal due to the rapid accumulation of ICG in the liver, which can impair the visualization of the biliary structures. Injecting ICG directly into the gallbladder could be a valid strategy to improve the visualization of the cystic duct and the common bile duct without suffering from the disturbing background liver enhancement. ICG cholangiography during laparoscopic cholecystectomy. In case of severe inflammatory reaction (e.g cholecystitis), ICG cholangiography enabled a significantly better visualization of Hartmann’s pouch, of the common bile duct and of the common hepatic duct. However, in case of cystic duct occlusion because of stone impaction, the biliary tree could not be visualized by means of NIR imaging, after intragallbladder ICG injection, which makes it necessary to remove the stones. ICG cholangiography, either administered intravenously or directly into the gallbladder is a valuable tool to increase the safety of laparoscopic cholecystectomy.
Published
Feb 2021
Acute appendicitis in puerperium is often diagnosed too late, as clinical signs can be unreliable. Abdominal wall rigidity is rarely noticed in puerperium because of weak abdominal wall muscles, laboratory parameters are not sufficiently reliable, and typical appendix presentation poses difficulties in diagnosis. Being aware of the clinical signs and symptoms of appendicitis, possible complications and early detection, provides a chance for a good surgical outcome. Taking the axillar and rectal temperature can lead to confusion, and delay surgical treatment. Leucocytosis in puerperium is not valid for diagnosis. With respect to results of published studies, laparoscopic approach to management of acute abdomen during pregnancy and puerperium should be regarded as safe and effective. Case A 41-year-old woman with no drug allergies and a history of twin births 10 days before. She was referred to our emergency department with a history of 48 hours’ abdominal pain, predominantly in the lower abdomen, and dysthermia. A blood test and an abdominal CT scan were performed for diagnosis. The analysis showed increased acute phase reactants and the CT scan showed an enlarged appendix with an appendicolith at the tip and some gas bubbles and free intraabdominal fluid with intra-abdominal fat trabeculation. Mesenteric lymph reagents were found in the lower right quadrant. The uterus was enlarged with respect to postpartum. There were no other findings. It was decided to perform an exploratory laparoscopy with guidance, and acute appendicitis was diagnosed. Treatment The patient is placed in the supine position with closed legs. The surgeon and the assistant stood on the left side of the patient. A total of 3 trocars were used: a 12mm port in the umbilical position, an additional 12mm suprapubic port and a 5mm port on the right flank. We used the umbilical port for 30º scope and the other two trocars as working channel. First we can see the multiple adhesions because of a purulent peritonitis throughout the abdominal cavity. Then we carefully released the adhesions between the bowel and the right parietocolic. At this level the large size of the uterus with respect to postpartum can be observed. It is important to be very careful when releasing adhesions to avoid iatrogenic injury. We tried to suck all the pus and clean as much fibrin as possible. Then we explored the cecum in search of the appendix. The appendix was the target, with signs of acute gangrenous appendicitis. We dissected the mesoappendix trying to find the appendicular base. We used clips to tie the vessels and continued the dissection. Then we finished the dissection of the appendicular base using the hook. At this stage the camera was transferred to the suprapubic port. The Mechanical suture was introduced through the umbilical port, which allows a better angle. We used a EndoGIA™ for appendicular base section and proceeded to remove the appendix through a endobag. Finally we cleaned up the remnants of fibrin and pus in the uterus and Douglas Pouch. We used gauze to complete the washing. A Blake drain was left in the Douglas pouch and in the surgical site, completing the surgery. Outcome The total operation time was 63 minutes, and the estimated blood loss was 0 mL. The patient was discharged with no complications on the fifth postoperative day. This approach is minimally invasive and can be performed safely.
Published
Sep 2015
Case A 40-year-old male patient with relevant medical record was brought to the emergency room suffering from abdominal pain, vomiting and fever. In the physical examination he had stated that he was in pain and had rebound tenderness at the right iliac fossa. There were leukocytosis and high levels of CRP and an abdominal ultrasound was carried out showing a thickened cecal appendix with surrounding inflammatory changes and a 6-cm abscess that could not be drained by the radiologist. Treatment Surgical treatment was performed with the patient in the supine position, and the surgeons located to the left of the patient. A total of three trocars were used: a 12mm trocar at the umbilicus for a 30° scope, a 12mm trocar at the right flank, and a 5mm trocar in the suprapubic position. The goal of the procedure was to drain the abscess and evaluate the possibility of removing the appendix. Examination of the abdominal cavity revealed a plastron composed of the sigmoid colon, the terminal ileum, the appendix and the cecum. Blunt dissection was performed in order to individualize the terminal ileum from the appendix. During this manoeuvre the abscess was drained, the separation plane became more evident. There was edema from the inflammatory process and tissues tend to bleed more easily. The sigmoid colon was detached from the plastron. Traction was performed against the pelvic wall. An evolved appendicitis made the surrounding organs rigid. Step by step the individualization was completed. The appendix was identified, its mesentery was also thickened and fused, the left hand of the surgeon performed countertraction and suction was used for blunt dissection, the correct plane was hard to identify. The peritoneum was accidentally detached during the mobilization of the appendix. Appendix assessment was performed to decide the best strategy to section it. The mesentery was thickened. Its division was performed with clips and the hook, there was bleeding from the appendicular artery despite the scaled section. It was controlled using clips. The appendicular base was prepared for section. The attached peritoneum was separated with the hook, now the appendicular base was released. An EndoGIA™ was used to improve a secure section appendix. The surgical specimen was removed in a bag. The surgeon performed revision for bleeding and lavage with iodine solution. A drain was placed for postoperative surveillance. Outcome The surgery took 120 minutes. The patient presented a mild ileum. Oral intake started on the third postoperative day and the patient left the hospital five days after the procedure. The pathological evaluation ruled out malignancy.
Published
May 2015
This video is focused in the key points to achieve a laparoscopic cholecystectomy in a case of acute cholecystitis. In this case a total of three trocars were used. Two of 12mm located at the umbilicus and the epigastrium and the other of 5mm in the right flank. First maneuver is to clear the surgical field suctioning all the free liquid or bilis when the gallbladder is perforated. Surrounding structures like the epiplon, duodenum and the colon can be attached to the inflamed gallbladder, the hook is helpful to separate them and minimize the bleeding. The gallbladder is distended with thickened walls, this can impair the traction during the surgery. Puncture with a veress needle and emptying the bilis is very useful, keeping in mind that it is possible to produce injuries of the liver with this maneuver. To start dissecting the posterior aspect of the neck is a good approach because it will improve the visualization of the anatomical structures of the Calot's triangle as you will appreciate later. The hook can be used for both electric and blunt dissection. Medial dissection is addressed to identify the cystic duct and the cystic artery. In this part of the procedure the surgeon must be focused, careful dissection must be done to avoid unexpected vascular or biliary injuries due to anatomical variations. In the normal disposition the cystic duct below and the artery above. The movements and traction must be dedicated, remember that the tissues can be easily torn. Clips are placed before section, make sure that the ducts end in the gallbladder. Place two below, in parallel to avoid them to getting crossed to prevent bleeding and a biliary leak. The posterior wall of the gallbladder is detached from the liver to complete the cholecystectomy. The correct plain can be difficult to identify, it is closer to the gallbladder than were it seems to be. Remember that a branch from the right portal vein can pass near this area, avoid going deep into the liver. The specimen is placed in a bag for extraction. Final lavage and revision for hemostasis is made. It is recommended to use a drain for postoperative surveillance of a leak, bleeding or collections.
Published
Jan 2015
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