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Surgical intervention
Winslow's hiatal hernia: laparoscopic treatment
Less than 200 cases of internal hernia have been described through the hiatus of Winslow, usually related to congenital or acquired anatomical defects. The most frequent affectation corresponds to the colon, small intestine and, rarely, to the gallbladder. There is usually occlusion with variable grade ischemia, but it can also occur as obstructive jaundice, biliary colic, secondary pancreatitis and non-symptomatic herniation.
The association of Winslow’s hiatus hernia with various anatomical abnormalities (high or subhepatic caecum, mobile ascending colon, large and long colonic mesentery, etc.) may actually correspond to different degrees of intestinal malrotation and, although the diagnosis of “malrotation” is not usually specified, we believe that this could underlie part of Winslow’s hiatus hernia associated with non-acquired anatomical defects.
Hiatal hernia corresponds to 0.2-0.9% of all cases of intestinal obstruction, of which 8% are from Winslow’s hiatus. If pre-surgical diagnosis is difficult, it occurs in less than 10% of cases.
Mortality is around 50% when it has vascular implication. We have not thought of applying the omentum to seal the defect because we did not have adequate surgical anchor sites since we were working millimeters from the vena cava, extrahepatic bile duct, duodenum, and perirenal area. We decided to fix the colon from the hepatic flexure to the right iliac fossa with continuous stitches, from the colonic serosa to Toldt’s fascia, as it is from the embryonic stage.
Winslow's hiatal hernia: laparoscopic treatment
JL Limon Aguilar, CO Castillo Cabrera
8 days ago
Surgical intervention
Proximal gastrectomy with stapled circular esophagogastrostomy: manual purse-string technique
Early tumors of the esophagogastric junction can be managed with a minimally invasive proximal gastrectomy. This operation has recently been reevaluated for early-stage tumors since it offers a good postoperative quality of life with oncological outcomes equivalent to more extended procedures. In this video, we present the case of a 72-year-old man presenting with a 2cm adenocarcinoma of the esophagogastric junction. The clinical stage of the lesion was T1N0. A laparoscopic proximal gastrectomy with stapled circular esophagogastrostomy was decided upon. Five ports were placed. The left trocar incision was enlarged to introduce the circular stapler for the anastomoses and for specimen extraction. The procedure began with a complete abdominal exploration to rule out peritoneal metastases. The gastrocolic and gastrosplenic ligaments were divided with an ultrasonic scalpel. Short splenic vessels were clipped and divided and the greater curvature completely isolated with careful preservation of the gastroepiploic arcade and of the right gastroepiploic artery and vein. Left gastric vessels were divided at their origin with a vascular stapler and the distal esophagus was isolated through the diaphragmatic hiatus. A gastric tube was created with multiple applications of a linear stapler. The anvil of the circular stapler was secured to the esophageal stump with a hand-sewn purse-string suture in order to avoid the overlap of two suture lines. The esophagogastric anastomosis was then achieved with a circular stapler.
Proximal gastrectomy with stapled circular esophagogastrostomy: manual purse-string technique
C Battiston, D Citterio, L Conti, M Virdis, V Mazzaferro
8 days ago
Surgical intervention
Leiomyosarcoma paracaval laparoscopic resection
Primary retroperitoneal tumors are rare, usually malignant and of mesenchymal origin. Surgery is the treatment of choice and complete tumor excision is the main factor which determines the prognosis. They represent between 0.3 and 0.8% of all neoplasms.
The most frequent tumors are sarcomas in their different varieties (totaling 83.7%), mainly liposarcomas (6-20%) and leiomyosarcomas (8-10%); 85% of retroperitoneal tumors are malignant and, of these, about 50% are sarcomas.
The involvement of the inferior vena cava in different tumor processes has long represented a criterion of inoperability and unresectability.
Extirpative surgery of the entire lesion is the treatment of choice for retroperitoneal tumors, but it is not always possible due to the infiltrative commitment of vital structures, despite the possibility of large visceral resections (stomach, kidney, spleen, tail of the pancreas, duodenum, colon, abdominal cava, etc.) and in which case we will not talk about recurrence but about residual tumor.
The laparoscopic approach performed by a multidisciplinary team with experience and expertise can help establish a correct diagnosis and achieve a fine dissection of the lesion, even if it is in difficult anatomical regions.
The video shows a laparoscopic resection of a paracaval mass of unknown origin. This is the case of a 39-year-old female patient who presents with abdominal pain in the epigastrium and right hypochondrium with 2 weeks of evolution. She receives analgesic treatment without any improvement accompanied by vomiting of gastrobiliary content, exacerbation of pain (VAS of 9/10). Hematic biometrics and blood chemistry demonstrated normal results. Ultrasound, CT-scan of the abdomen, and magnetic resonance cholangiography showed a pericaval tumor of about 6 or 4cm, not compromising the inferior vena cava with intimate interphase. After an appropriate assessment by the multidisciplinary team, it is decided to perform a laparoscopic resection.
Operating time was 110 minutes with insignificant blood loss. The procedure is performed successfully without any complications. There were no intraoperative complications. Oral feeding was reintroduced on the first postoperative day and the patient was discharged on postoperative day 2, without complications. Histopathological examination revealed a low-grade leiomyosarcoma. 5 years of follow-up without adjacent lesions.
Leiomyosarcoma paracaval laparoscopic resection
JL Limon Aguilar, CO Castillo Cabrera
9 days ago

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