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podcast

Beyond IRCAD - Surgical Journeys: Episode 8: A Wattiez

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you. 

Join us for a discussion with Professor Arnaud Wattiez, a world-leading gynecologic surgeon renowned for his dedication to excellence and mentorship. Professor Wattiez has not only advanced his field but also fostered a community of top surgeons through his teaching. We will also delve into his transformative journey from France to Dubai, exploring how this move profoundly impacted his personal and professional life, bringing him a newfound balance and contentment. Tune in for an inspiring tale of achievement and personal growth.

Beyond IRCAD - Surgical Journeys: Episode 8: Arnaud Wattiez

Beyond IRCAD - Surgical Journeys: Episode 7: M Galvao Neto

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you.

In this episode of "Beyond IRCAD", delve into Dr. Galvao Neto's journey as a modern surgeon, blending innovation with passion. Explore how he integrates music and dance into surgical preparation, highlighting the fusion of enjoyment and expertise. Discover the essential balance of surgical skills with empathy in the 21st century medical world, where active social media engagement is paramount.

Beyond IRCAD - Surgical Journeys: Episode 6: Nicolas Demartines

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you.

In this episode, Professor Nicolas Demartines discusses overcoming operating room challenges through humility, active listening, and humor. 

Explore the satisfaction of fostering empathy and giving back, as he emphasizes collaboration over competition in surgery for the benefit of the patient.

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you.

In this episode of Beyond IRCAD, Professor Jacques Marescaux shares his keys to success. He talks about his wife’s essential role in the history of IRCAD, how he became a citizen of Rwanda, he reveals how WebSurg almost disappeared, and why Alsace was the perfect place for IRCAD. Discover how he managed to become not only a groundbreaking surgeon, but also a successful businessman.

Beyond IRCAD - Surgical Journeys: Episode 5: Jacques Marescaux

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you.

In this episode, we interviewed Professor Mariano Gimenez, a globally renowned surgeon specializing in image-guided percutaneous surgery and HPB surgery. 

Join us for a unique perspective as Professor Gimenez emphasizes the personal dimensions that shape a distinguished surgical career, discussing the dangers of ego and the crucial role mentors play.

Beyond IRCAD - Surgical Journeys: Episode 4: Mariano Gimenez

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you.

In our third episode, we interviewed Professor Sébastien Froelich, a world-renowned skull base surgeon from France. Hear about his unexpected journey into surgery, how his work became a passionate pursuit, and the unique, humbling experiences with his patients. 

Join us for a captivating insight into Professor Froelich’s extraordinary career in skull base surgery!

Beyond IRCAD - Surgical Journeys: Episode 3: Sébastien Froelich

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you.

In our second episode, we are honored to feature the distinguished Dr. Xavier Serra Aracil, an innovative expert in the field of colorectal surgery from Spain. Tune in to gain insight into the remarkable path of Dr. Serra Aracil's outstanding career.



Discover the story behind his passion for surgery, the driving force that propels him forward, the values that guide his work and personal life, and explore the valuable advice he offers to the up-and-coming generation of aspiring surgeons.



Beyond IRCAD - Surgical Journeys: Episode 2: Xavier Serra Aracil

Beyond IRCAD - Surgical Journeys: Episode 1: Armando Melani

Introducing "Beyond IRCAD - Surgical Journeys". Join us on an inspiring and captivating monthly journey as we sit down with prestigious surgeons who have built remarkable careers in the field of medicine. In each episode, we explore the personal backgrounds and experiences of these exceptional individuals, as they share their inspiring stories of overcoming challenges, staying committed, and achieving success. Whether you're a medical professional, a student aspiring to be a surgeon, or simply someone looking for motivation from incredible human stories, this podcast is for you. 

In the very first episode, we have the privilege of hosting the renowned Dr. Armando Melani, a trailblazing colorectal surgeon hailing from Brazil. Join us as Dr. Melani takes us on a captivating exploration of his unique career path.



Discover the story behind his passion for surgery, the driving force that propels him forward, and the values that guide his work and life. Dr. Melani's dedication extends beyond the operating room, as he shares his profound commitment to passing on knowledge to the next generation of surgeons.



Stay tuned for an engaging conversation that goes "Beyond IRCAD”.

surgical intervention video

Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor. 

Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure. 

Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia. 

This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp. 

Dr. Shen-Ann Eugene Yeo, MBBS, MMed (Surg), FRCS (Ed) does not have any conflicts of interest or financial ties to disclose.

Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis

腹腔镜完全鼻息肉切除术（CME）右半结肠切除术与体内吻合术


Excision mésocolique laparoscopique complète (CME) hémicolectomie droite avec anastomose intracorporelle


Hemicolectomia direita com excisão completa do mesocólon (ECM) e anastomose intracorpórea


Лапароскопическая тотальная мезоколонэктомия, правосторонняя гемиколэктомия с интракорпоральным анастомозом

Hemicolectomía derecha con escisión completa del mesocolon (ECM) y anastomosis intracorpórea


This video of laparoscopic Nissen fundoplication is suitable for surgeons learning to perform this procedure. The patient is young with very few adhesions and the operative steps are very clearly presented by Dr. Dallemagne. Critical points and technical tips are emphasized throughout the procedure.



The author describes this as an ideal case for surgeons learning the procedure because this young patient with severe reflux has few adhesions. Working with a zero-degree scope, the author examines the peritoneal cavity. The dissection begins at the caudate lobe of the liver and moves toward the right crus of the diaphragm. After identifying the right and left crura, the author opens the lesser omentum to gain access to the right crus. It is important to identify the inferior vena cava as a landmark.

Laparoscopic Nissen fundoplication: a perfect case to start

Fundoplicatura de Nissen laparoscópica: um caso perfeito para começar


Fundoplicature de Nissen laparoscopique : un cas idéal pour commencer


腹腔镜尼森胃底折叠术：一个完美的开始


Este vídeo de fundoplicatura Nissen laparoscópica es recomendado para cirujanos que estén comenzando en aprender este procedimiento.  El paciente es joven, con pocas adherencias.  Los pasos operatorios son claramente presentados por el Dr. Dallemagne.  Se enfatizan los puntos críticos y los consejos técnicos a través de todo el procedimiento.

Fundoplicatura de Nissen Laparoscópico para RGE

Intervention interactive live : voie d’abord transabdominale prépéritonéale (TAPP) laparoscopique pour hernie inguinale bilatérale réductible

Лапароскопическая TAPP пластика двусторонней паховой грыжи: интерактивная LIVE процедура

We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.

Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure

Hystérectomie laparoscopique totale : approche par étapes

Laparoscopic hysterectomy is considered one of the main gynecological endoscopic surgeries. However, this percentage is still in a plateau phase, which could be explained by the surgical skills, proper anatomical knowledge, and unnecessary limitations to the laparoscopic approach; such as uterine size and previous scars. In this video, we demonstrate a stepwise approach for a total laparoscopic hysterectomy (TLH) for a large uterus, in order to demonstrate that by following standard steps surgeons can easily manage hysterectomy in an effective, safe, and reproducible way. 

Total laparoscopic hysterectomy: stepwise approach

In recent years, diastasis recti has become a condition that has sparked interest among general surgeons. Minimally invasive treatment has become a safe and effective alternative for resolving diastasis recti. Various techniques have been described between 2012 and 2020. Endoscopic repair through rectus muscle re-approximation and placement of a supra-aponeurotic mesh is the most widely used technique. 



References:



Hernández-Granados P, Henriksen NA, Berrevoet F, Cuccurullo D, López-Cano M, Nienhuijs S, Ross D, Montgomery A. European Hernia Society guidelines on management of rectus diastasis. Br J Surg. 2021 Oct 23;108(10):1189-1191. doi: 10.1093/bjs/znab128. PMID: 34595502.



Claus CM, Malcher F, Totti Cavazzola L, Furtado M, Morrell A, Azevedo M, Meirelles L, Santos H y Garcia R. Subcutaneous onlay laparoscopic approach (SCOLA) for ventral hernia and rectus abdominis diastasis repair: technical description and initial results. ABCD Arq Bras Cir Dig 2018;31(4):e1399.



Juárez Muas D. Preaponeurotic Endoscopic repair (REPA) of diastasis recti associated or not to midline hernias. Surg Endosc. 2018. https://doi.org/10.1007/s00464-018-6450-3.



Reinpold W, Köckerling F, Bittner R, Conze J, Fortelny R, Koch A, Kukleta J, Kuthe A, Lorenz R, Stechemesser B. Classification of Rectus Diastasis-A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front Surg. 2019 Jan 28;6:1. doi: 10.3389/fsurg.2019.00001. PMID: 30746364; PMCID: PMC6360174.



Malcher F, Lima DL, Lima RNCL, Cavazzola LT, Claus C, Dong CT, Sreeramoju P. Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review. Surg Endosc. 2021 Oct;35(10):5414-5421. doi: 10.1007/s00464-021-08560-5. Epub 2021 May 24. PMID: 34031740.

Systematization of technical steps in the endoscopic treatment of diastasis recti

Systématisation des étapes opératoires dans le traitement endoscopique du diastasis recti

Usually, medium-sized umbilical hernias are treated with an open approach since it is the most used technique. However, in situations of increased risk of surgical wound complications, such as immunosuppression, corticosteroid therapy, obesity or diabetes, as well as other associated hernia defects or diastasis of the rectus and in large hernias (>4cm), the use of the minimally invasive approach is indicated (1, 2). 

This video demonstrates a stepwise TARUP (transabdominal retromuscular umbilical prosthetic hernia repair) technique for hernia repair with mesh placement, with the use of the da Vinci Xi™ surgical robotic system, which offers a certain number of benefits.



References:

1. Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, et al. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. British Journal of Surgery 2020; 107:171–90.

2. Rodrigues V, López-Cano M. Técnica TARUP. Ventajas de la cirugía mínimamente invasiva de la pared abdominal asistida por robot. Cirugía Española 2021; 99:302–5.



Robotic transabdominal retromuscular umbilical prosthetic hernia repair (TARUP)

Cure d'éventration ombilicale par technique robot-assistée de type r-TARUP avec renforcement prothétique 

The critical view of the myopectineal orifice (MPO) is defined as the appropriate exposure of the anatomical area that must be obtained before placing the mesh during laparoscopic and robotic inguinal hernia repair. This concept is a consolidation of recommendations shown to reduce hernia recurrence and postoperative complications and standardizes the teaching and evaluation of minimally invasive inguinal hernia repair.

This video presents the case of a right-sided indirect inguinal hernia. The authors demonstrate here the steps to achieve the critical view of the MPO in an extended totally extraperitoneal (eTEP) inguinal hernia repair, followed by mesh placement.

Bibliography:

1. Daes J, Felix E. Critical view of the myopectineal orifice. Annals of surgery. 2017 Jul 1;266(1):e1-2.
2. Claus C, Furtado M, Malcher F, Cavazzola LT, Felix E. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surgical endoscopy. 2020 Apr;34:1458-64.
3. Felix E, Lourié D, Daes J. Understanding the Critical View of the Myopectineal Orifice (MPO) for Safe Minimally Invasive Surgical Inguinal Hernia Repair. In Newer Concepts and Procedures in Hernia Surgery-An Atlas 2023 Jan 1 (pp. 3-10). Singapore: Springer Nature Singapore.

Extended totally extraperitoneal (eTEP) repair of right-sided inguinal hernia demonstrating the critical view (CV) of the myopectineal orifice (MPO)

Cure de hernie inguinale droite totalement extrapéritonéale étendue (eTEP) avec identification formelle de l'orifice musculo-pectinéal

Abstract:

The transabdominal preperitoneal (TAPP) technique in ventral hernia repair allows for the placement of a much larger mesh than in the anterior surgical approach. It is also closer to current recommendations, especially for patients with additional risk factors, such as obesity without diastasis recti. The TAPP technique allows for mesh introduction into the preperitoneal space, which prevents direct contact between the mesh and the intestines. The mini ventral TAPP approach is feasible and safe.



Bibliographic references:

1. I.F. Megas, et al. A propensity‐score matched analysis of ventral‐TAPP vs. laparoscopic IPOM for small and mid‐sized ventral hernias. Comparison of perioperative data, surgical outcome and cost‐effectiveness. https://doi.org/10.1007/s10029-022-02586-x 

2. Muysoms, F.E., et al., Classication of primary and incisional abdominal wall hernias. https://doi.org/10.1007/s10029-009-0518-x 

3. Skolimowska-Rzewuska M., Romańczuk M., Mitura B., Wyrzykowska D., Mitura K. Laparoscopic transabdominal preperitoneal repair (umbilical TAPP) versus open ventral patch repair for medium size umbilical hernias in overweight and obese patients. https://doi.org/10.5114/wiitm.2021.110415 

4. Gillies M., Anthony L., Al-Roubaie A., Rockliff A., Phong J. Trends in Incisional and Ventral Hernia Repair: A Population Analysis From 2001 to 2021. https://doi.org/10.7759/cureus.35744 

5. Daes Jorge. Evolución de la reparación laparoscópica de las hernias ventrales y del sitio de la incisión. https://10.1016/j.rehah.2016.05.001 





Mini ventral transabdominal preperitoneal (TAPP) repair for small size ventral hernia (M2W1) in an overweight patient

Mini cure de hernie ventrale de petite taille (M2W1) par voie d'abord transabdominale prépéritonéale (technique TAPP) chez une patiente en surpoids

The advent of robotic systems has propelled minimally invasive surgery forward. However, the adoption of such systems in routine procedures is hindered by high costs and operational complexity (1). This mismatch between conventional telemanipulators and everyday surgical workflows demands innovative solutions to seamlessly integrate advanced robotics into the operating room.

This video showcases the Maestro System™ manufactured by Moon Surgical and its ScoPilot™ feature through a laparoscopic cholecystectomy use case. This dual arm system (2) reflects a significant progress in minimally invasive surgery as it allows for solo surgeries by providing real-time instrument tracking and enhanced ergonomics. First, a human study by Cadière et al. (3) showed surgical efficiency, safety, and surgeon satisfaction.

As artificial intelligence (AI) is gaining ground in the field of laparoscopic surgery with cholecystectomy as a largely studied use case (4), the ScoPilot™ feature, that allows the camera to follow instruments in real time, marks a pivotal shift toward highly efficient solo surgical procedures. By enabling precise real-time instrument tracking and reducing physical demands impacting surgical teams, it streamlines operations and surgical workflow. Its successful application in cholecystectomy cases underscores the system’s potential to improve standard procedures by reducing operative times and physical strain for surgical teams, promising a new era in digitally assisted solo surgeries.

Bibliography:

1. Higgins RM, Frelich MJ, Bosler ME, Gould JC. Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc. 2017 Jan;31(1):185-192. doi: 10.1007/s00464-016-4954-2. Epub 2016 May 2. PMID: 27139704.
2. Feasibility and safety study of the use of a new robot (MaestroTM) for laparoscopic surgery. \[Internet]. 2024 \[cited 2024 Mar 7]. Available from: [https://www.researchsquare.com](https://www.researchsquare.com)
3. Cadière GB, Himpens J, Poras M, Pau L, Boyer N, Cadière B. First human surgery using a surgical assistance robotics device for laparoscopic cholecystectomies. Surg Endosc. 2023 Oct;37(10):7812-7818. doi: 10.1007/s00464-023-10296-3. Epub 2023 Aug 21. PMID: 37605013; PMCID: PMC10520184.
4. Mascagni P, Vardazaryan A, Alapatt D, Urade T, Emre T, Fiorillo C, Pessaux P, Mutter D, Marescaux J, Costamagna G, Dallemagne B, Padoy N. Artificial Intelligence for Surgical Safety: Automatic Assessment of the Critical View of Safety in Laparoscopic Cholecystectomy Using Deep Learning. Ann Surg. 2022 May 1;275(5):955-961. doi: 10.1097/SLA.0000000000004351. Epub 2020 Nov 16. PMID: 33201104.

Empowered surgery using the Maestro System™ with its ScoPilot™ feature: a laparoscopic cholecystectomy use case

Chirurgie assistée par le Maestro System™ avec sa fonction ScoPilot™ : un cas d'utilisation lors d'une cholécystectomie laparoscopique

Prise en charge laparoscopique d'une récidive de hernie inguinale droite après cure laparoscopique par voie d'abord transabdominoprépéritonéale (TAPP) 

The video presents the clinical case of a 49-year-old male patient who had undergone a laparoscopic TAPP repair for a right inguinal hernia one year earlier. He presented with an internal recurrence of his right inguinal hernia and with a voluminous left inguinal hernia. On clinical exam and imaging, a 2 to 3cm direct hernia protrusion, Nyhus type IIIa, was found. It was decided to perform a laparoscopic repair for the left inguinal hernia and to explore the right inguinal hernia. Based on anatomical aspects, a laparoscopic redo was performed.

It is usually recommended to treat inguinal hernia recurrence after a laparoscopic transabdominal preperitoneal approach (TAPP) using an anterior approach to work on a non-operated site. In this video, it was decided to manage the patient’s contralateral hernia laparoscopically, and to simultaneously explore the hernia recurrence.

Laparoscopic management of a recurrent right inguinal hernia after primary laparoscopic TAPP repair

video lecture

In this authoritative lecture, Dr. Armando Melani looks into indocyanine green (ICG) fluorescence and 3D CT image-guided robotic colorectal surgery.&#x20;

ICG fluorescence – 3D CT image-guided robotic colorectal surgery

In 0.4 to 4.5% of individuals, the common hepatic artery arises from the superior mesenteric artery instead of the celiac trunk. It is a type IX anomaly, commonly referred to as hepatomesenteric trunk, according to the Michels’s comprehensive classification of hepatic arterial anatomy. The surgical strategy should take into account the variations in the vascular pattern of the celiac trunk and its branches. This hepatomesenteric trunk originates from the anterior aspect of the aorta, coursing inferiorly and to the right behind the portal vein to reach the superior border of the superior part of the duodenum, where it divides into the common hepatic artery and into the superior mesenteric artery. In the lesser omentum, after a small course, the common hepatic artery gives off the gastroduodenal artery that continues as the proper hepatic artery. This video aims to highlight a dissection in a patient with a hepatomesenteric trunk anomaly undergoing a laparoscopic pylorus-preserving pancreaticoduodenectomy for an ampullary adenocarcinoma. 

This is the case of 73-year-old man who was evaluated for jaundice. Pancreatic protocol CT-scan showed a periampullary lesion with a dilated biliary tract. Side-viewing endoscopy and endoscopic ultrasound biopsy confirmed the diagnosis, revealing an ampullary adenocarcinoma. On imaging, it was found to be resectable. The tumor board team decided to go for an upfront surgery. Preoperative biliary plastic stenting was performed for cholangitis. A laparoscopic pylorus-preserving pancreaticoduodenectomy with a feeding jejunostomy was performed. The procedure was uneventful, and the patient was discharged on postoperative day 6. Pathological findings revealed please complete 



Bibliography:

1. Kahraman G, Marur T, Tanyeli E, Yildirim M. Hepatomesenteric trunk. Surg Radiol Anat. 2001;23(6):433-5. doi: 10.1007/s00276-001-0433-z. PMID: 11963627.

2. Ramanadham S, Toomay SM, Yopp AC, Balch GC, Sharma R, Schwarz RE, Mansour JC. Rare hepatic arterial anatomic variants in patients requiring pancreatoduodenectomy and review of the literature. Case Rep Surg. 2012;2012:953195. doi: 10.1155/2012/953195. Epub 2012 Jul 30. PMID: 22900221; PMCID: PMC3413978.

3. Noussios G, Dimitriou I, Chatzis I, Katsourakis A. The Main Anatomic Variations of the Hepatic Artery and Their Importance in Surgical Practice: Review of the Literature. J Clin Med Res. 2017 Apr;9(4):248-252. doi: 10.14740/jocmr2902w. Epub 2017 Feb 21. PMID: 28270883; PMCID: PMC5330766.

Laparoscopic pylorus-preserving pancreaticoduodenectomy in a patient with hepatomesenteric trunk anomaly for ampullary adenocarcinoma

Pancréaticoduodénectomie laparoscopique avec préservation du pylore chez un patient présentant une anomalie du tronc hépatomésentérique pour adénocarcinome ampullaire

This is the case of a 71-year-old female patient presenting with colorectal cancer and liver metastases. The patient had previously undergone a laparotomic subtotal colectomy to address intestinal occlusion caused by an adenocarcinoma located in the stenotic descending colon. Six suspected secondary liver lesions were identified in liver segments VII, VIII, IV, VI, and V. 

After undergoing 7 cycles of adjuvant chemotherapy, magnetic resonance imaging (MRI) showed a progression in hepatic lesions. A robotic extended right hepatectomy using the intrahepatic extra-Glissonian approach was therefore proposed to the patient. 

This surgical technique allows precise control of the liver blood supply, minimizing the risks of bleeding and other surgical complications. Additionally, it provides improved visualization of the bile duct, helping to accurately identify and preserve biliary structures. The extra-Glissonian approach is complex and requires a specialized training and expertise. However, it can improve outcomes in patients undergoing a right hepatectomy.



Robotic right hepatectomy using the intrahepatic extra-Glissonian approach and indocyanine green (ICG) fluorescence

Hépatectomie droite robotisée en utilisant la voie d’abord extraglissonienne intrahépatique et la fluorescence au vert d'indocyanine 

Proctectomie complète et création d'une poche en J pour colite ulcéreuse 

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC) (1). The most common type of IPAA is achieved with a J pouch, where the ileal pouch is anastomosed with the rectal cuff, a 2 to 3cm string of anal canal which can include a few millimeters of rectal mucosa. This tiny portion of the rectum and anal canal is necessary for the stapled anastomosis. The ileorectal anastomosis is a totally different procedure, where the rectum is kept in place (while it is removed in the IPAA) and connected to the ileum, with no creation of an ileal pouch. 

This video presents the case of a laparoscopic proctectomy with a J-pouch construction as the second stage of a modified two-staged procedure (subtotal colectomy with end ileostomy, proctectomy, and IPAA). The two-staged approach for the restoration of intestinal continuity in UC patients is one of the most used approaches, given its safety in terms of postoperative complications and overall quality of life for patients who are diagnosed with acute severe colitis and who undergo total colectomy as an emergency surgery, and after 3 to 6 months are fit and ready for intestinal reconstruction through the IPAA without a protective stoma (5, 6). 

The procedure was divided into two major steps. The first one was a laparoscopic proctectomy, performed with a close rectal dissection (CRD), also known as "incomplete TME approach", to minimize the risks of neuromuscular injury (2). An image at the beginning of the video compares the two approaches for laparoscopic proctectomy. 

The second step was the extracorporeal J-pouch construction using an endoscopic stapling device and an ileal pouch-anal anastomosis creation using a 31mm circular stapler. 

Randomized clinical trials results showed how an incomplete TME leads to a lower rate of severe complications and better short-term quality of life when compared to TME (3). This video presents the authors’ standardized approach. 

Close rectal dissection, or incomplete TME, is a safe approach for laparoscopic proctectomy given the good results obtained in terms of protecting autonomic nerve function (4). This technique may be more challenging than TME if the surgeon is used to oncological dissections. A standardized technique for CRD is crucial to have the best outcomes in terms of sexual and urinary functions. 



Bibliography:

1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978 Jul 8;2(6130):85-8. doi: 10.1136/bmj.2.6130.85. PMID: 667572; PMCID: PMC1605901.

2. Reijntjes MA, de Jong DC, Bartels S, Wessels EM, Bocharewicz EK, Hompes R, Buskens CJ, d'Haens GR, Duijvestein M, Bemelman WA. Long-term outcomes after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis for ulcerative colitis. Tech Coloproctol. 2023  Apr;27(4):297-307. doi: 10.1007/s10151-022-02713-x. Epub 2022 Nov 6. PMID: 36336745; PMCID: PMC10008209.

3. Capelli, G., De Simone, I., Spolverato, G. et al. Non-Operative Management Versus Total Mesorectal Excision for Locally Advanced Rectal Cancer with Clinical Complete Response After Neoadjuvant Chemoradiotherapy: a GRADE Approach by the Rectal Cancer Guidelines Writing Group of the Italian Association of Medical Oncology (AIOM). J Gastrointest Surg 24, 2150–2159 (2020). https://doi.org/10.1007/s11605-020-04635-1

4. Garcia-Granero A, Pellino G, Fletcher-Sanfeliu D, Millan M, Primo-Romaguera V, Garcia-Gausí M, Fernandez M, Gonzalez-Argente X, Spinelli A, Valverde-Navarro A, Garcia-Granero E. "Near-TME": proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis. Tech Coloproctol. 2022 Mar;26(3):217-226. doi: 10.1007/s10151-022-02579-z. Epub 2022 Feb 1. PMID: 35103902; PMCID: PMC8857132.

5. Maspero, M., Hull, T.L. Clinical approach to patients with an ileal pouch. Abdom Radiol 48, 2918–2929 (2023). https://doi.org/10.1007/s00261-023-03888-z

6. Luo, W.Y., Singh, S., Cuomo, R. et al. Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis of observational research. Int J Colorectal Dis 35, 1817–1830 (2020). https://doi.org/10.1007/s00384-020-03696-7



Completion proctectomy and J-pouch construction for ulcerative colitis (UC)

This video presents the case of a 39-year-old female patient with no relevant medical history. The symptoms appeared one week before rectal bleeding and weight loss. Upon physical examination, a 3cm indurated bleeding mass was found in the anal margin. Colonoscopy showed a friable exophytic-looking tumor lesion located 3 to 5cm away from the anal verge and covering 30% of the circumference. Histopathological exam revealed a grade II invasive adenocarcinoma without lymphovascular invasion. Magnetic resonance imaging showed an inferior rectal neoplasm located 2.8cm away from the anal margin with an extension to the middle rectum (4.6cm) without sphincter involvement. No lymph nodes or metastasis were observed, conclusive for a rectal T2N0M0. As a result, it was decided to perform a laparoscopic two-stage Turnbull-Cutait pull-through coloanal anastomosis with ultralow anterior resection. 

A conventional ultra low anterior resection was performed, externalizing the colon through the anus and fixing it proximally to the skin. One week later, the anastomosis was completed manually.

The postoperative period was uneventful. The patient resumed oral intake one day after the second surgery. She was discharged on postoperative day 8. Histopathological findings showed that the surgical margins were negative for neoplasia, and 16 lymph nodes proved negative for dysplasia. 

Bibliography:

1. Biondo S, Trenti L, Espin E, Bianco F, Barrios O, Falato A, De Franciscis S, Solis A, Kreisler E; TURNBULL-BCN Study Group. Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial. JAMA Surg. 2020 Aug 1;155(8):e201625. doi: 10.1001/jamasurg.2020.1625. Epub 2020 Aug 19. PMID: 32492131; PMCID: PMC7270870.

2. Biondo S, Trenti L, Galvez A, Espin-Basany E, Bianco F, Romano G, Kreisler E; Turnbull-BCN study group. Two-stage Turnbull-Cutait pull-through coloanal anastomosis versus coloanal anastomosis with protective loop ileostomy for low rectal cancer. Protocol for a randomized controlled trial (Turnbull-BCN). Int J Colorectal Dis. 2017 Sep;32(9):1357-1362. doi: 10.1007/s00384-017-2842-4. Epub 2017 Jun 30. PMID: 28667499.

3. La Raja C, Foppa C, Maroli A, Kontovounisios C, Ben David N, Carvello M, Spinelli A. Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis. Tech Coloproctol. 2022 Aug;26(8):603-613. doi: 10.1007/s10151-022-02601-4. Epub 2022 Mar 28. PMID: 35344150.

4. Melka D, Leiritz E, Labiad C, Blondeau M, Frontali A, Giacca M, Monsinjon M, Panis Y. Delayed pull-through coloanal anastomosis without temporary stoma: an alternative to the standard manual side-to-end coloanal anastomosis with temporary stoma? A comparative study in 223 patients with low rectal cancer. Colorectal Dis. 2022 May;24(5):587-593. doi: 10.1111/codi.16069. Epub 2022 Feb 10. PMID: 35094470.

Laparoscopic two-stage Turnbull-Cutait pull-through coloanal anastomosis for low rectal cancer

Anastomose colo-anale de Turnbull-Cutait en deux étapes par voie d'abord laparoscopique pour cancer du bas rectum

Hyperhidrosis is defined as a pathologic condition of excessive sweating in amounts greater than physiologically needed for thermoregulation. It may either develop secondary to a variety of medical disorders or it may be primary or cryptogenic.



Endoscopic thoracic sympathectomy (ETS) with interruption of the sympathetic chain is the treatment of choice for patients with primary hyperhidrosis.



Interruption of the chain can be achieved by cauterizing, cutting, or clipping the sympathetic chain.



Although the level of interruption remains controversial based on the patient’s distribution of the hyperhidrosis, expert consensus based on a standardized anatomic classification and careful literature review provides the framework for treatment strategies.



For palmar hyperhidrosis, interruption at R3 and R4 levels will provide the most curative scenario, marked by completely dry hands, but with a higher risk of compensatory hyperhidrosis (CH).



For patients who prefer a lower risk of CH at the expense of less dry hands, the interruption can be achieved only at R4 level.



A R4-R5 interruption can be applied to patients with palmar-axillary and palmar-axillary-plantar hyperhidrosis.



Complications



Endoscopic thoracic sympathectomy (ETS) is a very well tolerated procedure and complications rarely occur. The most obvious intraoperative complications possible include lung injury, pneumothorax, major bleedings, chylothorax, phrenic nerve injury, and Horner’s syndrome. All of them are rare and can be prevented with a meticulous and careful surgical technique.



Bradycardia, if it occurs, is usually asymptomatic and clinically irrelevant in nearly all patients.



Postoperative pain is easily controlled by means of regular analgesics and anti-inflammatory non-steroid (AINS) drugs and is usually self-limited.



Persistence of the symptoms or early recurrence usually indicates surgical failure, mostly related to incomplete or inadequate denervation, and requires reoperation in most cases. Misinterpretations due to local anatomical variations, blood vessels crossing over the trunk, local pleural thickening or adhesions are among the possible causes, in addition to technical faults. Approaching the sympathetic trunk at wrong levels can also lead to unsatisfactory early postoperative results.



Late recurrence is not common but can occur, probably by nerve regeneration, prone to happen when the transected trunk ends remain close to each other or in children who might still grow after surgery. Both situations may also require reoperation.



Tiny collateral fibers arising from the trunk can be present in a variable number of patients. These are the “Kuntz nerves”. Acting as an alternative neural pathway to the brachial plexus, they can be responsible for persisting hyperhidrosis after endoscopic thoracic sympathectomy (ETS). In order to avoid that, it is advisable to extend the chain interruption in about 2cm laterally over the inner aspect of the ribs until the periosteum is denudated, so that these small nerves can be properly transected when they are present.



The stellate ganglion is the most cranial part of the intrathoracic sympathetic chain, and it must definitely be avoided in all thoracic sympathectomies for hyperhidrosis. This major structure is not always easily seen, but lies along the axis of the trunk, immersed within the adipose tissue below the subclavian artery and the first rib.



Case 1: This is the case of a 22-year-old male patient with a BMI of 25 who presented with primary focal palmar hyperhidrosis, which interfered with his daily activities and was associated with psychosocial problems.



He had no previous history of surgical operations or chronic illnesses. Sympathicotomies of the second and third ribs (R2-R3) were performed on both sides.



Case 2: This is the case of a 27-year-old male patient with a BMI of 28 who presented with primary focal palmar hyperhidrosis, which interfered with his daily activities, and was associated with psychosocial problems.



The patient had a previous history of anal fistula surgery, and he did not suffer from any chronic illnesses. R2 and R3 sympathicotomies were performed along with the eradication of the nerve of Kuntz.



Case 3: This is the case of a 16-year-old male patient with a BMI of 20 who presented with primary palmar and axillary hyperhidrosis, which interfered with his daily activities and was associated with axillary bromhidrosis (osmidrosis) and psychosocial problems.



He had no previous history of surgical operations and no chronic illnesses. R2, R3, and R4 sympathicotomies were performed along with the eradication of the nerve of Kuntz on the right side, while only R3 and R4 sympathicotomies were only performed on the left side.



Patient set-up



Patients underwent surgery in a supine position with arms abducted and fixed at 90 degrees. The trunk was elevated to 30 to 40 degrees. This elevation helped to displace the lung downward.



A gross cushion placed underneath the knees or a slight bed elevation at knee level was useful to safely place the patients and to prevent them from slipping down during the procedure. This semi-Fowler position offered a simple and easy way to perform the surgery bilaterally in a fast, safe, and effective manner. Rotating the bed laterally one side to another was a useful maneuver to enhance surgical exposure.



Port placement in relation to anatomical landmarks



The access to the pleural cavity was obtained via a two-port videothoracoscopy. Two 5mm ports were routinely used. The camera port was anterior, and the incision was placed in the fifth intercostal space on the anterior axillary line.



The second port was placed laterally at the third intercostal space, at the base of the axillary fossa, on the mid-axillary line.



The authors advocate starting the procedure by approaching the patient’s dominant side first. Consequently, if the patient is right-handed, the authors start by the right side, just because if any unexpected intraoperative complication occurs and surgery has to be aborted, there is a chance that at least the dominant side will be treated.



Carbon dioxide insufflation was applied at a maximum pressure of 10mmHg.



The authors used the technique of “sympathicotomy” or “sympathotomy”, which refers to the interruption of the sympathetic trunk only via its complete transection, which can be achieved using electrocautery.



Postoperative outcomes:



The postoperative course was uneventful for all 3 patients. The patients started oral intake 2 hours after surgery, and they were discharged the same day.



Follow-up was continued for 2 years, with satisfying results and no relapse, with only a mild degree of compensatory hyperhidrosis.



Bibliography:



1. Cerfolio RJ, De Campos JR, Bryant AS, et al. The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis. Ann Thorac Surg 2011;91:1642-8. PMID: 21524489 DOI: 10.1016/j.athoracsur.2011.01.105



2. Hwang JJ, Kim DH, Hong YJ, et al. A comparison between two types of limited sympathetic surgery for palmar hyperhidrosis. Surg Today 2013;43:397-402. PMID: 22798011 PMCID: PMC3599212 DOI: 10.1007/s00595-012-0246-1



3. Liu Y, Li H, Zheng X, et al. Sympathicotomy for palmar hyperhidrosis: the association between intraoperative palm temperature change and the curative effect. Ann Thorac Cardiovasc Surg 2015;21:359-63. PMID: 26041256 PMCID: PMC4904872 DOI: 10.5761/atcs.oa.14-00270



4. N. Esakkiammal, Khizer Hussain Afroze M, Renu Chauhan, Manickam Subramanian, Balaji T. K, Azmatulla Shaik. Anatomical variants of nerve of Kuntz and its clinical and surgical implications. Int J Anat Res 2016;4(2):2502-2507. DOI: 10.16965/ijar.2016.253 https://www.ijmhr.org/ijar.4.2/IJAR.2016.253.pdf



5. F, Araújo JA. Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results. J Thorac Dis 2017;9(Suppl 3):S178-S192. PMID: 28446983 PMCID: PMC5392541 DOI: 10.21037/jtd.2017.04.04



6. Ramsaroop L, Partab P, Singh B, et al. Thoracic origin of a sympathetic supply to the upper limb: the 'nerve of Kuntz' revisited. J Anat 2001;199:675-82. PMID: 11787821 PMCID: PMC1468385 DOI: 10.1046/j.1469-7580.2001.19960675.x



7. Zhang B, Li Z, Yang X, et al. Anatomical variations of the upper thoracic sympathetic chain. Clin Anat 2009;22:595-600. PMID: 19418453 DOI: 10.1002/ca.20803 

Endoscopic thoracic sympathectomy (ETS) for primary palmar hyperhidrosis

Sympathectomie thoracique endoscopique pour hyperhidrose palmaire primaire

Fenestration laparoscopique d'un kyste hépatique : utilisation de la fluorescence avec vert d'indocyanine

Background:

Laparoscopic fenestration (LF) for hepatic cysts is now considered a standard treatment for symptomatic and nonparasitic liver cysts. However, when resecting the cyst wall, it is difficult to identify all bile ducts, especially the smaller ones at risk for leakage. Indocyanine green-fluorescent cholangiography (ICG-FC) has recently been introduced intraoperatively to visualize and provide detailed information about the biliary tree. The authors report a case of LF with the intraoperative assistance of ICG-FC and three-dimensional multiparametric reconstruction (r3D).

Patient and methods:

This is the case of a 70-year-old male patient, ECOG 0, with a BMI of 21, Child-Pugh class A, and with a medical history of emphysema, chronic obstructive pulmonary disease (COPD), and Marfan’s syndrome with an endoscopically treated left aortoiliac aneurysm. In February 2021, shortness of breath, abdominal bloating, upper abdominal pain, and anorexia worsened. CT-scan showed multiple liver and splenic cysts. An r3D was acquired. ICG was administered intravenously at a dose of 0.3mg/kg one hour before surgery.

Results:

Intraperitoneal examination revealed three large cysts. There was a 10cm cyst in liver segments IV and V, another 16cm cyst in liver segments VI and VII, and another 22cm cyst in the left liver lobe, not at the level of the spleen, as erroneously shown on the preoperative CT-scan. The cysts were completely fenestrated. Intracystic bile ducts and bile leaks in the cysts were visualized with ICG-FC and clamping was achieved with a Hem-o-lok™ automatic clip applier. The patient was discharged early in good health condition.

Conclusions:

The use of ICG-FC in hepatobiliary surgery has become commonplace, and its use to identify the biliary tree is safe. ICG-FC and r3D play a key role in the prevention and treatment of bile duct injury during LF to minimize postoperative complications.

Bibliography:

1\. Boni L, David G, Mangano A, Dionigi G, Rausei S, Spampatti S, Cassinotti E, Fingerhut A. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc 2015 Jul;29(7):2046-55. doi: 10.1007/s00464-014-3895-x. Epub 2014 Oct 11. PMID: 25303914 PMCID: PMC4471386 DOI: 10.1007/s00464-014-3895-x

2\. Hanaki T, Yagyu T, Uchinaka E, Morimoto M, Watanabe J, Tokuyasu N, Takano S, Sakamoto T, Honjo S, Fujiwara Y. Avoidance of bile duct injury during laparoscopic liver cyst fenestration using indocyanine green: A case report. Clin Case Rep 2020 Jun 10;8(8):1419-1424. doi: 10.1002/ccr3.2840. eCollection 2020 Aug. PMID: 32884766 PMCID: PMC7455442 DOI: 10.1002/ccr3.2840

3\. Une N, Fujio A, Mitsugashira H, Kanai N, Saitoh Y, Ohta M, Sasaki K, Miyazawa K, Kashiwadate T, Nakanishi W, Tokodai K, Miyagi S, Unno M, Kamei T. Laparoscopic liver cyst fenestration with real-time indocyanine green fluorescence-guided surgery: a case report. J Surg Case Rep 2021 May 17;2021(5):rjab196. doi: 10.1093/jscr/rjab196. eCollection 2021 May. PMID: 34025978 PMCID: PMC8128400 DOI: 10.1093/jscr/rjab196

4\. Wilhelm D, Vogel T, Ostler D, Marahrens N, Kohn N, Koller S, Friess H, Kranzfelder M. Enhanced Visualization: From Intraoperative Tissue Differentiation to Augmented Reality. Visc Med 2018 Feb;34(1):52-59. doi: 10.1159/000485940. Epub 2018 Feb 16. PMID: 29594170 PMCID: PMC5869373 DOI: 10.1159/000485940

Laparoscopic liver cyst fenestration: use of ICG fluorescence 

Prise en charge robotique de maladie biliaire complexe : description vidéo de 3 cas

Complex gallstone disease is amongst the most challenging pathologies encountered by hepatobiliary and pancreatic (HBP) surgeons. Conventionally, this condition requires open procedures in patients with morbid obesity. In this video, we present 3 cases of patients, demonstrating a minimally invasive approach using the da Vinci Xi™ surgical robotic system for the management of complex gallstone disease. The first patient presented with dropped gallstone with fistulisation, the second patient had a Mirizzi syndrome, and the third patient a cholecystocolonic fistula.

Case 1: The patient was a 75-year-old man with a history of diabetes and hypertension. He had undergone a laparoscopic cholecystectomy in its acute presentation phase 6 years earlier, at one of our referral hospitals. Subsequently, he developed a recurrent abscess with chronic discharge in the right flank. After multiple local drainage procedures and endoscopic retrograde cholangiopancreatography (ERCP) procedures, he was sent to our centre for the management of a suspected biliocutaneous fistula. We first suspected a ‘dropped stone' with resultant fistulisation and, since the cutaneous component had been drained recently, we opted for a surgical exploration of the intra-abdominal component of the abscess cavity.

Case 2: The patient was a 36-year-old lady with a BMI of 43. She presented to one of our referral hospitals with cholecystitis during the first wave of the COVID-19 pandemic and she was managed with a cholecystostomy tube. Subsequently, she developed obstructive jaundice. Imaging studies demonstrated a Mirizzi syndrome and a stent was inserted during ERCP. She was then referred for ongoing surgical management.

Case 3: The patient was a 58-year-old lady referred after a laparoscopy, with intent to proceed to a cholecystectomy at one of our referral institutions. Due to a major inflammatory change around the gallbladder, the procedure was abandoned. A magnetic resonance cholangiopancreatography (MRCP) showed the presence of a cholecystocolonic fistula. She was referred for definitive management.

The video chapters are described in the video.





Bibliography:

- Indications and Outcomes of Completion Cholecystectomy: A 5-year Experience From a Rural Tertiary Center. Alser O et al. Am Surg 2023 Nov;89(11):4584-4589. doi: 10.1177/00031348221124331. https://pubmed.ncbi.nlm.nih.gov/36031961/

- Cost analysis of robot-assisted choledochotomy and common bile duct exploration as an option for complex choledocholithiasis. Almamar et al. Surg Endosc 2018 Mar;32(3):1223-1227. doi: 10.1007/s00464-017-5795-3. https://pubmed.ncbi.nlm.nih.gov/28812193/

Robotic management of complex gallstone disease: video description of 3 cases

Dr. Chen, MD, FACS focuses on the repair of inguinal hernia recurrence after previous preperitoneal mesh. Dr. Chen, MD, FACS has the following potential conflicts of interest to disclose, receiving consultant fees from Allergan/AbbieVie, BD, International Hernia Collaboration, Intuitive Surgical, and Medtronic. However, these industrial companies were never committed to the elaboration and running organization of his lecture presentations. There is neither commercial publicity nor commercial promotion in his lectures. Dr. Chen, MD, FACS declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Dr. Chen, MD, FACS declares that his lectures are fair, balanced, and free of commercial bias.
Dr. Chen has no financial affiliations that would affect the content of his presentations.

Repair of inguinal hernia recurrence after previous preperitoneal mesh

In this key lecture, Dr. Ulrich Dietz, MD outlines the preperitoneal repair (rTAPP ventral hernia) robotic approach. Dr. Ulrich Dietz, MD has no conflict of interest to disclose. There is neither commercial publicity nor commercial promotion in his lecture. He declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. He also declares that his lectures are fair, balanced, and free of commercial bias.

Preperitoneal repair (rTAPP ventral hernia) robotic approach

monthly focus

Since its first description in 2017, the enhanced-view totally extraperitoneal (eTEP) approach for laparoscopic retromuscular hernia repair has gained popularity as it combines the advantages of a retromuscular mesh placement according to the Rives-Stoppa technique, with the benefits of minimally invasive hernia surgery (1). This approach is technically challenging with a long learning curve. However, it seemingly offers several advantages as compared to the laparoscopic intraperitoneal onlay mesh placement technique (IPOM) (2).

This video presents the case of a 57-year-old female patient presenting with multiple midline incarcerated postoperative hernias after an emergency midline laparotomy. The multiple ‘Swiss cheese’ hernia defects started from the epigastrium, spanning all the way to the hypogastrium for a total length of 22cm and a maximum width of 4.5cm (M2-3-4, W2, according to the EHS classification). The patient had a BMI of 26 and was a heavy smoker with a 30 pack per year smoking history.

Three ports were placed laterally in the left side for the left retrorectus space dissection with the addition of two more ports for the dissection of the right retrorectus space and for the suturing of the abdominal wall. A 30 by 15cm macroporous polyvinylidene fluoride (PVDF) mesh was placed behind the rectus abdominis muscle and fixed with cyanoacrylate glue (3). No drain was used.

The patient was discharged on the first postoperative day (POD 1) and resumed work on POD 3. Four months after surgery, she had excellent cosmetic and functional results.

In spite of its technical challenges, the eTEP approach should be considered for patients with complex abdominal wall hernias.



Bibliographic references: 

1. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Igor Belyansky, Jorge Daes, Victor Gheorghe Radu, Ramana Balasubramanian, H Reza Zahiri, Adam S Weltz, Udai S Sibia, Adrian Park, Yuri Novitsky. Surg Endosc 2018;32(3):1525-32. doi: 10.1007/s00464-017-5840-2. Epub 2017 Sep 15. https://pubmed.ncbi.nlm.nih.gov/28916960/ 

2. Comparison of outcomes of the extended-view totally extraperitoneal rives-stoppa (eTEP-RS) and the intraperitoneal onlay mesh with defect closure (IPOM-plus) for W1-W2 midline incisional hernia repair-a single-center experience. Halil Afşin Taşdelen. Surg Endosc 2023;37(4):3260-71. doi: 10.1007/s00464-023-09922-x. Epub 2023 Feb 10. https://pubmed.ncbi.nlm.nih.gov/36764936/ 

3. Degradation resistance of PVDF mesh in vivo in comparison to PP mesh. Hongshi Wang, Bernd Klosterhalfen, Andreas Müllen, Thomas Otto, Axel Dievernich, Stefan Jockenhövel. J Mech Behav Biomed Mater 2021;119:104490. doi: 10.1016/j.jmbbm.2021.104490. Epub 2021 Mar 23. https://pubmed.ncbi.nlm.nih.gov/33780848/ 

eTEP Rives-Stoppa repair for M2-3-4, W2 postoperative ventral hernia

Technique eTEP selon Rives-Stoppa pour hernie ventrale postopératoire M2-3-4W2

Technique eTEP pour cure rétromusculaire de hernie ventrale (ombilicale et épigastrique) récidivante et hernie inguinale droite

In this educational video, the authors demonstrate the laparoscopic repair of recurrent umbilical and epigastric hernias with an extended totally extraperitoneal (eTEP) retromuscular technique. The authors perform this approach using 6 trocars: one 12mm balloon trocar, one 11mm trocar, and four 5mm trocars. Anatomical landmarks were marked with a skin marking pen on the patient’s abdomen. The authors performed the open insertion of a 12mm disposable trocar using a cylindrical balloon for the initial dissection performed from the retromuscular space to the left rectus abdominis muscle. The procedure was pursued while the authors dissected the pelvic preperitoneal space and performed a crossover dissection from the left to the right retromuscular space through the preperitoneal space. An incision to the medial edge of the left posterior rectus aponeurosis was subsequently performed. The upper crossover to the right was performed before the incision of the medial edge of the right posterior rectus aponeurosis and the dissection of the right retromuscular space with the reduction of the hernia sac. The right-sided dissection was advanced to the right preperitoneal space and ended with the dissection of the right inguinal hernia. Peritoneal tears were sutured and the rectus abdominis diastasis repaired with a continuous barbed suture, including the closure of the ventral hernia defect with plication of the hernia sac. A medium-weight polypropylene mesh of 25 by 15cm was placed in the retrorectus space, which was drained with a suction drain. 



References:

Morrell ALG, Morrell A, Morrell-Junior AC, Mendes JMF, Morrell AG. Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias. Rev Col Bras Cir. 2020 Oct 7;47:e20202622. English, Portuguese. doi: 10.1590/0100-6991e-20202622. PMID: 33053065.

Ramana B, Arora E, Belyansky I. Signs and landmarks in eTEP Rives-Stoppa repair of ventral hernias. Hernia. 2021 Apr;25(2):545-550. doi: 10.1007/s10029-020-02216-4. Epub 2020 May 18. PMID: 32424727.

Mitura K, Rzewuska A, Skolimowska-Rzewuska M, Romańczuk M, Kisielewski K, Wyrzykowska D. Laparoscopic enhanced-view totally extraperitoneal Rives-Stoppa repair (eTEP-RS) for ventral and incisional hernias - early operative outcomes and technical remarks on a novel retromuscular approach. Wideochir Inne Tech Maloinwazyjne. 2020 Dec;15(4):533-545. doi: 10.5114/wiitm.2020.99371. Epub 2020 Sep 25. PMID: 33294067; PMCID: PMC7687670.

Belyansky I, Daes J, Radu VG, Balasubramanian R, Reza Zahiri H, Weltz AS, Sibia US, Park A, Novitsky Y. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc. 2018 Mar;32(3):1525-1532. doi: 10.1007/s00464-017-5840-2. Epub 2017 Sep 15. PMID: 28916960.

Enhanced-view totally extraperitoneal (eTEP) retromuscular repair for ventral (umbilical and epigastric) recurrent hernia and right inguinal hernia

Abdominal wall surgery is in constant evolution. Complications related to surgical wounds and postoperative pain have been the subject of various analyses for many years, leading to the emergence of new techniques to address them. Laparoscopic hernia surgery emerged with the aim of improving postoperative pain and reducing wound complications (1). When the IPOM technique was initially described, it was observed that pain indeed decreases, but the high seroma rate may complicate the postoperative period (2). It appeared that closing the hernia defect provided clear benefits (3), and the LIRA (laparoscopic intracorporeal rectus aponeuroplasty) technique allowed for a tension-free closure of the defect and appropriate mesh integration, with positive results to date (3). It is a reproducible technique that allows progression to more complex techniques such as extended totally extraperitoneal repair (eTEP). The authors present the case of a male patient with a recurrent M2W2 hernia, in whom a LIRA technique was performed. In this video, key steps were demonstrated to facilitate the learning of the technique. The main objective of this video is to help novice surgeons to understand this technique. 

Bibliography:

1. Zhang Y, Zhou H, Chai Y, Cao C, Jin K, Hu Z (2014) Laparoscopic versus open incisional and ventral hernia repair: a systematic review and meta-analysis. World J Surg 38(9):2233–2240. https://doi.org/10.1007/s00268-014-2578-z

2. Van Hoef S, Tollens T (2019) Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach? Hernia 23(5):915–925. https://doi.org/10.1007/s10029-019-02031-6

3. Suwa K, Okamoto T, Yanaga K (2016) Closure versus non-closure of fascial defects in laparoscopic ventral and incisional hernia repairs: a review of the literature. Surg Today 46(7):764–773. https://doi.org/10.1007/s00595-015- 1219-y

4. Gómez-Menchero J, Balla A, García Moreno JL, Gila Bohorquez A, Bellido-Luque JA, Morales-Conde S. Laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique versus intraperitoneal onlay mesh (IPOM plus) for ventral hernia repair: a comparative analysis. Hernia. 2023 Aug 17. doi: 10.1007/s10029-023- 02858-0. Epub ahead of print. PMID: 37592164

LIRA (laparoscopic intracorporeal rectus aponeuroplasty) technique for recurrent epigastric hernia

Technique LIRA par voie d'abord laparoscopique pour hernies épigastriques récurrentes

Focus on abdominal wall hernia repair (AWHR)

Focus sur la cure de hernies de la paroi abdominale

Polycystic liver disease (PLD) is a rare genetic disease. It is caused by mutations in genes that encode proteins involved in the transport of fluid and growth of hepatic epithelial cells. Such mutations lead to the replacement of normal liver tissue by fluid-filled liver cysts (1). Most patients with PLD are asymptomatic and diagnosed incidentally on imaging (3). Symptomatic patients with PLD that are good surgical candidates should be treated surgically (2) (4). The main goal in such patients is to reduce the intracystic pressure. This can be achieved with unroofing and fenestration of the cysts where possible or with excision of the entire involved liver part (1). Both procedures have a high risk of recurrence, since new cysts could be induced, and some patients may even need liver transplantation (1). 

During surgery, the first step involves the marking of the unroofing line. The excision of the entire cyst’s wall is not the main goal of the procedure, due to a high risk for portal or hepatic vessel injury. When the cyst wall is excised, the omentum should be placed within the cyst’s cavity to prevent recurrence, a technique called omentoplasty. Although uncommon, complications of this procedure include trocar-site infection, bile leakage from cut edges of the cyst, and vascular injuries (2). 



Bibliography: 

1. Kothadia JP, Kreitman K, Shah JM. Polycystic Liver Disease. 2023 Feb 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31751072. 

2. Tanaka M, Inoue Y, Mise Y, Ishizawa T, Arita J, Takahashi Y, Saiura A. Laparoscopic deroofing for polycystic liver disease using laparoscopic fusion indocyanine green fluorescence imaging. Surg Endosc. 2016 Jun;30(6):2620-3. doi: 10.1007/s00464-015-4526-x. Epub 2015 Sep 28. PMID: 26416378. 

3. Kaul V V, Friedenberg F, Rothstein KD. Hepatic Cysts. Curr Treat Options Gastroenterol. 2000 Dec;3(6):439-444. doi: 10.1007/s11938-000-0031-x. PMID: 11096603. 

4. Robert E Glasgow, M. (2022a) Hepatic cysts guidelines, EASL Guidelines on Cystic Liver Disease. Available at: https://emedicine.medscape.com/article/190818-guidelines (Accessed: 24 September 2023). 

Laparoscopic liver cyst unroofing in a patient with polycystic liver disease

Résection d'un kyste hépatique par laparoscopie chez un patient atteint d'une maladie polykystique du foie

This video demonstrates a laparoscopic extrahepatic bile duct resection and a Roux-en-Y hepaticojejunostomy technique in a 48-year-old female patient for a choledochal cyst. Diagnostic imaging performed for abdominal pain was consistent with a Todani type Ic choledochal cyst. She had a surgical history of cholecystectomy for cholecystolithiasis and sleeve gastrectomy for morbid obesity. During the hepaticojejunostomy, tearing of the bile duct and its management are outlined in the video.



Bibliography:

1. Xiao J, Chen M, Hong T, Qu Q, Li B, Liu W, He X. Surgical Management and Prognosis of Congenital Choledochal Cysts in Adults: A Single Asian Center Cohort of 69 Cases. J Oncol. 2022 Jan 21;2022:9930710. doi: 10.1155/2022/9930710. PMID: 35096065

2. Zhang K, Zhao D, Xie X, Wang W, Xiang B. Laparoscopic surgery versus robot-assisted surgery for choledochal cyst excision: A systematic review and meta-analysis. Front Pediatr. 2022 Oct 26;10:987789. doi: 10.3389/fped.2022.987789. PMID: 36389347

3. Yin T, Chen S, Li Q, Huang T, Li L, Diao M. Comparison of outcomes and safety of laparoscopic and robotic-assisted cyst excision and hepaticojejunostomy for choledochal cysts: A systematic review and meta-analysis. Ann Med Surg (Lond). 2022 Feb 26;75:103412. doi: 10.1016/j.amsu.2022.103412. PMID: 35386800



Laparoscopic extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy for choledochal cyst

Résection extrahépatique de la voie biliaire principale par laparoscopie et hépaticojéjunostomie selon Roux pour kyste du cholédoque

A good knowledge of hepatic vascular distribution, both classical and its variations, is essential to plan and perform all surgical and radiological procedures in the upper abdomen. Total replaced hepatic arteries coming from the superior mesenteric artery represent 3 to 5% of all patients and this must be taken into consideration for an adequate periarterial lymphatic adipose tissue dissection and to avoid complications. 



Bibliography:

1. Japanese Gastric Cancer Association. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer 26, 1–25 (2023). https://pubmed.ncbi.nlm.nih.gov/36342574/.

2. Staśkiewicz, G., Torres, K., Denisow, M. et al. Clinically relevant anatomical parameters of the replaced right hepatic artery (RRHA). Surg Radiol Anat 37, 1225–1231 (2015). https://pubmed.ncbi.nlm.nih.gov/25982897/.

3. Huang CM, Chen RF, Chen QY, Wei J, Zheng CH, Li P, Xie JW, Wang JB, Lin JX, Lu J, Cao LL, Lin M. Application Value of a 6-Type Classification System for Common Hepatic Artery Absence During Laparoscopic Radical Resections for Gastric Cancer: A Large-Scale Single-Center Study. Medicine (Baltimore). 2015 https://pubmed.ncbi.nlm.nih.gov/26266363/.

Considerations in D2 lymphadenectomy: replaced hepatic artery 

Points importants lors d’un curage ganglionnaire D2 : replacement de l'artère hépatique

The author presents the case of a 35-year-old male patient who underwent a laparoscopic re-exploration after a laparoscopic subtotal cholecystectomy. Initially, the patient had an acute cholecystitis and a high suspicion of common bile duct lithiasis. He had been managed in another facility with endoscopic retrograde cholangiopancreatography (ERCP). He had a sphincterotomy and 2 stones extracted. He underwent a laparoscopic subtotal cholecystectomy. Following this, the patient complained of right upper quadrant pain. Six weeks later, as an outpatient he was diagnosed with remnant cholecystitis after subtotal reconstituting cholecystectomy.



Take-home messages:

Subtotal cholecystectomy is an appropriate exit strategy to resolve acute biliary pathology and prevent bile duct injury. Although reconstructive subtotal cholecystectomy has a lower rate of bile leak, it has a higher incidence of cholecystitis recurrence. Given the persistence or recurrence of digestive symptoms after a subtotal cholecystectomy, the possibility of recurrence of cholecystitis and the feasibility of cholecystectomy of the gallbladder remnant must be evaluated. 



Bibliography:

1. Jayant M, Kaushik R. Presentation and management of gallbladder remnant after partial cholecystectomy. Trop Gastroenterol. 2013 Apr-Jun;34(2):99-103. doi: 10.7869/tg.2012.106. PMID: 24377158.

2. Henneman, D., da Costa, D.W., Vrouenraets, B.C. et al. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc 27, 351–358 (2013). https://doi.org/10.1007/s00464-012-2458-2

3. Teshima, T., Nitta, H., Mitsuura, C. et al. How to treat remnant cholecystitis after subtotal cholecystectomy: two case reports. surg case rep 7, 109 (2021). https://doi.org/10.1186/s40792-021-01183-x

4. Parkland 4 acute cholecystitis: PAECIF/PAECOF systematic dissection technique, a new proposal for a 100% safe cholecystectomy. N Zaragoza Arias, MD, FJ Martínez Jiménez, MD. Epublication WebSurg.com, Jun 2022;22(06). URL: http://websurg.com/doi/vd01en6684



Gallbladder remnant acute cholecystitis after subtotal reconstituting cholecystectomy

Cholécystite aiguë avec moignon de vésicule biliaire restant après cholécystectomie subtotale reconstituante 

This video presents the case of a 50-year-old woman who underwent a laparoscopic pylorus-preserving pancreaticoduodenectomy (PPPD) for a 4cm mucinous cystic pancreatic neoplasm (MCPN). The authors demonstrate the key steps of this operation using a 3D laparoscopic technique. The pancreaticojejunostomy (PJ) was performed using a duct-to-mucosa technique in the setting of a soft pancreas and small 2mm pancreatic duct. The video shows that the duct-to-mucosa technique for PJ is technically feasible and safe, even in the setting of a soft pancreas and small pancreatic duct – traditionally known as risk factors for post-operative pancreatic fistulae (1). 



Take-home messages:

Our video shows that the duct-to-mucosa technique for pancreaticojejunostomy is technically feasible and safe, even in the setting of a soft pancreas and small pancreatic duct. 



Bibliography:

1. Hassan, R. A., Zidan, A. M., Jabir, M. A., Abdelshafy, M., Abdallah, M., & Taha, A. (2022, August 1). Risk factors predicting the development of a pancreatic fistula following pancreaticoduodenectomy: A retrospective cohort study. International Journal of Surgery Open. https://doi.org/10.1016/j.ijso.2022.100509

Laparoscopic pylorus-preserving pancreaticoduodenectomy for mucinous cystic neoplasm

This video presents the case of a 48-year-old male patient who presented with diarrhea. Colonoscopy showed two ulcerative adenocarcinomas in the descending colon and splenic flexure. CT-scan revealed two liver metastases. It was decided to perform a preoperative chemotherapy to reduce the liver metastases. A hepatectomy and a left colectomy were also performed simultaneously. 



Bibliographic references: 

1. Krell, R. W., & D’Angelica, M. I. (2019). Treatment sequencing for simultaneous colorectal liver metastases. Journal of Surgical Oncology, 119(5), 583‑593. https://doi.org/10.1002/jso.25424 

2. Avella, P., Vaschetti, R., Cappuccio, M., Gambale, F., DE Meis, L., Rafanelli, F., Brunese, M. C., Guerra, G., Scacchi, A., & Rocca, A. (2022). The role of liver surgery in simultaneous synchronous colorectal liver metastases and colorectal cancer resections: A literature review of 1730 patients underwent open and minimally invasive surgery. Minerva Surgery, 77(6), 582 590. https://doi.org/10.23736/S2724-5691.22.09716-7 

3. Reddy, S. K., Pawlik, T. M., Zorzi, D., Gleisner, A. L., Ribero, D., Assumpcao, L., Barbas, A. S., Abdalla, E. K., Choti, M. A., Vauthey, J.-N., Ludwig, K. A., Mantyh, C. R., Morse, M. A., & Clary, B. M. (2007). Simultaneous resections of colorectal cancer and synchronous liver metastases: A multi-institutional analysis. Annals of Surgical Oncology, 14(12), 3481‑3491. https://doi.org/10.1245/s10434-007-9522-5 



Laparoscopic left colectomy and lateral left hepatectomy for colorectal cancer and liver metastasis

Colectomie gauche laparoscopique et hépatectomie latérale gauche pour le traitement d’un cancer colorectal et de métastases hépatiques



This video presents the case of a 67-year-old man who was referred for surgical resection of a metachronous colorectal liver metastasis in liver segment 1, in contact with the inferior vena cava. The diagnosis of a 50mm mass was established after a 20-month oncological follow-up. The patient was asymptomatic. His CEA level was 6.9µg/L. Neoadjuvant chemotherapy with FOLFIRI-bevacizumab was administered but no downsizing was observed after six cycles. As a result, a surgical resection was decided upon. 

The first step of the procedure was a laparoscopic ultrasonographic assessment of the extension of vascular invasion. The evaluation revealed a preserved surface between the tumor and the inferior vena cava. Consequently, the procedure was continued laparoscopically. Liver segment 1 was resected and the inferior vena cava was completely exposed. No vascular resection was required. The postoperative period was uneventful, and the patient was discharged on postoperative day 3. 

Laparoscopic liver surgery offers many advantages when compared to open liver surgery. However, laparoscopy has still not proven its added value in vascular invasion and vascular reconstruction settings. This video aims to show how a stepwise approach with detailed perioperative ultrasonographic evaluation helps to refine the preoperative iconography and tailor the surgical strategy. The value of a meticulous anatomical dissection in laparoscopic liver surgery becomes more evident in cases of possible vascular invasion when precision surgery is vital. 



Bibliography:

1. Ferrero A, Russolillo N, Langella S, Forchino F, Stasi M, Fazio F, Lo Tesoriere R. Ultrasound liver map technique for laparoscopic liver resections: perioperative outcomes are not impaired by technical complexity. Updates Surg. 2019 Mar;71(1):49-56. doi: 10.1007/s13304-019-00646-z. Epub 2019 Mar 27. PMID: 30919242.

2. Kumon M, Kumon T, Tsutsui E, Ebashi C, Namikawa T, Ito K, Sakamoto Y. Definition of the caudate lobe of the liver based on portal segmentation. Glob Health Med. 2020 Oct 31;2(5):328-336. doi: 10.35772/ghm.2020.01088. PMID: 33330828; PMCID: PMC7731356.

Laparoscopic liver segment I resection of colorectal liver metastasis in contact with the inferior vena cava

Segmentectomie hépatique laparoscopique (segment 1) pour métastase hépatique colorectale en contact avec la veine cave inférieure

Laparoscopic left lobectomy for liver perivascular epithelioid cell neoplasm (PEComa) 

Lobectomie gauche laparoscopique pour la prise en charge d’une tumeur des cellules épithélioïdes périvasculaires (PECome) 

Résection laparoscopique du duodénum distal avec préservation du pancréas pour adénome duodénal

Introduction

Small bowel (SB) malignant tumors are rare and cause non-specific symptoms, often leading to a late diagnosis. Most SB adenocarcinomas are found in the duodenum and arise from adenomas. Surgery is usually reserved for endoscopically non-excisable adenomas.



Materials and methods

It is the case of a patient with a D3 duodenal adenoma who underwent a laparoscopic duodenectomy.



Results

This is the case of a 58-year-old woman without any relevant personal medical history. Due to dyspepsia and heartburn, an endoscopy was performed and showed an irregular sessile polyp in the duodenum (D3) located 5cm away from the ampulla of Vater and not excisable endoscopically. A tattoo was performed. Biopsies revealed an adenomatous polyp with low-grade dysplasia (LGD). CT-scan showed a 15 by 13mm polypoid focal parietal thickening in D3, without extraparietal extension. No other changes were noted.

MRI revealed a 19 by 13 by 28mm polypoid lesion in D3 to the right and anteriorly to the abdominal aorta, without invasion of adjacent structures.

A laparoscopic D3-D4 duodenectomy with a mechanical intracorporeal side-to-side duodenojejunostomy were performed uneventfully. Preservation of the ampulla of Vater was confirmed via intraoperative endoscopy. An intraoperative methylene blue test was performed and did not reveal any leaks. The postoperative period was uneventful, and the patient was discharged on postoperative day 5. Histological exam revealed a 45 by 15mm tubulovillous adenoma with low-grade dysplasia. The patient was asymptomatic and was followed up.



Conclusion

SB adenomas are benign lesions with a significant potential to become malignant and develop into villous adenomas. Duodenal adenomas larger than 2cm and with ampullary location carry a higher risk of malignancy. Upper endoscopy is performed either for diagnostic or therapeutic purposes. Endoscopic resection must be performed in experienced centers. Surgery is indicated in cases of endoscopic unresectability. The laparoscopic approach offers the best outcomes.



Bibliography

1. Chathadi K., et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2015 Nov;82(5):773-81.

2. Kemp C., et al. Resection of benign duodenal neoplasms. Am Surg. 2007 Nov;73(11):1086-91.

3. Talamonti MS., et al. Primary cancers of the small bowel: analysis of prognostic factors and results of surgical management. Arch Surg. 2002;137(5):564. 

4. Amitabh Yadav, Samiran Nundy. Case series of non-ampullary duodenal adenomas. Annals of Medicine and Surgery, Volume 69, 2021, 102730, ISSN 2049-0801.

Laparoscopic distal duodenal resection with pancreatic preservation for duodenal adenoma

Focus en chirurgie hépatobiliaire et pancréatique

Focus on HPB surgery

Traitement laparoscopique d'une cholédocholithiase chez un patient ayant subi une gastrectomie partielle

This video presents the management of a choledocholithiasis in a patient who previously underwent a subtotal gastrectomy with a Roux-en-Y reconstruction for an oncologic condition. 

The patient was a 75-year-old man who presented with abdominal pain originating from the upper quadrants with an onset of jaundice. 

Eighteen years earlier, the patient had undergone a laparoscopic subtotal gastrectomy performed with a Roux-en-Y reconstruction for gastric cancer. 

CT-scan revealed a dilatation of the intrahepatic and extrahepatic biliary duct due to the presence of a 15mm gallstone in the common bile duct. 

In this case, the authors were faced with a common pathology, usually treated with an endoscopic retrograde cholangiopancreatography (ERCP). They subsequently had to tailor a procedure fitting the patient’s altered anatomy. 

Two surgical strategies were proposed during the preoperative meeting: a combined laparoscopic and endoscopic approach, or a total laparoscopic bile duct clearance followed by a cholecystectomy. 

Since the authors were not able to clearly identify the biliary loop to be passed through the gastroscope, an intraoperative laparoscopic biliary duct exploration was performed. 



Laparoscopic treatment of choledocholithiasis in a patient who underwent subtotal gastrectomy

Gastrectomie totale par laparoscopie pour cancer gastrique, une approche par étapes

Introduction: 

Total gastrectomy is a complex and often difficult procedure to perform. It involves the removal of the entire stomach, including the gastroesophageal junction (GEJ). It is usually performed in patients with proximal gastric cancer, in whom a subtotal gastrectomy with a 5 to 6cm proximal margin does not leave a reasonable gastric remnant. The laparoscopic total gastrectomy technique has drawn increasing attention over the years.



Objectives: 

In this video, the authors present a laparoscopic radical gastrectomy with a Roux-en-Y reconstruction in a stepwise fashion. It is their procedure of choice in patients with proximal gastric cancer involving neoadjuvant therapy. 



Methodology: 

The patient was a 43-year-old woman with a T4N1M0 poorly cohesive cells gastric carcinoma invading the gastric body, as well as the lesser and greater curvature. A perioperative chemotherapy with 4 cycles of FLOT was proposed to the patient. CT-scan evaluation showed a favorable response to the treatment. The authors performed a laparoscopic radical total gastrectomy with a Roux-en-Y reconstruction. The patient had no major complications and was discharged on postoperative day 6.



Conclusion:

Laparoscopic total gastrectomy has been increasingly performed in many hospitals. Recent studies have shown that the laparoscopic technique, although complex and often difficult to perform, offers significant advantages. It has been shown that it decreases postoperative hospital stay, allows earlier gastric tube removal, and has similar postoperative complication rates and overall survival as compared to open total gastrectomy for patients with gastric cancer involving neoadjuvant therapy.

In conclusion, laparoscopic total gastrectomy can be considered a first-line surgical treatment in experienced centers, since it is an effective and safe curative procedure.



Bibliography:

1. Park, K. B., Kim, E. Y., & Song, K. Y. (2019). Esophagojejunal anastomosis after laparoscopic total gastrectomy for gastric cancer : Circular versus linear stapling. Journal of Gastric Cancer, 19(3), 344‑354. https://doi.org/10.5230/jgc.2019.19.e34

2. Hu, H.-T., Ma, F.-H., Xiong, J.-P., Li, Y., Jin, P., Liu, H., Ma, S., Kang, W.-Z., & Tian, Y.-T. (2022). Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy : A propensity score matching analysis. World Journal of Gastrointestinal Surgery, 14(2), 161‑173. https://doi.org/10.4240/wjgs.v14.i2.161

3. Chan, B. Y. O., Yau, K. K. W., & Chan, C. K. O. (2019). Totally laparoscopic versus open gastrectomy for advanced gastric cancer : A matched retrospective cohort study. Hong Kong Medical Journal = Xianggang Yi Xue Za Zhi, 25(1), 30‑37. https://doi.org/10.12809/hkmj177150 

4. Mulholland, Michael W., et al., Operative Thechniques in Surgery, volume two, 2015, Wolters Kluwer Health



Laparoscopic total gastrectomy for gastric carcinoma, a stepwise approach

Echinococcosis is a parasitic infection caused by the larval stage of the Echinococcus tapeworm. The liver (70%) and lungs (25%) are the most commonly affected organs. Splenic involvement is rare with about 0.5-8% of cystic echinococcus (CE) cases. Cases of solitary splenic cyst are even rarer (0.5-4%). 

This video shows a hemisplenectomy performed using a fully laparoscopic approach for the management of a 7cm echinococcal solitary cyst located in the upper pole of the spleen. The patient, a 23-year-old male, presented with upper abdominal pain, nausea, and vomiting. Diagnosis was established through ultrasound monitoring and was confirmed via serological tests and magnetic resonance imaging. The postoperative period was uneventful, and the drain was removed on postoperative day 1. The patient was discharged on postoperative day 3. After 3 months of follow-up, no further issues were noted. This case emphasizes the safety and feasibility of the laparoscopic approach for spleen preservation. 



Bibliography

1. Akhan O, Koroglu M. Hydatid disease of the spleen. Semin Ultrasound CT MR. 2007;28(1):28-34. doi:10.1053/j.sult.2006.10.002

2. Yotsov TI, Dyulgerova S, Draganova D. Laparoscopic splenectomy for solitary splenic hydatid cyst: Case report. J Minim Access Surg. 2023;19(2):317-319. doi:10.4103/jmas.jmas_113_22

3. Akbulut S, Sogutcu N, Eris C. Hydatid disease of the spleen: single-center experience and a brief literature review. J Gastrointest Surg. 2013;17(10):1784-1795. doi:10.1007/s11605-013-2303-5

4. Rasheed K, Zargar SA, Telwani AA. Hydatid cyst of spleen: a diagnostic challenge. N Am J Med Sci. 2013;5(1):10-20. doi:10.4103/1947-2714.106184

Laparoscopic hemisplenectomy for solitary splenic hydatid cyst 

Hémisplénectomie laparoscopique pour kyste hydatique solitaire splénique

The retroperitoneum can host primary or metastatic lesions, and occasionally a complete surgical resection is the only potential curative treatment (1). The laparoscopic approach has proven feasible and safe for the removal of intra-abdominal lesions (2) including large lesions in close proximity to vital structures. However, the anatomical location impacts the feasibility of a minimally invasive approach for a central retroperitoneal lesion (3, 4). This video shows the management of a retrocaval lesion via a totally laparoscopic surgical approach. A 24-year-old female patient experienced episodes of early satiety and abdominal discomfort. Abdominal ultrasound and MRI revealed a solid mass in the right adrenal lodge, extending up to the region between the vena cava and the portal vein. The 55 by 44mm retrocaval lesion was suspected to be a retroperitoneal tumor, and an explorative laparoscopy was proposed. Despite the close proximity of the lesion to major vessels (i.e., vena cava, aorta, portal vein) and visceral organs (liver and duodenum), the surgeon performed a total laparoscopic wide radical resection. To obtain macroscopically complete clearance, the resection mandated a right adrenalectomy due to vascular supply involvement. Operative time was 95 minutes without intraoperative complications. Postoperative outcomes were uneventful. The patient rapidly recovered on postoperative day 3, with optimal cosmetic results. The final diagnosis was established through the histopathological analysis and evidenced metastatic melanoma with HMB and MART-1 positivity. This video showed that the laparoscopic approach was safe and feasible but challenging for retroperitoneal lesions, suggesting that a retrocaval location is not an absolute contraindication to this method if performed by an expert laparoscopic surgeon. The patient underwent endoscopic examinations for the lower and upper GI, as well as dermatological, ophthalmological, and gynecological examination. All tests proved negative and it was not possible to identify the primary site of the melanoma. Therefore, the oncology group proposed NED (non-evidence of disease) as the final diagnosis. The patient started immunotherapy and was followed up clinically.



Bibliography: 

1. Mota, M. M. D. S., Bezerra, R. O. F., & Garcia, M. R. T. (2018). Practical approach to primary retroperitoneal masses in adults. Radiologia brasileira, 51(6), 391–400. https://doi.org/10.1590/0100-3984.2017.0179.



2. Bracale, U., Pacelli, F., Milone, M., Bracale, U. M., Sodo, M., Merola, G., Troiani, T., & Di Salvo, E. (2017). Laparoscopic treatment of abdominal unicentric castleman's disease: a case report and literature review. BMC surgery, 17(1), 38. https://doi.org/10.1186/s12893-017-0238-6.



3. Strauss, D. C., Hayes, A. J., Thway, K., Moskovic, E. C., Fisher, C., & Thomas, J. M. (2010). Surgical management of primary retroperitoneal sarcoma. The British journal of surgery, 97(5), 698–706. https://doi.org/10.1002/bjs.6994.



4. Strauss, D. C., Hayes, A. J., & Thomas, J. M. (2011). Retroperitoneal tumours: review of management. Annals of the Royal College of Surgeons of England, 93(4), 275–280. https://doi.org/10.1308/003588411X571944.

Totally laparoscopic management of retrocaval metastatic melanoma in a young patient

Prise en charge entièrement laparoscopique d'un mélanome métastatique rétrocave chez une jeune patiente

Traitement laparoscopique d'une intussusception chez l'adulte

Adult intussusception is rare and often recognized as an abdominal emergency. Unlike children, adult intussusception is frequently associated with secondary causes such as benign and malignant tumors (Hirotaka Honjo. World J Surg. 2015 Jan;39 (1): 134-8). This video demonstrates the laparoscopic management of colonic intussusception in a young adult patient with severe acute abdominal pain, nausea, and vomiting. During the preoperative work-up, CT-scan revealed the “pseudokidney sign” and several enlarged lymph nodes around the loop (Anderson DR. The pseudokidney sign. (1999) Radiology. 211 (2): 395-7.). Since the patient was an adult and there were several enlarged mesenteric lymph nodes suggesting a possible malignant cause, an oncological right hemicolectomy with D3 lymphadenectomy was performed.

Laparoscopic management of an adult intussusception

Rôle de la compresse chirurgicale en chirurgie laparoscopique

The authors present a didactic video highlighting the use of a surgical sponge in laparoscopic surgery with various surgical demonstrations and examples.

The video shows clips from various pelvic gynecologic procedures demonstrating the versatility and spectrum of applications of the surgical sponge to increase the efficiency of the surgical procedure. 



Bibliography:

1. Bariol SV, Heng CT, Lau HM. Intracorporeal ribbon gauze in laparoscopic surgery. ANZ J Surg. 2004 Jan-Feb;74(1-2):68. doi: 10.1046/j.1445-1433.2003.02890.x. PMID: 14725709.

2. Gholami SS, Shekarriz B, Rudnick D, Duh QY, Stoller ML. The laparoscopic cigarette sponge. J Urol. 2001 Jul;166(1):194. PMID: 11435855.

3. Maccabee D, Sheppard BC. The laparoscopic sponge. Surg Endosc. 2003 Aug;17(8):1320-1. doi: 10.1007/s00464-002-8779-9. Epub 2003 Apr 28. PMID: 15039864.



Role of surgical sponge (gauze) in laparoscopic surgery

Améliorer la précision de la cure chirurgicale de hernie hiatale : intégration de la laparoscopie et de la gastroscopie peropératoire pour des résultats optimaux

Hiatal hernia repair has witnessed significant advancements in recent years, with a paradigm shift towards a laparoscopic approach accompanied by the incorporation of intraoperative gastroscopy. This video delves into the pivotal role of laparoscopy in hiatal hernia surgical repair and underscores the added benefits conferred by real-time intraoperative gastroscopic guidance. The laparoscopic approach has revolutionized hiatal hernia repair, offering patients a less invasive alternative to traditional open surgeries. This technique involves smaller incisions, reduced postoperative pain, and shorter recovery times, presenting a paradigm shift that aligns with the principles of minimally invasive surgery. Moreover, laparoscopy provides superior visualization of the hiatal defect, enabling meticulous dissection and precise anatomical reconstruction. In conjunction with laparoscopy, the integration of intraoperative gastroscopy emerges as a valuable adjunct in hiatal hernia repair. Real-time visualization of the gastroesophageal junction during surgery allows for accurate identification of hiatal defects and assessment of the gastroesophageal valve. This dynamic approach facilitates tailored and patient-specific repairs, contributing to improved surgical outcomes and reduced rates of postoperative complications. 

Furthermore you will find a panel expert discussion about the use or not of absorbable and non absorbable mesh for the hiatal repair and indication about the extension of the dissection of the short gastric vessels are discussed. 

In conclusion, this video highlights the transformative impact of laparoscopic surgery on hiatal hernia repair, emphasizing its benefits in terms of reduced invasiveness and enhanced visualization. The synergistic integration of intraoperative gastroscopy further elevates the precision of the procedure, allowing surgeons to tailor interventions based on real-time insights. 



Bibliography: 

1. Hashemi M, Peters JH. "Current concepts in the management of paraesophageal hiatal hernia." Journal of Clinical Gastroenterology, 2008; 42(6): 594-601. 

2. Dallemagne B, Perretta S. Long-term Efficacy of Total and Partial Posterior Fundoplication to Treat Gastroesophageal Reflux Disease. JAMA Surg. 2022 Jun 1;157(6):480. doi: 10.1001/jamasurg.2022.0806. PMID: 35442405.

3. Watson DI, Pike GK, Baigrie RJ. "Prospective double-blind randomized trial of laparoscopic Nissen fundoplication with division and without division of short gastric vessels." Annals of Surgery, 1997; 226(5): 642–652. 

4. Swanström LL, Jobe BA, Kinzie LR. "Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication." The American Journal of Surgery, 1999; 177(5): 359-363.

5. Luketich JD, Nason KS, Christie NA. "Outcomes after a decade of laparoscopic giant paraesophageal hernia repair." Journal of Thoracic and Cardiovascular Surgery, 2010; 139(2): 395-404. 



Advancing precision in hiatal hernia surgical repair: integration of laparoscopy and intraoperative gastroscopy for optimal outcomes 

Traitement laparoscopique d'une péritonite biliaire post-cholécystectomie

In this video, the authors present the case of a patient admitted to hospital with biliary peritonitis following a laparoscopic cholecystectomy. The patient was operated on again using a laparoscopic approach and a biliary peritonitis was found in relation to a leak through an aberrant duct. Peritoneal lavage was performed, and the aberrant duct was sutured. Nowadays, the laparoscopic approach is increasingly used in the management of biliary complications secondary to cholecystectomy.



Bibliography: 

Dokmak S, Amharar N, Aussilhou B, Cauchy F, Sauvanet A, Belghiti J, Soubrane O. Laparoscopic Repair of Post-cholecystectomy Bile Duct Injury: an Advance in Surgical Management. J Gastrointest Surg. 2017 Aug;21(8):1368-1372. doi: 10.1007/s11605-017-3400-7. Epub 2017 Mar 27. PMID: 28349333. 



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