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Manuel TRÍAS FOLCH

Hospital de la Santa Creu i Pau
Barcelona, Spain
MD, PhD
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Laparoscopic resection of extra-adrenal paraganglioma
Introduction
Paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells. These tumors arise from dispersed paraganglia that tend to be symmetrically distributed in close relation to the aorta and to the sympathetic nervous system. Paragangliomas have a higher malignancy potential than adrenal pheochromocytomas.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Laparoscopic resections of such tumors have been described in isolated cases.

Material and methods
We present the case of a 16-year-old female patient who presents with repeated urinary tract infection. An ultrasound demonstrates the presence of a retropancreatic mass. The study was completed by abdominal CT-scan and PET-scan (123-MIBG) where a solid mass of 4.5cm in diameter, homogeneous, encapsulated, without calcifications, located between the third duodenal portion (which is displaced anteriorly) and the inferior vena cava from the level of the right renal vein to the level of the right renal lower pole, is found. The patient presents MIBG (metaiodobenzylguanidine) tracer uptake in the Iodine-123-MIBG scintigraphy, suggesting the diagnosis of adrenal medullary tumor. The hormonal study shows a significant increase in plasmatic normetanephrine (25 times the normal upper limit). A genetic study has found no mutation of the most frequent responsible genes.
Given radiological and hormonal findings, laparoscopic surgery is decided upon with suspected diagnosis of extra-adrenal paraganglioma.

Discussion
In this video, we present a laparoscopic approach to this mass, using an 11mm optical trocar and four 5mm working trocars. As can be appreciated, a very careful dissection is carried out to separate the mass from adjacent structures, dissecting small vessels that drain directly into the inferior vena cava.
Final pathology reports a 5cm retroperitoneal paraganglioma, with vascular invasion. In the immunohistochemical study, cells are positive for Synaptophysin and Chromogranin A. The postoperative course was uneventful, and the patient was discharged on postoperative day 4.
The laparoscopic excision of paraganglioma is safe and feasible, reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
As a general conclusion, it is essential to diagnose, localize, and treat paragangliomas, because of the potential cure of symptoms associated with functional tumors, prevention of a lethal hypertensive paroxysm, and early diagnosis of malignant tumors.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Tumors located between major vessels rarely invade these vessels, but careful and meticulous dissection of the surrounding small vessels is necessary.
The laparoscopic excision of paraganglioma reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
Surgical intervention
5 years ago
1030 views
34 likes
0 comments
12:04
Laparoscopic resection of extra-adrenal paraganglioma
Introduction
Paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells. These tumors arise from dispersed paraganglia that tend to be symmetrically distributed in close relation to the aorta and to the sympathetic nervous system. Paragangliomas have a higher malignancy potential than adrenal pheochromocytomas.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Laparoscopic resections of such tumors have been described in isolated cases.

Material and methods
We present the case of a 16-year-old female patient who presents with repeated urinary tract infection. An ultrasound demonstrates the presence of a retropancreatic mass. The study was completed by abdominal CT-scan and PET-scan (123-MIBG) where a solid mass of 4.5cm in diameter, homogeneous, encapsulated, without calcifications, located between the third duodenal portion (which is displaced anteriorly) and the inferior vena cava from the level of the right renal vein to the level of the right renal lower pole, is found. The patient presents MIBG (metaiodobenzylguanidine) tracer uptake in the Iodine-123-MIBG scintigraphy, suggesting the diagnosis of adrenal medullary tumor. The hormonal study shows a significant increase in plasmatic normetanephrine (25 times the normal upper limit). A genetic study has found no mutation of the most frequent responsible genes.
Given radiological and hormonal findings, laparoscopic surgery is decided upon with suspected diagnosis of extra-adrenal paraganglioma.

Discussion
In this video, we present a laparoscopic approach to this mass, using an 11mm optical trocar and four 5mm working trocars. As can be appreciated, a very careful dissection is carried out to separate the mass from adjacent structures, dissecting small vessels that drain directly into the inferior vena cava.
Final pathology reports a 5cm retroperitoneal paraganglioma, with vascular invasion. In the immunohistochemical study, cells are positive for Synaptophysin and Chromogranin A. The postoperative course was uneventful, and the patient was discharged on postoperative day 4.
The laparoscopic excision of paraganglioma is safe and feasible, reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
As a general conclusion, it is essential to diagnose, localize, and treat paragangliomas, because of the potential cure of symptoms associated with functional tumors, prevention of a lethal hypertensive paroxysm, and early diagnosis of malignant tumors.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Tumors located between major vessels rarely invade these vessels, but careful and meticulous dissection of the surrounding small vessels is necessary.
The laparoscopic excision of paraganglioma reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
Laparoscopic enucleation of horseshoe-shaped esophageal leiomyoma: use of mini-instruments
Introduction:
Leiomyoma is the most common benign tumor of the esophagus, usually arising in the inner circular muscle layer of the distal esophagus. Middle-aged men are most frequently affected. Most patients remain asymptomatic and when they become symptomatic, the main signs are usually dysphagia and epigastric pain, but they are not specific to the disease. Malignization is rare but should not be ignored.
The minimally invasive approach to these tumors allows for complete extirpation with minimal morbidity and provides excellent results.

Materials and methods:
We present the case of a 31-year-old woman with no medical history, who underwent a CT-scan for other reasons, namely for urinary symptoms. A 3cm homogeneous, low attenuated mass was found at the gastroesophageal junction. Endoscopic ultrasound is performed and showed a 50mm horseshoe-shaped tumor affecting three quarters of the esophageal circumference. Because of clinical deterioration, and mainly of dysphagia, elective surgery was decided upon.

Results:
In this video, it is possible to appreciate the laparoscopic enucleation of this horseshoe-shaped tumor, which depends on the distal esophageal wall, mainly using blunt dissection. The intervention is completed with a Toupet fundoplication. The postoperative course was uneventful, and the patient is discharged on the third postoperative day, and symptoms are resolved.

Conclusions:
Minimally invasive laparoscopic resection of distal esophageal benign tumors is technically safe and provides the well-known advantages of laparoscopic access, achieving quick patient recovery and a short hospital stay.
Some authors recommend to perform an anti-reflux procedure in order to protect the surgical resection area and therefore prevent complications due to the weakening of the lower esophageal sphincter, such as reflux symptoms.
Surgical intervention
5 years ago
781 views
4 likes
0 comments
08:45
Laparoscopic enucleation of horseshoe-shaped esophageal leiomyoma: use of mini-instruments
Introduction:
Leiomyoma is the most common benign tumor of the esophagus, usually arising in the inner circular muscle layer of the distal esophagus. Middle-aged men are most frequently affected. Most patients remain asymptomatic and when they become symptomatic, the main signs are usually dysphagia and epigastric pain, but they are not specific to the disease. Malignization is rare but should not be ignored.
The minimally invasive approach to these tumors allows for complete extirpation with minimal morbidity and provides excellent results.

Materials and methods:
We present the case of a 31-year-old woman with no medical history, who underwent a CT-scan for other reasons, namely for urinary symptoms. A 3cm homogeneous, low attenuated mass was found at the gastroesophageal junction. Endoscopic ultrasound is performed and showed a 50mm horseshoe-shaped tumor affecting three quarters of the esophageal circumference. Because of clinical deterioration, and mainly of dysphagia, elective surgery was decided upon.

Results:
In this video, it is possible to appreciate the laparoscopic enucleation of this horseshoe-shaped tumor, which depends on the distal esophageal wall, mainly using blunt dissection. The intervention is completed with a Toupet fundoplication. The postoperative course was uneventful, and the patient is discharged on the third postoperative day, and symptoms are resolved.

Conclusions:
Minimally invasive laparoscopic resection of distal esophageal benign tumors is technically safe and provides the well-known advantages of laparoscopic access, achieving quick patient recovery and a short hospital stay.
Some authors recommend to perform an anti-reflux procedure in order to protect the surgical resection area and therefore prevent complications due to the weakening of the lower esophageal sphincter, such as reflux symptoms.
Laparoscopic splenectomy in a patient with cirrhosis and splenomegaly
Introduction
The first laparoscopic splenectomy was initially described more than 20 years ago. Hypersplenism associated with thrombocytopenia in cirrhotic patients could compromise quality of life and also limit therapeutic options such as interferon treatment.
Material and methods
We present the case of a 48-year-old woman with a history of parenteral drug abuse, HCV/HIV co-infection, cirrhosis (Child-Pugh B). Treatment with interferon and antiretrovirals must be discontinued for severe thrombocytopenia. As a result, laparoscopic splenectomy stands out as a therapeutic measure.
Results
In this video, we present a laparoscopic splenectomy approach in a cirrhotic patient with splenomegaly and hypersplenism in order to initiate interferon and antiretroviral treatment. It is possible to note the presence of collateral circulation, cirrhotic liver, and moderate splenomegaly (final spleen weight of 735 grams).
Conclusions
Laparoscopic access proves safe and effective in cirrhotic patients in order to extend the therapeutic managements of their underlying diseases. It can also improve the Child-Pugh score.
Surgical intervention
6 years ago
7084 views
131 likes
0 comments
08:01
Laparoscopic splenectomy in a patient with cirrhosis and splenomegaly
Introduction
The first laparoscopic splenectomy was initially described more than 20 years ago. Hypersplenism associated with thrombocytopenia in cirrhotic patients could compromise quality of life and also limit therapeutic options such as interferon treatment.
Material and methods
We present the case of a 48-year-old woman with a history of parenteral drug abuse, HCV/HIV co-infection, cirrhosis (Child-Pugh B). Treatment with interferon and antiretrovirals must be discontinued for severe thrombocytopenia. As a result, laparoscopic splenectomy stands out as a therapeutic measure.
Results
In this video, we present a laparoscopic splenectomy approach in a cirrhotic patient with splenomegaly and hypersplenism in order to initiate interferon and antiretroviral treatment. It is possible to note the presence of collateral circulation, cirrhotic liver, and moderate splenomegaly (final spleen weight of 735 grams).
Conclusions
Laparoscopic access proves safe and effective in cirrhotic patients in order to extend the therapeutic managements of their underlying diseases. It can also improve the Child-Pugh score.
Laparoscopic excision of a large leiomyoma of the esophagogastric junction
Esophageal leiomyomas represent a benign pathology that usually affects the distal third and the esophagogastric junction, and that is perfectly suitable for a laparoscopic enucleation. A correct preoperative diagnosis is mandatory, as the most common differential diagnosis in this localization is represented by gastrointestinal stromal tumors (GIST), a pathology that could benefit from neo-adjuvant therapy. Occasionally, leiomyomas can be adherent to the mucosal layer, in which case-limited mucosal excision is necessary.
We present a laparoscopic enucleation of a large leiomyoma of the esophagogastric junction, requiring the use of an endostapler for complete resection.
Surgical intervention
7 years ago
1506 views
7 likes
0 comments
09:00
Laparoscopic excision of a large leiomyoma of the esophagogastric junction
Esophageal leiomyomas represent a benign pathology that usually affects the distal third and the esophagogastric junction, and that is perfectly suitable for a laparoscopic enucleation. A correct preoperative diagnosis is mandatory, as the most common differential diagnosis in this localization is represented by gastrointestinal stromal tumors (GIST), a pathology that could benefit from neo-adjuvant therapy. Occasionally, leiomyomas can be adherent to the mucosal layer, in which case-limited mucosal excision is necessary.
We present a laparoscopic enucleation of a large leiomyoma of the esophagogastric junction, requiring the use of an endostapler for complete resection.