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Riccardo MEMEO

Policlinico di Bari
Bari, Italy
MD, PhD
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Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
Surgical intervention
1 year ago
7046 views
939 likes
0 comments
32:12
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
Surgical intervention
1 year ago
4439 views
570 likes
0 comments
51:19
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
Laparoscopic distal pancreatectomy with splenectomy
In this video, a laparoscopic distal pancreatectomy with a splenectomy is demonstrated. The colon is mobilized from the omentum and the splenic flexure is lowered completely. The dissection is completed towards the right side in order to access the pancreatic isthmus. The dissection is initiated at the level of the inferior pancreatic port in order to identify the mesentericoportal axis. The retropancreatic dissection is performed. The splenic vein and the splenic artery are dissected and taped. A tape is placed around the pancreas in order to facilitate the dissection thanks to the traction exerted. The pancreas is divided by means of a stapler, tan cartridge. The splenic vessels were divided through Hem-o-lok™ Polymer Locking Ligation Systems. The dissection is performed from the right to the left side of the retropancreatic region. The greater omentum is dissected in close contact with the greater curvature of the stomach. The short gastric vessels are progressively divided. The division of the posterior mesogastrium allows to completely free the specimen, which is then placed in a bag. The specimen is removed through a suprapubic Pfannenstiel’s incision.
Surgical intervention
2 years ago
2401 views
161 likes
0 comments
21:51
Laparoscopic distal pancreatectomy with splenectomy
In this video, a laparoscopic distal pancreatectomy with a splenectomy is demonstrated. The colon is mobilized from the omentum and the splenic flexure is lowered completely. The dissection is completed towards the right side in order to access the pancreatic isthmus. The dissection is initiated at the level of the inferior pancreatic port in order to identify the mesentericoportal axis. The retropancreatic dissection is performed. The splenic vein and the splenic artery are dissected and taped. A tape is placed around the pancreas in order to facilitate the dissection thanks to the traction exerted. The pancreas is divided by means of a stapler, tan cartridge. The splenic vessels were divided through Hem-o-lok™ Polymer Locking Ligation Systems. The dissection is performed from the right to the left side of the retropancreatic region. The greater omentum is dissected in close contact with the greater curvature of the stomach. The short gastric vessels are progressively divided. The division of the posterior mesogastrium allows to completely free the specimen, which is then placed in a bag. The specimen is removed through a suprapubic Pfannenstiel’s incision.
Robotic pancreaticoduodenectomy for vaterian ampulloma
We report the case of a robot-assisted pancreaticoduodenectomy for vaterian ampulloma. The patient is positioned in the French position with the assistant between the legs and the robot at the head. Five trocars are used: the camera is introduced through the umbilical trocar. The operation begins with the exploration of the peritoneum and of the liver. The gastric antrum is divided. Each structure of the hepatic pedicle is skeletonized. The superior border of the pancreas is dissected, hence allowing to approach the mesentericoportal axis.
The surgeon proceeds to the inferior border of the pancreas in order to find the mesentericoportal axis and to achieve a retropancreatic passage, which is where the pancreas will be divided. The pancreas is divided using the Sonicision™ cordless ultrasonic dissection device. The first jejunal loop is divided with a stapler. The specimen is totally mobilized ‘en bloc’, and freed from the portal vascular axis with a dissection of the right border of the coeliac trunk. At the end of the dissection, the different arterial and venous structures are skeletonized with a lymph node resection. The reconstruction is performed with a pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy.
Surgical intervention
2 years ago
2375 views
236 likes
0 comments
28:02
Robotic pancreaticoduodenectomy for vaterian ampulloma
We report the case of a robot-assisted pancreaticoduodenectomy for vaterian ampulloma. The patient is positioned in the French position with the assistant between the legs and the robot at the head. Five trocars are used: the camera is introduced through the umbilical trocar. The operation begins with the exploration of the peritoneum and of the liver. The gastric antrum is divided. Each structure of the hepatic pedicle is skeletonized. The superior border of the pancreas is dissected, hence allowing to approach the mesentericoportal axis.
The surgeon proceeds to the inferior border of the pancreas in order to find the mesentericoportal axis and to achieve a retropancreatic passage, which is where the pancreas will be divided. The pancreas is divided using the Sonicision™ cordless ultrasonic dissection device. The first jejunal loop is divided with a stapler. The specimen is totally mobilized ‘en bloc’, and freed from the portal vascular axis with a dissection of the right border of the coeliac trunk. At the end of the dissection, the different arterial and venous structures are skeletonized with a lymph node resection. The reconstruction is performed with a pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy.
Robot-assisted ultrasound-guided transgastric cystogastrostomy
We report the case of a 57-year-old woman with a voluminous pseudocyst in the lesser sac after several episodes of acute pancreatitis of biliary origin managed by a robot-assisted transgastric cystogastrostomy. The patient is lying supine, legs apart. Five ports are positioned. The intervention is begun with an anterior gastrotomy, which allows to introduce a balloon-tipped trocar transgastrically. A second gastrotomy is performed in the prepyloric region. It allows to introduce a second transgastric trocar. Finally, a third gastrotomy is performed at the level of the fundus to introduce a third transgastric balloon-tipped trocar. After transgastric insufflation, the trocars are connected to the robot, which is positioned at the patient’s head. A transgastric ultrasonography is performed to visualize the pseudocyst, which has a heterogeneous content, with fibrotic debris. The gastrotomy is initiated with Ultracision™ at the posterior aspect of the stomach. The cyst is multilocular. The gastric wall is controlled by means of a Doppler ultrasound in order not to pass through the gastric varices, which had been identified on endoscopic ultrasound. A second cavity with some more heterogeneous content is subsequently opened. This cavity presents some pancreatic necrosis. The cystogastrostomy is enlarged at its most. Trocars are then removed to proceed intraperitoneally. The three anterior gastrotomy incisions are then sutured using the robot. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
Surgical intervention
3 years ago
1193 views
54 likes
0 comments
06:04
Robot-assisted ultrasound-guided transgastric cystogastrostomy
We report the case of a 57-year-old woman with a voluminous pseudocyst in the lesser sac after several episodes of acute pancreatitis of biliary origin managed by a robot-assisted transgastric cystogastrostomy. The patient is lying supine, legs apart. Five ports are positioned. The intervention is begun with an anterior gastrotomy, which allows to introduce a balloon-tipped trocar transgastrically. A second gastrotomy is performed in the prepyloric region. It allows to introduce a second transgastric trocar. Finally, a third gastrotomy is performed at the level of the fundus to introduce a third transgastric balloon-tipped trocar. After transgastric insufflation, the trocars are connected to the robot, which is positioned at the patient’s head. A transgastric ultrasonography is performed to visualize the pseudocyst, which has a heterogeneous content, with fibrotic debris. The gastrotomy is initiated with Ultracision™ at the posterior aspect of the stomach. The cyst is multilocular. The gastric wall is controlled by means of a Doppler ultrasound in order not to pass through the gastric varices, which had been identified on endoscopic ultrasound. A second cavity with some more heterogeneous content is subsequently opened. This cavity presents some pancreatic necrosis. The cystogastrostomy is enlarged at its most. Trocars are then removed to proceed intraperitoneally. The three anterior gastrotomy incisions are then sutured using the robot. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
Robotic partial splenectomy for cystic lesion of the spleen
We report the case of a 21-year-old woman with a cystic lesion of the spleen treated with a robotic partial splenectomy. The patient is placed in a right lateral decubitus position. Four ports are introduced into the left hypochondrium. The robot is placed at the level of the patient’s left shoulder. The intervention is begun with a lowering of the splenic flexure. Dissection is initiated at the upper pole of the spleen by retracting the stomach and by progressively dividing the different short vessels. It is decided to start the parenchymotomy approximately 1cm from the devascularized area. Transection is begun using an ultrasonic dissector. Hemostasis is subsequently achieved progressively. Transection is completed by means of a firing of the Endo GIA™ linear stapler. Hemostasis is further completed using the Aquamantys® system and bipolar sealers. The specimen is fully mobilized and placed in a bag. It is extracted by means of a small suprapubic Pfannenstiel’s incision. Pathological findings demonstrate the presence of an epidermoid cyst. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
Surgical intervention
3 years ago
1836 views
70 likes
0 comments
09:14
Robotic partial splenectomy for cystic lesion of the spleen
We report the case of a 21-year-old woman with a cystic lesion of the spleen treated with a robotic partial splenectomy. The patient is placed in a right lateral decubitus position. Four ports are introduced into the left hypochondrium. The robot is placed at the level of the patient’s left shoulder. The intervention is begun with a lowering of the splenic flexure. Dissection is initiated at the upper pole of the spleen by retracting the stomach and by progressively dividing the different short vessels. It is decided to start the parenchymotomy approximately 1cm from the devascularized area. Transection is begun using an ultrasonic dissector. Hemostasis is subsequently achieved progressively. Transection is completed by means of a firing of the Endo GIA™ linear stapler. Hemostasis is further completed using the Aquamantys® system and bipolar sealers. The specimen is fully mobilized and placed in a bag. It is extracted by means of a small suprapubic Pfannenstiel’s incision. Pathological findings demonstrate the presence of an epidermoid cyst. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
Surgical intervention
3 years ago
694 views
18 likes
0 comments
16:09
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
Surgical intervention
3 years ago
1698 views
58 likes
0 comments
13:06
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
Surgical intervention
3 years ago
2061 views
42 likes
0 comments
08:07
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
Laparoscopic enucleation of a pancreatic tumor: posterior approach
We report the case of a 55-year-old woman with a hypervascularized lesion at the posterior aspect of the pancreatic tail, which is evocative of an endocrine tumor of the pancreas. We decided to perform a laparoscopic enucleation of this tumor using a posterior approach. The patient is positioned in a right lateral decubitus. The intervention begins with the opening of the posterior mesogastrium, which allows to tilt the entire splenopancreatic block to the right. The tumor located on the posterior aspect clearly appears. An enucleation of the tumor is then performed using the monopolar cautery hook. In order to facilitate the lesion's exposure, a traction suture will be placed. This helps to expose the tumor. The inferior border of the tumor is freed from the splenic vein and the monopolar hook allows to perform a step-by-step enucleation. An intrapancreatic freeing of the lesion's deep plane is achieved using the Sonicision™ device. The tumor is placed into a bag and extracted through a port. The extemporaneous exam confirms the diagnosis of an endocrine tumor. Hemostasis is controlled. The splenopancreatic block is put back in its original anatomical position. There is no pancreatic fistula. The patient is discharged on postoperative day 5. The final diagnosis confirms a G1 endocrine tumor.
Surgical intervention
4 years ago
1258 views
46 likes
0 comments
11:04
Laparoscopic enucleation of a pancreatic tumor: posterior approach
We report the case of a 55-year-old woman with a hypervascularized lesion at the posterior aspect of the pancreatic tail, which is evocative of an endocrine tumor of the pancreas. We decided to perform a laparoscopic enucleation of this tumor using a posterior approach. The patient is positioned in a right lateral decubitus. The intervention begins with the opening of the posterior mesogastrium, which allows to tilt the entire splenopancreatic block to the right. The tumor located on the posterior aspect clearly appears. An enucleation of the tumor is then performed using the monopolar cautery hook. In order to facilitate the lesion's exposure, a traction suture will be placed. This helps to expose the tumor. The inferior border of the tumor is freed from the splenic vein and the monopolar hook allows to perform a step-by-step enucleation. An intrapancreatic freeing of the lesion's deep plane is achieved using the Sonicision™ device. The tumor is placed into a bag and extracted through a port. The extemporaneous exam confirms the diagnosis of an endocrine tumor. Hemostasis is controlled. The splenopancreatic block is put back in its original anatomical position. There is no pancreatic fistula. The patient is discharged on postoperative day 5. The final diagnosis confirms a G1 endocrine tumor.
Laparoscopic right hemihepatectomy with augmented reality
We report the case of a 42-year-old woman who underwent a laparoscopic right hemihepatectomy for a hepatic metastasis. The intervention is begun with the exploration of the entire peritoneal cavity and an intraoperative ultrasound exam of the liver. The lesion is identified by means of augmented reality. Dissection of the different vascular structures is then performed at the level of the hepatic pedicle. A clamping test of the right branches is achieved. The right branch of the hepatic artery and the right portal vein are clamped, hence creating the demarcation area, which is identified by means of the coagulating hook. Declamping of portal and arterial structures coursing towards the right liver is achieved. The right branch of the portal vein is divided between two clips. The right branch of the hepatic vein is also divided between two clips. After mobilization of the right liver, the hepatotomy is begun. The first superficial centimeters are divided using an ultrasonic dissector (Ultracision®). Dissection is then carried on by means of a Cusa® Dissectron® Ultrasonic Surgical Aspirator. The largest structures are subsequently dissected intraparenchymally, and then clipped and divided. Hemostasis is completed using a radiofrequency instrument. The right biliary tract is dissected intraparenchymally, clipped and divided. The right hepatic vein is divided by means of a stapler. The specimen is placed in a bag, which is extracted by means of a small Pfannenstiel incision. Hemostasis is controlled as the pneumoperitoneum is reduced. A blade is positioned in the hepatectomy area.
Surgical intervention
4 years ago
2485 views
68 likes
0 comments
12:53
Laparoscopic right hemihepatectomy with augmented reality
We report the case of a 42-year-old woman who underwent a laparoscopic right hemihepatectomy for a hepatic metastasis. The intervention is begun with the exploration of the entire peritoneal cavity and an intraoperative ultrasound exam of the liver. The lesion is identified by means of augmented reality. Dissection of the different vascular structures is then performed at the level of the hepatic pedicle. A clamping test of the right branches is achieved. The right branch of the hepatic artery and the right portal vein are clamped, hence creating the demarcation area, which is identified by means of the coagulating hook. Declamping of portal and arterial structures coursing towards the right liver is achieved. The right branch of the portal vein is divided between two clips. The right branch of the hepatic vein is also divided between two clips. After mobilization of the right liver, the hepatotomy is begun. The first superficial centimeters are divided using an ultrasonic dissector (Ultracision®). Dissection is then carried on by means of a Cusa® Dissectron® Ultrasonic Surgical Aspirator. The largest structures are subsequently dissected intraparenchymally, and then clipped and divided. Hemostasis is completed using a radiofrequency instrument. The right biliary tract is dissected intraparenchymally, clipped and divided. The right hepatic vein is divided by means of a stapler. The specimen is placed in a bag, which is extracted by means of a small Pfannenstiel incision. Hemostasis is controlled as the pneumoperitoneum is reduced. A blade is positioned in the hepatectomy area.
Laparoscopic distal splenopancreatectomy for a caudal cystic pancreatic lesion
We report the case of a 51-year-old woman who underwent laparoscopic left splenopancreatectomy for a caudal cystic pancreatic lesion evocative of a mucinous cyst.
The patient is placed in a right lateral supine position, legs apart. A reverse Trendelenburg position is used. Four ports are placed. After the colon has been detached from the omentum, the dissection is begun at the superior border of the pancreas. It makes it possible to dissect the splenic artery, which is placed on a tape. The dissection is carried on at the inferior border of the pancreas in order to identify the venous mesentericoportal axis. A retropancreatic passage is achieved along the mesentericoportal axis, and a tape is passed around the pancreatic isthmus, which was immediately divided by means of a stapler. The splenic vein is identified at the posterior border of the pancreas. It is dissected and placed on a tape. The splenic artery is divided between two clips. The splenic vein is divided. It is freed from attachments, then clipped, and finally divided. The distal pancreas with the spleen was dissected to perform an ‘en-bloc’ left splenopancreatectomy. The specimen is placed in a bag and extracted through a Pfannenstiel incision, with an extemporaneous exam on the slice, which allows to rule out any neoplastic infiltration. A blade is placed in the left hypochondrium with an amylase activity assay performed on postoperative day 3. The blade is extracted through the leftmost port.
Surgical intervention
4 years ago
2097 views
56 likes
0 comments
10:52
Laparoscopic distal splenopancreatectomy for a caudal cystic pancreatic lesion
We report the case of a 51-year-old woman who underwent laparoscopic left splenopancreatectomy for a caudal cystic pancreatic lesion evocative of a mucinous cyst.
The patient is placed in a right lateral supine position, legs apart. A reverse Trendelenburg position is used. Four ports are placed. After the colon has been detached from the omentum, the dissection is begun at the superior border of the pancreas. It makes it possible to dissect the splenic artery, which is placed on a tape. The dissection is carried on at the inferior border of the pancreas in order to identify the venous mesentericoportal axis. A retropancreatic passage is achieved along the mesentericoportal axis, and a tape is passed around the pancreatic isthmus, which was immediately divided by means of a stapler. The splenic vein is identified at the posterior border of the pancreas. It is dissected and placed on a tape. The splenic artery is divided between two clips. The splenic vein is divided. It is freed from attachments, then clipped, and finally divided. The distal pancreas with the spleen was dissected to perform an ‘en-bloc’ left splenopancreatectomy. The specimen is placed in a bag and extracted through a Pfannenstiel incision, with an extemporaneous exam on the slice, which allows to rule out any neoplastic infiltration. A blade is placed in the left hypochondrium with an amylase activity assay performed on postoperative day 3. The blade is extracted through the leftmost port.
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
Surgical intervention
4 years ago
1312 views
27 likes
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12:38
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
Pure laparoscopic posterior sectionectomy and wedge resections for bilobar colorectal liver metastases
We report the case of a 74-year-old gentleman who underwent a laparoscopic liver resection for bilobar colorectal liver metastases. The patient presented with newly diagnosed liver metastases one year after undergoing a right hemi-colectomy followed by six cycles of adjuvant chemotherapy for a T3N1 adenocarcinoma. After six cycles of preoperative systemic therapy, a 30 percent reduction in the volume of the liver lesions is obtained. Preoperative three-dimensional reconstruction of the cross-sectional imaging is obtained to plan a laparoscopic liver resection. Virtual hepatectomy is then performed using the virtual three-dimensional model. Five trocars are used as depicted. The camera is initially positioned in a 10mm umbilical port. It will be placed in a 12mm port during parenchymal transection. The subxiphoid port is used by the assistant for liver traction and suctioning. The procedure is initiated by lyzing adhesions that resulted from the previous cholecystectomy and right hemi-colectomy. An umbilical tape is placed around the portal pedicle for eventual intermittent clamping during the resection. An intraoperative ultrasound confirms that no additional lesions are present. The transection line is drawn on the liver surface under ultrasound guidance.
The portal pedicle is clamped to begin the parenchymal transection. The liver capsule is first divided using an energy device. Deeper parenchymal transection is performed with an ultrasonic dissector. After 15 minutes, the pedicle clamping is taken down by melting and extracting the proximal clip previously placed. This procedure will be repeated throughout the parenchymal transection to obtain a posterior sectionectomy. Hemostasis of the transected liver is obtained. A non-anatomical segment III resection is then performed. Finally, the fourth lesion is resected with a non-anatomical segment IV resection. These specimens are placed in a bag and extracted through a small extension of the umbilical port.
Surgical intervention
4 years ago
1809 views
54 likes
0 comments
10:01
Pure laparoscopic posterior sectionectomy and wedge resections for bilobar colorectal liver metastases
We report the case of a 74-year-old gentleman who underwent a laparoscopic liver resection for bilobar colorectal liver metastases. The patient presented with newly diagnosed liver metastases one year after undergoing a right hemi-colectomy followed by six cycles of adjuvant chemotherapy for a T3N1 adenocarcinoma. After six cycles of preoperative systemic therapy, a 30 percent reduction in the volume of the liver lesions is obtained. Preoperative three-dimensional reconstruction of the cross-sectional imaging is obtained to plan a laparoscopic liver resection. Virtual hepatectomy is then performed using the virtual three-dimensional model. Five trocars are used as depicted. The camera is initially positioned in a 10mm umbilical port. It will be placed in a 12mm port during parenchymal transection. The subxiphoid port is used by the assistant for liver traction and suctioning. The procedure is initiated by lyzing adhesions that resulted from the previous cholecystectomy and right hemi-colectomy. An umbilical tape is placed around the portal pedicle for eventual intermittent clamping during the resection. An intraoperative ultrasound confirms that no additional lesions are present. The transection line is drawn on the liver surface under ultrasound guidance.
The portal pedicle is clamped to begin the parenchymal transection. The liver capsule is first divided using an energy device. Deeper parenchymal transection is performed with an ultrasonic dissector. After 15 minutes, the pedicle clamping is taken down by melting and extracting the proximal clip previously placed. This procedure will be repeated throughout the parenchymal transection to obtain a posterior sectionectomy. Hemostasis of the transected liver is obtained. A non-anatomical segment III resection is then performed. Finally, the fourth lesion is resected with a non-anatomical segment IV resection. These specimens are placed in a bag and extracted through a small extension of the umbilical port.