monthly focus

surgical intervention video

Patients with foregut cancer are often unable to be fed perorally. Feeding jejunostomy is thus commonly performed in these patients to maintain their nutritional support during neoadjuvant chemotherapy. This is the case of a 77-year-old man with an epidermoid cancer of the thoracic esophagus undergoing staging. Surgical treatment was decided upon along with a laparoscopic Witzel jejunostomy and the insertion of a totally implantable venous access device. 

Due to the advent of minimally invasive surgery, feeding jejunostomy could also be performed laparoscopically, benefiting from all the advantages of a laparoscopic approach. The technical laparoscopic surgical aspects of a patient’s right-side approach are highlighted such as trocar placement, number of ports, tube tunnelization through the Witzel approach, and fixation of the jejunal loop to the anterior abdominal wall to prevent any axial rotation. 

Given the fact that the surgeon did not have a percutaneous jejunostomy tube at his disposal, a sixth 5mm trocar was placed at the jejunostomy exiting site to allow for the use of a 14 French jejunostomy tue (MIC* Jejunostomy Feeding Tube®), often used for a conventional open approach. 



Take-home messages:

Laparoscopic Witzel feeding jejunostomy is a safe and feasible procedure with comparable outcomes to the open technique. 

Before tunnelization, the patency of the feeding tube must be tested, allowing to detect any leakage and confirm the correct position of the distal end of the tube. 

Once tunnelization is complete, the jejunal loop must be attached to the anterior abdominal wall with seromuscular sutures to prevent rotation around the axis of the feeding tube. 

Advisable sutures to consider include a 3/0 Vicryl absorbable multifilament and a 3/0 PDS absorbable monofilament, although an absorbable barbed suture can also be used.



Bibliography:

1. Yang SM, Hsiao WL, Lin JH, Huang PM, Lee JM. Laparoscopic percutaneous jejunostomy with intracorporeal V-loc jejunopexy in esophageal cancer. Surg Endosc. 2017; 31:2678–86. [https://pubmed.ncbi.nlm.nih.gov/27752817/]

2. Speer EA, Chow SC, Dunst CM, Shada AL, Halpin V, Reavis KM, et al. Clinical burden of laparoscopic feeding jejunostomy tubes. J Gastrointest Surg. 2016; 20:970–5. [https://pubmed.ncbi.nlm.nih.gov/26895952/]

3. Pili D, Ciotola F, Riganti JM, Badaloni A, Nieponice A. Autoadjustable sutures and modified seldinger technique applied to laparoscopic jejunostomy. World J Surg. 2015; 39:325–7. [https://pubmed.ncbi.nlm.nih.gov/25318452/]

4. Ye P, Zeng L, Sun F, An Z, Li Z, Hu J. A new modified technique of laparoscopic needle catheter jejunostomy: A 2-year follow-up study. Ther Clin Risk Manag. 2016; 12:103–8. [https://pubmed.ncbi.nlm.nih.gov/26869794/]



Laparoscopic Witzel feeding jejunostomy

Jéjunostomie d'alimentation par voie d'abord laparoscopique : technique de Witzel

Approximately 15% of patients with symptomatic cholelithiasis harbor concomitant choledocholithiasis. Choledocholithiasis can be treated using either open, laparoscopic, percutaneous or endoscopic approaches. The laparoscopic common bile duct exploration (LCBDE) is an advantageous option for managing stones within the common bile duct (CBD) with the benefits of a single stage approach and high success rates. Choledochoscopy is useful in difficult cases to verify the location and number of gallstones and confirm that there are no residual gallstones. 

A 67-year-old man with hypercholesterolemia and no previous surgeries was admitted to the emergency department with acute biliary cholangitis –Tokyo grade III– with multiorgan dysfunction. He was admitted to the intensive care unit and submitted to an urgent ERCP: a prosthesis was placed with drainage of pus, biliary sludge, and dark bile. The CT-scan showed a cholelithiasis and a pronounced dilatation of intrahepatic and extrahepatic bile ducts. The CBD was 19mm and had an 18mm gallstone, causing the dilatation of the upstream biliary tree. Two months later, the patient underwent a laparoscopic cholecystectomy with LCBDE and a transductal LCBDE was performed with a choledochoscope. The endoscopic prosthesis was removed. The gallstones were excised through a Dormia basket and vigorous intraluminal lavage was performed through a Foley catheter. The procedure was uneventful, and the patient was discharged on postoperative day 3. LCBDE is a safe and effective single-stage treatment of choledocholithiasis. In challenging cases, intraoperative choledochoscopy makes the difference. Its performance in experienced centers allows the treatment of patients using different techniques.



Take-home messages

Choledocholithiasis can be treated with either an open, laparoscopic, percutaneous, or an endoscopic approach. 

Laparoscopic common bile duct exploration (LCBDE) is a safe and effective single-stage treatment in patients with common bile duct stones.

LCBDE is a beneficial option for managing stones within the biliary tree, and when performed by an experienced surgeon, it allows the treatment of choledocholithiasis with acceptable morbidity rates and high success rates, which makes it a first-line therapy in the treatment of choledocholithiasis.



Biliography:

1. Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches. World J Gastroenterol. 2021 Jul 28;27(28):4536-4554. doi: 10.3748/wjg.v27.i28.4536. PMID: 34366622; PMCID: PMC8326257.

2. Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013 Sep 3;(9):CD003327. doi: 10.1002/14651858.CD003327.pub3. Update in: Cochrane Database Syst Rev. 2013;(12):CD003327. PMID: 23999986.

3. Chaouch MA, Dougaz MW, Jerraya H, Khalfallah M, Ghariani W, Nouira R, Bouasker I, Dziri C. Mini-Invasive management of concomitant gallstones and common bile duct stones : where is the evidence ( Review article). Tunis Med. 2019 Aug-Sep;97(8-9):997-1004. PMID: 32173848.

4. Bekheit M, Smith R, Ramsay G, Soggiu F, Ghazanfar M, Ahmed I. Meta-analysis of laparoscopic transcystic versus transcholedochal common bile duct exploration for choledocholithiasis. BJS Open. 2019 Jan 23;3(3):242-251. doi: 10.1002/bjs5.50132. PMID: 31183439; PMCID: PMC6551404.



Usefulness of laparoscopic choledochoscopy in the treatment of choledocholithiasis

Utilité de la cholédochoscopie laparoscopique dans le traitement de la cholédocholithiase

Introduction: The superior mesenteric artery (SMA) syndrome is a rare cause of small bowel obstruction, which occurs due to the loss of the mesenteric fat pad with associated decrease in the angle between this vessel and the aorta. This causes an extrinsic compression of the duodenum with consequent obstruction. 

Case report: An otherwise healthy 27-year-old woman has complained of persisting postprandial abdominal pain for the past year. She reported a 20 Kg voluntary weight loss previously to the onset of symptoms. CT-scan showed a gastroduodenal distension upstream from the SMA, with a distance of 10mm between this vessel and the aorta. She was proposed for a laparoscopic Strong’s procedure (namely mobilization of the duodenum by dividing the ligament of Treitz). 

Results: There were no perioperative complications and recovery was uneventful, with remission of complaints. 

Conclusion: The diagnosis of superior mesenteric artery syndrome is challenging and controversial as a high index of suspicion is required and symptoms may not correlate with anatomical findings. Additionally, symptoms may not resolve after treatment. Despite a high rate of failure, this procedure is associated with fewer perioperative complications. 



Take-home messages

The superior mesenteric artery (SMA) syndrome is a well-described disease entity, which must be considered as a cause of vomiting associated with significant weight loss in young adults. Rapid weight loss of any cause should raise immediate suspicion for this diagnosis.



Bibliography:

1. Ozkurt H, Cenker MM, Bas N, et al. Measurement of the distance and angle between the aorta and superior mesenteric artery: normal values in different BMI categories. Surg Radiol Anat 2007; 29:595.

2. Merrett ND, Wilson RB, Cosman P, Biankin AV. Superior mesenteric artery syndrome: diagnosis and treatment strategies. J Gastrointest Surg 2009; 13:287.

3. Lee TH, Lee JS, Jo Y, et al. Superior mesenteric artery syndrome: where do we stand today? J Gastrointest Surg 2012; 16:2203.



Laparoscopic Strong procedure for superior mesenteric artery (SMA) syndrome

In this educational video, the authors present the case of a symptomatic giant hepatic hemangioma. A laparoscopic resection was decided upon using humid bipolar coagulation and Thunderbeat™ device, that is ultrasonic and advanced bipolar energies. Note: The extremities of the bipolar forceps are moistened with saline solution to increase the capacity of bipolar coagulation (like Aquamantys™ bipolar sealers). 



Take-home messages:

Excessive intraoperative blood loss is a major issue in hepatic resections. Several instruments have been introduced in order to decrease the blood loss during parenchymal transection in liver surgery.

In this video, the authors showed that the use of humid bipolar coagulation and the Thunderbeat™ device contribute to the feasibility of the technique in laparoscopic liver resection. The surgeon’s laparoscopic skills can provide a safe and effective liver parenchymal transection without the adoption of novel technologies (e.g., the Cavitron Ultrasonic Surgical Aspirator, CUSA), by adapting surgical techniques initially developed for open liver surgery.



Bibliography:

• Gurusamy KS, Pamecha V, Sharma D, Davidson BR. Techniques for liver parenchymal transection in liver resection. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006880. doi: 10.1002/14651858.CD006880.pub2. PMID: 19160307.

• Otsuka Y, Kaneko H, Cleary SP, Buell JF, Cai X, Wakabayashi G. What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection. J Hepatobiliary Pancreat Sci. 2015 May;22(5):363-70. doi: 10.1002/jhbp.216. Epub 2015 Jan 29. PMID: 25631462.

• Iida H, Maehira H, Mori H, Tani M. Efficiency of a radiofrequency sealer (Aquamantys) for parenchymal transection during laparoscopic hepatectomy. Asian J Endosc Surg. 2020 Oct;13(4):505-513. doi: 10.1111/ases.12785. Epub 2020 Jan 29. PMID: 31997578.



Giant hepatic hemangioma: tips and tricks for laparoscopic resection without liver ultrasonic dissection

Hémangiome hépatique géant : trucs et astuces pour la résection laparoscopique sans dissection ultrasonique du foie

Exploration laparoscopique et cholécystectomie pour calculs de la vésicule biliaire et du canal cholédoque

Introduction: 

Choledocholithiasis originates in the gallbladder in 85% of cases and is symptomatic in only 50% of cases. It may present as biliary colic, obstructive jaundice, cholangitis, or pancreatitis. The need for treatment is indisputable. However, the method of treatment depends on the patient's concomitant diseases, the surgeon's experience, and may involve performing ERCP or surgery. Bile duct exploration and ideally laparoscopic choledocholithotomy are surgical options when complete removal of stones is achieved, and bile duct stenosis is not present. 



Objective: 

This video aims to demonstrate a cholecystectomy technique with biliary tract exploration, as well as an ideal laparoscopic choledocholithotomy.



Methodology: 

The authors present the clinical case of a 67-year-old male patient with a history of gallstones, abdominal pain in the right upper quadrant, generalized pruritus, jaundice, choluria, and acholic stools. Abdominal ultrasonography revealed a 1.5 cm stone in the common bile duct and multiple gallbladder stones. Cholestasis blood tests were high with normal inflammatory parameters. The authors present a video of laparoscopic cholecystectomy with intraoperative cholangiography, followed by choledocholithotomy and choledochoscopy with stone removal and closure with an uninterrupted suture of the common bile duct. The patient was discharged on postoperative day 4. 



Conclusion: 

Laparoscopic choledocholithotomy is an ideal, safe procedure as long as the absence of lithiasis, or any other cause of obstruction is confirmed before primary closure, with a reduction in length of hospital stay and costs. However, its performance requires a highly skilled surgeon.



Take-home messages:

Cholecystectomy and choledocholithotomy with laparoscopic primary closure in patients with gallbladder and common bile duct stones are safe. This procedure helps to avoid choledochostomy under a Kehr’s drain, as long as the absence of lithiasis or another cause of obstruction is confirmed before primary closure. It allows for a reduced hospital stay and lower hospital costs. 

However, a major obstacle to performing this technique is the requirement of a high level of laparoscopic experience.



Bibliography:

1. Bansal VK, Misra MC, Rajan K, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc. 2014;28(3):875-885.

2. Singh AN, Kilambi R. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis. Surg Endosc. 2018;32(9):3763-3776.

3. Vu AN, Eskander J, Chan STF, Houli N, Bui HT. Impact of single-stage laparoscopic trans-cystic exploration on hospital procedures, admissions and length-of-stay in common bile duct stone clearance. ANZ J Surg. 2021;91(12):2695-2700.



Single-stage laparoscopic common bile duct exploration and cholecystectomy in a patient with gallbladder and common bile duct stones

This video highlights the most important steps of a laparoscopic subtotal gastrectomy with a D1+ lymphadenectomy, combined with a Billroth II reconstruction using a 45mm linear stapler. Subtotal gastrectomy is a frequent procedure and it is recommended for surgeons to watch a short video before a surgery to bear in mind the key steps. It may also help them to decide which reconstruction type to perform. 

This is the case of a 72-year-old female patient with a history of depression and hypertension. There was no previous abdominal surgery, and no other relevant comorbidities. In September 2022, she presented with anemia. In October 2022, an upper endoscopy revealed a gastric tumor of the antrum on the anterior wall. A histological exam revealed an intestinal-type adenocarcinoma. 

The multidisciplinary team decided to perform an exploratory laparoscopy, as well as a preoperative chemotherapy, followed by surgery. 

The patient underwent a laparoscopic subtotal gastrectomy with a D1+ lymphadenectomy, combined with a Billroth II reconstruction using a 45mm linear stapler. There were no intraoperative or postoperative complications. The patient was discharged on postoperative day 6. 

The histological findings demonstrated the presence of a tubular adenocarcinoma, with a tumoral regression grade 2 (ypT4bN0). Sixty-six lymph nodes without metastasis were found. 



Take-home messages:

To perform this surgery, it is crucial to be prepared and to take time to review the procedure since there is no room for improvisation. One must perform surgery in a stepwise fashion, which helps to avoid sudden movements and rushing, which is also very important to maintain control throughout the procedure. 



Bibliography:

1. Celentano, V., Smart, N., McGrath, J., Cahill, R. A., Spinelli, A., Obermair, A., Hasegawa, H., Lal, P., Almoudaris, A. M., Hitchins, C. R., Pellino, G., Browning, M. G., Ishida, T., Luvisetto, F., Cingiloglu, P., Gash, K., Harries, R., Harji, D., Di Candido, F., … Coleman, M. G. (2018). Lap-vegas practice guidelines for reporting of educational videos in laparoscopic surgery : A joint trainers and trainees consensus statement. Annals of Surgery, 268(6), 920‑926. https://doi.org/10.1097/SLA.0000000000002725.

2. Schmidt, B., & Yoon, S. S. (2013). D1 versus D2 lymphadenectomy for gastric cancer. Journal of Surgical Oncology, 107(3), 259‑264. https://doi.org/10.1002/jso.23127.

Warm-up to a laparoscopic subtotal gastrectomy with D1+ lymphadenectomy and a Billroth II linear stapled gastrojejunostomy for adenocarcinoma 

Entraînement pratique pour gastrectomie subtotale avec lymphadénectomie D1+ et gastrojéjunostomie linéaire par agrafage de type Billroth II en présence d'adénocarcinome

This video aims to highlight the most important steps of a laparoscopic subtotal gastrectomy with a D2 lymphadenectomy and a Billroth II reconstruction. 

This is the case of 78-year-old man who was evaluated for dyspepsia and heartburn. An upper endoscopy found a gastric ulcer on the posterior surface of the gastric body. The biopsy study confirmed the presence of an intestinal-type moderately differentiated adenocarcinoma according to the Lauren classification. The CT-scan confirmed the absence of secondary lesions. The upper endoscopic ultrasound showed a T3N+ adenocarcinoma and the laparoscopic cytology was negative. The multidisciplinary team decided to perform a preoperative chemotherapy followed by surgery. 

The patient was submitted to a laparoscopic subtotal gastrectomy with a D2 lymphadenectomy and a Billroth II reconstruction. The procedure was uneventful and the patient was discharged on postoperative day 6. 

Pathological findings revealed an intestinal-type gastric adenocarcinoma according to the Lauren classification with free margins and 25 negative lymph nodes (TNM staging ypT2 N0 M0). The patient completed adjuvant chemotherapy without any complications.



Bibliography:

1. Smyth EC, Nilsson M, Grabsch HI, van Grieken NC, Lordick F. Gastric cancer. Lancet. 2020 Aug 29;396(10251):635-648. https://pubmed.ncbi.nlm.nih.gov/32861308/ 

2. Lordick F, Carneiro F, Cascinu S, Fleitas T, Haustermans K, Piessen G, Vogel A, Smyth EC; ESMO Guidelines Committee. Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2022 Oct;33(10):1005-1020. https://pubmed.ncbi.nlm.nih.gov/35914639/ 

3. Beyer K. Surgery Matters: Progress in Surgical Management of Gastric Cancer. Curr Treat Options Oncol. 2023 Feb;24(2):108-129. https://pubmed.ncbi.nlm.nih.gov/36656504/

Focus on general and digestive surgery