monthly focus

surgical intervention video

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

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

Traitement laparoscopique d'une intussusception chez l'adulte

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

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 

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

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. 



Laparoscopic treatment of post-cholecystectomy biliary peritonitis

Traitement laparoscopique d'une péritonite biliaire post-cholécystectomie

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

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

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

Focus on general surgery