IRCAD Webinar : Laparoscopic and Endoluminal Bariatric and Metabolic Surgery - Gastric bypass : RYGB or SLGB?

Pancreatic endocrine tumors (PETs) are uncommon but clinically challenging and fascinating tumors. Small, benign neoplasms are readily curable by surgical resection. This video presents the case of a 40-year-old woman with a tumor at the level of the pancreatic body. The patient’s virtual reconstruction is used during surgery to help the surgeon pinpoint the lesion accurately. A laparoscopic approach is used.

The video "Enucleation of a pancreatic nonfunctioning endocrine tumor localized with intraoperative US and augmented reality" authored by B Dallemagne and J Marescaux is analysed by Dr. A Park, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

A 72-year-old woman was addressed to the endocrinologist for arterial hypertension and US finding of a 5cm nodule in the aortocaval space of the celiac region. The diagnostic workup revealed raised urinary metanephrines. A CT-scan confirmed the US findings, and the nodule was also positive at PET CT-scan. A fine needle biopsy was performed, which was suggestive of a paraganglioma.
Medical treatment with Doxazosine 44mg qd was required for the adequate control of hypertension, and surgical excision was required.
A laparoscopic lateral transabdominal approach was chosen, to displace the hepatoduodenal ligament and allow for a wide access to the inferior vena cava. The operative time was 75 minutes. The patient recovered with no complications and was discharged on postoperative day 3.
Her symptoms recovered and she was found with normal metanephrines at follow-up.

Laparoscopic adrenalectomy is considered to be the standard of care for the surgical excision of the adrenal gland. Transperitoneal and retroperitoneal approaches are the two major laparoscopic routes to the adrenal gland. Although the transperitoneal approach is used more widely, the retroperitoneal approach offers distinct advantages which make it a valuable alternative route to the adrenal gland. This video describes a retroperitoneal laparoscopic adrenalectomy for colon cancer metastasis in a 65-year-old patient who underwent a left colectomy 3 years earlier.

In this video, we show the indications, technique and contraindications of direct port entry in laparoscopic surgery. Although this way of entry is not popular, recent data show that there are no differences in terms of safety for a way of entry (i.e., Veress needle, open laparoscopy, Hasson's technique, direct entry, etc.) when compared to another. We also discuss some hints and tips and tricks to use when performing this entry technique.

Median arcuate ligament syndrome is caused by the extrinsic compression of the celiac trunk by the median arcuate ligament, prominent fibrous bands, and peri-aortic nodal tissue. In many cases, it is asymptomatic, even though postprandial abdominal pain or, during exercise, nauseas, vomiting, and weight loss could be found. Doppler ultrasound and angiotomography are used for diagnosis while arteriography is the gold standard. Only symptomatic patients might require surgical treatment, and the laparoscopic approach has been proposed as a safe and effective technique. We present a case of laparoscopic approach for the treatment of arcuate ligament syndrome.

This video demonstrates a laparoscopic ileocecal resection using a medial approach in a patient with appendicular mucocele. The mesentery is divided using ligasure. The anastamosis is performed extracorporeally.

Patients presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. This video shows the case of a 48-year-old female patient operated upon previously for a collection at the rectouterine (Douglas') pouch following a suspected acute appendicitis. A laparoscopic exploration was performed along with a laparoscopic drainage of the collection, but the appendix had not been identified. Fifteen days later and the patient presents with a 15cm residual collection for which we performed a puncture under CT-scan guidance. Following a 3-month interval, the patient is admitted to our Department to perform an appendectomy.

This video shows the case of a 40-year-old woman complaining of pain in the right iliac fossa. Clinical history and complementary exams were suggestive of an appendicitis alleviated by an antibiotic treatment. However, they did not contribute to rule out the presence of a mucoid tumor of the appendix or of any gynecologic origin. The laparoscopic approach makes it possible to define the etiology of the lesion and to treat it. A centripetal strategy is used to safely perform the resection of this appendicular phlegmon.

This is the case of a 36-year-old woman who has had an exploratory laparoscopy in another institution 2 months earlier. Acute appendicitis was suspected, based on ultrasound exam. However, exploration has shown an inflammatory appendicular mass, impossible to dissect. The patient was administered antibiotics for a period of 3 weeks. A laparoscopic appendectomy was decided upon at an interval of 2 months. Work-up included CT-scan and colonoscopy, which did not demonstrate anything specific.
Laparoscopic exploration demonstrated important fibrotic and scarry tissues around the appendix and the cecum. Despite painstaking dissection, appendectomy was impossible. Ileocecal resection was decided upon. Operative steps, namely exposure, division of the last ileal loop, division of the meso, division of the right colon above the ampulla coli and the intracorporeal side-to-side stapled anastomosis are demonstrated. Pathological findings evidenced an endometriotic nodule. The postoperative course was uneventful.