monthly focus

surgical intervention video

In this educational video, the authors demonstrate a hepaticojejunostomy for an extrahepatic cholangiocarcinoma type 1 according to the Bismuth-Corlette classification. One of the limitations of robotic surgery is the difficulty in adjusting the operative field once the focus is fixed and the robotic arms are placed on the target anatomy. The technique performed here solves this problem. 

This video shows the case of a 59-year-old male patient with no relevant medical history. The patient presents with a clinical history of asthenia, weight loss, and analytic parameters of dissociated cholestasis (total bilirubin 1.5 mg/dL, direct bilirubin 1 mg/dL, GGT 1993 UI/l, FA 378 UI/l, GOT 274 UI/l, GPT 509 UI/l, CA 19-9 91 UI/l). MRCP and CT-scan show a tumor in the common bile duct of 1cm in size below the hepatic confluence that involves the cystic duct. No signs of distant disease were noted, neither in the abdomen or thorax.



Take-home messages:

It is critical to set all organs in the same working field before docking, in order to decrease the number of movements of the robotic arms. 

The specimen should be removed ‘en bloc’. The gallbladder may be useful to mobilize the common bile duct. 

Intraoperative pathology assessment is needed. A duodenopancreatectomy or hepatic resection should be prepared in case it is indicated. 



Bibliography:

1. Radtke A, Königsrainer A. Surgical Therapy of Cholangiocarcinoma. Visc Med. 2016 Dec;32(6):422-426. doi: 10.1159/000452921. Epub 2016 Nov 30. PMID: 28229077; PMCID: PMC5290435.

2. Guadagni S, Comandatore A, Furbetta N, Di Franco G, Carpenito C, Bechini B, Vagelli F, Ramacciotti N, Palmeri M, Di Candio G, Morelli L. Robotic Hepatectomy plus Biliary Reconstruction for Bismuth Type III and Type IV Hilar Cholangiocarcinoma: State of the Art and Literature Review. J Pers Med. 2023 Dec 21;14(1):12. doi: 10.3390/jpm14010012. PMID: 38276227; PMCID: PMC10817587.

3. Banales JM, Marin JJG, Lamarca A, Rodrigues PM, Khan SA, Roberts LR, Cardinale V, Carpino G, Andersen JB, Braconi C, Calvisi DF, Perugorria MJ, Fabris L, Boulter L, Macias RIR, Gaudio E, Alvaro D, Gradilone SA, Strazzabosco M, Marzioni M, Coulouarn C, Fouassier L, Raggi C, Invernizzi P, Mertens JC, Moncsek A, Rizvi S, Heimbach J, Koerkamp BG, Bruix J, Forner A, Bridgewater J, Valle JW, Gores GJ. Cholangiocarcinoma 2020: the next horizon in mechanisms and management. Nat Rev Gastroenterol Hepatol. 2020 Sep;17(9):557-588. doi: 10.1038/s41575-020-0310-z. Epub 2020 Jun 30. PMID: 32606456; PMCID: PMC7447603.

Common bile duct cholangiocarcinoma managed with hepaticojejunostomy: robotic assisted approach

Cholangiocarcinome de la voie biliaire traité par hépaticojéjunostomie : intervention assistée par robot

Résection laparoscopique d'un schwannome rétropéritonéal

Schwannomas are tumors, usually benign, that arise from peripheral neural sheaths. They are mostly present in the head and trunk extremities. Less frequently, they appear in the abdominal cavity, typically in the paravertebral and presacral spaces. Retroperitoneal schwannomas are rare and account for 3% of all schwannomas and 4% of retroperitoneal tumors. Because of their slow growth, they are commonly asymptomatic and found as an incidental diagnosis in imaging studies. Surgery is the gold standard of treatment, which also provides an excisional biopsy for definite diagnosis. 

The authors present the case of a 67-year-old female patient with persistent abdominal discomfort, postprandial bloating, and pyrosis over the course of 3 months. Blood analysis showed no relevant alterations. The CT-scan revealed a peripancreatic mass, near the pancreatic tail and adjacent to the superior pole of the left kidney. An MRI was performed for better clarification, showing a nodular lesion of 17mm with a well-defined wall. A scintigraphy excluded the hypothesis of a supernumerary spleen. Endoscopic ultrasonography showed a hypoechogenic mass with homogeneous content measuring 10 by 13mm. Aspiration was not performed due to the risk of hemorrhage. The patient was admitted for a laparoscopic surgical exploration using intraoperative ultrasonography. A 2cm mass was resected without complications. The patient was discharged after 2 days. The histopathology showed a benign tumor of the nerve sheath compatible with a schwannoma. The patient was kept under surveillance through follow-up visits. Intra-abdominal schwannomas are rare and difficult to diagnose. Differential diagnosis of a retroperitoneal mass includes benign and malignant neoplasms arising from the pancreas, spleen, kidney or the adrenal gland. The preoperative diagnosis is challenging since there are no specific radiological indicators and because of the iatrogenic risk related to aspiration and biopsy procedures. As a result, surgery is considered the gold standard treatment to ensure an adequate diagnosis.



Bibliography:

1. Theodosopoulos T, Stafyla VK, Tsiantoula P, et al. “Special problems encountering surgical management of large retroperitoneal schwannomas”. World J Surg Oncol. 2008; 6:107.

2. Dede M, Yaqci G, Yenen MC, et al. “Retroperitoneal benign schwannoma: report of three cases and analysis of clinic radiologic findings”. Tohoku J Exp Med 2003;200:93-7.

3. E. P. Scali et al. “Primary retroperitoneal masses”. Abdominal Imaging (2014); 40(6), 1887-1903.

4. Lee NJ, Hruban HR, Fishman EK, “Abdominal schwannomas: review of imaging findings and pathology”. Abdom Radiology (2017) 42:1864–1870.



Laparoscopic resection of a retroperitoneal schwannoma

Technique eTEP Rives pour hernie d'éventration après cure de hernie ombilicale par chirurgie ouverte

The incidence of incisional hernia ranges from 2 to 20% and varies greatly from one series to another. The surgical treatment of incisional hernia markedly improves patient quality of life (QoL). In recent years, we have observed a further evolution of operational techniques used in order to reduce the number of complications, and this evolution is currently going in two directions: first, the reduction of tissue tension in the suture line and secondly, the minimally invasive techniques, which allow placement of large synthetic meshes without the need for extensive tissue dissection using open repair. 

The enhanced-view totally extraperitoneal (eTEP) technique is a novel approach for the repair of ventral hernia introduced by Igor Belyansky et al. This minimally invasive technique consists in placing the mesh in a large retrorectus and preperitoneal space, like Rives-Stoppa repair, without entering the abdominal cavity. According to several meta-analyses, this space is ideal to place the mesh because of the lower rates of complications. The eTEP technique can also be readily combined with transversus abdominis release for large hernias.



Bibliography:

1. Holihan JL, Nguyen DH, Nguyen MT, Mo J, Kao LS, Liang MK. Mesh Location in Open Ventral Hernia Repair: A Systematic Review and Network Meta-analysis. World J Surg. 2016 Jan;40(1):89-99.

2. Radu VG, Lica M. The endoscopic retromuscular repair of ventral hernia: the eTEP technique and early results. Hernia. 2019 Oct;23(5):945-955. 

3. Daes J. Enhanced-view totally extraperitoneal access for repair of ventral hernias: Advantages and liabilities. Cir Esp (Engl Ed). 2023 May;101 Suppl 1:S33-S39.



eTEP Rives for incisional hernia after open umbilical hernia repair

Ventral defects, both primary and incisional, are very common. Usually, simple closure or prosthetic correction via an anterior approach is associated with wound complications and high recurrence rates, up to 30%, especially in overweight or obese patients. The transabdominal preperitoneal (TAPP) approach is one of the new techniques for ventral hernia correction, which involves entering the abdominal cavity and dissecting the preperitoneal space. This technique is indicated in primary or incisional hernia repair (up to 5cm), allowing for the placement of a larger mesh compared to open surgery. It also helps to prevent wound complications or insufficient repair associated with this technique. Additionally, placing the mesh in the preperitoneal space requires less fixation, which leads to less postoperative pain. It allows the procedure to be performed in an outpatient setting, avoiding contact with the abdominal viscera, which helps to prevent intra-abdominal adhesions compared to an intraperitoneal onlay mesh (IPOM) with or without defect closure (IPOM+). It would be especially recommended in patients with risk factors such as overweight or obesity and coexisting rectus abdominis diastasis (RAD). The laparoscopic TAPP ventral hernia repair is a safe and reproducible technique, with a low rate of complications and recurrences. It is also a valuable and new alternative to conventional methods.



Take-home messages

The ventral TAPP technique is reproducible and safe. It is crucial to properly select patients, and this technique is particularly recommended in overweight patients with substantial adipose tissue in the preperitoneal space and in patients with parietal defects up to 5cm. One must always be prepared to convert to a conventional technique or to an IPOM/IPOM + if there is any technical difficulty such as a massive tear of the peritoneum or an impossibility to achieve a good preperitoneal space.



Bibliography:

1. Ruíz J, Barrios A, Lora A, Vega V, Florez G, Mendivelso F. Extraperitoneal laparoscopic ventral hernia repair: one step beyond. Hernia. 2019 Oct;23(5):909-914

2. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli G, Fortelny R, Köckerling F, Kukleta J, LeBlanc K, Lomanto D, Misra M, Morales-Conde S, Ramshaw B, Reinpold W, Rim S, Rohr M, Schrittwieser R, Simon T, Smietanski M, Stechemesser B, Timoney M, Chowbey P. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society [IEHS])-Part III. Surg Endosc. 2014 Feb;28(2):380-404

3. Megas IF, Benzing C, Winter A, Raakow J, Chopra S, Pratschke J, Fikatas P. A propensity-score matched analysis of ventral-TAPP vs. laparoscopic IPOM for small and mid-sized ventral hernias. Comparison of perioperative data, surgical outcome and cost-effectiveness. Hernia. 2022 Dec;26(6):1521-1530

4. Skolimowska-Rzewuska M, Romańczuk M, Mitura B, Wyrzykowska D, Mitura K. Laparoscopic transabdominal preperitoneal repair (umbilical TAPP) versus open ventral patch repair for medium size umbilical hernias in overweight and obese patients. Wideochir Inne Tech Maloinwazyjne. 2022 Mar;17(1):170-178

Laparoscopic TAPP ventral hernia repair for umbilical hernia

Cure laparoscopique ventrale par approche TAPP pour hernie ombilicale

The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with conventional techniques when the intention is single stage clearance. Robotic assisted surgery (RAS) can assist in allowing the pancreatic surgeon to undertake minimally invasive necrosectomy in select patients suitable for this approach. Advantages of robotic assisted surgery (RAS) include use of articulated instruments, improved views (3D enhancement), and minimising physical stress to the surgeon. 

We describe a case of robotic infracolic necrosectomy with Roux-en-Y cystojejunostomy and concomitant cholecystectomy as single stage management of complex gallstone pancreatitis, performed with the da Vinci X™ surgical robotic system. 

This is the case of a 28-year-old female patient who originally presented 6 weeks postpartum, with a BMI of 41 with abdominal pain and biochemistry showing elevated levels of serum amylase (3,500U/L) indicative of acute pancreatitis. Aetiology was secondary to gallstones. CT-scan imaging showed necrotising pancreatitis. She made a gradual recovery with close follow-up in the outpatient setting. Due to her remaining asymptomatic condition, the patient herself opted for non-operative intervention to look after her newborn child. Follow-up CT-scan at a 10-month interval demonstrated a 60 by 65mm walled-off necrosis (WON) with concomitant disconnected pancreatic duct syndrome (DPDS). Decision was made to intervene due to ongoing abdominal pain and early satiety. 

Following the surgical intervention, the patient remained well. Operative time was 327 minutes. Intraoperative fluid amylase was 3,435U/L confirming underlying DPDS. Drain fluid amylase on postoperative (POD) day 3 was 35U/L, hence drains were removed and the patient was discharged on POD 4. Face-to-face follow-up 4 months postoperatively confirmed the patient’s good recovery. 

Infracolic necrosectomy with Roux-en-Y cystojejunostomy is an effective and safe operation option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by conventional techniques. It provides single stage intervention for complicated SAP and allows concomitant cholecystectomy to be undertaken when the underlying aetiology is gallstones. The robotic platform can facilitate the execution of this intervention and theoretical benefits of RAS include improved views, especially at the site of necrosectomy and improved ergonomics for suturing of the Roux-en-Y cystojejunostomy. 



Take-home messages



Infracolic necrosectomy with Roux-en-Y cystojejunostomy is an effective procedure in managing walled off pancreatic necrosis (WON) with disrupted pancreatic duct syndrome (DPDS) for symptomatic, non-septic patients when they are not amenable to drainage or debridement using conventional techniques.

This technique provides a single stage intervention for WON and allows for a concomitant cholecystectomy, in select cases when the aetiology is gallstones.

The robotic platform can facilitate the surgical procedure execution making the most of the theoretical benefits of RAS, which include improved visualisation of the WON cavity and superior ergonomics for suturing of the Roux-en-Y cystojejunostomy.



Bibliography



1.	Latif J, Creedon L, Mistry P, Thurley P, Bhatti I, Awan A. Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach. Journal of Gastrointestinal Surgery. 2022 Aug;26(8):1686-96. Link: https://pubmed.ncbi.nlm.nih.gov/35581460/ 

2.	Wang Y, Yoshino O, Driedger MR, Beckman MJ, Vrochides D, Martinie JB. Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis. HPB. 2023 Mar 30. Link: https://pubmed.ncbi.nlm.nih.gov/37045742/ 

3.	Maatman TK, Roch AM, Lewellen KA, Heimberger MA, Ceppa EP, House MG, Nakeeb A, Schmidt CM, Zyromski NJ. Disconnected pancreatic duct syndrome: spectrum of operative management. journal of surgical research. 2020 Mar 1;247:297-303. Link: https://pubmed.ncbi.nlm.nih.gov/31685250/ 

4.	Cuschieri SA, Jakimowicz JJ, Stultiens G. Laparoscopic infracolic approach for complications of acute pancreatitis. InSeminars in laparoscopic surgery 1998 Sep (Vol. 5, No. 3, pp. 189-194). Sage CA: Thousand Oaks, CA: Sage Publications. Link: https://pubmed.ncbi.nlm.nih.gov/9787206/ 



Robotic infracolic necrosectomy with Roux-en-Y cystojejunostomy and concomitant cholecystectomy for single stage management of complex gallstone pancreatitis

The simple suturing of the hernia defect and the open mesh repair both lead to a high incidence of infections and recurrences, hence the evolution of the operating techniques used in order to reduce the number of complications. Minimally invasive techniques allowed the introduction of large synthetic meshes without the need for extensive tissue dissection using an open repair. 

The eTEP access concept can be defined as a set of operative maneuvers and strategies used to enhance the useable extraperitoneal space for the minimally invasive repair of inguinal, ventral, and lumbar hernias. These maneuvers include the remote access and the creation of a large extraperitoneal space complemented by the division of its natural boundaries. The eTEP concept offers the advantage of working in an extraperitoneal space. It has demonstrated its efficiency and safety. 



Bibliography:

1. Mishra, A., Jabbal, H. S., Nar, A. S., & Mangla, R. (2023). Analysis of ‘enhanced-view totally extra-peritoneal’ (Etep) approach for ventral hernia : Early results. Journal of Minimal Access Surgery, 19(3), 361‑370. https://doi.org/10.4103/jmas.jmas_129_22

2. Kudsi, O. Y., & Gokcal, F. (2021). Lateral approach totally extraperitoneal (Tep) robotic retromuscular ventral hernia repair. Hernia: The Journal of Hernias and Abdominal Wall Surgery, 25(1), 211‑222. https://doi.org/10.1007/s10029-019-02082-9

3. Salido Fernandez, S., Fraile Vilarrasa, M., Osorio Silla, I., Georgiev Hristov, T., Bernar de Oriol, J., González-Ayora, S., Pardo García, R., & Guadalajara Labajo, H. (2020). Extended totally extraperitoneal (Etep) approach for ventral hernia repair : Initial results. Cirugia Espanola, 98(5), 260‑266. https://doi.org/10.1016/j.ciresp.2020.01.006 

4. Khetan, M., Kalhan, S., John, S., Sethi, D., Kannaujiya, P., & Ramana, B. (2022). MIS retromuscular repair of lateral incisional hernia : Technological deliberations and short-term outcome. Hernia: The Journal of Hernias and Abdominal Wall Surgery, 26(5), 1325‑1336. https://doi.org/10.1007/s10029-022-02671-1 



Extended totally extraperitoneal repair transversus abdominis muscle release (eTEP TAR) for ventral hernias

Approche totalement extrapéritonéale étendue et libération du muscle transverse de l'abdomen (eTEP TAR) pour hernies ventrales

This is the case of a 24-year-old female patient with a history of a cesarean section, 2 years prior to the procedure. In December 2021, she presented with dull epigastric abdominal pain, with irradiation to the left upper quadrant. A couple of days afterwards, she presented with jaundice, nausea, and vomiting. 

The patient underwent an abdominal ultrasound, which revealed a bile duct dilatation up to 4cm. As a result, a biliary cyst was suspected. Contrast-enhanced abdominal computed tomography (CT) showed the presence of a 4cm biliary cyst. An abdominal MRI scan was therefore performed and showed evidence of a type 1C Todani choledochal cyst.

In this context of a type 1C choledochal cyst with a history of biliary pancreatitis, a laparoscopic hepaticojejunostomy was proposed.

A laparoscopic resection of the choledochal cyst and a hepaticojejunostomy (HJ) were performed. The patient was discharged on postoperative day 5.

Pathological findings showed a simple choledochal cyst with no dysplasia or cancer. There were no complications on postoperative year 2.

The aim of this video is to show the feasibility of both the laparoscopic resection of a choledochal cyst and bilioenteric anastomosis.



Take-home messages:

Choledochal cysts are a rare congenital anomaly affecting the biliary tree. A choledochal cyst is a dilation of the bile duct which can affect extrahepatic or intrahepatic segments of the biliary tree. Diagnosis and management are essential. They can be evaluated via either MRI and/or CT-scan. Defining the extension of the bile duct involvement is critical to define the adequate management, either endoscopic, surgical or transplantation. The elective treatment for type 1A choledochal cyst is the resection of the cyst with a Roux-en Y hepaticojejunostomy. It can be performed laparoscopically with minimal morbidity in centers with experience in hepatobiliary and laparoscopic surgery. 



Bibliography: 

1. Yuan, H., Dong, G., Zhang, N., Sun, X., & Zhao, H. (2021). Minimally invasive strategy for type I choledochal cyst in adult: combination of laparoscopy and choledochoscopy. Surgical endoscopy, 35(3), 1093–1100. https://doi.org/10.1007/s00464-020-07473-z https://pubmed.ncbi.nlm.nih.gov/32095950/

2. Senthilnathan, P., Patel, N. D., Nair, A. S., Nalankilli, V. P., Vijay, A., & Palanivelu, C. (2015). Laparoscopic Management of Choledochal Cyst-Technical Modifications and Outcome Analysis. World journal of surgery, 39(10), 2550–2556. https://doi.org/10.1007/s00268-015-3111-8 

https://pubmed.ncbi.nlm.nih.gov/26067634/

3. Ojha, S., Bharadia, L., Sharma, R., Bansal, R. K., & Chaturvedi, A. (2024). Laparoscopic choledochal cyst excision and biliary reconstruction in patients with previous surgery/ intervention: Feasibility and outcome. Journal of minimal access surgery, 10.4103/jmas.jmas_269_22. Advance online publication. https://doi.org/10.4103/jmas.jmas_269_22 

https://pubmed.ncbi.nlm.nih.gov/38214346/

4. Liem, N. T., Agrawal, V., & Aison, D. S. (2021). Laparoscopic management of choledochal cyst in children: Lessons learnt from low-middle income countries. Journal of minimal access surgery, 17(3), 279–286. https://doi.org/10.4103/jmas.JMAS_114_20 

https://pubmed.ncbi.nlm.nih.gov/32964871/

Focus on general surgery