monthly focus

surgical intervention video

Impaction of a mechanical lithotripsy basket during endoscopic retrograde cholangiopancreatography (ERCP) is a rare, but serious complication resulting from technical failure. The authors present a video of lithotripsy basket retrieval assisted by means of laser fragmentation. It is the case of an 87-year-old man who underwent an emergency laparoscopic subtotal cholecystectomy, common bile duct (CBD) exploration, and laser lithotripsy. After attempts at endoscopic mechanical lithotripsy, a stone-basket complex became impacted within the CBD. In the absence of endoscopic salvage techniques, a laparoscopic common bile duct exploration (LCBDE) is a valid and safe option where surgical expertise permits.

Bibliography:

1\. Thomas M, Howell DA, Carr-Locke D, Mel Wilcox C, Chak A, Raijman I, et al. Mechanical lithotripsy of pancreatic and biliary stones: complications and available treatment options collected from expert centers. Am J Gastroenterol. 2007 Sep;102(9):1896-902. doi: 10.1111/j.1572-0241.2007.01350.x. Epub 2007 Jun 15. PMID: 17573790

2\. Garg PK, Tandon RK, Ahuja V, Makharia GK, Batra Y. Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones. Gastrointest Endosc. 2004 May;59(6):601-5. doi: 10.1016/s0016-5107(04)00295-0. PMID: 15114300

3\. Yilmaz S, Ersen O, Ozkececi T, Turel KS, Kokulu S, Kacar E, et al. Results of the open surgery after endoscopic basket impaction during ERCP procedure. World J Gastrointest Surg. 2015 Feb 27;7(2):15-20. doi: 10.4240/wjgs.v7.i2.15. PMID: 25722797; PMCID: PMC4325280

Laparoscopic common bile duct exploration (CBDE) and retrieval of endoscopic lithotripsy basket

Exploration laparoscopique de la voie biliaire principale et récupération d'un panier de lithotripsie endoscopique

The laparoscopic Whipple procedure for the treatment of a pancreatic head tumor appears to be a valid, safe, and feasible alternative. There has been increased awareness of structured training and patient selection for laparoscopic management. This case of a patient with a standard BMI and a tumor which allows for the adequate visualization of anatomical structures is valuable to recognize the resective steps, and to select a minimally invasive reconstructive option. As familiarity with the robotic platform increases, studies have shown an expansion of indications. 



Bibliography:

1. Comparison of safety and effectiveness between laparoscopic and open pancreatoduodenectomy: A systematic review and meta-analysis. Yin T, Qin T, Wei K, Shen M, Zhang Z, Wen J, Pan S, Guo X, Zhu F, Wang M, Zhang H, Hilal MA, Qin R. Int J Surg. 2022 Sep;105:106799. doi: 10.1016/j.ijsu.2022.106799. Epub 2022 Aug 19

2. Minimally invasive pancreatoduodenectomy. Kendrick ML, van Hilst J, Boggi U, de Rooij T, Walsh RM, Zeh HJ, Hughes SJ, Nakamura Y, Vollmer CM, Kooby DA, Asbun HJ; Minimally Invasive Pancreatic Resection Organizing Committee. HPB (Oxford). 2017 Mar;19(3):215-224. doi: 10.1016/j.hpb.2017.01.023

3. Laparoscopic pancreatoduodenectomy with open or laparoscopic reconstruction during the learning curve: a multicenter propensity score matched study. van Hilst J, de Rooij T, van den Boezem PB, Bosscha K, Busch OR, van Duijvendijk P, Festen S, Gerhards MF, de Hingh IH, Karsten TM, Kazemier G, Lips DJ, Luyer MD, Nieuwenhuijs VB, Patijn GA, Stommel MW, Zonderhuis BM, Daams F, Besselink MG; Dutch Pancreatic Cancer Group. HPB (Oxford). 2019 Jul;21(7):857-864. doi: 10.1016/j.hpb.2018.11.003. Epub 2018 Dec 5

Laparoscopic Whipple procedure for the management of a pancreatic head tumor

Intervention de Whipple par voie d'abord laparoscopique pour prise en charge d'une tumeur de la tête du pancréas

Introduction: Liver cancer is globally the fifth most common cancer and the fourth most common cause of cancer-related death. Currently, surgical resection is still considered a curative option and is reserved for the early stages of hepatocellular carcinoma (HCC). Laparoscopy shows comparable results to open liver resection regarding long-term oncologic outcomes such as overall survival and disease-free survival, while delivering superior results in terms of morbidity and perioperative outcomes. Using indocyanine green (ICG) fluorescence makes it possible to accurately determine the boundaries of anatomical resections, improving the navigation and precision of surgical techniques.

Methods:

The authors demonstrate a laparoscopic left paramedian sectorectomy (S3-S4 bisegmentectomy) with lymphadenectomy using negative ICG staining in a 73-year-old male patient, with hepatitis C and Child-Pugh class A (score of 6 points) liver cirrhosis.

Results:

The operation lasted 180 minutes and total blood loss was 80mL. The postoperative period was uneventful, and the patient was discharged on postoperative day 6. The histological examination revealed the presence of a G2 HCC at the pT1aN0M0 stage, with tumor-free surgical margins.

Conclusion:

The combination of a minimally invasive approach with ICG negative staining for “small” anatomical liver resection, in a patient with chronic cirrhosis and early-stage HCC has shown good perioperative results and oncologic outcomes.

 

Bibliography:

1\. Manon Allaire, Claire Goumard, Chetana Lim, Aline Le Cleach, Mathilde Wagner, Olivier Scatton. New frontiers in liver resection for hepatocellular carcinoma. JHEP Rep. 2020 Jun 4;2(4):100134. doi: 10.1016/j.jhepr.2020.100134. eCollection 2020 Aug. PMID: 32695968 PMCID: PMC7360891 DOI: 10.1016/j.jhepr.2020.100134

2\. Stefano Di Sandro, Maria Danieli, Fabio Ferla, Andrea Lauterio, Riccardo De Carlis, Laura Benuzzi, Vincenzo Buscemi, Isabella Pezzoli, Luciano De Carlis. The current role of laparoscopic resection for HCC: a systematic review of past ten years. Transl Gastroenterol Hepatol. 2018 Sep 18:3:68. doi: 10.21037/tgh.2018.08.05. eCollection 2018. PMID: 30363804 PMCID: PMC6182043 DOI: 10.21037/tgh.2018.08.05

3\. Junichi Kaneko, Takashi Kokudo, Yoshinori Inagaki, Kiyoshi Hasegawa. Innovative treatment for hepatocellular carcinoma (HCC). Transl Gastroenterol Hepatol. 2018 Oct 22;3:78. doi: 10.21037/tgh.2018.10.04. PMID: 30505965; PMCID: PMC6232072

Laparoscopic liver segment III and IV (S3-S4) bisegmentectomy with lymphadenectomy and indocyanine green (ICG) for hepatocellular carcinoma (HCC) 

Bisegmentectomie laparoscopique des segments III et IV du foie (S3-S4) avec lymphadénectomie et vert d'indocyanine pour carcinome hépatocellulaire (CHC) 

Chronic calcific pancreatitis (CCP) is a debilitating condition, which often causes intractable pain unresponsive to conservative treatment. Conventional surgical interventions have limitations in achieving optimal outcomes, as they often lead to prolonged recovery and increased morbidity. Laparoscopic lateral pancreaticojejunostomy (LPJ) offers a minimally invasive surgical approach in such patients. The use of robotic technology enhances the precision and efficacy of pancreaticojejunostomy, offering patients a minimally invasive alternative with improved postoperative outcomes. This video showcases the key steps of the procedure, including patient set-up, robotic port placement, meticulous dissection of the pancreatic head, and creation of a side-to-side pancreaticojejunostomy. 

This video shows the case of a 27-year-old woman presenting with persistent abdominal pain, uncontrolled diabetes mellitus, and steatorrhea. Investigations revealed random plasma glucose at 390mg/dL and HbA1C at 8.6. Contrast-enhanced CT-scan of the abdomen showed an atrophic pancreas, a dilated main pancreatic duct (MPD) with a diameter of approximately 9mm filled with multiple calculi. The patient underwent a robotic assisted laparoscopic lateral pancreaticojejunostomy. The procedure was uneventful, and the patient was discharged on postoperative day 5. 

Bibliography: 

1. George Michel Eid, Fateh Entabi, Andrew R. Watson, Brian S. Zuckerbraun, Mark A. Wilson, Robotic-assisted laparoscopic side-to-side lateral pancreaticojejunostomy, Journal of Gastrointestinal Surgery, Volume 15, Issue 7, 2011, Page 1243, ISSN 1091-255X, https://doi.org/10.1007/s11605-011-1495-9.

2. Balduzzi A, Zwart MJW, Kempeneers RMA, Boermeester MA, Busch OR, Besselink MG. Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis. J Vis Exp. 2019 Dec 14;(154). doi: 10.3791/60301. PMID: 31885388.

3. Nayak K, Shinde RK, Gattani RG, Thakor T. Surgical Perspectives of Open vs. Laparoscopic Approaches to Lateral Pancreaticojejunostomy: A Comprehensive Review. Cureus. 2024 Jan 6;16(1):e51769. doi: 10.7759/cureus.51769. PMID: 38322062; PMCID: PMC10844796.

4. Palanivelu C, Shetty R, Jani K, Rajan PS, Sendhilkumar K, Parthasarthi R, Malladi V. Laparoscopic lateral pancreaticojejunostomy: a new remedy for an old ailment. Surg Endosc. 2006 Mar;20(3):458-61. doi: 10.1007/s00464-005-0680-x. Epub 2006 Jan 19. PMID: 16424983.

Robotic assisted laparoscopic lateral pancreaticojejunostomy (LPJ) for chronic calcific pancreatitis (CCP)

Pancréaticojéjunostomie latérale assistée par robot pour pancréatite calcifiante chronique 

Cholécystectomie laparoscopique pour cholécystite chronique avec mucocèle en cas de situs inversus avec dextrocardie

The authors present the case of a 74-year-old male patient with situs inversus totalis (SIT), undergoing laparoscopic cholecystectomy for persistent severe symptomatic gallstone disease. Situs inversus totalis is a rare congenital condition, with incidence estimates ranging from 1 in 5,000 to 1 in 20,000, and effectively results in a mirror image transposition of thoracic and abdominal organs. This gentleman had initially presented with left upper quadrant pain and fever, with CT imaging confirming both situs inversus and inflammation of the gallbladder. His only other past medical history of note was Kartagener’s syndrome, which is often associated with SIT. The procedure was performed with port placement mirroring that of a typical laparoscopic cholecystectomy set-up, with the surgeon, assistant, and scrub nurse standing to the patient’s right, screen on the patient’s left, and port placement again mirroring that of the usual set-up. The procedure was slightly complicated by the acute on chronic presentation of cholecystitis. However, it was successfully performed with careful consideration of mirrored anatomical landmarks and accounting for this in a right-handed surgeon. The case underscores the importance of preoperative planning and the technical modifications required in laparoscopic surgery for patients with situs inversus totalis.

 

Bibliography:

1\. Eitler K, Bibok A, Telkes G. Situs Inversus Totalis: A Clinical Review. Int J Gen Med. 2022 Mar 3;15:2437-2449. doi: 10.2147/IJGM.S295444. PMID: 35264880; PMCID: PMC8901252.

2\. Shah AY, Patel BC, Panchal BA. Laparoscopic cholecystectomy in-patient with situs inversus. *J Minim Access Surg.* (2006) 2:27–28. 10.4103/0972-9941.25674

3\. AlKhlaiwy O, AlMuhsin AM, Zakarneh E, Taha MY. Laparoscopic cholecystectomy in situs inversus totalis: Case report with review of techniques. Int J Surg Case Rep. 2019;59:208-212. doi: 10.1016/j.ijscr.2019.05.050. Epub 2019 May 31. PMID: 31181389; PMCID: PMC6556755.

Laparoscopic cholecystectomy for chronic cholecystitis with mucocele in situs inversus totalis

Pancréaticoduodénectomie laparoscopique avec préservation du pylore chez un patient présentant une anomalie du tronc hépatomésentérique pour adénocarcinome ampullaire

In 0.4 to 4.5% of individuals, the common hepatic artery arises from the superior mesenteric artery instead of the celiac trunk. It is a type IX anomaly, commonly referred to as hepatomesenteric trunk, according to the Michels’s comprehensive classification of hepatic arterial anatomy. The surgical strategy should take into account the variations in the vascular pattern of the celiac trunk and its branches. This hepatomesenteric trunk originates from the anterior aspect of the aorta, coursing inferiorly and to the right behind the portal vein to reach the superior border of the superior part of the duodenum, where it divides into the common hepatic artery and into the superior mesenteric artery. In the lesser omentum, after a small course, the common hepatic artery gives off the gastroduodenal artery that continues as the proper hepatic artery. This video aims to highlight a dissection in a patient with a hepatomesenteric trunk anomaly undergoing a laparoscopic pylorus-preserving pancreaticoduodenectomy for an ampullary adenocarcinoma. 

This is the case of 73-year-old man who was evaluated for jaundice. Pancreatic protocol CT-scan showed a periampullary lesion with a dilated biliary tract. Side-viewing endoscopy and endoscopic ultrasound biopsy confirmed the diagnosis, revealing an ampullary adenocarcinoma. On imaging, it was found to be resectable. The tumor board team decided to go for an upfront surgery. Preoperative biliary plastic stenting was performed for cholangitis. A laparoscopic pylorus-preserving pancreaticoduodenectomy with a feeding jejunostomy was performed. The procedure was uneventful, and the patient was discharged on postoperative day 6. Pathological findings revealed please complete 



Bibliography:

1. Kahraman G, Marur T, Tanyeli E, Yildirim M. Hepatomesenteric trunk. Surg Radiol Anat. 2001;23(6):433-5. doi: 10.1007/s00276-001-0433-z. PMID: 11963627.

2. Ramanadham S, Toomay SM, Yopp AC, Balch GC, Sharma R, Schwarz RE, Mansour JC. Rare hepatic arterial anatomic variants in patients requiring pancreatoduodenectomy and review of the literature. Case Rep Surg. 2012;2012:953195. doi: 10.1155/2012/953195. Epub 2012 Jul 30. PMID: 22900221; PMCID: PMC3413978.

3. Noussios G, Dimitriou I, Chatzis I, Katsourakis A. The Main Anatomic Variations of the Hepatic Artery and Their Importance in Surgical Practice: Review of the Literature. J Clin Med Res. 2017 Apr;9(4):248-252. doi: 10.14740/jocmr2902w. Epub 2017 Feb 21. PMID: 28270883; PMCID: PMC5330766.

Laparoscopic pylorus-preserving pancreaticoduodenectomy in a patient with hepatomesenteric trunk anomaly for ampullary adenocarcinoma

The most common etiology of pancreatic pseudocyst is acute pancreatitis and exacerbations of chronic pancreatitis, presenting a spontaneous resolution in approximately 50% of cases. Treatment is indicated in persistent symptomatic or complicated pseudocysts. Endoscopic and surgical approaches can be performed (1).

Two treatment options are available: endoscopic treatment, in cysts adjacent to the gastric or duodenal wall, or surgical treatment, which is more invasive, but with a low rate of recurrence and complications, even surpassing endoscopic management.

The video shows the case of a previously healthy 54-year-old male patient with a surgical history of cholecystectomy 14 years earlier. In 2022, he presented two episodes of pancreatitis treated in another institution, which required an endoscopic retrograde cholangiopancreatography (ERCP) to manage the choledocholithiasis in the last episode. The patient complained of abdominal pain. In a follow-up exam and MRI, a 7cm pancreatic pseudocyst was found. Significant oral intolerance was developed by the patient and a new CT-scan was performed. An increase in the cyst’s volume was observed.

The multidisciplinary committee decided to perform an endoscopic ultrasound-guided cystogastrostomy with stent placement. The procedure was complicated with upper gastrointestinal bleeding, which accounts for stent removal. Multiple subsequent endoscopies were performed due to a persistent collection with pigtail placement and necrosectomies.

The patient had an initial good response. However, two months later, he presented with severe abdominal pain associated with vomiting. A control CT-scan showed a cystic recurrence with total disruption of Wirsung’s duct. Due to the failure of the endoscopic treatment, a videolaparoscopic cystogastrostomy was subsequently performed. The patient was discharged on postoperative day 5, and postoperative outcomes were uneventful.

 

<u>Bibliography:</u>

1\. Clark CJ, Ray JW, Pawa S, et al. A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era. Surg Open Sci. 2024 Jan 15;18:1-5. doi: 10.1016/j.sopen.2024.01.008. PMID: 38312303; PMCID: PMC10831243.

2\. José Luis Martínez-Ordaz, Carlos Toledo-Toral, Norma Franco-Guerrero, Mauro Tun-Abraham, Luis Manuel Souza-Gallardo. Tratamiento quirúrgico del seudoquiste de páncreas \[Surgical treatment of pancreatic pseudocysts]. Cir Cir. 2016 Jul-Aug;84(4):288-92. doi: 10.1016/j.circir.2015.09.001. Epub 2015 Dec 19. PMID: 26707249.

3\. B A Crisanto-Campos, E Arce-Liévano, L E Cárdenas-Lailson, L S Romero-Loera, M E Rojano-Rodríguez, M A Gallardo-Ramírez, J Cabral-Oliver, M Moreno-Portillo. Laparoscopic management of pancreatic pseudocysts: experience at a general hospital in Mexico City. Rev Gastroenterol Mex. 2015 Jul-Sep;80(3):198-204. doi: 10.1016/j.rgmx.2015.05.003. Epub 2015 Aug 3. PMID: 26249139

Laparoscopic cystogastrostomy for pancreatic pseudocyst

Cystogastrostomie laparoscopique pour pseudokyste pancréatique

Video-assisted retroperitoneal debridement (VARD) is a minimally invasive surgical procedure for the management of severe pancreatitis, especially in cases of necrotizing pancreatitis characterized by significant tissue necrosis and infection (1). This technique entails the access to the retroperitoneal space via small incisions in the lumbar region through percutaneous drain guidance and using video-assisted methodologies for the removal of necrotic tissue and for the drainage of fluid collections. VARD presents several potential advantages as compared to conventional open surgical methods, including reduced invasiveness and recovery times. In addition, when associated with the anterior transabdominal approach, it prevents abdominal cavity contamination, hence reducing the risk of open abdomen and enterocutaneous fistulas (2). However, managing patients is challenging. In this video, the authors present the case of a 65-year-old male patient with severe acute pancreatitis complicated by an infected necrosis. A step-up approach was performed using VARD for control after percutaneous drainage failure.&#x20;

Bibliography:

1\. Wei W, Tang Y, Peng Z, Xie J, Deng Z, Yuan T, Tang C, Pi R, Wang S, Zhao S, Wang L, Li C, Wang Y, Zhang P, Wu Z, Wan Y, Ma Y, Tang W, Liang X, Liu K, Wang W, Liang X, Zeng D, Li S, Liu H. Minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (VARTD) in the management of infected walled-off pancreatic necrosis with deep extension: initial experience from a prospective single-arm study. Eur J Med Res. 2023 Feb 9;28(1):72. doi: 10.1186/s40001-023-01030-9. PMID: 36755332; PMCID: PMC9909852.

2\. Horvath K, Freeny P, Escallon J, Heagerty P, Comstock B, Glickerman DJ, Bulger E, Sinanan M, Langdale L, Kolokythas O, Andrews RT. Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch Surg. 2010 Sep;145(9):817-25. doi: 10.1001/archsurg.2010.178. PMID: 20855750.

Video-assisted retroperitoneal debridement (VARD) for severe pancreatitis

Débridement rétropéritonéal vidéo-assisté pour pancréatite sévère

Colorectal cancer is the third most common neoplasm worldwide (1). The liver is its main site of metastasis, and 20 to 30% of patients will develop colorectal liver metastasis (2).

The treatment for colorectal cancer with liver metastasis has evolved into a multidisciplinary approach, such as chemotherapy, local ablation, portal vein embolization. However, survival increases dramatically with surgery, and it is therefore considered the gold standard (1, 2).

Radiofrequency ablation or microwave ablation (3) could well be an alternative to deep lesions or lesions which are difficult to access.

Associated liver tourniquet and portal vein ligation for staged hepatectomy (ALTPS) is indicated in cases of unresectable tumors or extensive bilobar disease, as it provides excellent results (4).

The video shows the case of a 38-year-old female patient who was diagnosed with colorectal liver metastases. The primary cancer was resected, and subsequent control chemotherapy and reduction of liver lesions were performed.

Initially, it was decided to perform multiple hepatectomies with parenchyma preservation. Due to the intraoperative discovery of more lesions than expected, it was decided to perform a laparoscopic ALTPS.

 

Bibliography:

1\. Kristel Mils, Laura Lladó, Josefina López-Domínguez, Oriana Barrios, David Leiva, Cristina Santos, Teresa Serrano, Emilio Ramos. Have we improved postoperative and long-term outcomes of liver surgery for colorectal cancer metastasis? Analysis of 1736 hepatectomies performed over 3 decades in a single center. Cir Esp (Engl Ed). 2024 Feb 10:S2173-5077(24)00044-9. doi: 10.1016/j.cireng.2023.11.025. PMID: 38346559.

2\. Pratik Chandra, Greg D Sacks. Contemporary surgical management of colorectal liver metastases. Cancers (Basel). 2024 Feb 26;16(5):941. doi: 10.3390/cancers16050941. PMID: 38473303; PMCID: PMC10930601. PMID: 38473303 PMCID: PMC10930601.

3\. Okan Akhan, Ahmet Gürkan Erdemir, Sevilay Karahan, Emre Ünal, Türkmen Turan Çiftçi, Devrim Akıncı, Şuayib Yalçın. Long-term results of liver thermal ablation in patients with hepatocellular carcinoma and colorectal cancer liver metastasis regarding spatial features and tumor-specific variables. Diagn Interv Radiol 2024 May 13;30(3):183-192. doi: 10.4274/dir.2023.221986. Epub 2023 Mar 20. PMID: 36994643; PMCID: PMC11095064.

4\. Mohammad Golriz, Ali Ramouz, Ahmed Hammad , Ehsan Aminizadeh, Nastaran Sabetkish, Elias Khajeh, Omid Ghamarnejad, Carlos Carvalho, Hugo Rio-Tinto, De-Hua Chang, Ana Alagoa Joao, Gil Goncalves, Arianeb Mehrabi. Promising results of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma in a systematic review and single-arm meta-analysis. Cancers (Basel). 2024 Feb 13;16(4):771. doi: 10.3390/cancers16040771. PMID: 38398162. PMCID: PMC10887221.

Laparoscopic associating liver tourniquet and portal vein ligation for staged hepatectomy (ALTPS) technique for colorectal liver metastases

Technique laparoscopique associant garrot hépatique et ligature de la veine porte pour une hépatectomie par étapes pour métastases hépatiques colorectales

The authors present the case of a 75-year-old man who underwent an elective surgery for chronic cholecystitis. He had a history of high blood pressure under medical treatment. During surgery, a PAECOF systematic dissection technique was performed, leading to a subtotal fenestrating cholecystectomy for a Parkland 5 acute cholecystitis. Using this approach, the authors want to show that even in such cases, laparoscopy is decisive, feasible, and safe with a low complication rate and no bile duct injury. 

Bibliography:

1. Dissanaike, Sharmila MD, FACS*. A Step-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder. Journal of the American College of Surgeons 223(2):p e15-e18, August 2016. | DOI: 10.1016/j.jamcollsurg.2016.05.006.

2. Strasberg, S. M., Pucci, M. J., Brunt, L. M., & Deziel, D. J. Subtotal Cholecystectomy-"Fenestrating" vs "Reconstituting" Subtypes and the Prevention of Bile Duct Injury: Definition of the Optimal Procedure in Difficult Operative Conditions. J Am Coll Surg 2016. 222(1), 89-96. https://doi.org/10.1016/j.jamcollsurg.2015.09.019

3. Zaragoza, Noe MD. Parkland 4 acute cholecystitis PAECIF/PAECOF https://websurg.com/doi/vd01en6684

4. Navez, B. Prevention of bile duct injury (BDI) during cholecystectomy. Acta Chir Belg 2003 Apr;103(2):151-3. doi: 10.1080/00015458.2003.11679399. PMID: 12768856 DOI: 10.1080/00015458.2003.11679399

Parkland 5 acute cholecystitis: bailout strategy 

Cholécystite aiguë, Parkland 5 : stratégie de sauvetage

Splénopancréatectomie distale laparoscopique pour néoplasme kystique mucineux : technique dans le sens horaire modifiée 

The authors present the case of a 33-year-old female patient. The patient has a previous medical history of hypothyroidism, insulin resistance, and acute pancreatitis. She presented with upper abdominal pain and did not report any other associated symptoms. A CT-scan, MRI, and EUS were performed, establishing the diagnosis of mucinous cystic neoplasm, for which the surgical team decided to perform a distal pancreatectomy using the clockwise modified technique. The patient presented a grade B pancreatic fistula and was discharged on postoperative day 3. The objective of the authors was to demonstrate the advantage of the laparoscopic approach in pancreatic laparoscopic surgery. 

Surgical distal pancreatic resection has the best chance to cure a disease of the pancreatic body and tail, including malignancy, precancerous lesions, and inflammatory involvement (1, 2). Laparoscopic distal pancreatic resection requires excellent surgical skills, training experience with proctors, and case-load concentration in high-volume hospitals with the best resources (1). 

In cases of a premalignant and symptomatic benign condition, the spleen must be preserved either using Kimura’s splenic vessel preservation technique or Warshaw’s splenic vessel resection technique (2). 

Laparoscopic distal pancreatectomy is a safe and feasible treatment for left pancreatic malignancies, with the same surgical efficacy as open distal pancreatectomy. Laparoscopic distal pancreatectomy has also the advantages of minimally invasive surgery, such as minimal trauma and enhanced recovery after surgery (3). 

A laparoscopic distal pancreatectomy performed using the clockwise technique provides satisfactory outcomes (4). However, in this approach, a modified clockwise technique was used. 



Take-home messages:

Patients with a pancreatic cyst tumor can be treated using a laparoscopic modified clockwise technique even with a previous medical history of acute pancreatitis. This surgery can be performed as it offers safe, optimal results, as well as excellent postoperative outcomes. 



Bibliography:

1. Bencini L, Minuzzo A. Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy. World J Gastrointest Surg. 2023;15(6):1020-1032. doi:10.4240/wjgs.v15.i6.1020

2. Coco D, Leanza S, Schillaci R, Reina GA. Laparoscopic distal pancreatectomy for benign and malignant disease: a review of techniques and results. Prz Gastroenterol. 2022;17(2):103-109. doi:10.5114/pg.2021.109625

3. Hao T, Shiming J, Yong C. Analysis of safety and efficacy of laparoscopic distal pancreatectomy in the treatment of left pancreatic malignant tumors. J Int Med Res. 2021;49(12). doi:10.1177/03000605211063098

4. Gamo GDO, Reichardt GS, Guetter CR, et al. Esofagogástrica e esplenectomia influencia a variação. 2022;34(2):1-5.



Laparoscopic distal splenopancreatectomy for mucinous cystic neoplasm: modified clockwise technique

This video presents the management of a pancreatic tumor with a left splenopancreatectomy. The aim of this video is to present the ‘clockwise’ technique in a laparoscopic distal pancreatectomy setting. 



Bibliography:

Asbun, H. J., Van Hilst, J., Tsamalaidze, L., Kawaguchi, Y., Sanford, D., Pereira, L., Besselink, M. G., & Stauffer, J. A. (2020). Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement. Surgical Endoscopy, 34(1), 231‑239. https://doi.org/10.1007/s00464-019-06757-3



Laparoscopic left splenopancreatectomy for a cystic tumor

Splénopancréatectomie gauche laparoscopique pour le traitement d'une tumeur kystique

Cholangioscopie laparoscopique transcystique des voies biliaires : simulation

Recent studies highlight the effectiveness of laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) in managing cholecystocholedocholithiasis (1). Standard treatments involve preoperative endoscopic procedures. However, advances in laparoscopy have reintroduced one-stage approaches, particularly LCBDE alongside LC (2). Transcystic (TC) and transductal (TD) routes influence outcomes whereas the literature showed that the TC extraction is deemed safer, with comparable stone clearance rates (3). 

Laparoscopic transcystic CBD techniques (LTCBDE) have been developed to treat CBD stones in one session, minimizing complications with an applicability reaching over 85% of cases, and success rates of 85 to 95%, proving their cost-effectiveness as compared to postoperative endoscopic procedures (3, 4). Ongoing technological advances, including robot-assisted surgery and advanced imaging methods, such as laparoscopic CT cholangioscopy, enhance this approach to CBD treatment, becoming the primary strategy for most patients.

Bibliography:

1. Durán M, Silvestre J, Hernández J, Briceño J, Martínez-Isla A, Martínez-Cecilia D. Learning curve for performing laparoscopic common bile duct exploration in biliary surgery 2.0 era. J Hepatobiliary Pancreat Sci. 2023;30(3):374-382. doi:10.1002/jhbp.1228. Link: https://pubmed.ncbi.nlm.nih.gov/35947065/

2. Zhou Y, Wu XD, Zha WZ, et al. Three modalities on common bile duct exploration. Drei Modalitäten für das Management der Choledocholithiasis. Z Gastroenterol. 2017;55(9):856-860. doi:10.1055/s-0043-112655. Link: https://pubmed.ncbi.nlm.nih.gov/28763814/

3. Reinders JS, Gouma DJ, Ubbink DT, van Ramshorst B, Boerma D. Transcystic or transductal stone extraction during single-stage treatment of choledochocystolithiasis: a systematic review. World J Surg. 2014;38(9):2403-2411. doi:10.1007/s00268-014-2537-8. Link: https://pubmed.ncbi.nlm.nih.gov/24705779/

Transcystic laparoscopic bile duct cholangioscopy: simulation

video lecture

Ablation de tumeurs hépatiques

In this authoritative lecture, Professor Mariano Giménez outlines the management of liver tumors considering their ablation.

Focus on hepatobiliary and pancreatic (HBP) surgery