monthly focus

video lecture

Cholécystectomie laparoscopique - Règles élémentaires - Lésions des voies biliaires

Лапароскопическая холецистэктомия: основные правила, травма желчных протоков

There is twice as much risk of incidental biliary injuries in laparoscopic cholecystectomy than in open cholecystectomy. 

About half of surgeons will cause a bile duct injury during their careers. In this lecture, Dr. Dallemagne provides key national data of bile duct injury and explains that the lack of surgical experience or visual misperception leads to an increase in the rate of incidental injuries, mentioning his own cases. Dr. Dallemagne also outlines the fundamental techniques to prevent injuries and use bailout procedures (partial and subtotal cholecystectomy) in laparoscopic cholecystectomy, according to the latest version of the Tokyo guidelines.

Laparoscopic cholecystectomy - Basic rules - Bile duct injury

In this key lecture, Dr. Soubrane outlines the various types of bile duct injuries (BDI) and demonstrates how to manage them, classifying them into bile duct injuries during or after index surgery. When injuries are detected during index surgery, surgeons either have to add stitches combined with drainage in case of minor injuries or create an anastomosis in case of complete common bile duct (CBD) division. When injuries are detected after index surgery, surgeons may either solve them with endoscopic stenting in case of minor injuries or have to wait at least 2 months in case of complete CBD division. As an example of major liver resection for severe bile duct injuries, Dr. Soubrane also shows a case of right liver resection for severe bile duct injury with concomitant arterial interruption and massive portal vein thrombosis after laparoscopic cholecystectomy.

Bile duct injury (BDI): what to do?

Что делать при травме желчных протоков?

Lésions des voies biliaires : quelle prise en charge ?

In distal pancreatectomy or pancreas-preserving procedures, splenic vessel preservation is concern. In this key lecture, Dr. Conrad provides tips and tricks related to laparoscopic procedures for preserved splenic vessel in distal pancreatectomy, enucleation, and central pancreatectomy with major clinical cases.

Laparoscopic pancreatic enucleation and distal pancreatectomy

Énucléation pancréatique laparoscopique et pancréatectomie distale

Лапароскопическая энуклеация опухоли поджелудочной железы и дистальная панкреатэктомия

Laparoscopic liver surgery requires an appropriate vascular control with meticulous parenchymal transection techniques. Because of its limited surgical area, the relevant ergonomics and appropriate device selection are essential. In this lecture, Dr. Scatton explains his setting of laparoscopic liver resection in terms of patient position, port position, device selection, and transection methods. Finally, Dr. Scatton demonstrates the importance of suturing preparation in case of major bleeding, with representative cases.

Basic principles in laparoscopic hepatobiliary: position of trocars – position of patient

Базовые принципы лапароскопической гепатобилиарной хиррургии: расположение троакаров, положение пациента

Principes fondamentaux en chirurgie hépatobiliaire laparoscopique : trocarts et position du patient

Imagerie de fluorescence en chirurgie hépatobiliopancréatique

In this key lecture, Dr. Diana outlines the physiological principle of fluorescence imaging and the clinical application of indocyanine green (ICG), in hepatobiliary surgery, highlighting major publications. Dr. Diana emphasizes the current limitations and future perspectives of fluorescence image-guided surgery.

Fluorescence imaging in HBP surgery

Флуоресцентная визуализация в гепатобилиарной и панкреатической хирургии

Лапароскопическая субтотальная холецистэктомия при остром холецистите

In this authoritative lecture, Dr. Wakabayashi emphasizes the key operative steps, according to the latest version of the Tokyo guidelines, and recommendations regarding the appropriate imaginative lower limit of the surgical area, to prevent injuries to the anterior Glissonian trunk in laparoscopic cholecystectomy. Dr. Wakabayashi also recommends to intraoperatively consider this imaginative line, in order to know where to stop in the bailout surgery dome down technique for especially inflamed cholecystitis.

Laparoscopic subtotal cholecystectomy for severe cholecystitis

Cholécystectomie subtotale laparoscopique pour cholécystite grave

The laparoscopic biliary approach for benign diseases has been discussed for a quarter of a century. However, there were few articles in the literature about laparoscopic bilioenteric anastomoses, such as choledochoduodenostomy and hepatico/choledochojejunostomy which require advanced laparoscopic skills and experience. In this key lecture, Dr. Asbun demonstrates his own laparoscopic techniques for bilioenteric anastomoses. For choledochal cysts representative of benign biliary diseases, cyst excision is required. The difficulty lies in the fact that the cyst extends towards the intrapancreatic portion. Dr. Asbun demonstrates the techniques for complete exposure of the intrapancreatic bile duct portion in such cases. Finally, Dr. Asbun shows bile duct injury cases managed using a hepaticojejunostomy.

Minimal access surgery approach to benign biliary disease

Хирургия из мини-доступа по поводу доброкачественной болезни билиарной системы

Pathologies biliaires bénignes : approche mini-invasive

In this key lecture, Dr. Kaneko outlines the important role of fluorescence imaging in hepatopancreatobiliary surgery to confirm the resection area, to identify liver cancer, and to visualize the bile duct in liver cysts.

Comments on Fluorescence imaging in HBP surgery

Commentaires sur l’imagerie de fluorescence en chirurgie hépatobiliopancréatique

Комментарии по поводу флуоресцентной визуализации в гепатобилиарной и панкреатической хирургии

surgical intervention video

This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis. 

After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards. 

The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing. 

Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure. 

Laparoscopic Frey's procedure with management of intraoperative complication

Intervention de Frey par voie d’abord laparoscopique et prise en charge des complications peropératoires

Лапароскопическая операция Фрея с контролем интраоперационного осложнения

Лапароcкопическая дистальная панкреатэктомия по поводу внутрипротоковой папиллярно-муцинозной опухоли (ВПМО)

Pancréatectomie distale laparoscopique pour tumeur intracanalaire papillaire et mucineuse (TIPMP)

This is the case of a 76-year-old female patient who was referred to our hospital because of intraductal papillary mucinous neoplasm (IPMN). The patient has a medical history of renal insufficiency, sleep apnea syndrome, type 2 diabetes mellitus (T2DM), and hypertension. She has also a history of previous total hysterectomy. 

MRI findings showed that the patient’s IPMN affected secondary pancreatic ducts entirely. 

The main pancreatic duct is dilated, especially in the distal part at 6mm, but there are no remarkable findings of cystic wall thickening or intracystic nodules. A laparoscopic distal pancreatectomy was planned. 

The postoperative course was uneventful and the patient was discharged on postoperative day 8. 

Pathological findings showed that the intraductal papillary mucinous neoplasm was without any malignant component. 

Laparoscopic distal pancreatectomy for intraductal papillary mucinous neoplasm (IPMN)

We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma. 

Laparoscopic partial liver resection for hepatocellular adenoma

Лапароскопическая частичная резекция печени по поводу гепатоцеллюлярной аденомы

Hépatectomie partielle pour adénome hépatocellulaire

This video demonstrates a laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC) in a cirrhotic liver with hemochromatosis. This is the case of a 77-year-old patient who presented with a 40mm HCC located in Couinaud’s liver segment II and III. After left liver mobilization, parenchymal transection was initiated along the left side of the falciform ligament, mainly using the cavitron ultrasonic surgical aspirator (CUSA®). Tissue Select mode was used during the exposure of the vascular structure. The Glissonian pedicles of segments III and II were encircled and transected, and finally the suprahepatic vein was divided using an Endo GIA™ linear stapler. The specimen was extracted with a short suprapubic incision. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of a well-differentiated HCC.

Laparoscopic left lateral sectionectomy for hepatocarcinoma in a cirrhotic patient

Segmentectomie gauche latérale laparoscopique pour carcinome hépatocellulaire chez un patient cirrhotique

Лапароскопическая правосторонняя боковая секционэктомия по поводу гепатокарциномы у пациента с циррозом печени

In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter, at the pancreatic isthmus. Scintigraphy does not evidence any intense uptake. 

The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall. 

A postoperative pancreatic fistula grade B was reported. It was successfully managed. The presence of a well-differentiated neuroendocrine tumor was confirmed. The patient was discharged on postoperative day 22. 

Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor 

Роботическая центральная панкреатэктомия по поводу высокодифференцированной нейроэндокринной опухоли

Pancréatectomie centrale robotique pour tumeur neuro-endocrine bien différenciée

This is the case of a 69-year-old male patient presenting to the emergency department for abdominal pain and fever. After CT-scan and liver MRI, a biliary cystadenoma was suspected. CEA and CA 19-9 were normal. Hydatid cyst serology was negative. Considering the localization and the size of the tumor, a left laparoscopic hepatectomy was indicated. The patient’s surgical history included laparoscopic sigmoidectomy, intestinal occlusion for internal hernia, appendectomy, and bilateral inguinal hernia repair. Dissection of adhesions and cholecystectomy were performed first. After transection of the left hepatic artery and the left portal vein, parenchymal transection was performed by exposing the middle hepatic vein under intermittent clamping using blood flow occlusion. During parenchymal transection, the left hepatic duct and the left hepatic vein were divided. The specimen was extracted through a suprapubic incision. The postoperative outcome was uneventful. Pathological findings showed the presence of a biliary cyst communicating with the biliary system, without any malignant characteristics. 

Laparoscopic left hepatectomy for a suspected biliary cystadenoma 

Hépatectomie laparoscopique gauche pour suspicion de cystadénome biliaire

Лапароскопическая левосторонняя гепатэктомия

Робот-ассистированная холецистэктомия по поводу камней в желчном пузыре после острого панкреатита

This video demonstrates the case of a 28-year-old female patient who underwent a robotic cholecystectomy for symptomatic calculous gallbladder. The patient had no past medical or surgical history. In October 2018, the patient presented with an acute mild pancreatitis which had a favorable evolution under medical treatment. Blood tests showed cytolysis without cholestasis. Bili-MRI showed a calculous gallbladder with no signs of complication and no biliary tract dilatation. A cholecystectomy was then indicated. Preoperative work-up did not show anything abnormal.

Robot-assisted cholecystectomy for calculous gallbladder after acute pancreatitis

Cholécystectomie par voie robotique pour lithiase vésiculaire symptomatique après pancréatite aiguë

The objective of this video is to present a surgical approach to a left adrenal mass caused by the invasion of a pancreatic lesion. A pulmonary lesion was also found. However, a preoperative biopsy of that lesion was impossible to perform. In order to distinguish the primary origin of this lung lesion, a laparoscopic ‘en bloc’ splenopancreatectomy combined with a left adrenalectomy and a para-aortic lymphadenectomy were planned. 

Retrograde distal pancreatectomy with splenectomy is the standard procedure for cancers of the body and tail of the pancreas. In the literature, fewer studies describe the feasibility and the oncological safety of the laparoscopic approach. 

This video aims to show the different operative steps of the procedure beginning with laparoscopic adrenalectomy followed by distal pancreatectomy and para-aortic lympadenectomy.

Laparoscopic en bloc splenopancreatectomy with left adrenalectomy and para-aortic lymphadenectomy

Лапароскопическая спленопанкреатэктомия en bloc с левосторонней адреналэктомией и парааортальной лимфаденэктомией

Splénopancréatectomie laparoscopique en bloc, surrénalectomie gauche et lymphadénectomie para-aortique

A 32-year-old asymptomatic female patient presented an incidental finding of a liver mass during pregnancy. The mass grew during pregnancy, and a biopsy confirmed the diagnosis of hepatocellular adenoma. On MRI, a hypodense 7 by 6.1cm mass with adipose infiltration was identified. Previously, it was a 5.8 by 5.1cm mass, located in liver segments IV, V, and VIII inferiorly. 

The cystic duct and its artery were ligated. However, the gallbladder was kept in place for traction. After dissection of the anterior pedicle, a linear stapler was applied. The right lobe was mobilized and the right transection line was made according to the ischemia line of the anterior sector. 

During the liver transection of segment IVB, the pedicle was identified, and linear stapling helped to control it. The parenchymal transection was performed with an ultrasonic scalpel and bipolar cautery. The liver surface of the anterior sector was demarcated and transected. Both the left and the right plane of transection were inferiorly joined. The middle and right hepatic vein branches were stapled. 

The specimen was mobilized. Argon beam and bipolar forceps provided the hemostasis. The specimen was removed via a Pfannenstiel’s incision and a drain was placed. The duration of the procedure was 345 minutes. The estimated blood loss was 1200mL. 

The patient was discharged from the intensive care unit on postoperative day 1 and from hospital on postoperative day 4. No complication was noted in 90 days. Pathological findings showed a mass of 10.7 by 8.4 by 4.8cm. The lesion represented a hepatocellular adenoma with negative margins.

Laparoscopic central hepatectomy using a Glissonian approach for hepatocellular adenoma

Hépatectomie centrale laparoscopique pour adénome hépatocellulaire : approche glissonienne

Лапароскопическая центральная гепатэктомия по поводу гепатоцеллюлярной аденомы

This is the case of a 73-year-old asymptomatic female patient who presented with an incidental pancreatic lesion on CT-scan. Her previous medical history was relevant for systemic lupus erythematosus. On the CT-scan, a single hypervascular lesion in the arterial phase was identified in the distal pancreas. The lesion size was 3.1 by 3.3 by 4.3cm. Neither suspicious nodes nor distant metastases were found. The patient was considered to be ASA2 and ECOG0. 

The patient was placed in a reverse Trendelenburg position. A 12mm port was placed in the umbilicus for the camera, and three 8mm ports were inserted to accommodate the robotic arms, and another 12mm auxiliary port was used. 

The greater curvature of the stomach was released from the transverse colon to expose the supramesocolic area. The neck of the pancreas was dissected close to the splenic-mesenteric confluence. The inferior mesenteric vein opening to the splenic vein was identified, clipped and cut. The splenic artery was dissected, clipped and cut close to the celiac trunk. A stapler was placed in the neck of the pancreas and it was safely stapled. The splenic vein was dissected close to the confluence, and then clipped and cut. The distal pancreas and splenic ligaments were cut and . detached. The specimen was removed using a Pfannenstiel’s incision. 

The duration of the procedure was 255 minutes. The estimated blood loss was 100mL. The patient was discharged on postoperative day 5 and no complication was observed over a period of 90 days. Pathology confirmed the presence of a neuroendocrine tumor (grade 2) as a 4cm single lesion and negative margins. One positive node was detected among 10 nodes harvested.

Focus on minimally invasive and robotic hepatobiliary and pancreatic surgery