monthly focus

surgical intervention video

Pancréatectomie caudale convertie en splénopancréatectomie gauche (SPG) par laparoscopie

This video demonstrates a laparoscopic distal pancreatectomy converted into a left splenopancreatectomy.

Laparoscopic Kimura distal pancreatectomy converted to distal splenopancreatectomy: difficulties of laparoscopy over the robotic approach

Authors report the laparoscopic resection of a solitary colorectal metastasis in contact with the middle hepatic vein (MHV) near the hepatocaval confluence to illustrate the importance of ultrasound evaluation during minimally invasive surgery to guide operative planning. 

Preoperative imaging with MRI and work-up with 3D reconstruction could not exclude any vascular invasion of the middle hepatic vein. There were no communicating veins identified on imaging. Surgical planning was elaborated with three alternatives. The first option was to perform an R1 vascular resection if there was tumoral contact with the vein without any invasion. Intraoperative ultrasound showed tumoral invasion of the middle hepatic vein. After clamping the middle hepatic vein at the hepatocaval confluence, no congestion in the central segments (Sg 4, 5, 8) was observed and the portal flow remained hepatopetal in these segments. In other words, adequate venous drainage was maintained by collaterals. Therefore, a local resection of the tumor ‘en bloc’ with a segment of the middle hepatic vein was performed with exposure of the dorsal side of the middle hepatic vein in a craniocaudal fashion at a safe distance from the tumor. Otherwise, a central hepatectomy would have been required. This case illustrates how a stepwise approach with detailed intraoperative ultrasonographic evaluation can refine preoperative imaging and tailor the surgical plan in a parenchyma-sparing strategy for colorectal metastases. The value of meticulous anatomical dissection in laparoscopic liver surgery becomes more evident in cases of vascular invasion when such a method is required in order to obtain a free resection margin. The procedure was not recorded during a live broadcast.

Disclosure statement: The authors declare that they have no competing interest.

Parenchyma-sparing laparoscopic liver resection of a colorectal metastasis in contact with the middle hepatic vein near the hepatocaval confluence

Hépatectomie laparoscopique avec épargne parenchymateuse pour métastase colorectale en contact avec la veine hépatique médiane

video lecture

Pancréatectomie gauche assistée par robot

In this key lecture, Dr. Melissa Ellen Hogg, MD addresses robotic left pancreatectomy.

 Robotic left pancreatectomy

This video demonstrates a totally robotic pancreaticoduodenectomy performed for a pancreatic head mass with a preoperative diagnosis of intraductal papillary mucinous neoplasm (IPMN) associated carcinoma. 

Robotic pancreaticoduodenectomy for pancreatic head cancer

Pancréaticoduodénectomie robotisée pour cancer de la tête du pancréas

Authors present the case of a laparoscopic distal pancreatectomy with portal vein resection and graft interposition for a neuroendocrine tumor of the tail of the pancreas and portal vein tumor thrombus.



A 57-year old male patient presenting with mild epigastric pain was admitted with a neoplasm of the tail of the pancreas detected by abdominal ultrasound. Pancreatic protocol CT-scan revealed a 5 

cm round-shaped tumor in the tail of the pancreas and splenic vein thrombosis extended to the portal vein with left-sided portal hypertension (LSPH). The CT features of the lesion were consistent with neuroendocrine tumor.



An ultrasound-guided percutaneous core needle biopsy was performed and confirmed the diagnosis of moderately differentiated neuroendocrine tumor.    



Taking into account signs of portal vein tumor thrombosis complicated with LSPH and the morphology of the lesion, a surgery-first approach was recommended. The patient was referred to a distal pancreatectomy with thrombectomy. Laparoscopic approach was used. During the procedure, once the thrombus was extracted, it was noted that the portal vein wall was not amenable for primary suture. This has led us to resect the portal vein and perform graft interposition. A PTFE graft was used. By the end of the procedure an intraoperative ultrasound confirmed sufficient portal blood flow was restored.    



The purpose of the video is to demonstrate the feasibility of laparoscopic approach in complicated pancreatic surgery.

Laparoscopic distal pancreatectomy with portal vein resection and PTFE graft interposition for neuroendocrine tumor of the tail of the pancreas and portal vein tumor thrombus

Pancréatectomie distale laparoscopique avec résection de la veine porte et interposition d'un greffon prothétique en PTFE pour tumeur neuroendocrine de la queue du pancréas et thrombose tumorale de la veine porte

In this key lecture, Dr. Melissa Hogg, MD provides a state of the art of robotic pancreatectomy.

State of the art in robotic pancreatic surgery

Etat de l'art de la pancréatectomie assistée par robot

Chirurgie hépatique avancée : l'histoire d'un parcours explorant les limites

In this authoritative lecture, Professor Guido Torzilli, MD, PhD, outlines advanced liver surgery developing the story of a path exploring the boundaries.

Professor Torzilli focuses on hepatobiliary surgery and intraoperative ultrasound. His research areas include the diagnosis and treatment of primitive and secondary tumors of the liver, intraoperative liver ultrasound, and liver regeneration.

He introduced new concepts into practice such as parenchymal-sparing liver surgery in the presence of vascular contact (R1vascular) and parenchymal-sparing liver surgery in the presence of vascular infiltration (communicating veins).

Professor Torzilli also established new surgical procedures, i.e., mini-mesohepatectomy, SERPS (Systematic Extended Right Posterior Sectionectomy), liver tunnel, and transversal resections such as rollercoaster resections and upper transversal hepatectomy. He pioneered ultrasound-guided surgical maneuvers, such as the hooking technique and compression anatomical segmentectomies, and the intraoperative use of contrast-enhanced ultrasonography. He also designed a new probe for intraoperative ultrasound.

He has worked in Humanitas Research Hospital (Rozzano, Italy) for more than 15 years. His team in Humanitas, although relatively young with an average of 40 years, is one of the leading teams internationally recognized in the field of liver surgery, with an expertise of more than 2,500 hepatectomies, of which more than 500 hundred were for advanced metastatic involvement of the liver.

His activity has reached the highest level of safety with an overall mortality of less than 1%, and with the highest oncological complexity of patients treated, with one of the largest series of single session removals of colorectal liver metastases, the highest number of lesions ever removed in a patient in a single operation, and one of the highest rate of advanced primary tumors successfully treated.

Professor Torzilli currently teaches at Humanitas University as Professor of surgery.

He specialized in General Surgery at Milan University in 1993, and in 1999 he obtained his PhD at the School of Medicine of Tokyo University in Japan.

His academic career started at the University of Tokyo where he acted as Assistant Professor of Surgery at the Department of Hepatobiliopancreatic Surgery, chaired at that time by his mentor, Professor Masatoshi Makuuchi. He also worked as Professor at Milan University.

He was appointed Fellow of the Japanese Foundation for Promotion of Cancer Research. He is also Board member of the European Surgical Association, IASGO, E-AHPBA, SSAT, SICO, and Fellow of the American College of Surgeons (ACS). He was appointed Honorary member of several international surgical societies, was visiting Professor in several International Institutions and Universities, and founded the Italian Association of Hepatobiliopancreatic Surgery, and the Italian Chapter of the SSAT.



Focus on HPB surgery

Parenchyma-sparing laparoscopic liver resection of a colorectal metastasis in contact with the middle hepatic vein near the hepatocaval confluence

Robotic pancreaticoduodenectomy for pancreatic head cancer

Laparoscopic distal pancreatectomy with portal vein resection and PTFE graft interposition for neuroendocrine tumor of the tail of the pancreas and portal vein tumor thrombus

Robotic left pancreatectomy

State of the art in robotic pancreatic surgery

Advanced liver surgery: the story of a path exploring the boundaries