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Single incision transumbilical laparoscopic left hepatic lobectomy
Background: Single-incision laparoscopy (SIL) recently gained interest mainly to improve the cosmetic outcomes. This video shows a patient submitted to left hepatic lobectomy by transumbilical SIL.

Video: A 24 year-old woman with a BMI of 24.4 kg/m2 consulted for a hydatid cyst of the II-III hepatic segments. Preoperative work-up showed a hepatic hydatid cyst of the segment III, partially involving the segment II. A transumbilical SIL was performed using an 11mm trocar for a 10mm, standard length, 30-degree scope, and a curved grasping forceps, and Ligasure V. At the end of the resection, a custom-made plastic bag was inserted in the abdomen through the 11mm trocar, and the specimen was morcellated at the umbilicus inside it without tearing.

Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 114 minutes and laparoscopic time 96 minutes. Final umbilical incision length was 20mm. The patient’s pain medication could be kept low and the patient was discharged on the 5th postoperative day. After 6 months, the patient was well with no visible scar.

Conclusion: Left hepatic lobectomy for benign lesions can safely be performed through transumbilical SIL. In the absence of malignancy, the final incision length can be kept minimal.
G Dapri, V Donckier, J Himpens, GB Cadière
Surgical intervention
7 years ago
2732 views
25 likes
0 comments
05:12
Single incision transumbilical laparoscopic left hepatic lobectomy
Background: Single-incision laparoscopy (SIL) recently gained interest mainly to improve the cosmetic outcomes. This video shows a patient submitted to left hepatic lobectomy by transumbilical SIL.

Video: A 24 year-old woman with a BMI of 24.4 kg/m2 consulted for a hydatid cyst of the II-III hepatic segments. Preoperative work-up showed a hepatic hydatid cyst of the segment III, partially involving the segment II. A transumbilical SIL was performed using an 11mm trocar for a 10mm, standard length, 30-degree scope, and a curved grasping forceps, and Ligasure V. At the end of the resection, a custom-made plastic bag was inserted in the abdomen through the 11mm trocar, and the specimen was morcellated at the umbilicus inside it without tearing.

Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 114 minutes and laparoscopic time 96 minutes. Final umbilical incision length was 20mm. The patient’s pain medication could be kept low and the patient was discharged on the 5th postoperative day. After 6 months, the patient was well with no visible scar.

Conclusion: Left hepatic lobectomy for benign lesions can safely be performed through transumbilical SIL. In the absence of malignancy, the final incision length can be kept minimal.
Minimal access surgery approach to benign biliary disease
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.
HJ Asbun
Lecture
8 months ago
1066 views
8 likes
2 comments
24:34
Minimal access surgery approach to benign biliary disease
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.
Laparoscopic resection of giant hepatic cystadenoma
This is the case of a 22-month-old female infant. The pathology started two weeks before with a gradual increase of abdominal circumference and intermittent hypo-colic stools. A CT-scan of the abdomen showed a large cystic tumor with interior partitions measuring 16.5 in width by 10.6 in length by 12.1cm in depth, originating in segments V and VI of the liver, displacing the remaining liver to the left and compressing the right kidney, bowel, celiac artery, gallbladder, and pancreas. A laparoscopic approach for tumor resection was decided on due to the scarce tumor vascularization and entirely cystic consistency. The procedure required 4 ports, three of 5mm and one of 3mm, emptying the cystic content of approximately 2 liters of citrine fluid. Dissection was performed using the Ligasure™ vessel-sealing device and monopolar cautery, preserving adjacent vital structures and preventing bleeding. The surgical specimen was removed through the umbilical scar. No transfusion was required and surgery lasted four hours. There were no postoperative complications. As a result, laparoscopic surgery is considered a safe procedure for the excision of large tumors in children provided they are cystic and benign, as emptying the cyst gives broader visualization of the area and permits better tissue handling.
A Parilli, W Garcia, I Galdon, G Contreras
Surgical intervention
7 years ago
1153 views
10 likes
0 comments
08:03
Laparoscopic resection of giant hepatic cystadenoma
This is the case of a 22-month-old female infant. The pathology started two weeks before with a gradual increase of abdominal circumference and intermittent hypo-colic stools. A CT-scan of the abdomen showed a large cystic tumor with interior partitions measuring 16.5 in width by 10.6 in length by 12.1cm in depth, originating in segments V and VI of the liver, displacing the remaining liver to the left and compressing the right kidney, bowel, celiac artery, gallbladder, and pancreas. A laparoscopic approach for tumor resection was decided on due to the scarce tumor vascularization and entirely cystic consistency. The procedure required 4 ports, three of 5mm and one of 3mm, emptying the cystic content of approximately 2 liters of citrine fluid. Dissection was performed using the Ligasure™ vessel-sealing device and monopolar cautery, preserving adjacent vital structures and preventing bleeding. The surgical specimen was removed through the umbilical scar. No transfusion was required and surgery lasted four hours. There were no postoperative complications. As a result, laparoscopic surgery is considered a safe procedure for the excision of large tumors in children provided they are cystic and benign, as emptying the cyst gives broader visualization of the area and permits better tissue handling.
Total laparoscopic right hepatectomy for large hepatoma using the Glissonian pedicle control with anterior approach
Background: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic right hepatectomy remains a challenging procedure, especially in patients with large tumor. This video illustrates a useful technique for total laparoscopic right hepatectomy which was successfully performed in patient with large hepatoma.

Methods: We demonstrate the case of a patient with a large tumor located in the right liver who underwent a total laparoscopic right hepatectomy. An anterior approach technique combined with Glissonian approach were used. The main steps of this technique are extraparenchymal control of right Glissonian pedicle en masse without liver dissection, parenchymal transection along the demarcation line, transection of right Glissonian pedicle, separation of whole right liver parenchyma, control and division of right hepatic vein and mobilization of the right liver from surrounding ligaments. No Pringle's maneuver was used.

Results: The technique was successfully performed without complication. Operative time was 560 min. Intraoperative blood loss was 1.100mL. The length of hospital stay was 6 days. The pathological report was well-differentiated HCC and free surgical margin.

Conclusion: Total laparoscopic right hepatectomy for large hepatoma by using the Glissonian pedicle control with anterior approach is feasible and safe.
R Chanwat, C Bunchaliew, T Khuhaprema
Surgical intervention
7 years ago
6275 views
40 likes
0 comments
09:19
Total laparoscopic right hepatectomy for large hepatoma using the Glissonian pedicle control with anterior approach
Background: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic right hepatectomy remains a challenging procedure, especially in patients with large tumor. This video illustrates a useful technique for total laparoscopic right hepatectomy which was successfully performed in patient with large hepatoma.

Methods: We demonstrate the case of a patient with a large tumor located in the right liver who underwent a total laparoscopic right hepatectomy. An anterior approach technique combined with Glissonian approach were used. The main steps of this technique are extraparenchymal control of right Glissonian pedicle en masse without liver dissection, parenchymal transection along the demarcation line, transection of right Glissonian pedicle, separation of whole right liver parenchyma, control and division of right hepatic vein and mobilization of the right liver from surrounding ligaments. No Pringle's maneuver was used.

Results: The technique was successfully performed without complication. Operative time was 560 min. Intraoperative blood loss was 1.100mL. The length of hospital stay was 6 days. The pathological report was well-differentiated HCC and free surgical margin.

Conclusion: Total laparoscopic right hepatectomy for large hepatoma by using the Glissonian pedicle control with anterior approach is feasible and safe.
Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
U Cillo, E Gringeri, R Boetto, G Zanus
Surgical intervention
7 years ago
3985 views
31 likes
0 comments
05:20
Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
Laparoscopic splenic flexure mobilization during low anterior resection (LAR), extra central connection between the superior and inferior mesenteric arterial systems
This is the case of two adult patients who presented with a low rectal carcinoma. A low anterior resection was performed laparoscopically. In both cases, the procedure was begun with a mobilization of the splenic flexure to ensure sufficient length on the proximal colonic segment to facilitate a tension-free low colorectal anastomosis. In the first case, a small aberrant artery, and during the second case, an aberrant artery of greater caliber can be appreciated. Anatomical studies report an extra central arterial connection between the superior and inferior mesenteric arterial systems in addition to the marginal artery of Drummond in 10 to 30% of cases. In such cases, there is an extra connection from the ascending branch of the left colic artery to the middle colic artery or the marginal artery of Drummond. Different names have been given to these connections, such as for example the meandering mesenteric artery, the artery of Moskovitch and Riolan’s arch.
A Wijsmuller, RJ Franken, JB Tuynman, J Bonjer
Surgical intervention
1 year ago
8470 views
43 likes
0 comments
19:46
Laparoscopic splenic flexure mobilization during low anterior resection (LAR), extra central connection between the superior and inferior mesenteric arterial systems
This is the case of two adult patients who presented with a low rectal carcinoma. A low anterior resection was performed laparoscopically. In both cases, the procedure was begun with a mobilization of the splenic flexure to ensure sufficient length on the proximal colonic segment to facilitate a tension-free low colorectal anastomosis. In the first case, a small aberrant artery, and during the second case, an aberrant artery of greater caliber can be appreciated. Anatomical studies report an extra central arterial connection between the superior and inferior mesenteric arterial systems in addition to the marginal artery of Drummond in 10 to 30% of cases. In such cases, there is an extra connection from the ascending branch of the left colic artery to the middle colic artery or the marginal artery of Drummond. Different names have been given to these connections, such as for example the meandering mesenteric artery, the artery of Moskovitch and Riolan’s arch.
Laparoscopic closed cystopericystectomy in liver hydatidosis
A 54-year-old woman presented to our Department with epigastric pain. Abdominal ultrasound and MRI showed a cystic lesion of 30 x 36 x 37mm located in segment III of the liver. The left portal trunk, which divides into branches, can be found close to the lesion. Serological test of hydatidosis was positive (1/2560). The surgical intervention was decided upon. In our opinion, radical surgery (total cystectomy or liver resection) should be the technique of choice in liver hydatidosis, since better results are obtained, especially in terms of morbidity, relapse and hospital stay. Totally laparoscopic closed cystopericystectomy, when feasible, could be done, but it is more technically demanding than conservative techniques.
JM Ramia, JE Quiñones, R de la Plaza, J García-Parreño
Surgical intervention
8 years ago
2794 views
88 likes
0 comments
10:03
Laparoscopic closed cystopericystectomy in liver hydatidosis
A 54-year-old woman presented to our Department with epigastric pain. Abdominal ultrasound and MRI showed a cystic lesion of 30 x 36 x 37mm located in segment III of the liver. The left portal trunk, which divides into branches, can be found close to the lesion. Serological test of hydatidosis was positive (1/2560). The surgical intervention was decided upon. In our opinion, radical surgery (total cystectomy or liver resection) should be the technique of choice in liver hydatidosis, since better results are obtained, especially in terms of morbidity, relapse and hospital stay. Totally laparoscopic closed cystopericystectomy, when feasible, could be done, but it is more technically demanding than conservative techniques.
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
B Dallemagne, S Perretta, R Araujo
Surgical intervention
1 year ago
5591 views
600 likes
0 comments
38:09
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
2 years ago
2033 views
178 likes
1 comment
07:49
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
A Wattiez, R Nasir, I Argay
Surgical intervention
2 years ago
5484 views
314 likes
2 comments
42:42
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
Laparoscopic right hepatectomy for colorectal liver metastases
Major anatomical liver resections, initially considered to be unsuitable for laparoscopy, are increasingly reported by several centers worldwide. It is widely accepted that standards of open liver surgery should not be compromised during laparoscopic interventions. The video describes a totally laparoscopic right hepatectomy in an adipose patient (BMI of 44) for metastases of a rectal carcinoma.
24 months after sphincter-preserving radical rectal resection with TME (ypT3, ypN 0 (0/20), M0), metastases of the right liver were diagnosed during routine follow-up. According to MRI, endoscopy and PET-scan, metastases were limited to the right liver.
The procedure includes the following steps: positioning of the adipose patient, intermittent pneumatic calf compression for prevention of deep vein thrombosis, trocar placement, explorative laparoscopy, intraoperative diagnostic ultrasound, cholecystectomy, mobilization of the right liver, preparation of the hepatoduodenal ligament without Pringle’s maneuver, dissection and ligation of the right hepatic artery, right portal branch, and right hepatic duct, parenchymal dissection with ultrasonic surgical aspirator, a bipolar vessel-sealing device, vascular stapler only for larger vessels, ligation of right hepatic vein, sealing of the resection surface with bipolar coagulation, Argon beamer and fibrin glue, extraction of the resected specimen.
During surgery, the central venous pressure was kept low, no blood transfusions were performed and the postoperative course was uneventful. The pathological findings confirmed metastases of an adenocarcinoma with a maximal diameter of 6cm and clear resection margins. The patient was discharged 8 days after resection.
Laparoscopic right hepatectomy was carried out without compromising surgical principles established for open surgery. It is demonstrated that laparoscopic equipment such as intraoperative ultrasound, ultrasonic surgical aspirator, bipolar and Argon beamer coagulation and fibrin glue sealing can be used to their fullest extent. However, proficiency in both open liver surgery and advanced laparoscopy is compulsory.
M Schön
Surgical intervention
9 years ago
8797 views
31 likes
0 comments
16:10
Laparoscopic right hepatectomy for colorectal liver metastases
Major anatomical liver resections, initially considered to be unsuitable for laparoscopy, are increasingly reported by several centers worldwide. It is widely accepted that standards of open liver surgery should not be compromised during laparoscopic interventions. The video describes a totally laparoscopic right hepatectomy in an adipose patient (BMI of 44) for metastases of a rectal carcinoma.
24 months after sphincter-preserving radical rectal resection with TME (ypT3, ypN 0 (0/20), M0), metastases of the right liver were diagnosed during routine follow-up. According to MRI, endoscopy and PET-scan, metastases were limited to the right liver.
The procedure includes the following steps: positioning of the adipose patient, intermittent pneumatic calf compression for prevention of deep vein thrombosis, trocar placement, explorative laparoscopy, intraoperative diagnostic ultrasound, cholecystectomy, mobilization of the right liver, preparation of the hepatoduodenal ligament without Pringle’s maneuver, dissection and ligation of the right hepatic artery, right portal branch, and right hepatic duct, parenchymal dissection with ultrasonic surgical aspirator, a bipolar vessel-sealing device, vascular stapler only for larger vessels, ligation of right hepatic vein, sealing of the resection surface with bipolar coagulation, Argon beamer and fibrin glue, extraction of the resected specimen.
During surgery, the central venous pressure was kept low, no blood transfusions were performed and the postoperative course was uneventful. The pathological findings confirmed metastases of an adenocarcinoma with a maximal diameter of 6cm and clear resection margins. The patient was discharged 8 days after resection.
Laparoscopic right hepatectomy was carried out without compromising surgical principles established for open surgery. It is demonstrated that laparoscopic equipment such as intraoperative ultrasound, ultrasonic surgical aspirator, bipolar and Argon beamer coagulation and fibrin glue sealing can be used to their fullest extent. However, proficiency in both open liver surgery and advanced laparoscopy is compulsory.
Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection
Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.
D Mutter, L Soler, J Marescaux
Surgical intervention
10 years ago
1694 views
45 likes
0 comments
05:42
Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection
Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.
Combining VATS and laparoscopic approach in the resection of ovarian carcinoma metastasis
This is the case of a 64-year-old woman with a history of hysterectomy and left adnexectomy. In 2012, a vaginal ultrasound revealed a right ovarian mass diagnosed as a right ovarian cancer. In December 2012, she underwent a right adnexectomy with pelvic, lumbo-aortic lymphadenectomy and omentectomy. Final pathological staging of the ovarian cystadenocarcinoma was pT3cpN1Mx (IIIC). She completed 6 cycles of adjuvant chemotherapy with carboplatin and paclitaxel. During the follow-up exam, the patient remained symptom-free and presented with a stable perihepatic lesion. In 2015, two new lesions were found on CT-scan: one in the anterior mediastinum (14mm) and another in the abdominal diaphragm in contact with a liver segment VIII (19mm). In addition, CA 125 raised from 19 to 50kU/L. PET-scan only evidenced these two new lesions (SUV= 10). Taking into account the patient’s excellent performance status, long disease-free survival, stability of lesions, with CT-scans performed with a 3-month interval, and the possibility of video-assisted surgery, it was decided to use VATS and laparoscopy to remove the lesions. Final pathological findings showed ovarian cystadenocarcinoma metastases in 2 lesions (R0). The third perihepatic lesion was a cyst. The patient was discharged on postoperative day 4.
F Cabral, JA Pereira, P Calvinho, P Amado, R Maio
Surgical intervention
3 years ago
2794 views
91 likes
0 comments
11:33
Combining VATS and laparoscopic approach in the resection of ovarian carcinoma metastasis
This is the case of a 64-year-old woman with a history of hysterectomy and left adnexectomy. In 2012, a vaginal ultrasound revealed a right ovarian mass diagnosed as a right ovarian cancer. In December 2012, she underwent a right adnexectomy with pelvic, lumbo-aortic lymphadenectomy and omentectomy. Final pathological staging of the ovarian cystadenocarcinoma was pT3cpN1Mx (IIIC). She completed 6 cycles of adjuvant chemotherapy with carboplatin and paclitaxel. During the follow-up exam, the patient remained symptom-free and presented with a stable perihepatic lesion. In 2015, two new lesions were found on CT-scan: one in the anterior mediastinum (14mm) and another in the abdominal diaphragm in contact with a liver segment VIII (19mm). In addition, CA 125 raised from 19 to 50kU/L. PET-scan only evidenced these two new lesions (SUV= 10). Taking into account the patient’s excellent performance status, long disease-free survival, stability of lesions, with CT-scans performed with a 3-month interval, and the possibility of video-assisted surgery, it was decided to use VATS and laparoscopy to remove the lesions. Final pathological findings showed ovarian cystadenocarcinoma metastases in 2 lesions (R0). The third perihepatic lesion was a cyst. The patient was discharged on postoperative day 4.
Laparoscopic splenectomy
In this video, Professor Martin Walz provides an overview of laparoscopic splenectomy. Since the first laparoscopic splenectomy in 1991, the procedure has become increasingly precise. The main indications for laparoscopic splenectomy are hypersplenism, splenomegaly, and associated diseases. Splenomegaly (> 20-25cm or > 1,000g) is the main contraindication. Immunization is essential for splenectomy. The patient is either placed in a left decubitus position with a 45-degree rotation or in a right decubitus position with a 90-degree rotation. The main steps of laparoscopic splenectomy are briefly demonstrated in this video. Laparoscopic splenectomy is the gold standard in small tumors with lower blood loss, low morbidity and mortality with a shorter hospital stay.
M Walz
Lecture
3 years ago
4781 views
232 likes
2 comments
19:41
Laparoscopic splenectomy
In this video, Professor Martin Walz provides an overview of laparoscopic splenectomy. Since the first laparoscopic splenectomy in 1991, the procedure has become increasingly precise. The main indications for laparoscopic splenectomy are hypersplenism, splenomegaly, and associated diseases. Splenomegaly (> 20-25cm or > 1,000g) is the main contraindication. Immunization is essential for splenectomy. The patient is either placed in a left decubitus position with a 45-degree rotation or in a right decubitus position with a 90-degree rotation. The main steps of laparoscopic splenectomy are briefly demonstrated in this video. Laparoscopic splenectomy is the gold standard in small tumors with lower blood loss, low morbidity and mortality with a shorter hospital stay.
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
A Prado de Resende
Surgical intervention
3 years ago
1670 views
66 likes
0 comments
26:34
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
P Pessaux, J Hallet, R Memeo, JB Delhorme, D Mutter, J Marescaux
Surgical intervention
4 years ago
1372 views
28 likes
0 comments
12:38
Robotic distal pancreatectomy with spleen preservation with splenic vascular resection (Warshaw's technique)
We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.
Laparoscopic management of extrauterine leiomyomas
Uterine leiomyomas affect 20 to 30% of women older than 35 years. Extrauterine leiomyomas are rarer, and they present a greater diagnostic challenge. These histologically benign leiomyomas occasionally occur with unusual growth patterns or in unusual locations which make their identification more challenging both clinically and radiologically. Unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. Diffuse peritoneal leiomyomatosis manifests as innumerable peritoneal nodules resembling those in peritoneal carcinomatosis. Parasitic leiomyoma and retroperitoneal leiomyomatosis usually manifest as single or multiple pelvic or retroperitoneal masses. Retroperitoneal growth is yet another unusual growth pattern of leiomyomas. Multiple leiomyomatous masses are usually seen in the pelvic retroperitoneum in women with a concurrent uterine leiomyoma or a history of uterine leiomyoma. Rarely, the extrauterine masses may extend to the upper retroperitoneum, as high as the level of the renal hilum. Occasionally, leiomyomas become adherent to surrounding structures (e.g., broad ligament, omentum, or retroperitoneal connective tissue), develop an auxiliary blood supply, and lose their original attachment to the uterus, hence becoming “parasitic.” We are presenting a case of extrauterine leiomyoma, which was operated for laparoscopic myomectomy for huge cervical leiomyoma 4 years back but was converted to an abdominal myomectomy.
D Limbachiya
Surgical intervention
3 years ago
2967 views
174 likes
0 comments
09:11
Laparoscopic management of extrauterine leiomyomas
Uterine leiomyomas affect 20 to 30% of women older than 35 years. Extrauterine leiomyomas are rarer, and they present a greater diagnostic challenge. These histologically benign leiomyomas occasionally occur with unusual growth patterns or in unusual locations which make their identification more challenging both clinically and radiologically. Unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. Diffuse peritoneal leiomyomatosis manifests as innumerable peritoneal nodules resembling those in peritoneal carcinomatosis. Parasitic leiomyoma and retroperitoneal leiomyomatosis usually manifest as single or multiple pelvic or retroperitoneal masses. Retroperitoneal growth is yet another unusual growth pattern of leiomyomas. Multiple leiomyomatous masses are usually seen in the pelvic retroperitoneum in women with a concurrent uterine leiomyoma or a history of uterine leiomyoma. Rarely, the extrauterine masses may extend to the upper retroperitoneum, as high as the level of the renal hilum. Occasionally, leiomyomas become adherent to surrounding structures (e.g., broad ligament, omentum, or retroperitoneal connective tissue), develop an auxiliary blood supply, and lose their original attachment to the uterus, hence becoming “parasitic.” We are presenting a case of extrauterine leiomyoma, which was operated for laparoscopic myomectomy for huge cervical leiomyoma 4 years back but was converted to an abdominal myomectomy.
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
A Wattiez, R Nasir, A Host
Surgical intervention
3 years ago
4099 views
162 likes
0 comments
31:22
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
Laparoscopic management of bladder endometriosis
Endometriosis is an enigmatic disorder, which affects women in their reproductive age. Failure of recent clinical trials on non-surgical management of endometriosis confirms the role of surgery as a viable treatment of choice. However, recurrence after surgery is common. Recurrence rate varies according to the surgeon’s skills, instrumentation, surgical techniques, and to the postoperative intervention outcome. In patients with severe endometriosis, lesions usually involve the posterior cul-de-sac, anterior rectum, one or both pelvic sidewalls, involving the ureters, the rectosigmoid, and less commonly the anterior bladder, the appendix, and the small bowel. Ureteral retroperitoneal dissection becomes mandatory in extensive endometriosis due to pelvic anatomical distortion. It also leaves the bowel intact without injuring it as the pseudo-peritoneum is lifted along with the inflamed bowel. Consequently, in the surgical practice of benign pathologies, a proper knowledge of the retroperitoneal anatomy ensures complete clearance in cases of advanced endometriosis and frozen pelvis. Here, we present a very interesting case of bladder endometriosis associated with hematuria during menstruation. Partial cystectomy is the treatment of choice for patients with bladder endometriosis in most cases. Provided surgeons are skilled and lesions require no ureteral reimplantation, operative laparoscopy is a valid alternative to laparotomy for partial cystectomy.
D Limbachiya
Surgical intervention
4 years ago
2232 views
65 likes
0 comments
06:56
Laparoscopic management of bladder endometriosis
Endometriosis is an enigmatic disorder, which affects women in their reproductive age. Failure of recent clinical trials on non-surgical management of endometriosis confirms the role of surgery as a viable treatment of choice. However, recurrence after surgery is common. Recurrence rate varies according to the surgeon’s skills, instrumentation, surgical techniques, and to the postoperative intervention outcome. In patients with severe endometriosis, lesions usually involve the posterior cul-de-sac, anterior rectum, one or both pelvic sidewalls, involving the ureters, the rectosigmoid, and less commonly the anterior bladder, the appendix, and the small bowel. Ureteral retroperitoneal dissection becomes mandatory in extensive endometriosis due to pelvic anatomical distortion. It also leaves the bowel intact without injuring it as the pseudo-peritoneum is lifted along with the inflamed bowel. Consequently, in the surgical practice of benign pathologies, a proper knowledge of the retroperitoneal anatomy ensures complete clearance in cases of advanced endometriosis and frozen pelvis. Here, we present a very interesting case of bladder endometriosis associated with hematuria during menstruation. Partial cystectomy is the treatment of choice for patients with bladder endometriosis in most cases. Provided surgeons are skilled and lesions require no ureteral reimplantation, operative laparoscopy is a valid alternative to laparotomy for partial cystectomy.
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.
S Gordts
Lecture
4 years ago
1087 views
33 likes
1 comment
30:53
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.