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Laparoscopic distal splenopancreatectomy for pancreatic cystadenoma: clockwise technique assisted with T’Lift device
Serous cystic neoplasm is a cystic neoplasm of the pancreas, which is increasingly detected at an asymptomatic stage. Serous cystadenomas are benign cystic tumors which occur more often in women than in men, and particularly in the seventh decade of life. Despite this, in the literature, three patients were reported to have malignant serous cystadenomas, with sizes greater than 7cm. The serous cystic neoplasm was confirmed by an imaging characteristic appearance, with multiple small or different-sized cysts, but when the diagnosis is doubtful, which often leads to surgery.
The clinical case is the one of a 79-year-old woman with a cystadenoma of the pancreas. She had a history of partial cystectomy for bladder neoplasia and recently (in 2017), she was submitted to laparoscopic focal cryotherapy for the treatment of a left unilateral renal tumor. At that time, she underwent a CT-can, which found a cystic neoplasm of the tail of the pancreas. A heterogeneous 5cm lesion appeared in the left hypochondrium, near the lower pole of the spleen, with no evidence of adenopathies highly suggestive of a serous cystadenoma of the pancreas.
In October 2018, in a follow-up CT-scan, there was an increase in size of the lesion (6.6cm) and a surgical resection was planned. A distal splenopancreatectomy using a clockwise technique was performed using the Signia™ stapling system with no complications. Histological examination confirmed a serous cystadenoma of the pancreas.
M Rui Martins, J Correia, D Jordão, S Martins, H Ferrão
Surgical intervention
6 months ago
1140 views
5 likes
0 comments
20:59
Laparoscopic distal splenopancreatectomy for pancreatic cystadenoma: clockwise technique assisted with T’Lift device
Serous cystic neoplasm is a cystic neoplasm of the pancreas, which is increasingly detected at an asymptomatic stage. Serous cystadenomas are benign cystic tumors which occur more often in women than in men, and particularly in the seventh decade of life. Despite this, in the literature, three patients were reported to have malignant serous cystadenomas, with sizes greater than 7cm. The serous cystic neoplasm was confirmed by an imaging characteristic appearance, with multiple small or different-sized cysts, but when the diagnosis is doubtful, which often leads to surgery.
The clinical case is the one of a 79-year-old woman with a cystadenoma of the pancreas. She had a history of partial cystectomy for bladder neoplasia and recently (in 2017), she was submitted to laparoscopic focal cryotherapy for the treatment of a left unilateral renal tumor. At that time, she underwent a CT-can, which found a cystic neoplasm of the tail of the pancreas. A heterogeneous 5cm lesion appeared in the left hypochondrium, near the lower pole of the spleen, with no evidence of adenopathies highly suggestive of a serous cystadenoma of the pancreas.
In October 2018, in a follow-up CT-scan, there was an increase in size of the lesion (6.6cm) and a surgical resection was planned. A distal splenopancreatectomy using a clockwise technique was performed using the Signia™ stapling system with no complications. Histological examination confirmed a serous cystadenoma of the pancreas.
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
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.
O Soubrane, P Pessaux, E Felli, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
5 months ago
1880 views
2 likes
0 comments
34:11
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
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 distal pancreatectomy for mucinous cystadenoma
This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.
F Costantino, M Shahbaz, D Mutter, J Marescaux
Surgical intervention
3 years ago
1978 views
95 likes
0 comments
12:01
Laparoscopic distal pancreatectomy for mucinous cystadenoma
This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.
Laparoscopic spleen-preserving distal pancreatectomy for mucinous cystadenoma (Warshaw’s technique)
The video presents the case of a surgical procedure performed in a 58-year old woman presenting with mucinous cystadenoma in the left pancreas. The patient complained of early satiety and her CT-scan demonstrated the existence of a huge cystic tumor replacing her pancreatic body and tail. The tumor involved the splenic vein and artery, resulting in a left segmental portal hypertension. Preoperative CT-scan showed that collaterals from the short gastric vessels maintained splenic vascularization.
A spleen-preserving distal pancreatectomy, sacrificing splenic vessels, according to Warshaw’s technique was decided upon.
Fa Madureira, Fe Madureira, D Madureira
Surgical intervention
4 years ago
3083 views
52 likes
0 comments
10:43
Laparoscopic spleen-preserving distal pancreatectomy for mucinous cystadenoma (Warshaw’s technique)
The video presents the case of a surgical procedure performed in a 58-year old woman presenting with mucinous cystadenoma in the left pancreas. The patient complained of early satiety and her CT-scan demonstrated the existence of a huge cystic tumor replacing her pancreatic body and tail. The tumor involved the splenic vein and artery, resulting in a left segmental portal hypertension. Preoperative CT-scan showed that collaterals from the short gastric vessels maintained splenic vascularization.
A spleen-preserving distal pancreatectomy, sacrificing splenic vessels, according to Warshaw’s technique was decided upon.
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
6 years ago
1140 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.
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
1620 views
65 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
1326 views
27 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.
Image of the month: anterior abdominal mass after hysterectomy
This video demonstrates the case of a woman presenting with a mass appended to the anterior abdominal wall. In the patient’s surgical history, a hysterectomy performed a few years earlier can be noted. The operative report of that intervention is not available. Laparoscopy is therefore decided upon. The first impression is that of an ovarian lesion appended to the anterior abdominal wall. Consequently, an appendicular lesion must be ruled out. The appendix is therefore searched for and dissected. It remains distal from the mass and its pedicle. The presence of a tubular structure in the mass’s pedicle mandates the identification of the right ureter, which also remains distally. From then onwards, resection of the mass does not pose any particular problem. The pathological finding confirms the nature of the mass, namely a benign ovarian cystadenoma.
M Vix, J Marescaux
Surgical intervention
6 years ago
2617 views
40 likes
0 comments
10:47
Image of the month: anterior abdominal mass after hysterectomy
This video demonstrates the case of a woman presenting with a mass appended to the anterior abdominal wall. In the patient’s surgical history, a hysterectomy performed a few years earlier can be noted. The operative report of that intervention is not available. Laparoscopy is therefore decided upon. The first impression is that of an ovarian lesion appended to the anterior abdominal wall. Consequently, an appendicular lesion must be ruled out. The appendix is therefore searched for and dissected. It remains distal from the mass and its pedicle. The presence of a tubular structure in the mass’s pedicle mandates the identification of the right ureter, which also remains distally. From then onwards, resection of the mass does not pose any particular problem. The pathological finding confirms the nature of the mass, namely a benign ovarian cystadenoma.
Transumbilical single incision laparoscopic left ovariectomy
Background: Transumbilical single incision laparoscopy has been reported to be a feasible and safe procedure to treat gynecologic diseases. This video presents a left ovariectomy performed in a patient with a symptomatic giant ovarian cyst.

Clinical case: A 56-year-old female with a body mass index of 20.5 kg/m2, was consulted for abdominal pain localized in the left iliac fossa. Preoperative work-up showed a left ovarian cyst of 12cm in diameter. The cyst appeared to be round, with smooth walls, homogenic liquid, and without intracystic proliferations. The procedure was performed using an 11mm reusable port for a 10mm, 30-degree standard length scope, and curved reusable instruments according to Dapri (Karl Storz Endoskope). The specimen was extracted through the umbilicus in a custom-made plastic bag.

Results: No conversion to open surgery nor additional ports were necessary. The laparoscopy lasted 37 minutes and the final umbilical incision length was 15mm. Pathological data revealed a serous cystadenoma. The patient was discharged on postoperative day 1. At 7-month follow-up, no late complications were found and the patient was asymptomatic.

Conclusions: Transumbilical single incision laparoscopy is beneficial for gynecologic diseases and this technique allow for a final scar of minimal size. The cost of the procedure is similar to that of multi-port laparoscopy.
G Dapri, M Degueldre
Surgical intervention
6 years ago
2921 views
33 likes
0 comments
03:46
Transumbilical single incision laparoscopic left ovariectomy
Background: Transumbilical single incision laparoscopy has been reported to be a feasible and safe procedure to treat gynecologic diseases. This video presents a left ovariectomy performed in a patient with a symptomatic giant ovarian cyst.

Clinical case: A 56-year-old female with a body mass index of 20.5 kg/m2, was consulted for abdominal pain localized in the left iliac fossa. Preoperative work-up showed a left ovarian cyst of 12cm in diameter. The cyst appeared to be round, with smooth walls, homogenic liquid, and without intracystic proliferations. The procedure was performed using an 11mm reusable port for a 10mm, 30-degree standard length scope, and curved reusable instruments according to Dapri (Karl Storz Endoskope). The specimen was extracted through the umbilicus in a custom-made plastic bag.

Results: No conversion to open surgery nor additional ports were necessary. The laparoscopy lasted 37 minutes and the final umbilical incision length was 15mm. Pathological data revealed a serous cystadenoma. The patient was discharged on postoperative day 1. At 7-month follow-up, no late complications were found and the patient was asymptomatic.

Conclusions: Transumbilical single incision laparoscopy is beneficial for gynecologic diseases and this technique allow for a final scar of minimal size. The cost of the procedure is similar to that of multi-port laparoscopy.