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Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
G Baiocchi, S Molfino, B Molteni, L Arru, F Gheza, M Diana
Surgical intervention
9 months ago
4073 views
11 likes
0 comments
12:41
Laparoscopic subtotal gastrectomy with ICG-oriented extended D2 (D2+) lymphadenectomy
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
Three-trocar laparoscopic total gastrectomy and D2 lymphadenectomy with intracorporeal manual esophagojejunostomy
Background: Minimally invasive surgery (MIS) has proven to be oncologically feasible and safe. Over the last decade, a new philosophy of MIS reducing abdominal trauma and improving cosmetic results has been made popular. The authors report a three-trocar laparoscopic total gastrectomy combined with a D2 lymphadenectomy for smaller curvature gastric adenocarcinoma.
Video: A 52-year-old woman presenting with a non-differentiated gastric adenocarcinoma at the incisura angularis was admitted to our department. Preoperative work-up showed a T3N+M0 tumor. After neoadjuvant chemotherapy, laparoscopy was scheduled. Three ports (5mm, 12mm, 5mm) were placed in the abdomen. Exposure of the operative field was improved with percutaneous sutures. En-bloc total gastrectomy and omentectomy were performed with a D2 lymphadenectomy, including the nodes of stations 1, 2, 3, 4, 5, 6, 7, 8a, 8p, 9, 10, 11p, 11d, and 12a. A completely manual end-to-side esophagojejunostomy, and a linear mechanical side-to-side jejunojejunostomy were performed, with closure of both mesenteric and mesocolic defects. The specimen was retrieved through a suprapubic access.
Results: Operative time was 4 hours and 45 minutes (anastomosis: 30) and perioperative bleeding amounted to 100cc. The pathological report confirmed the presence of a non-differentiated adenocarcinoma, mucinous, G3, interesting the gastric wall completely, with 63 (4 positive) nodes removed; 7 edition UICC stage: pT4aN2aM0; keratine AE1/AE3 negative, HER2/neu and HER2/CEP17 non-amplified. During the postoperative follow-up, no recurrence was demonstrated at 12 months.
Conclusions: Reduced port laparoscopic surgery provides the same quality of oncologic surgery as conventional multiport laparoscopy. However, a superior cosmesis and a reduced abdominal trauma are offered.
G Dapri, HK Yang
Surgical intervention
3 years ago
3113 views
97 likes
0 comments
11:03
Three-trocar laparoscopic total gastrectomy and D2 lymphadenectomy with intracorporeal manual esophagojejunostomy
Background: Minimally invasive surgery (MIS) has proven to be oncologically feasible and safe. Over the last decade, a new philosophy of MIS reducing abdominal trauma and improving cosmetic results has been made popular. The authors report a three-trocar laparoscopic total gastrectomy combined with a D2 lymphadenectomy for smaller curvature gastric adenocarcinoma.
Video: A 52-year-old woman presenting with a non-differentiated gastric adenocarcinoma at the incisura angularis was admitted to our department. Preoperative work-up showed a T3N+M0 tumor. After neoadjuvant chemotherapy, laparoscopy was scheduled. Three ports (5mm, 12mm, 5mm) were placed in the abdomen. Exposure of the operative field was improved with percutaneous sutures. En-bloc total gastrectomy and omentectomy were performed with a D2 lymphadenectomy, including the nodes of stations 1, 2, 3, 4, 5, 6, 7, 8a, 8p, 9, 10, 11p, 11d, and 12a. A completely manual end-to-side esophagojejunostomy, and a linear mechanical side-to-side jejunojejunostomy were performed, with closure of both mesenteric and mesocolic defects. The specimen was retrieved through a suprapubic access.
Results: Operative time was 4 hours and 45 minutes (anastomosis: 30) and perioperative bleeding amounted to 100cc. The pathological report confirmed the presence of a non-differentiated adenocarcinoma, mucinous, G3, interesting the gastric wall completely, with 63 (4 positive) nodes removed; 7 edition UICC stage: pT4aN2aM0; keratine AE1/AE3 negative, HER2/neu and HER2/CEP17 non-amplified. During the postoperative follow-up, no recurrence was demonstrated at 12 months.
Conclusions: Reduced port laparoscopic surgery provides the same quality of oncologic surgery as conventional multiport laparoscopy. However, a superior cosmesis and a reduced abdominal trauma are offered.
Laparoscopic en bloc splenopancreatectomy with left adrenalectomy and para-aortic lymphadenectomy
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.
R Romito, L Portigliotti, G Bondonno, M Zacchero, A Volpe
Surgical intervention
7 months ago
1381 views
11 likes
0 comments
13:28
Laparoscopic en bloc splenopancreatectomy with left adrenalectomy and para-aortic lymphadenectomy
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.
Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.
G Dapri, NA Bascombe, L Gerard, C Samaniego Ballar, C Jiménez Viñas
Surgical intervention
2 years ago
2921 views
229 likes
1 comment
10:22
Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.
Laparoscopic D2 lymphadenectomy with preservation of an aberrant left hepatic artery during distal gastric resection for cancer
During laparoscopic D2 lymphadenectomy for gastric cancer, an aberrant left hepatic artery (ALHA) can be found arising from the left gastric artery (LGA). It is recommended to preserve this vessel since it is impossible to intraoperatively determine whether it is a “replaced” or “accessory” left hepatic artery. In the present video, we show the technique to preserve the ALHA during a laparoscopic distal gastrectomy performed for a cancer of the antrum in a 78-year-old male patient.
A typical D2 laparoscopic lymphadenectomy is performed until the division of the left gastric vein and the identification of the LGA: the ALHA is identified at this time and the anterior side of the LGA is exposed towards its origin; the branch of the LGA towards the stomach is clipped and resected and the lymph nodes located posterior to the ALHA are then dissected completely. Lymphadenectomy is then completed with the dissection of the lymph nodes along the lesser curvature and the right cardiac nodes.
Pathological examination revealed a T2N0M0 tumor with 56 lymph nodes examined. The present video demonstrates that preservation of the ALHA is laparoscopically feasible and does not decrease the extent of D2 lymph node dissection.
B Badii, F Staderini, I Skalamera, G Fiorenza, G Perigli, F Cianchi
Surgical intervention
5 years ago
3372 views
96 likes
0 comments
16:07
Laparoscopic D2 lymphadenectomy with preservation of an aberrant left hepatic artery during distal gastric resection for cancer
During laparoscopic D2 lymphadenectomy for gastric cancer, an aberrant left hepatic artery (ALHA) can be found arising from the left gastric artery (LGA). It is recommended to preserve this vessel since it is impossible to intraoperatively determine whether it is a “replaced” or “accessory” left hepatic artery. In the present video, we show the technique to preserve the ALHA during a laparoscopic distal gastrectomy performed for a cancer of the antrum in a 78-year-old male patient.
A typical D2 laparoscopic lymphadenectomy is performed until the division of the left gastric vein and the identification of the LGA: the ALHA is identified at this time and the anterior side of the LGA is exposed towards its origin; the branch of the LGA towards the stomach is clipped and resected and the lymph nodes located posterior to the ALHA are then dissected completely. Lymphadenectomy is then completed with the dissection of the lymph nodes along the lesser curvature and the right cardiac nodes.
Pathological examination revealed a T2N0M0 tumor with 56 lymph nodes examined. The present video demonstrates that preservation of the ALHA is laparoscopically feasible and does not decrease the extent of D2 lymph node dissection.
Minimally invasive redo esophagojejunostomy for postoperative dehiscence after laparoscopic total gastrectomy for gastric cancer
This is the case of an 87-year-old man receiving dual antiplatelet therapy, with aortic steno-insufficiency, chronic heart and renal failure, admitted to our service for anemia due to lesser curvature gastric cancer.
The patient underwent an uneventuful laparoscopic total gastrectomy with D1 lymph node dissection with Roux-en-Y reconstruction. Pathological findings were consistent with a poorly differentiated pT4bN2M0 adenocarcinoma (TNM classification, 7th edition).
A fifth postoperative day gastrografin swallow revealed a large anastomotic leak at the esophagojejunostomy.
A conservative approach was considered to treat this complication with a multispecialty approach. However, this approach was rejected for two reasons:
- Firstly, the occurrence of a broad anastomotic leakage in the early postoperative period is often due to necrosis of perianastomotic tissues;
- Secondly, the patient’s age, the poor nutritional status and the early signs of hemodynamic instability - hypertension and tachycardia - called for a more timely and potentially resolutive approach.
Additionally, in our experience, the use of self-expandable metallic stents is associated with a high rate of stent migration in the setting of end-to-side anastomoses.
As a result, a decision was made to perform an emergency explorative laparoscopy with a minimally invasive redo esophagojejunostomy.
The procedure was performed using 5 trocars through the same incisions as the first surgery. Operative time was 180 minutes, with minimal blood loss and no intraoperative transfusion.

Results:
After surgery, the patient required admission to the postoperative intensive care unit for 9 days because of respiratory failure, hemodynamic instability, and the development of a subdiaphragmatic collection, treated by percutaneous drainage.
An upper gastrointestinal gastrografin swallow on postoperative day 10 showed a patent esophagojejunostomy without any leak. The patient was started on a clear fluid diet, and advanced to a solid diet as tolerated, until discharge on postoperative day 14.
I Maruri Chimeno, I Otero Martinez, V Vigorita, M Bertucci Zoccali, H Pardellas Rivera, P Troncoso Pereira , JE Casal Núñez
Surgical intervention
5 years ago
1475 views
17 likes
0 comments
12:54
Minimally invasive redo esophagojejunostomy for postoperative dehiscence after laparoscopic total gastrectomy for gastric cancer
This is the case of an 87-year-old man receiving dual antiplatelet therapy, with aortic steno-insufficiency, chronic heart and renal failure, admitted to our service for anemia due to lesser curvature gastric cancer.
The patient underwent an uneventuful laparoscopic total gastrectomy with D1 lymph node dissection with Roux-en-Y reconstruction. Pathological findings were consistent with a poorly differentiated pT4bN2M0 adenocarcinoma (TNM classification, 7th edition).
A fifth postoperative day gastrografin swallow revealed a large anastomotic leak at the esophagojejunostomy.
A conservative approach was considered to treat this complication with a multispecialty approach. However, this approach was rejected for two reasons:
- Firstly, the occurrence of a broad anastomotic leakage in the early postoperative period is often due to necrosis of perianastomotic tissues;
- Secondly, the patient’s age, the poor nutritional status and the early signs of hemodynamic instability - hypertension and tachycardia - called for a more timely and potentially resolutive approach.
Additionally, in our experience, the use of self-expandable metallic stents is associated with a high rate of stent migration in the setting of end-to-side anastomoses.
As a result, a decision was made to perform an emergency explorative laparoscopy with a minimally invasive redo esophagojejunostomy.
The procedure was performed using 5 trocars through the same incisions as the first surgery. Operative time was 180 minutes, with minimal blood loss and no intraoperative transfusion.

Results:
After surgery, the patient required admission to the postoperative intensive care unit for 9 days because of respiratory failure, hemodynamic instability, and the development of a subdiaphragmatic collection, treated by percutaneous drainage.
An upper gastrointestinal gastrografin swallow on postoperative day 10 showed a patent esophagojejunostomy without any leak. The patient was started on a clear fluid diet, and advanced to a solid diet as tolerated, until discharge on postoperative day 14.
Laparoscopic total gastrectomy with D2 lymphadenectomy for adenocarcinoma
Total gastrectomy with D2 lymphadenectomy is recommended for T1-T2 gastric cancer.
The laparoscopic approach for this procedure has been validated by extensive clinical randomized trials in Asia, leading to fewer postoperative complications and morbidity and identical oncological outcome.
This video presents a laparoscopic total gastrectomy with D2 lymphadenectomy in a 54-year-old woman presenting with a T1-T2 poorly differentiated adenocarcinoma of the lesser curvature of the stomach. Due to the location of the tumor, lymphadenectomy of stations 10 and 11d are not performed. An original technique of circular eso-jejunal anastomosis is described.
A Talvane Torres de Oliveira, C Lacerda, PA Bertulucci
Surgical intervention
6 years ago
5266 views
79 likes
0 comments
25:53
Laparoscopic total gastrectomy with D2 lymphadenectomy for adenocarcinoma
Total gastrectomy with D2 lymphadenectomy is recommended for T1-T2 gastric cancer.
The laparoscopic approach for this procedure has been validated by extensive clinical randomized trials in Asia, leading to fewer postoperative complications and morbidity and identical oncological outcome.
This video presents a laparoscopic total gastrectomy with D2 lymphadenectomy in a 54-year-old woman presenting with a T1-T2 poorly differentiated adenocarcinoma of the lesser curvature of the stomach. Due to the location of the tumor, lymphadenectomy of stations 10 and 11d are not performed. An original technique of circular eso-jejunal anastomosis is described.
Laparoscopic total gastrectomy
A multimodality approach remains the only potential treatment for advanced gastric cancer. Oncological outcomes seem to be equivalent either in open surgery or in minimally invasive surgery. Therefore, laparoscopic gastric resection is expanding in expert centers.
The authors present a clinical case of a 70-year-old woman with no relevant clinical past. She presented with a 1-month complaint of epigastric pain and melena. She underwent an upper endoscopy, which showed an ulcerated gastric lesion at the lesser curvature. Biopsy revealed a poorly cohesive gastric carcinoma with signet ring cells. Thoraco-abdominal-pelvic CT-scan revealed a thickening of the gastric wall associated with multiple perigastric and celiac trunk lymph nodes. She was proposed for perioperative chemotherapy. On the restaging CT-scan, there was no evidence of disease progression and therefore she underwent a laparoscopic radical total gastrectomy.
The benefits of minimally invasive surgery, combined with the increasing evidence of oncological results overlapping with open surgery, have contributed to the progressive implementation of laparoscopic surgery in the treatment of malignant gastric pathology.
J Magalhães, C Osorio, L Frutuoso, AM Pereira, A Trovão, R Ferreira de Almeida, M Nora
Surgical intervention
8 months ago
4597 views
17 likes
0 comments
09:44
Laparoscopic total gastrectomy
A multimodality approach remains the only potential treatment for advanced gastric cancer. Oncological outcomes seem to be equivalent either in open surgery or in minimally invasive surgery. Therefore, laparoscopic gastric resection is expanding in expert centers.
The authors present a clinical case of a 70-year-old woman with no relevant clinical past. She presented with a 1-month complaint of epigastric pain and melena. She underwent an upper endoscopy, which showed an ulcerated gastric lesion at the lesser curvature. Biopsy revealed a poorly cohesive gastric carcinoma with signet ring cells. Thoraco-abdominal-pelvic CT-scan revealed a thickening of the gastric wall associated with multiple perigastric and celiac trunk lymph nodes. She was proposed for perioperative chemotherapy. On the restaging CT-scan, there was no evidence of disease progression and therefore she underwent a laparoscopic radical total gastrectomy.
The benefits of minimally invasive surgery, combined with the increasing evidence of oncological results overlapping with open surgery, have contributed to the progressive implementation of laparoscopic surgery in the treatment of malignant gastric pathology.
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
F Signorini, HK Yang
Surgical intervention
2 months ago
1719 views
5 likes
1 comment
10:02
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
F Signorini, S Reimondez, M España, L Obeide, F Moser
Surgical intervention
1 year ago
10852 views
427 likes
0 comments
06:41
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.
WJ Hyung, S Perretta, B Dallemagne, B Seeliger, D Mutter, J Marescaux
Surgical intervention
9 months ago
2192 views
15 likes
0 comments
04:27
LIVE INTERACTIVE SURGERY: robotic total gastrectomy highlighting esojejunal anastomosis
This video presents the case of a 71-year-old man with a BMI of 29. He was admitted to the emergency room for fatigue, severe anemia, and abdominal pain. His past medical history was significant for cardiac disease, aortic valve stenosis, and small adrenal adenoma. His past surgical history included a cholecystectomy and a prostatectomy. Work-up started with an endoscopy which showed an ulcer at the antrum, which was biopsied and showed signet cell adenocarcinoma. CT-scan confirmed the presence of a large bulky lesion and ruled out the presence of a metastatic disease. The patient was admitted again for bleeding and hematemesis and he was scheduled for a total gastrectomy. He had an exploratory laparoscopy which showed no signs of carcinomatosis. He also had preoperative chemotherapy.
This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
P Pessaux, R Memeo, J Hallet, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
1 year ago
7277 views
940 likes
0 comments
32:12
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
Laparoscopic transhiatal esophagectomy for adenocarcinoma of the lower esophagus
Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
9 years ago
5669 views
162 likes
0 comments
21:14
Laparoscopic transhiatal esophagectomy for adenocarcinoma of the lower esophagus
Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
N Fukami
Lecture
3 years ago
436 views
21 likes
0 comments
29:26
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
Totally laparoscopic gastrectomy and D2 lymphadenectomy with repair of a positive leak test
The objective of this video is to demonstrate a laparoscopic total gastrectomy with D2 lymphadenectomy for antral gastric cancer. The patient we present is a 40 year-old gentleman who presented with epigastric pain. Endoscopy revealed a neoplastic lesion at the gastric antrum. Biopsies confirmed the presence of an adenocarcinoma. This was staged as a T2 lesion and there was no distant metastasis. A total gastrectomy was planned using a total laparoscopic approach. For reconstruction, the authors used a Roux En Y esophagojejunal anastomosis using the transoral delivery of the OrVil® device (Covidien, Mansfield, MA, USA). We also demonstrate how to deal with a positive intraoperative leak test at the end of the procedure.
AE Salih, S Smolarek, SA Naqi, M Arumugasamy
Surgical intervention
3 years ago
6710 views
407 likes
0 comments
12:35
Totally laparoscopic gastrectomy and D2 lymphadenectomy with repair of a positive leak test
The objective of this video is to demonstrate a laparoscopic total gastrectomy with D2 lymphadenectomy for antral gastric cancer. The patient we present is a 40 year-old gentleman who presented with epigastric pain. Endoscopy revealed a neoplastic lesion at the gastric antrum. Biopsies confirmed the presence of an adenocarcinoma. This was staged as a T2 lesion and there was no distant metastasis. A total gastrectomy was planned using a total laparoscopic approach. For reconstruction, the authors used a Roux En Y esophagojejunal anastomosis using the transoral delivery of the OrVil® device (Covidien, Mansfield, MA, USA). We also demonstrate how to deal with a positive intraoperative leak test at the end of the procedure.
Totally laparoscopic total gastrectomy for stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma
A 66-year-old man was admitted to our hospital with complaints of epigastric pain. His hemoglobin level was 9.3g/dL. Endoscopy of the upper gastrointestinal tract (EGD) showed an advanced gastric carcinoma that had invaded the middle and lower third of the stomach. A biopsy specimen revealed a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) showed that the tumor had invaded the stomach wall. Enlarged lymph nodes were present only around the lesser curvature (regional lymph nodes No. 3). The patient was diagnosed with stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma according to the Japanese classification of gastric carcinoma1. The patient was then taken to the operating room for exploratory laparoscopy and laparoscopic total gastrectomy with D2 lymphadenectomy. The operation time was 260 minutes. No further evidence of intra-abdominal disease or liver involvement was noted. The patient did well postoperatively and was subsequently discharged home on postoperative day 9. Four metastatic lymph nodes/twenty eight regional lymph nodes were found; so the pathological findings confirmed stage IIIA. The patient is disease-free at 10 months. Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer 1998;1:10-24.
G Pignata, M Barone, U Bracale, E Gianetta, F Badessi
Surgical intervention
9 years ago
5384 views
34 likes
0 comments
26:02
Totally laparoscopic total gastrectomy for stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma
A 66-year-old man was admitted to our hospital with complaints of epigastric pain. His hemoglobin level was 9.3g/dL. Endoscopy of the upper gastrointestinal tract (EGD) showed an advanced gastric carcinoma that had invaded the middle and lower third of the stomach. A biopsy specimen revealed a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) showed that the tumor had invaded the stomach wall. Enlarged lymph nodes were present only around the lesser curvature (regional lymph nodes No. 3). The patient was diagnosed with stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma according to the Japanese classification of gastric carcinoma1. The patient was then taken to the operating room for exploratory laparoscopy and laparoscopic total gastrectomy with D2 lymphadenectomy. The operation time was 260 minutes. No further evidence of intra-abdominal disease or liver involvement was noted. The patient did well postoperatively and was subsequently discharged home on postoperative day 9. Four metastatic lymph nodes/twenty eight regional lymph nodes were found; so the pathological findings confirmed stage IIIA. The patient is disease-free at 10 months. Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer 1998;1:10-24.
Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach
Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.
B Dallemagne, F Costantino, J Marescaux
Surgical intervention
9 years ago
7616 views
24 likes
0 comments
15:53
Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach
Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.
Laparoscopy-assisted pylorus-preserving gastrectomy using near-infrared imaging combined with indocyanine green (ICG) submucosal injection - (LAPPG - Near-infrared ICG camera)
Using a near infrared camera, lymph nodes can be visualized. For early gastric cancer located in the middle third of the stomach, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) can be performed. Approximately, a 3cm cuff of distal antrum is preserved. Technically speaking, the preservation of infrapyloric vessels and of the hepatic branch of the vagus nerve represents the technical difference as compared to conventional radical distal gastrectomy. In this video, the audience can see how a near-infrared camera can be used to assist lymph node dissection.
HK Yang
Surgical intervention
5 years ago
1834 views
38 likes
0 comments
22:18
Laparoscopy-assisted pylorus-preserving gastrectomy using near-infrared imaging combined with indocyanine green (ICG) submucosal injection - (LAPPG - Near-infrared ICG camera)
Using a near infrared camera, lymph nodes can be visualized. For early gastric cancer located in the middle third of the stomach, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) can be performed. Approximately, a 3cm cuff of distal antrum is preserved. Technically speaking, the preservation of infrapyloric vessels and of the hepatic branch of the vagus nerve represents the technical difference as compared to conventional radical distal gastrectomy. In this video, the audience can see how a near-infrared camera can be used to assist lymph node dissection.
SILS (single access) transhiatal esophagectomy for cancer
An 82-year-old man was referred to our department for a 3cm long esophageal cancer.
He was smoking 40 cigarettes a day and drinking 1.5L of wine a day. He had a BMI of 21 and he was ASA 2.
A CT-scan showed a 3cm tumor not entering the muscle layer and no nodes were found in the mediastinum.
No liver metastases were visible on CT-scan and ultrasonography (US).
During GI endoscopy, a biopsy showed an esophageal adenocarcinoma.
Ejection fraction (EF) during cardiac ultrasound was 55%.
After 15 days of gym workouts in our department (15 minutes of exercise bike in the morning and 20 minutes in the afternoon, and inflating 30 balloons in the morning, 30 at lunchtime and 30 before nighttime), the patient was operated on.
A laparoscopic transhiatal single port esophagectomy was performed according to Orringer’s technique.
Procedure time was 195 minutes. Estimated blood loss was nihil. Time in ICU was 24 hours and hospital stay was 7 days.
This was our 11th case using this technique.
C Huscher
Surgical intervention
5 years ago
2633 views
105 likes
0 comments
08:29
SILS (single access) transhiatal esophagectomy for cancer
An 82-year-old man was referred to our department for a 3cm long esophageal cancer.
He was smoking 40 cigarettes a day and drinking 1.5L of wine a day. He had a BMI of 21 and he was ASA 2.
A CT-scan showed a 3cm tumor not entering the muscle layer and no nodes were found in the mediastinum.
No liver metastases were visible on CT-scan and ultrasonography (US).
During GI endoscopy, a biopsy showed an esophageal adenocarcinoma.
Ejection fraction (EF) during cardiac ultrasound was 55%.
After 15 days of gym workouts in our department (15 minutes of exercise bike in the morning and 20 minutes in the afternoon, and inflating 30 balloons in the morning, 30 at lunchtime and 30 before nighttime), the patient was operated on.
A laparoscopic transhiatal single port esophagectomy was performed according to Orringer’s technique.
Procedure time was 195 minutes. Estimated blood loss was nihil. Time in ICU was 24 hours and hospital stay was 7 days.
This was our 11th case using this technique.
Full laparoscopic pancreaticoduodenectomy for malignant ampulloma
In the first description of Laparoscopic PancreaticoDuodenectomy (LPD) by Gagner and Pomp in 1994, the authors reported the technical feasibility of the procedure, but questioned its advantages as compared with the open approach. Recent reports on large series of LPD demonstrated that the procedure might not only be feasible, but that it might have advantages as compared with open pancreaticoduodenectomy. Blood loss, ICU length of stay and overall hospital length of stay were shorter in the LPD group at the cost of significantly higher operative times. This video demonstrates a full LPD performed for a malignant ampulloma. All major steps of the procedure are extensively and clearly demonstrated.
A Talvane Torres de Oliveira, C Lacerda, PA Bertulucci
Surgical intervention
6 years ago
7545 views
78 likes
0 comments
40:39
Full laparoscopic pancreaticoduodenectomy for malignant ampulloma
In the first description of Laparoscopic PancreaticoDuodenectomy (LPD) by Gagner and Pomp in 1994, the authors reported the technical feasibility of the procedure, but questioned its advantages as compared with the open approach. Recent reports on large series of LPD demonstrated that the procedure might not only be feasible, but that it might have advantages as compared with open pancreaticoduodenectomy. Blood loss, ICU length of stay and overall hospital length of stay were shorter in the LPD group at the cost of significantly higher operative times. This video demonstrates a full LPD performed for a malignant ampulloma. All major steps of the procedure are extensively and clearly demonstrated.
Single incision laparoscopic gastrojejunal bypass with intraoperative ultrasonography for obstructive pancreatic head tumor
Background: Pancreatic head tumors can be diagnosed immediately as symptomatic although the biliary tract is not involved. Single incision laparoscopy can be proposed as a valid option to allow an early beginning of neo-adjuvant chemotherapy.

Video: A 56-year-old man was admitted to hospital for vomiting and weight loss. Preoperative work-up showed the presence of an advanced and obstructive pancreatic head adenocarcinoma, not interesting the biliary tract. A laparoscopic gastro-jejunal bypass with staging laparoscopy, through a transumbilical single-access, was proposed to the patient. The technique consisted in the insertion of an 11mm reusable trocar, two 6mm flexible reusable trocars, and curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) through the same umbilical incision. The procedure started with the exploration of the parietal peritoneum, lavage of the cavity, opening of the lesser sac for perioperative ultrasonography, and ended with linear mechanical side-to-side gastrojejunostomy.

Results: The obstructive status of the patient resolved during the postoperative course and the patient started neo-adjuvant chemotherapy after 10 days.

Conclusions: Single incision laparoscopic gastrojejunostomy for obstructive pancreatic head tumor, after staging laparoscopy including perioperative ultrasonography, permits the resolution of the clinical status as well as an early beginning of neo-adjuvant chemotherapy.
G Dapri
Surgical intervention
6 years ago
2279 views
54 likes
0 comments
06:40
Single incision laparoscopic gastrojejunal bypass with intraoperative ultrasonography for obstructive pancreatic head tumor
Background: Pancreatic head tumors can be diagnosed immediately as symptomatic although the biliary tract is not involved. Single incision laparoscopy can be proposed as a valid option to allow an early beginning of neo-adjuvant chemotherapy.

Video: A 56-year-old man was admitted to hospital for vomiting and weight loss. Preoperative work-up showed the presence of an advanced and obstructive pancreatic head adenocarcinoma, not interesting the biliary tract. A laparoscopic gastro-jejunal bypass with staging laparoscopy, through a transumbilical single-access, was proposed to the patient. The technique consisted in the insertion of an 11mm reusable trocar, two 6mm flexible reusable trocars, and curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) through the same umbilical incision. The procedure started with the exploration of the parietal peritoneum, lavage of the cavity, opening of the lesser sac for perioperative ultrasonography, and ended with linear mechanical side-to-side gastrojejunostomy.

Results: The obstructive status of the patient resolved during the postoperative course and the patient started neo-adjuvant chemotherapy after 10 days.

Conclusions: Single incision laparoscopic gastrojejunostomy for obstructive pancreatic head tumor, after staging laparoscopy including perioperative ultrasonography, permits the resolution of the clinical status as well as an early beginning of neo-adjuvant chemotherapy.
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy in obese patients
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy using a circular stapler or manual anastomosis has recently been described by a few authors.
We performed this challenging technique with a completely thoracoscopic hand-sewn esophagogastric anastomosis in two obese patients in prone position (one female and one male), affected by an adenocarcinoma of the lower third of the esophagus without lymph node invasion (pT2 N0) and with a BMI of 35 and 32 respectively. The first female patient is the subject of this video.
Thoracoscopy lasted 150 minutes (anastomosis was 50 minutes long), laparoscopy lasted 130 minutes, and second laparoscopy lasted 20 minutes. Blood loss was estimated at 150 mL.
The gastrografin swallows (on postoperative day 7 in both patients) showed absence of stenosis and leak. The patients had an uneventful postoperative course and were discharged on postoperative day 12 and 10, respectively.
Thoracoscopy in prone position allows the surgeon to perform a thoracoscopic esophagogastric anastomosis completely hand-sewn without selective lung exclusion, and using only three trocars.
In obese patients, although the technique is foremost challenging, the advantages of minimally invasive surgery are undeniable —better intraoperative respiratory function (avoiding selective lung exclusion) and less complicated postoperative course.
P Ubiali, M Andretta, M Ciocca Vasino, A Mancin, S Pastori, F Maffeis
Surgical intervention
8 years ago
8349 views
132 likes
0 comments
18:36
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy in obese patients
Totally thoracoscopic and laparoscopic Ivor Lewis esophagectomy using a circular stapler or manual anastomosis has recently been described by a few authors.
We performed this challenging technique with a completely thoracoscopic hand-sewn esophagogastric anastomosis in two obese patients in prone position (one female and one male), affected by an adenocarcinoma of the lower third of the esophagus without lymph node invasion (pT2 N0) and with a BMI of 35 and 32 respectively. The first female patient is the subject of this video.
Thoracoscopy lasted 150 minutes (anastomosis was 50 minutes long), laparoscopy lasted 130 minutes, and second laparoscopy lasted 20 minutes. Blood loss was estimated at 150 mL.
The gastrografin swallows (on postoperative day 7 in both patients) showed absence of stenosis and leak. The patients had an uneventful postoperative course and were discharged on postoperative day 12 and 10, respectively.
Thoracoscopy in prone position allows the surgeon to perform a thoracoscopic esophagogastric anastomosis completely hand-sewn without selective lung exclusion, and using only three trocars.
In obese patients, although the technique is foremost challenging, the advantages of minimally invasive surgery are undeniable —better intraoperative respiratory function (avoiding selective lung exclusion) and less complicated postoperative course.
Minimally invasive Ivor Lewis esophagectomy for cancer
Minimally invasive Ivor Lewis esophagectomy is technically challenging but feasible in experienced minimally invasive surgery centers. This video illustrates the surgical approach of an Ivor-Lewis esophagectomy. This surgery was carried out in a patient presenting with a type 2 cardia tumor according to Siewert’s classification. The preoperative workup confirmed the presence of an adenocarcinoma with locoregional lymph nodes. After neoadjuvant chemotherapy, a massive melt of the tumor was evidenced without any residual lesion or any local or distant metastasis. In this context, a curative resection has been proposed. Considering the tumor’s type, a resection combining an abdominal with a thoracic approach was decided upon.
B Dallemagne, J Marescaux
Surgical intervention
9 years ago
3640 views
226 likes
0 comments
18:46
Minimally invasive Ivor Lewis esophagectomy for cancer
Minimally invasive Ivor Lewis esophagectomy is technically challenging but feasible in experienced minimally invasive surgery centers. This video illustrates the surgical approach of an Ivor-Lewis esophagectomy. This surgery was carried out in a patient presenting with a type 2 cardia tumor according to Siewert’s classification. The preoperative workup confirmed the presence of an adenocarcinoma with locoregional lymph nodes. After neoadjuvant chemotherapy, a massive melt of the tumor was evidenced without any residual lesion or any local or distant metastasis. In this context, a curative resection has been proposed. Considering the tumor’s type, a resection combining an abdominal with a thoracic approach was decided upon.