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ICG fluorescent cholangiography in difficult laparoscopic cholecystectomy with inflammatory biliary fusion post-cholecystitis and pancreatitis
Laparoscopic cholecystectomy in the presence of inflammatory billiary fusion is a technically challenging procedure associated with a 0.5% risk of injury to major extrahepatic bile ducts.
Preoperative planning and intraoperative visualization of the anatomy of the biliary tree using an intraoperative cholangiogram reduces the risk or the severity of injury to major biliary ducts.
Indocyanine green cholangiography has emerged as a promising non-invasive modality for visualization of extra-hepatic biliary ducts, having the advantage of very easy use repetitively at various stages of critical areas of dissection.
This video demonstrates a laparoscopic cholecystectomy in a patient who had an emergency admission for mild acute cholecystitis (as per Tokyo guidelines, 2018) and concomitant moderately severe acute gallstone pancreatitis (revised Atlanta classification) with a preoperative MRCP predictive of biliary inflammatory fusion between the gallbladder neck and the common hepatic duct.
Consequently, we planned and performed a laparoscopic cholecystectomy with an indocyanine green cholangiogram as a non-invasive method to help identify the intraoperative anatomy of the extra-hepatic biliary ducts.
The main feature of our video is the use of indocyanine green during the difficult dissection of the gallbladder neck and exposure of the critical view of safety in Calot’s triangle as cased with clear features of significant biliary inflammatory fusion between the cystic duct and the common hepatic duct.
ICG fluorescent demonstration of the extra-hepatic biliary tree is used in real time and with ease repeatedly at several stages of this difficult dissection, facilitating a safe completion of a difficult laparoscopic cholecystectomy and may become a standard practice.
G Kumar, S Ramachandran, M Paraoan
Surgical intervention
8 months ago
339 views
6 likes
1 comment
13:21
ICG fluorescent cholangiography in difficult laparoscopic cholecystectomy with inflammatory biliary fusion post-cholecystitis and pancreatitis
Laparoscopic cholecystectomy in the presence of inflammatory billiary fusion is a technically challenging procedure associated with a 0.5% risk of injury to major extrahepatic bile ducts.
Preoperative planning and intraoperative visualization of the anatomy of the biliary tree using an intraoperative cholangiogram reduces the risk or the severity of injury to major biliary ducts.
Indocyanine green cholangiography has emerged as a promising non-invasive modality for visualization of extra-hepatic biliary ducts, having the advantage of very easy use repetitively at various stages of critical areas of dissection.
This video demonstrates a laparoscopic cholecystectomy in a patient who had an emergency admission for mild acute cholecystitis (as per Tokyo guidelines, 2018) and concomitant moderately severe acute gallstone pancreatitis (revised Atlanta classification) with a preoperative MRCP predictive of biliary inflammatory fusion between the gallbladder neck and the common hepatic duct.
Consequently, we planned and performed a laparoscopic cholecystectomy with an indocyanine green cholangiogram as a non-invasive method to help identify the intraoperative anatomy of the extra-hepatic biliary ducts.
The main feature of our video is the use of indocyanine green during the difficult dissection of the gallbladder neck and exposure of the critical view of safety in Calot’s triangle as cased with clear features of significant biliary inflammatory fusion between the cystic duct and the common hepatic duct.
ICG fluorescent demonstration of the extra-hepatic biliary tree is used in real time and with ease repeatedly at several stages of this difficult dissection, facilitating a safe completion of a difficult laparoscopic cholecystectomy and may become a standard practice.
Single stage diagnosis and treatment by EUS and ERCP of a pancreatic stone causing an acute pancreatitis
Biliopancreatic stones are the ‘primum movens’ of acute pancreatitis. Pure pancreatic stones are rare. However, when present, they are the main cause of acute obstruction of the main pancreatic duct. Conversely, when present in chronic pancreatitis, they are mostly responsible for pancreatic glandular insufficiency. Medical treatment, radiologic evaluation (by MRI or CT-scan), and therapeutic endoscopy constitute the standard of care (SOC).
Here, we report the case of a 25-year-old man, admitted for upper middle abdominal pain and hyperamylasemia, without anomalies in liver function tests, and who underwent biliopancreatic EUS. A pancreatic stone was diagnosed and immediately treated by endoscopic pancreatic sphincterotomy and extraction.
Gf Donatelli, B Meduri
Surgical intervention
4 years ago
1179 views
41 likes
0 comments
05:10
Single stage diagnosis and treatment by EUS and ERCP of a pancreatic stone causing an acute pancreatitis
Biliopancreatic stones are the ‘primum movens’ of acute pancreatitis. Pure pancreatic stones are rare. However, when present, they are the main cause of acute obstruction of the main pancreatic duct. Conversely, when present in chronic pancreatitis, they are mostly responsible for pancreatic glandular insufficiency. Medical treatment, radiologic evaluation (by MRI or CT-scan), and therapeutic endoscopy constitute the standard of care (SOC).
Here, we report the case of a 25-year-old man, admitted for upper middle abdominal pain and hyperamylasemia, without anomalies in liver function tests, and who underwent biliopancreatic EUS. A pancreatic stone was diagnosed and immediately treated by endoscopic pancreatic sphincterotomy and extraction.
Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.
JM Cabada-Lee
Surgical intervention
2 years ago
1971 views
106 likes
0 comments
10:55
Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.
Laparoscopic Frey's procedure with management of intraoperative complication
This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.
After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards.
The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing.
Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure.
P Agami, A Andrianov, V Shchadrova, M Baychorov, R Izrailov
Surgical intervention
7 months ago
5177 views
21 likes
4 comments
12:28
Laparoscopic Frey's procedure with management of intraoperative complication
This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.
After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards.
The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing.
Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure.
Tips 'n tricks: cholecystectomy: antegrade approach for difficult dissection
Today, laparoscopic cholecystectomy is a routinely performed surgical intervention. In certain cases, the identification of Calot’s triangle may be difficult due to adhesions or inflammatory infiltrations of adjacent structures. Hydrodissection can allow for an atraumatic dissection but in more complex cases, an antegrade freeing of the gallbladder should be envisaged.
Here we present the case of a man benefiting from a difficult laparoscopic cholecystectomy for a pancreatitis with common bile duct stone migration. The flag technique, with an antegrade freeing, must be applied in order to complete the procedure laparoscopically.
L Marx, C Hild, J Leroy, J Marescaux
Surgical intervention
6 years ago
4929 views
76 likes
0 comments
06:50
Tips 'n tricks: cholecystectomy: antegrade approach for difficult dissection
Today, laparoscopic cholecystectomy is a routinely performed surgical intervention. In certain cases, the identification of Calot’s triangle may be difficult due to adhesions or inflammatory infiltrations of adjacent structures. Hydrodissection can allow for an atraumatic dissection but in more complex cases, an antegrade freeing of the gallbladder should be envisaged.
Here we present the case of a man benefiting from a difficult laparoscopic cholecystectomy for a pancreatitis with common bile duct stone migration. The flag technique, with an antegrade freeing, must be applied in order to complete the procedure laparoscopically.
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
P Agami, A Andrianov, M Baychorov, R Izrailov
Surgical intervention
3 months ago
1562 views
12 likes
3 comments
17:23
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor
In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter, at the pancreatic isthmus. Scintigraphy does not evidence any intense uptake.
The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall.
A postoperative pancreatic fistula grade B was reported. It was successfully managed. The presence of a well-differentiated neuroendocrine tumor was confirmed. The patient was discharged on postoperative day 22.
P Pessaux, E Felli, T Wakabayashi, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
7 months ago
2614 views
5 likes
3 comments
07:01
Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor
In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter, at the pancreatic isthmus. Scintigraphy does not evidence any intense uptake.
The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall.
A postoperative pancreatic fistula grade B was reported. It was successfully managed. The presence of a well-differentiated neuroendocrine tumor was confirmed. The patient was discharged on postoperative day 22.
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
M Vix, B Seeliger, D Mutter, J Marescaux
Surgical intervention
10 months ago
904 views
2 likes
0 comments
13:25
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
Fully robotically assisted transabdominal right adrenalectomy for a right adrenal incidentaloma
This video presents the case of a female patient in whom a right adrenal incidentaloma was found. It was 40mm in size and was found incidentally during a pancreatitis treatment.
Endocrinologists controlled the absence of abnormal secretion. The size of the lesion increased slightly over a period of 6 months and allowed to establish an indication for surgery. Our team performs adrenalectomies using a transabdominal laparoscopic approach with the patient in a lateral decubitus position. In order to facilitate the intervention, we asked the Visible Patient company to use the CT-scan images to make a 3D model. This reconstruction allowed to better indentify the relationships of the gland, to improve resection, and confirm the operative strategy. During the intervention, the surgeon can use it to better understand the anatomy hidden by peri-adrenal adipose tissue and operate accordingly. We now have a surgical robot (da Vinci Xi™ robotic surgical system, Intuitive Surgical) and we use it for most of the adrenalectomies we perform. It provides great stability of the operative field. The precise dissection is facilitated by the dexterity of the articulated instruments.
M Vix, B Seeliger, L Soler, D Mutter, J Marescaux
Surgical intervention
10 months ago
1346 views
2 likes
0 comments
11:41
Fully robotically assisted transabdominal right adrenalectomy for a right adrenal incidentaloma
This video presents the case of a female patient in whom a right adrenal incidentaloma was found. It was 40mm in size and was found incidentally during a pancreatitis treatment.
Endocrinologists controlled the absence of abnormal secretion. The size of the lesion increased slightly over a period of 6 months and allowed to establish an indication for surgery. Our team performs adrenalectomies using a transabdominal laparoscopic approach with the patient in a lateral decubitus position. In order to facilitate the intervention, we asked the Visible Patient company to use the CT-scan images to make a 3D model. This reconstruction allowed to better indentify the relationships of the gland, to improve resection, and confirm the operative strategy. During the intervention, the surgeon can use it to better understand the anatomy hidden by peri-adrenal adipose tissue and operate accordingly. We now have a surgical robot (da Vinci Xi™ robotic surgical system, Intuitive Surgical) and we use it for most of the adrenalectomies we perform. It provides great stability of the operative field. The precise dissection is facilitated by the dexterity of the articulated instruments.
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
I Boškoski, M Morar, I Crisan, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
2 years ago
879 views
83 likes
0 comments
18:14
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
I Boškoski, RA Ciurezu, M Morar, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
2 years ago
1048 views
66 likes
0 comments
11:04
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
Removal of large biliary stones
Biliary stones can be easy or difficult to remove, depending on their dimensions. Understanding bile ducts anatomy, choosing the appropriate devices/extraction technique, developing confidence with biliary lithotripsy, choosing the appropriate size of the sphincterotomy, performing large balloon biliary dilation in appropriate cases and management of failed stones extraction are the basic key issues in the management of biliary stones. Here, we present the case of a 96-year-old female patient who had an episode of cholangitis one week ago and ERCP was performed with a biliary precut to access the bile duct. Since the biliary stones were large, a biliary plastic stent was placed and after unintentional pancreatic duct cannulation, a pancreatic stent was also placed to prevent pancreatitis. ERCP was repeated. The biliary stent was removed since the stones were approximately 12mm in diameter. A biliary balloon dilation was carried out to facilitate the removal. At the end, the pancreatic stent was also removed.
I Boškoski, M Morar, RA Ciurezu, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
2 years ago
1057 views
84 likes
0 comments
12:52
Removal of large biliary stones
Biliary stones can be easy or difficult to remove, depending on their dimensions. Understanding bile ducts anatomy, choosing the appropriate devices/extraction technique, developing confidence with biliary lithotripsy, choosing the appropriate size of the sphincterotomy, performing large balloon biliary dilation in appropriate cases and management of failed stones extraction are the basic key issues in the management of biliary stones. Here, we present the case of a 96-year-old female patient who had an episode of cholangitis one week ago and ERCP was performed with a biliary precut to access the bile duct. Since the biliary stones were large, a biliary plastic stent was placed and after unintentional pancreatic duct cannulation, a pancreatic stent was also placed to prevent pancreatitis. ERCP was repeated. The biliary stent was removed since the stones were approximately 12mm in diameter. A biliary balloon dilation was carried out to facilitate the removal. At the end, the pancreatic stent was also removed.
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
I Boškoski, I Crisan, M Morar, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
2 years ago
698 views
54 likes
0 comments
18:35
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
Robot-assisted ultrasound-guided transgastric cystogastrostomy
We report the case of a 57-year-old woman with a voluminous pseudocyst in the lesser sac after several episodes of acute pancreatitis of biliary origin managed by a robot-assisted transgastric cystogastrostomy. The patient is lying supine, legs apart. Five ports are positioned. The intervention is begun with an anterior gastrotomy, which allows to introduce a balloon-tipped trocar transgastrically. A second gastrotomy is performed in the prepyloric region. It allows to introduce a second transgastric trocar. Finally, a third gastrotomy is performed at the level of the fundus to introduce a third transgastric balloon-tipped trocar. After transgastric insufflation, the trocars are connected to the robot, which is positioned at the patient’s head. A transgastric ultrasonography is performed to visualize the pseudocyst, which has a heterogeneous content, with fibrotic debris. The gastrotomy is initiated with Ultracision™ at the posterior aspect of the stomach. The cyst is multilocular. The gastric wall is controlled by means of a Doppler ultrasound in order not to pass through the gastric varices, which had been identified on endoscopic ultrasound. A second cavity with some more heterogeneous content is subsequently opened. This cavity presents some pancreatic necrosis. The cystogastrostomy is enlarged at its most. Trocars are then removed to proceed intraperitoneally. The three anterior gastrotomy incisions are then sutured using the robot. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
P Pessaux, R Memeo, V De Blasi, O Perotto, D Mutter, J Marescaux
Surgical intervention
3 years ago
1236 views
54 likes
0 comments
06:04
Robot-assisted ultrasound-guided transgastric cystogastrostomy
We report the case of a 57-year-old woman with a voluminous pseudocyst in the lesser sac after several episodes of acute pancreatitis of biliary origin managed by a robot-assisted transgastric cystogastrostomy. The patient is lying supine, legs apart. Five ports are positioned. The intervention is begun with an anterior gastrotomy, which allows to introduce a balloon-tipped trocar transgastrically. A second gastrotomy is performed in the prepyloric region. It allows to introduce a second transgastric trocar. Finally, a third gastrotomy is performed at the level of the fundus to introduce a third transgastric balloon-tipped trocar. After transgastric insufflation, the trocars are connected to the robot, which is positioned at the patient’s head. A transgastric ultrasonography is performed to visualize the pseudocyst, which has a heterogeneous content, with fibrotic debris. The gastrotomy is initiated with Ultracision™ at the posterior aspect of the stomach. The cyst is multilocular. The gastric wall is controlled by means of a Doppler ultrasound in order not to pass through the gastric varices, which had been identified on endoscopic ultrasound. A second cavity with some more heterogeneous content is subsequently opened. This cavity presents some pancreatic necrosis. The cystogastrostomy is enlarged at its most. Trocars are then removed to proceed intraperitoneally. The three anterior gastrotomy incisions are then sutured using the robot. The postoperative outcome is uneventful. The patient is discharged on postoperative day 4.
Laparoscopic distal pancreatectomy with spleen preservation
Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. Nowadays, more than 80% of distal pancreatectomies are performed laparoscopically. The basic advantages of this approach over the open approach are the following: reduced blood loss, fewer complications, and shorter hospital stay. Pancreatic neoplasms, chronic pancreatitis, and pancreatic cysts are the main indications for laparoscopic distal pancreatectomy. Distal pancreatosplenectomy and spleen-preserving pancreatectomy are contraindicated in metastatic diseases, peritoneal carcinosis, vascular invasion, and pancreatitis involving the entire pancreas. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Spleen preservation should preferably be achieved by preserving the splenic vessels (Kimura technique), but also by resecting the splenic vessels and maintaining vascularity through the short gastric vessels and the left gastroepiploic artery (Warshaw’s technique).
AM Cury
Lecture
3 years ago
2030 views
74 likes
0 comments
11:42
Laparoscopic distal pancreatectomy with spleen preservation
Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. Nowadays, more than 80% of distal pancreatectomies are performed laparoscopically. The basic advantages of this approach over the open approach are the following: reduced blood loss, fewer complications, and shorter hospital stay. Pancreatic neoplasms, chronic pancreatitis, and pancreatic cysts are the main indications for laparoscopic distal pancreatectomy. Distal pancreatosplenectomy and spleen-preserving pancreatectomy are contraindicated in metastatic diseases, peritoneal carcinosis, vascular invasion, and pancreatitis involving the entire pancreas. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Spleen preservation should preferably be achieved by preserving the splenic vessels (Kimura technique), but also by resecting the splenic vessels and maintaining vascularity through the short gastric vessels and the left gastroepiploic artery (Warshaw’s technique).
Laparoscopic choledochal cyst excision with intraoperative cholangiogram, hepatic duct cholangioscopy, extracorporeal Roux-en-Y hepaticojejunostomy and closure of mesenteric defects
The laparoscopic treatment of a choledochal cyst begins with a careful preoperative understanding of the anatomy, including bile ducts, as well as the presence of any abnormal pancreatobiliary anatomy. If a hepaticojejunostomy using a Roux-en-Y anastomosis is performed, we prefer an extracorporeal, transumbilical anastomosis, with a retrocolic approach. A series of interrupted or continuous absorbable sutures can be used for the bilioenteric anastomosis. For the last part of the procedure, we emphasize the importance of closure of mesenteric defects with non-absorbable sutures, including both the retrocolic space and Petersen’s defect to prevent future internal herniations.
GA Villalona, D Ozgediz
Surgical intervention
3 years ago
1740 views
74 likes
0 comments
10:31
Laparoscopic choledochal cyst excision with intraoperative cholangiogram, hepatic duct cholangioscopy, extracorporeal Roux-en-Y hepaticojejunostomy and closure of mesenteric defects
The laparoscopic treatment of a choledochal cyst begins with a careful preoperative understanding of the anatomy, including bile ducts, as well as the presence of any abnormal pancreatobiliary anatomy. If a hepaticojejunostomy using a Roux-en-Y anastomosis is performed, we prefer an extracorporeal, transumbilical anastomosis, with a retrocolic approach. A series of interrupted or continuous absorbable sutures can be used for the bilioenteric anastomosis. For the last part of the procedure, we emphasize the importance of closure of mesenteric defects with non-absorbable sutures, including both the retrocolic space and Petersen’s defect to prevent future internal herniations.
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
1355 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.
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
D Ntourakis, D Mutter, J Marescaux
Surgical intervention
4 years ago
3257 views
125 likes
1 comment
20:03
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
Redo management of Crohn's disease after ileocaecal resection 20 years ago: new ileocolic laparoscopic resection
Crohn’s disease is an evolutive inflammatory bowel disease. Surgery may be performed several times during the patient’s life. Using a laparoscopic approach limits the risk of adhesions and the possibilities of re-operations in those patients.
In this film, the surgeon comes across difficulties due to postoperative adhesions and the interest of using new energy devices such as the LigaSure™ blunt tip device and the Sonicision™ cordless ultrasonic dissection device to free the small bowel and divide the mesos with an easy and secure hemostasis.
Concerning the anastomosis between the small bowel and the colon, the use of the new generation of staples manufactured by Covidien is extremely worthy of interest because of the ergonomics of the new handle and the perfect closure and hemostasis of the stapling line of the Tri-staple™ cartridge technology.
J Leroy, J Marescaux
Surgical intervention
7 years ago
1363 views
9 likes
0 comments
16:40
Redo management of Crohn's disease after ileocaecal resection 20 years ago: new ileocolic laparoscopic resection
Crohn’s disease is an evolutive inflammatory bowel disease. Surgery may be performed several times during the patient’s life. Using a laparoscopic approach limits the risk of adhesions and the possibilities of re-operations in those patients.
In this film, the surgeon comes across difficulties due to postoperative adhesions and the interest of using new energy devices such as the LigaSure™ blunt tip device and the Sonicision™ cordless ultrasonic dissection device to free the small bowel and divide the mesos with an easy and secure hemostasis.
Concerning the anastomosis between the small bowel and the colon, the use of the new generation of staples manufactured by Covidien is extremely worthy of interest because of the ergonomics of the new handle and the perfect closure and hemostasis of the stapling line of the Tri-staple™ cartridge technology.
Tips 'n tricks: successful ERCP in the presence of periampullary diverticula
Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP).
Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age.
Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome
In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.
Gf Donatelli, P Dhumane, S Perretta, B Dallemagne, J Marescaux
Surgical intervention
8 years ago
2086 views
12 likes
0 comments
09:19
Tips 'n tricks: successful ERCP in the presence of periampullary diverticula
Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP).
Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age.
Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome
In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.
Endoscopic extraction of a giant common bile duct stone
The Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has become the gold standard for the treatment of cholelithiasis with a success rate of 95%.
The dimensions of a giant biliary calculus are equal to or bigger than 2cm.
Various endoscopic tools such as the mechanical lithotripsy or extracorporeal shock wave lithotripsy (ESWL) have been described to treat this pathology. Surgery is offered to cases unresolved by endoscopic therapy.
Recently, the sphincteroplasty with a large-size balloon dilatation of the papilla has been described as an option for the endoscopic management of the giant biliary stone.
This is a case of extraction of giant common bile duct calculus using the combination of sphincterotomy and large-size balloon sphincteroplasty.
Gf Donatelli, P Dhumane, S Perretta, B Dallemagne, J Marescaux
Surgical intervention
8 years ago
2772 views
17 likes
0 comments
03:56
Endoscopic extraction of a giant common bile duct stone
The Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has become the gold standard for the treatment of cholelithiasis with a success rate of 95%.
The dimensions of a giant biliary calculus are equal to or bigger than 2cm.
Various endoscopic tools such as the mechanical lithotripsy or extracorporeal shock wave lithotripsy (ESWL) have been described to treat this pathology. Surgery is offered to cases unresolved by endoscopic therapy.
Recently, the sphincteroplasty with a large-size balloon dilatation of the papilla has been described as an option for the endoscopic management of the giant biliary stone.
This is a case of extraction of giant common bile duct calculus using the combination of sphincterotomy and large-size balloon sphincteroplasty.
Laparoscopic left pancreatectomy with spleen preservation for a suspicion of IPMN
Laparoscopic distal pancreatectomy is suitable for benign and premalignant neoplasms located in the body and tail of the pancreas. Spleen preservation following distal pancreatectomy is known to be safe. There are two distinct approaches to preserve the spleen during the dissection of the distal pancreas. The classic design is to identify, isolate, and preserve the splenic artery and vein. Alternatively, the splenic artery and vein are ligated with the pancreas, and perfusion of the spleen is assured by the short gastric vessels. Both are accepted as appropriate techniques to address a mass in the tail of the pancreas. This video demonstrates a left pancreatic resection with spleen preservation and ligation of the splenic artery and vein.
B Dallemagne, S Perretta, L Soler, J Marescaux
Surgical intervention
9 years ago
1042 views
48 likes
0 comments
19:27
Laparoscopic left pancreatectomy with spleen preservation for a suspicion of IPMN
Laparoscopic distal pancreatectomy is suitable for benign and premalignant neoplasms located in the body and tail of the pancreas. Spleen preservation following distal pancreatectomy is known to be safe. There are two distinct approaches to preserve the spleen during the dissection of the distal pancreas. The classic design is to identify, isolate, and preserve the splenic artery and vein. Alternatively, the splenic artery and vein are ligated with the pancreas, and perfusion of the spleen is assured by the short gastric vessels. Both are accepted as appropriate techniques to address a mass in the tail of the pancreas. This video demonstrates a left pancreatic resection with spleen preservation and ligation of the splenic artery and vein.
Laparoscopic splenopancreatectomy assisted by augmented reality for pancreatic cancer
Soper et al. in 1994 were able to establish the safety and efficacy of laparoscopic distal pancreatectomy in an animal model, with no evidence of pancreatic leaks or fistulas. Later, in 1996, Cuschieri et al. described the technique they used to perform laparoscopic distal 70–80% pancreatectomy with en-bloc splenectomy in a group of five patients with intractable pain due to chronic pancreatitis. The authors demonstrated that this operation can be performed laparoscopically within an acceptable operating time and without major complications with advantages that include smaller incisions, less pain, and shorter postoperative recovery.
Identification of anatomical landmarks is crucial for this kind of procedure expecially when treating cancer. Augmented reality is a new tool to improve oncological safety, confirming the ideal dissection plane and anatomical landmarks, and to maximize functional preservation. The objective of this video is to demonstrate how to perform a splenopancreatectomy with removal of pancreatic cancer while keeping sufficient safety margins. Augmented reality is used in order to clearly identify the position of the anatomical landmarks: the splenic vein and artery, as well as the exact position of the tumor so that a sufficient resection margin can be identified.
D Mutter, J Marescaux, L Soler
Surgical intervention
10 years ago
1375 views
41 likes
0 comments
18:27
Laparoscopic splenopancreatectomy assisted by augmented reality for pancreatic cancer
Soper et al. in 1994 were able to establish the safety and efficacy of laparoscopic distal pancreatectomy in an animal model, with no evidence of pancreatic leaks or fistulas. Later, in 1996, Cuschieri et al. described the technique they used to perform laparoscopic distal 70–80% pancreatectomy with en-bloc splenectomy in a group of five patients with intractable pain due to chronic pancreatitis. The authors demonstrated that this operation can be performed laparoscopically within an acceptable operating time and without major complications with advantages that include smaller incisions, less pain, and shorter postoperative recovery.
Identification of anatomical landmarks is crucial for this kind of procedure expecially when treating cancer. Augmented reality is a new tool to improve oncological safety, confirming the ideal dissection plane and anatomical landmarks, and to maximize functional preservation. The objective of this video is to demonstrate how to perform a splenopancreatectomy with removal of pancreatic cancer while keeping sufficient safety margins. Augmented reality is used in order to clearly identify the position of the anatomical landmarks: the splenic vein and artery, as well as the exact position of the tumor so that a sufficient resection margin can be identified.
Totally laparoscopic duodenal pancreatectomy for cancer
Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism. Laparoscopic proximal pancreatectomies for cancer with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy is technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences of highly skilled surgeons.
This interesting video shows all steps and landmarks of a totally laparoscopic duodenopancreatectomy for cancer performed by a very experienced surgeon.
F Corcione, J Marescaux
Surgical intervention
10 years ago
8856 views
36 likes
0 comments
21:13
Totally laparoscopic duodenal pancreatectomy for cancer
Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism. Laparoscopic proximal pancreatectomies for cancer with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy is technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences of highly skilled surgeons.
This interesting video shows all steps and landmarks of a totally laparoscopic duodenopancreatectomy for cancer performed by a very experienced surgeon.
Laparoscopic common bile duct exploration: choledochotomy approach
The description of the laparoscopic common bile duct exploration: choledochotomy approach covers all aspects of the surgical procedure used for the management of common bile duct stones.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, choledochotomy, stone extraction, common bile duct closure.
Consequently, this operating technique is well standardized for the management of this condition.
D Bacal, JC Berthou, D Mutter, I Jourdan
Operative technique
16 years ago
3864 views
216 likes
0 comments
Laparoscopic common bile duct exploration: choledochotomy approach
The description of the laparoscopic common bile duct exploration: choledochotomy approach covers all aspects of the surgical procedure used for the management of common bile duct stones.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, choledochotomy, stone extraction, common bile duct closure.
Consequently, this operating technique is well standardized for the management of this condition.