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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
1 year ago
3276 views
6 likes
4 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 right hemicolectomy with excision of a pancreatic neuroendocrine tumor (pNET)
Pancreatic neuroendocrine tumors (pNETs) are rare neoplasms, which account for less than 5% of all pancreatic tumors, with an incidence of 0.48 cases/100,000. They may be benign or malignant and tend to grow slower than exocrine tumors. They develop from the abnormal growth of endocrine cells in the pancreas and are either functional or nonfunctional, and may or may not cause signs or symptoms. Pancreatic NETs that have not spread outside the pancreas should be completely removed, if possible, because these tumors are more likely to be cured with surgery. This video shows a case of a pNET of the uncinate process, discovered in the study of a right colon cancer. Because of the small size of the pNET and its location, the association of a right laparoscopic hemicolectomy with a pancreatic tumor excision was deemed feasible. The mobilization of the mesenteric root allowed to identify the uncinate process and to prepare for the pNET excision. After the exposure of the duodenum and the retroperitoneal plane, the surgery continued with a right hemicolectomy and a complete mesocolic excision. An intracorporeal anastomosis was constructed and the surgical specimen was retrieved through a suprapubic incision. The pathological report revealed a T2N1 caecal adenocarcinoma and a G2 pNET.
A Canaveira Manso, M Rosete, R Nemésio, R Martins
Surgical intervention
6 months ago
1001 views
10 likes
0 comments
17:16
Laparoscopic right hemicolectomy with excision of a pancreatic neuroendocrine tumor (pNET)
Pancreatic neuroendocrine tumors (pNETs) are rare neoplasms, which account for less than 5% of all pancreatic tumors, with an incidence of 0.48 cases/100,000. They may be benign or malignant and tend to grow slower than exocrine tumors. They develop from the abnormal growth of endocrine cells in the pancreas and are either functional or nonfunctional, and may or may not cause signs or symptoms. Pancreatic NETs that have not spread outside the pancreas should be completely removed, if possible, because these tumors are more likely to be cured with surgery. This video shows a case of a pNET of the uncinate process, discovered in the study of a right colon cancer. Because of the small size of the pNET and its location, the association of a right laparoscopic hemicolectomy with a pancreatic tumor excision was deemed feasible. The mobilization of the mesenteric root allowed to identify the uncinate process and to prepare for the pNET excision. After the exposure of the duodenum and the retroperitoneal plane, the surgery continued with a right hemicolectomy and a complete mesocolic excision. An intracorporeal anastomosis was constructed and the surgical specimen was retrieved through a suprapubic incision. The pathological report revealed a T2N1 caecal adenocarcinoma and a G2 pNET.
Fully laparoscopic right colectomy for caecal tumor with “vessels first’ approach
Over the last few years, laparoscopic colorectal surgery has increased exponentially worldwide. When combined with an enhanced recovery program, a significant reduction in the length of hospital stay can be achieved, coupled with an early return to normal activities for the patient.
This is the case of a 68-year-old obese woman with a BMI of 30 presenting with a caecal tumor. Her major co-morbidities are chronic obstructive pulmonary disease (COPD) and high blood pressure. The patient complained of chronic abdominal pain and presented a positive fecal occult blood test. Colonoscopy showed a caecal tumor. Biopsy confirmed an adenocarcinoma. CT-scan did not show any distant metastasis. A full laparoscopic approach with a medial-to-lateral and ‘vessels first’ approach is shown.
A D'Urso, M Rodriguez, D Mutter, J Marescaux
Surgical intervention
6 months ago
3810 views
39 likes
4 comments
13:27
Fully laparoscopic right colectomy for caecal tumor with “vessels first’ approach
Over the last few years, laparoscopic colorectal surgery has increased exponentially worldwide. When combined with an enhanced recovery program, a significant reduction in the length of hospital stay can be achieved, coupled with an early return to normal activities for the patient.
This is the case of a 68-year-old obese woman with a BMI of 30 presenting with a caecal tumor. Her major co-morbidities are chronic obstructive pulmonary disease (COPD) and high blood pressure. The patient complained of chronic abdominal pain and presented a positive fecal occult blood test. Colonoscopy showed a caecal tumor. Biopsy confirmed an adenocarcinoma. CT-scan did not show any distant metastasis. A full laparoscopic approach with a medial-to-lateral and ‘vessels first’ approach is shown.
Endoscopic mucosal resection (EMR) of laterally spreading tumor in rectum and resolution of late bleeding
The objectives of this video are manifold, namely to present the totally endoscopic treatment of a laterally spreading tumor in the upper rectum with a piecemeal technique, and how to act against one of its most frequent complications, post-polypectomy bleeding.
Methods: The procedure was performed in an advanced flexible endoscopy unit, with the patient lying supine, with anesthesia (Propofol), and insufflation of carbon dioxide. A videocolonoscope was used, the lesion was identified and elevated with hydroxyethyl starch (Voluven). It was dried with a hot snare in parts ("piecemeal" technique), thereby achieving complete resection. The defect was closed with metal clips. The specimen was recovered for histopathological study.
Results: During screening colonoscopy, a 56-year-old patient was found with a 30mm granular laterally spreading tumor of the rectum (LST-G or nodular mixed type), located 15cm from the anal verge. Complete endoscopic resection of the lesion with a curative intent was performed. On postoperative day 5, proctorrhagia presented without hemodynamic alteration. Emergency endoscopy was decided upon. Upon entering with the colonoscope, we identified a clot attached to the surgical site. Once the bleeding had been confirmed, a saline solution with 1/20,000 adrenaline was injected. And then, with a hot snare, electrocoagulation was performed in the same area, combining an injection method with a thermal one and achieving a satisfying hemostasis. The patient was discharged on the same day without any other complications. The pathology report showed a villous adenoma with low-grade dysplasia, including patches of high-grade dysplasia, and injury-free resection margins.
Conclusions: EMR of laterally spreading tumors is safe, although it is not devoid of complications such as bleeding, which is present in up to 9.8 of every 100,000 polypectomies in some series (Reumkens et al., AJG 2016). It is essential to suspect and know how to solve it efficiently with the tools available at that time of emergency.
J Isaguirre, A Insausti
Surgical intervention
1 year ago
616 views
1 like
0 comments
05:38
Endoscopic mucosal resection (EMR) of laterally spreading tumor in rectum and resolution of late bleeding
The objectives of this video are manifold, namely to present the totally endoscopic treatment of a laterally spreading tumor in the upper rectum with a piecemeal technique, and how to act against one of its most frequent complications, post-polypectomy bleeding.
Methods: The procedure was performed in an advanced flexible endoscopy unit, with the patient lying supine, with anesthesia (Propofol), and insufflation of carbon dioxide. A videocolonoscope was used, the lesion was identified and elevated with hydroxyethyl starch (Voluven). It was dried with a hot snare in parts ("piecemeal" technique), thereby achieving complete resection. The defect was closed with metal clips. The specimen was recovered for histopathological study.
Results: During screening colonoscopy, a 56-year-old patient was found with a 30mm granular laterally spreading tumor of the rectum (LST-G or nodular mixed type), located 15cm from the anal verge. Complete endoscopic resection of the lesion with a curative intent was performed. On postoperative day 5, proctorrhagia presented without hemodynamic alteration. Emergency endoscopy was decided upon. Upon entering with the colonoscope, we identified a clot attached to the surgical site. Once the bleeding had been confirmed, a saline solution with 1/20,000 adrenaline was injected. And then, with a hot snare, electrocoagulation was performed in the same area, combining an injection method with a thermal one and achieving a satisfying hemostasis. The patient was discharged on the same day without any other complications. The pathology report showed a villous adenoma with low-grade dysplasia, including patches of high-grade dysplasia, and injury-free resection margins.
Conclusions: EMR of laterally spreading tumors is safe, although it is not devoid of complications such as bleeding, which is present in up to 9.8 of every 100,000 polypectomies in some series (Reumkens et al., AJG 2016). It is essential to suspect and know how to solve it efficiently with the tools available at that time of emergency.
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
Background: Minimally invasive surgery (MIS) was shown to offer advantages in general and oncologic surgery (1). Over the last decade, reduced port laparoscopy (RPL) has been introduced to reduce the risks related to ports and abdominal wall trauma, with enhanced cosmetic outcomes (2). In this video, the authors report the case of a 59-year-old man with a small bowel neuroendocrine tumor, and who underwent a three-trocar right ileocolectomy.
Video: Preoperative work-up, including endoscopic ultrasound, octreoscan, PET-scan, and FDG PET-CT, showed a 15mm small bowel tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the third portion of the duodenum. The biopsy revealed a low-grade well-differentiated neuroendocrine tumor. The procedure was performed using three abdominal trocars: a 12mm one in the umbilicus, a 5mm one in the right flank, and a 5mm port in the left flank (Figure 1). Abdominal cavity exploration demonstrated the presence of a tumor located in the mesentery of the last small bowel loop, with consequent bowel retraction, dislocation of the caecum and appendix, located under the right lobe of the liver, and tumoral extension into the proximal transverse mesocolon. After mobilization of the right colon from laterally to medially, the second and third duodenal segments were exposed, showing tumor extension towards the anterior duodenal wall of these segments. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape (Figure 2), an endoscopic linear stapler was inserted through the umbilical trocar under the visual guidance of a 5mm scope in the left flank (Figure 3a), and it was fired (Figure 3b). The specimen was removed through a suprapubic access. Perioperative frozen section biopsy showed a free duodenal margin, and the procedure was subsequently completed with an ileocolic anastomosis, performed in a side-to-side handsewn intracorporeal fashion. At the end, the mesocolic defect was closed.

Results: Operative time was 4 hours. No added trocars were necessary. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Pathological findings showed a grade I well-differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration (1/20 metastatic nodes, free margins, stage: pT3N1 (8 UICC edition). A follow-up under somatostatin therapy was put forward.

Conclusions: RPL is a feasible option when performing advanced oncological surgery. Patients benefit from all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
G Dapri
Surgical intervention
2 years ago
7396 views
112 likes
0 comments
11:10
Three-trocar laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor
Background: Minimally invasive surgery (MIS) was shown to offer advantages in general and oncologic surgery (1). Over the last decade, reduced port laparoscopy (RPL) has been introduced to reduce the risks related to ports and abdominal wall trauma, with enhanced cosmetic outcomes (2). In this video, the authors report the case of a 59-year-old man with a small bowel neuroendocrine tumor, and who underwent a three-trocar right ileocolectomy.
Video: Preoperative work-up, including endoscopic ultrasound, octreoscan, PET-scan, and FDG PET-CT, showed a 15mm small bowel tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the third portion of the duodenum. The biopsy revealed a low-grade well-differentiated neuroendocrine tumor. The procedure was performed using three abdominal trocars: a 12mm one in the umbilicus, a 5mm one in the right flank, and a 5mm port in the left flank (Figure 1). Abdominal cavity exploration demonstrated the presence of a tumor located in the mesentery of the last small bowel loop, with consequent bowel retraction, dislocation of the caecum and appendix, located under the right lobe of the liver, and tumoral extension into the proximal transverse mesocolon. After mobilization of the right colon from laterally to medially, the second and third duodenal segments were exposed, showing tumor extension towards the anterior duodenal wall of these segments. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape (Figure 2), an endoscopic linear stapler was inserted through the umbilical trocar under the visual guidance of a 5mm scope in the left flank (Figure 3a), and it was fired (Figure 3b). The specimen was removed through a suprapubic access. Perioperative frozen section biopsy showed a free duodenal margin, and the procedure was subsequently completed with an ileocolic anastomosis, performed in a side-to-side handsewn intracorporeal fashion. At the end, the mesocolic defect was closed.

Results: Operative time was 4 hours. No added trocars were necessary. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Pathological findings showed a grade I well-differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration (1/20 metastatic nodes, free margins, stage: pT3N1 (8 UICC edition). A follow-up under somatostatin therapy was put forward.

Conclusions: RPL is a feasible option when performing advanced oncological surgery. Patients benefit from all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
Laparoscopic pylorus-preserving pancreaticoduodenectomy for Gruber-Frantz tumor
This video demonstrates our technique for laparoscopic pylorus-preserving pancreaticoduodenectomy performed in a 15-year-old girl presenting with a history of episodic mild abdominal colic pain and right upper quadrant mass.
The preoperative diagnosis of a solid pseudo-papillary tumor (Gruber-Frantz tumor) was made, based on ultrasonography and computed tomography.
Laparoscopic resection was decided upon based on the fact that there were clearly defined surgical planes despite of the size of the mass. The usual sequence of steps for a pancreaticoduodenectomy was altered in this particular case because of tumor dimensions.
The procedure was carried out in 438 minutes without complications. There were no symptoms of delayed gastric emptying, and the patient was discharged on postoperative day 5. The microscopic study of the tumor confirmed a 10.5 by 9 by 5.5cm solid pseudo-papillary tumor of the pancreatic head.
JM Cabada-Lee
Surgical intervention
4 years ago
892 views
25 likes
0 comments
09:00
Laparoscopic pylorus-preserving pancreaticoduodenectomy for Gruber-Frantz tumor
This video demonstrates our technique for laparoscopic pylorus-preserving pancreaticoduodenectomy performed in a 15-year-old girl presenting with a history of episodic mild abdominal colic pain and right upper quadrant mass.
The preoperative diagnosis of a solid pseudo-papillary tumor (Gruber-Frantz tumor) was made, based on ultrasonography and computed tomography.
Laparoscopic resection was decided upon based on the fact that there were clearly defined surgical planes despite of the size of the mass. The usual sequence of steps for a pancreaticoduodenectomy was altered in this particular case because of tumor dimensions.
The procedure was carried out in 438 minutes without complications. There were no symptoms of delayed gastric emptying, and the patient was discharged on postoperative day 5. The microscopic study of the tumor confirmed a 10.5 by 9 by 5.5cm solid pseudo-papillary tumor of the pancreatic head.
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
HK Yang, SH Kong
Surgical intervention
3 years ago
2109 views
80 likes
1 comment
15:56
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
Laparoscopic enucleation of a cystic tumor of the pancreas in a child
This short video describes the laparoscopic enucleation of a benign congenital excretory cyst of the pancreas in a 13-year-old girl.
No prenatal diagnosis had been envisaged and this teen girl was admitted in an emergency setting, with iterative abdominal pain followed by vomiting and weight loss (3Kg) over the last two months.
The entire work-up allowed to rule out the presence of parenchymal tumor involvement and the perfectly regular isolated and apparently normal nature of a cyst situated on the posterior aspect of the pancreatic head, which is totally separate from the biliary tract and from the duodenum.
In these conditions, the diagnosis of Frantz tumor was ruled out and the most probable hypothesis was that of a congenital cystic pancreatic tumor which had recently increased in size. The specificity of the technique used consisted in a pancreatic detachment using a Kocher’s maneuver. The posterior aspect of the pancreatic head was then detached in order to "plicate" or fold the pancreas upon itself.
Once turned over 180 degrees to the left, the posterior aspect of the pancreatic head was perfectly exposed. In addition, after puncture of the cyst, the clear fluid content of the cyst was replaced by a blue dye in order to perfectly identify it through a thin layer of pancreatic parenchyma.
The cyst’s enucleation was subsequently facilitated. No adhesion impaired its detachment from the remainder of the pancreatic tissue. Since the pericystic area was preserved, the risk of secondary pancreatic fistula was prevented, especially because the cyst had been previously opacified, which allowed to rule out any potential communication with the excretory ducts of the pancreas.
I Kauffmann, F Becmeur
Surgical intervention
4 years ago
704 views
13 likes
0 comments
02:59
Laparoscopic enucleation of a cystic tumor of the pancreas in a child
This short video describes the laparoscopic enucleation of a benign congenital excretory cyst of the pancreas in a 13-year-old girl.
No prenatal diagnosis had been envisaged and this teen girl was admitted in an emergency setting, with iterative abdominal pain followed by vomiting and weight loss (3Kg) over the last two months.
The entire work-up allowed to rule out the presence of parenchymal tumor involvement and the perfectly regular isolated and apparently normal nature of a cyst situated on the posterior aspect of the pancreatic head, which is totally separate from the biliary tract and from the duodenum.
In these conditions, the diagnosis of Frantz tumor was ruled out and the most probable hypothesis was that of a congenital cystic pancreatic tumor which had recently increased in size. The specificity of the technique used consisted in a pancreatic detachment using a Kocher’s maneuver. The posterior aspect of the pancreatic head was then detached in order to "plicate" or fold the pancreas upon itself.
Once turned over 180 degrees to the left, the posterior aspect of the pancreatic head was perfectly exposed. In addition, after puncture of the cyst, the clear fluid content of the cyst was replaced by a blue dye in order to perfectly identify it through a thin layer of pancreatic parenchyma.
The cyst’s enucleation was subsequently facilitated. No adhesion impaired its detachment from the remainder of the pancreatic tissue. Since the pericystic area was preserved, the risk of secondary pancreatic fistula was prevented, especially because the cyst had been previously opacified, which allowed to rule out any potential communication with the excretory ducts of the pancreas.
Mixed robotic laparoscopic synchronous left colectomy and left renal tumor enucleation
A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.
M Lotti, RLJ Naspro, L Rocchini, L Campanati, L Da Pozzo, L Ansaloni
Surgical intervention
3 years ago
1416 views
44 likes
0 comments
16:25
Mixed robotic laparoscopic synchronous left colectomy and left renal tumor enucleation
A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.
Laparoscopic enucleation of a pancreatic tumor: posterior approach
We report the case of a 55-year-old woman with a hypervascularized lesion at the posterior aspect of the pancreatic tail, which is evocative of an endocrine tumor of the pancreas. We decided to perform a laparoscopic enucleation of this tumor using a posterior approach. The patient is positioned in a right lateral decubitus. The intervention begins with the opening of the posterior mesogastrium, which allows to tilt the entire splenopancreatic block to the right. The tumor located on the posterior aspect clearly appears. An enucleation of the tumor is then performed using the monopolar cautery hook. In order to facilitate the lesion's exposure, a traction suture will be placed. This helps to expose the tumor. The inferior border of the tumor is freed from the splenic vein and the monopolar hook allows to perform a step-by-step enucleation. An intrapancreatic freeing of the lesion's deep plane is achieved using the Sonicision™ device. The tumor is placed into a bag and extracted through a port. The extemporaneous exam confirms the diagnosis of an endocrine tumor. Hemostasis is controlled. The splenopancreatic block is put back in its original anatomical position. There is no pancreatic fistula. The patient is discharged on postoperative day 5. The final diagnosis confirms a G1 endocrine tumor.
P Pessaux, R Memeo, D Ntourakis, H Jeddou, D Mutter, J Marescaux
Surgical intervention
4 years ago
1320 views
47 likes
0 comments
11:04
Laparoscopic enucleation of a pancreatic tumor: posterior approach
We report the case of a 55-year-old woman with a hypervascularized lesion at the posterior aspect of the pancreatic tail, which is evocative of an endocrine tumor of the pancreas. We decided to perform a laparoscopic enucleation of this tumor using a posterior approach. The patient is positioned in a right lateral decubitus. The intervention begins with the opening of the posterior mesogastrium, which allows to tilt the entire splenopancreatic block to the right. The tumor located on the posterior aspect clearly appears. An enucleation of the tumor is then performed using the monopolar cautery hook. In order to facilitate the lesion's exposure, a traction suture will be placed. This helps to expose the tumor. The inferior border of the tumor is freed from the splenic vein and the monopolar hook allows to perform a step-by-step enucleation. An intrapancreatic freeing of the lesion's deep plane is achieved using the Sonicision™ device. The tumor is placed into a bag and extracted through a port. The extemporaneous exam confirms the diagnosis of an endocrine tumor. Hemostasis is controlled. The splenopancreatic block is put back in its original anatomical position. There is no pancreatic fistula. The patient is discharged on postoperative day 5. The final diagnosis confirms a G1 endocrine tumor.
Transanal minimally invasive surgery (TAMIS) for rectal cancer with transabdominal and transrectal ICG-guided sentinel node
Transanal minimally invasive surgery (TAMIS) for rectal cancer is gaining interest, with the objective of maximum sparing for physiological functions. Although this approach may be considered appropriate for treating stage T1m tumors, a large proportion of T1sm and T2 tumors could well benefit from this. The greatest limitation to the application of TAMIS is represented by the difficulty of obtaining an adequate lymph node sample of the mesorectum. The use of indocyanine green (ICG) has recently been suggested as a possible lymph node marker after peritumoral injection. The case described in this video presents an innovative proposal for the detection and removal of lymph nodes draining a tumor of the lower rectum, with the aim of obtaining an adequate lymph node staging. After endoscopic peritumoral ICG injection, we proceeded to the search and removal of sentinel lymph nodes both with a laparoscopic transabdominal approach and with a transrectal approach (after specimen removal). If validated in a prospective series, this technique could represent the best lymph node harvesting strategy during TAMIS for early stage rectal cancer.
G Baiocchi, R Nascimbeni, N Vettoretto, N de Manzini, M Morino
Surgical intervention
1 year ago
2219 views
7 likes
0 comments
09:24
Transanal minimally invasive surgery (TAMIS) for rectal cancer with transabdominal and transrectal ICG-guided sentinel node
Transanal minimally invasive surgery (TAMIS) for rectal cancer is gaining interest, with the objective of maximum sparing for physiological functions. Although this approach may be considered appropriate for treating stage T1m tumors, a large proportion of T1sm and T2 tumors could well benefit from this. The greatest limitation to the application of TAMIS is represented by the difficulty of obtaining an adequate lymph node sample of the mesorectum. The use of indocyanine green (ICG) has recently been suggested as a possible lymph node marker after peritumoral injection. The case described in this video presents an innovative proposal for the detection and removal of lymph nodes draining a tumor of the lower rectum, with the aim of obtaining an adequate lymph node staging. After endoscopic peritumoral ICG injection, we proceeded to the search and removal of sentinel lymph nodes both with a laparoscopic transabdominal approach and with a transrectal approach (after specimen removal). If validated in a prospective series, this technique could represent the best lymph node harvesting strategy during TAMIS for early stage rectal cancer.
Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.
HK Yang, SH Kong
Surgical intervention
4 years ago
2388 views
120 likes
0 comments
03:36
Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.
Laparoscopic left hemicolectomy with manual intracorporeal anastomosis
The best surgical approach for splenic flexure tumors is not well defined yet.
The distal third of the transverse colon has an embryological origin in the hindgut, and the splenic flexure classically shows a dual lymphatic drainage, the proximal retropancreatic and the distal to the lymphatic pedicle of both the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV). Nakagoe et al. showed that the majority of positive nodes have distal lymphatic spread to the paracolic archway and up to the origin of the left colic artery. Lymph nodes of the middle colic artery and its left branch are positive in a small percentage (0 and 4.2% respectively).
As a result, a left segmental colectomy is a valid option for splenic flexure and distal transverse colon tumors because it allows vascular ligation at the root of the vessels, dissection along the embryological planes, and adequate bowel margins from the tumor. The preservation of the IMV should reduce impaired venous drainage of the sigmoid colon, which can be associated with anastomotic leakage, without compromising complete mesocolic excision.
An intracorporeal anastomosis for left colonic resection may have the same advantages as for a right hemicolectomy, but can be technically more challenging.
This video shows a laparoscopic left hemicolectomy with manual intracorporeal anastomosis and preservation of the IMV for a tumor of the distal transverse colon.
A Canaveira Manso, M Rosete, R Nemésio, M Fernandes
Surgical intervention
6 months ago
3183 views
28 likes
0 comments
16:43
Laparoscopic left hemicolectomy with manual intracorporeal anastomosis
The best surgical approach for splenic flexure tumors is not well defined yet.
The distal third of the transverse colon has an embryological origin in the hindgut, and the splenic flexure classically shows a dual lymphatic drainage, the proximal retropancreatic and the distal to the lymphatic pedicle of both the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV). Nakagoe et al. showed that the majority of positive nodes have distal lymphatic spread to the paracolic archway and up to the origin of the left colic artery. Lymph nodes of the middle colic artery and its left branch are positive in a small percentage (0 and 4.2% respectively).
As a result, a left segmental colectomy is a valid option for splenic flexure and distal transverse colon tumors because it allows vascular ligation at the root of the vessels, dissection along the embryological planes, and adequate bowel margins from the tumor. The preservation of the IMV should reduce impaired venous drainage of the sigmoid colon, which can be associated with anastomotic leakage, without compromising complete mesocolic excision.
An intracorporeal anastomosis for left colonic resection may have the same advantages as for a right hemicolectomy, but can be technically more challenging.
This video shows a laparoscopic left hemicolectomy with manual intracorporeal anastomosis and preservation of the IMV for a tumor of the distal transverse colon.
Robotic distal pancreatectomy with splenectomy
This is the case of a 73-year-old asymptomatic female patient who presented with an incidental pancreatic lesion on CT-scan. Her previous medical history was relevant for systemic lupus erythematosus. On the CT-scan, a single hypervascular lesion in the arterial phase was identified in the distal pancreas. The lesion size was 3.1 by 3.3 by 4.3cm. Neither suspicious nodes nor distant metastases were found. The patient was considered to be ASA2 and ECOG0.
The patient was placed in a reverse Trendelenburg position. A 12mm port was placed in the umbilicus for the camera, and three 8mm ports were inserted to accommodate the robotic arms, and another 12mm auxiliary port was used.
The greater curvature of the stomach was released from the transverse colon to expose the supramesocolic area. The neck of the pancreas was dissected close to the splenic-mesenteric confluence. The inferior mesenteric vein opening to the splenic vein was identified, clipped and cut. The splenic artery was dissected, clipped and cut close to the celiac trunk. A stapler was placed in the neck of the pancreas and it was safely stapled. The splenic vein was dissected close to the confluence, and then clipped and cut. The distal pancreas and splenic ligaments were cut and . detached. The specimen was removed using a Pfannenstiel’s incision.
The duration of the procedure was 255 minutes. The estimated blood loss was 100mL. The patient was discharged on postoperative day 5 and no complication was observed over a period of 90 days. Pathology confirmed the presence of a neuroendocrine tumor (grade 2) as a 4cm single lesion and negative margins. One positive node was detected among 10 nodes harvested.
R Araujo, MA Sanctis, F Felippe, D Burgardt, D Wohnrath
Surgical intervention
1 year ago
2168 views
7 likes
1 comment
08:04
Robotic distal pancreatectomy with splenectomy
This is the case of a 73-year-old asymptomatic female patient who presented with an incidental pancreatic lesion on CT-scan. Her previous medical history was relevant for systemic lupus erythematosus. On the CT-scan, a single hypervascular lesion in the arterial phase was identified in the distal pancreas. The lesion size was 3.1 by 3.3 by 4.3cm. Neither suspicious nodes nor distant metastases were found. The patient was considered to be ASA2 and ECOG0.
The patient was placed in a reverse Trendelenburg position. A 12mm port was placed in the umbilicus for the camera, and three 8mm ports were inserted to accommodate the robotic arms, and another 12mm auxiliary port was used.
The greater curvature of the stomach was released from the transverse colon to expose the supramesocolic area. The neck of the pancreas was dissected close to the splenic-mesenteric confluence. The inferior mesenteric vein opening to the splenic vein was identified, clipped and cut. The splenic artery was dissected, clipped and cut close to the celiac trunk. A stapler was placed in the neck of the pancreas and it was safely stapled. The splenic vein was dissected close to the confluence, and then clipped and cut. The distal pancreas and splenic ligaments were cut and . detached. The specimen was removed using a Pfannenstiel’s incision.
The duration of the procedure was 255 minutes. The estimated blood loss was 100mL. The patient was discharged on postoperative day 5 and no complication was observed over a period of 90 days. Pathology confirmed the presence of a neuroendocrine tumor (grade 2) as a 4cm single lesion and negative margins. One positive node was detected among 10 nodes harvested.
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
This is the case of a 69-year-old male patient presenting to the emergency department for abdominal pain and fever. After CT-scan and liver MRI, a biliary cystadenoma was suspected. CEA and CA 19-9 were normal. Hydatid cyst serology was negative. Considering the localization and the size of the tumor, a left laparoscopic hepatectomy was indicated. The patient’s surgical history included laparoscopic sigmoidectomy, intestinal occlusion for internal hernia, appendectomy, and bilateral inguinal hernia repair. Dissection of adhesions and cholecystectomy were performed first. After transection of the left hepatic artery and the left portal vein, parenchymal transection was performed by exposing the middle hepatic vein under intermittent clamping using blood flow occlusion. During parenchymal transection, the left hepatic duct and the left hepatic vein were divided. The specimen was extracted through a suprapubic incision. The postoperative outcome was uneventful. Pathological findings showed the presence of a biliary cyst communicating with the biliary system, without any malignant characteristics.
O Soubrane, P Pessaux, E Felli, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
1 year ago
2973 views
5 likes
0 comments
34:11
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
This is the case of a 69-year-old male patient presenting to the emergency department for abdominal pain and fever. After CT-scan and liver MRI, a biliary cystadenoma was suspected. CEA and CA 19-9 were normal. Hydatid cyst serology was negative. Considering the localization and the size of the tumor, a left laparoscopic hepatectomy was indicated. The patient’s surgical history included laparoscopic sigmoidectomy, intestinal occlusion for internal hernia, appendectomy, and bilateral inguinal hernia repair. Dissection of adhesions and cholecystectomy were performed first. After transection of the left hepatic artery and the left portal vein, parenchymal transection was performed by exposing the middle hepatic vein under intermittent clamping using blood flow occlusion. During parenchymal transection, the left hepatic duct and the left hepatic vein were divided. The specimen was extracted through a suprapubic incision. The postoperative outcome was uneventful. Pathological findings showed the presence of a biliary cyst communicating with the biliary system, without any malignant characteristics.
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
WTL Chen, J Verde
Surgical intervention
1 year ago
4614 views
19 likes
0 comments
47:24
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)
Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.
S Puntambekar, V Sharma, H Parikh, G Joshi, S Mitkare, A Dokrimare
Surgical intervention
4 years ago
17132 views
605 likes
0 comments
11:00
Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)
Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.