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Thoracoscopic thymectomy using a subxiphoid camera port
A 71-year old female patient was admitted with a pancreatic neck lesion detected by abdominal ultrasound performed for mild epigastric pain she has been suffering from for 3 months prior to admission. Her past medical history is significant for right nephrectomy performed 25 years ago. The patient stated that she had an acquired cystic kidney disease, but no medical records were available to confirm that. A multidisciplinary investigation was performed. Pancreatic protocol CT-scan revealed a 2.5cm hyper-enhancing round-shaped tumor, located within the pancreatic neck. The patient had no carcinoid syndrome, and levels of PNET specific markers (Chromogranin A, NSE, Insulin, 5-HIIA) were not elevated. CA 19-9 and CEA levels were also normal. The tumor was [111In]-octreotide negative on octreotide scan. As a result, a non-functioning pancreatic neuroendocrine tumor was suspected considering its CT-scan characteristics.
A laparoscopic pancreatic enucleation was planned with possible central pancreatectomy in case the enucleation would turn out to be unfeasible. The attempt to perform enucleation failed due to intensive bleeding from an intrapancreatic vessel, unclear borders of the tumor, and high risk of postoperative pancreatic fistula formation. It was decided to continue the surgery with central pancreatectomy.
The postoperative course was complicated by a postoperative pancreatic fistula (POPF) grade B (according to the ISGPF classification), which was managed successfully using interventional percutaneous drainage. Final histopathological examination revealed a clear cell renal cell carcinoma (RCC) metastatic lesion to the pancreas. A CT-scan performed 2 years after the surgery revealed no signs of disease progression. The pancreaticojejunostomy shows no signs of obstruction. The patient has neither exocrine nor endocrine pancreatic insufficiency.
The purpose of the video is to demonstrate the feasibility of laparoscopic central pancreatectomy, which is an organ-preserving procedure and is accompanied with better long-term results.
Laparoscopic central pancreatectomy for renal cell carcinoma metastasis
Laparoscopic Sugarbaker parastomal hernia repair
The patient presented with an acute coronary syndrome in the immediate postoperative period, which was managed with medical treatment. Subsequently, the patient had symptoms of paralytic ileus, which were managed conservatively with subsequent recovery of bowel transit. The patient was discharged on postoperative day 10.
Colonic perforation: laparoscopic approach
We present the case of an elderly patient aged 86 with a serious medical history. She is endoscopically diagnosed with a gastric lesion located in the incisura angularis with a biopsy of high-grade dysplasia/carcinoma “in situ”.
Given the patient's age and her medical history, the multidisciplinary committee decided to perform a minimally invasive surgery. Submucosal dissection of the lesion using a hybrid approach (intragastric endoscopy/laparoscopy) was proposed.
The pathological area was marked and stained by endoscopy, followed by intragastric submucosal dissection with laparoscopic instruments assisted by means of endoscopy.
The surgery went smoothly and the patient could be discharged 48 hours after surgery.
Final pathological findings reported a well-differentiated tubular adenocarcinoma infiltrating the lamina propria and surgical resection margins free of tumor infiltration (pT1a Nx Mx (TNM 8th Ed. 2017)).
Endoscopy-assisted laparoscopic intragastric resection of early gastric cancer
Total laparoscopic Hudson’s procedure, pelvic and para-aortic node dissection, omentectomy with primary re-anastomosis and loop ileostomy
Anatomic thoracoscopic repair of esophageal atresia
A 13-year-old boy presented with one-month of dysphagia and a history of a recent tick bite prophylactically treated. Esophagram showed a mid-esophageal externally compressing mass confirmed by endoscopy. Chest MRI showed a 5cm mediastinal mass. Differential diagnosis included infected esophageal duplication cyst versus histoplasmoma. A thoracoscopic mass resection was scheduled.
Upon accessing the right chest, a mid-thoracic lesion next to the esophagus was noted. The mass was adherent to the esophageal wall during dissection. Intraoperative biopsy revealed a cottage cheese-like substance in the mass. Frozen section suspected a duplication cyst in the esophageal musculature. As a result, we proceeded with the resection. The cavity was then irrigated and some fluid was noted at the endotracheal tube. A 5mm right mainstem bronchus tear was found. Flexible bronchoscopy was used to repair the injury with absorbable sutures. The mass was removed from the esophageal wall and repaired with absorbable sutures. A small pleural flap was created to prevent the sutures from communicating. The patient had a small persistent pneumothorax several days postoperatively. Repeat flexible bronchoscopy showed no leak or narrowing on postoperative day (POD) 7. The patient was discharged home on POD 8. Final pathology showed a mediastinal lymph node with a non-caseating granuloma. He had positive antibodies to Francisella tularensis (tularemia Ab). His final diagnosis was mediastinal tularemia.
This video demonstrates mediastinal mass diagnostic and treatment challenges. It also shows that concomitant bronchial injuries are safe and effective to repair thoracoscopically.
Right thoracoscopic mediastinal mass resection and bronchial injury repair