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The last contributions
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.
His white blood cell (WBC) count was 11.9x109/L and his C-reactive protein value was 11.7mg/dL.
His abdominal CT-scan and MRI showed a 12.5cm omental mass, suggestive of omental infarction with a hemorrhagic component. His gastroscopy and colonoscopy were negative, and the needle biopsy of the mass was not suggestive of malignancy. Exploratory laparoscopy with biopsy or resection of the omental lesion was indicated. The total duration of the operation was 1 hour, and the omental mass was resected. The patient completely recovered from his symptoms, and was discharged after two days. Final histology of his lesion demonstrated an omental infarction with thrombosis, hemorrhage, and fat cell necrosis.
A twenty-year-old healthy woman was referred to the emergency department with localized discomfort and a foul smelling purulent discharge from the umbilicus with three days of evolution. The patient was afebrile with periumbilical inflammatory signs, without signs of peritoneal irritation on physical exam. Blood tests were all normal, apart from a raised C-reactive protein (2.52mg/dL). Abdominal ultrasound was suggestive of an infected urachal cyst with umbilical fistulization. Empirical treatment with antibiotics was started and an abdominopelvic CT-scan, made as outpatient surgery, showed a probable 26mm urachal cyst, posterior and adjacent to the umbilicus, without bladder attachment.
The patient was treated surgically with a laparoscopic excision of the remainder of the urachus, without intraoperative complications. A good clinical evolution was observed during the hospital stay, and the patient was discharged on the fourth postoperative day. On follow-up, the patient did not complain of anything.
This clinical case emphasizes the importance of the high index of diagnostic suspicion in the management and treatment of the rare causes of abdominal pain, often with the possibility of a minimally invasive approach.
Two female infants diagnosed with type IV and type III sacrococcygeal teratomas underwent preoperative evaluation in the postnatal period. The first patient was an 18-month-old female patient who presented with a metastatic type IV teratoma resected after neoadjuvant therapy. The second patient was a 6-day-old female infant with a prenatal diagnosis of cystic type III teratoma. Using laparoscopy in both patients, the presacral space was reached by opening the peritoneal reflection with blunt dissection and the middle sacral artery was identified. It was then carefully isolated and divided with a 5mm LigaSure™ vessel-sealing device. The pelvic components of the tumors were partially dissected using laparoscopy. The first patient’s tumor resection was completed using a posterior sagittal approach and the second patient required a standard Chevron incision.
Both patients underwent a successful laparoscopic division of the middle sacral artery and resection of the sacrococcygeal teratomas without complications. As a result, laparoscopic middle sacral artery division before sacrococcygeal teratoma excision offers a safe approach which can reduce the risk of hemorrhage during surgery.
Hydatid cyst is a parasitic disease caused by the Echinococcus granulosus tapeworm. Laparoscopic treatment of a hydatid cyst of the liver remains controversial and few series have been published. The aim of this work is to present a case of liver hydatid cyst in an 8-year-old girl treated laparoscopically.
An 8-year-old child was admitted to our department for the management of a voluminous liver hydatid cyst. The patient underwent a thoraco-abdominal CT-scan, which concluded to a left lobe liver hydatid cyst. The laparoscopic open access is achieved at the umbilicus using a 10mm port. Carbon dioxide pneumoperitoneum pressure is maintained at 10mmHg. Two other 5mm ports are introduced in the right and left hypochondrium. A 0-degree laparoscope is then used. The cyst is protected by means of pads filled with a 10% hypertonic saline solution. After we proceed to a puncture aspiration of the cyst, sterilization is achieved via injection of a hypertonic saline solution during 15 minutes, then reaspiration is performed with a Veress needle. The cyst is opened with a coagulating hook and the proligerous membrane is removed and put in a bag. The last step is the resection of the dome and the search for biliary fistula. We drained the residual cavity. The pads are removed. The Redon drain was removed on day 2 and the patient was discharged from hospital on postoperative day 3. Postoperatively, the patient was put on albendazole (10mg/kg) for one month.
Laparoscopy stands for an excellent approach to the treatment of a hydatid cyst of the liver in children by respecting appropriate indications.
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.