monthly focus

video lecture

Chirurgie robotisée du foie

In this key lecture, Dr. John Martinie outlines robotic liver surgery. 

Robotic liver surgery

Segmentectomie anatomique laparoscopique avec coloration de fluorescence par vert d'indocyanine : de S1 à S8

In this key lecture, Dr. Xiaoying Wang focuses on laparoscopic anatomical segmentectomy with ICG fluorescence staining (from S1 to S8).

Laparoscopic anatomical segmentectomy with ICG fluorescence staining: from S1 to S8

surgical intervention video

The authors present the case of a 74-year-old woman with obesity, hypertension, diabetes mellitus, stage 3 chronic kidney disease, and no previous surgeries. She presented at her general practice office with complaints of abdominal pain and sporadic vomiting for the past 6 months. An abdominal CT-scan was requested and the patient was referred to our center. The CT-scan showed a 25mm solid lesion in the proximal portion of the pancreatic tail, with intimate contact with the splenic artery and vein, with the splenomesenteric confluence that was spared. The study was complemented with a thoracic and pelvic CT-scan which did not show any other lesions or any metastatic disease. Tumor markers were evaluated and the CEA marker was elevated. After evaluation in a multidisciplinary meeting, surgical treatment was decided upon and a laparoscopic distal pancreatectomy with splenectomy was put forward to the patient. The objective of the authors was to demonstrate the feasibility and advantage of this approach in an obese patient with multiple comorbidities, and to illustrate oncological safety in case of lesions of adenocarcinoma either suspected or confirmed. 

Laparoscopic distal pancreatectomy with splenectomy for pancreatic adenocarcinoma

Pancréatectomie distale laparoscopique avec splénectomie pour adénocarcinome du pancréas

Pancréatectomie centrale robotisée pour tumeur neuroendocrine chez un patient avec antécédent de bypass gastrique 

In this educational video, authors present the case of a 45-year-old female patient with a diagnosis of a single resectable 12mm histologically proven G1 neuroendocrine tumor (NET) of the pancreatic isthmus. In her past medical history, we noted that a laparoscopic gastric bypass was performed for morbid obesity. Preoperative work-up included pancreatic MRI, thoracic CT-scan, and blood exams. Chromogranin A was within limits. After a multidisciplinary discussion, either resection or surveillance were anticipated considering size and grading. The patient preferred surgical resection in order to avoid any lifelong surveillance and because of the fear of having a pancreatic lesion potentially evolving. A robotic minimally invasive approach was then considered. The surgical strategy focused on the distal pancreatic stump anastomosis. Intraoperative ultrasound confirmed the absence of other pancreatic lesions. A pancreaticogastric anastomosis was performed on the excluded stomach tutored by a biliary catheter. Postoperative outcomes were uneventful, and the patient was discharged on postoperative day 9 (POD 9). The biliary catheter was clamped on POD 14 and withdrawn one month after the operation. 

Robotic central pancreatectomy for neuroendocrine tumor (NET) in a patient with a Roux-en-Y gastric bypass (RYGB)

Sectionectomie latérale gauche robotisée pour carcinome hépatocellulaire sur foie cirrhotique

In this educational video, authors present the case of an 82-year-old female patient affected by hepatitis C virus (HCV) liver fibrosis with a diagnosis of a single resectable 2cm hepatocellular carcinoma (HCC) of the superior border of segment II. Preoperative work-up included liver MRI, thoracic CT-scan, and blood exams. Findings were as follows: Child-Pugh score A5, MELD score 8, normal platelet count, and AFP within normal values. Gastroscopy was normal. After a multidisciplinary discussion, a liver resection was indicated using a robotic minimally invasive approach. During intraoperative ultrasound, after excluding other missed lesions, a careful evaluation of the tumor is performed in order to accurately determine the relationship with the terminal part of the left hepatic vein. A Kelly clamp crushing technique is performed with an assistant-driven irrigation of the instrument. When dissection needs to be more precise, a cavitron ultrasonic surgical aspirator (CUSA) is used, introduced into the assistant trocar and guided via the robotic arm. Final division of the hepatic vein is achieved with scissors after vascular clamping. A double 5/0 polypropylene running suture is performed to close the venous stump. The specimen is then extracted through a Pfannenstiel’s incision. There were no intraoperative complications. The postoperative course was uneventful and the patient was discharged on postoperative day (POD) 4. 

Robotic left lateral sectionectomy for hepatocellular carcinoma (HCC) on cirrhotic liver

Résection robotisée atypique du segment II du foie pour carcinome hépatocellulaire sur foie fibrotique (F3) 

In this educational video, authors present the case of a 78-year-old male patient affected by hepatitis C virus (HCV) cirrhosis with a diagnosis of a single resectable 2cm hepatocellular carcinoma (HCC) of segment II in contact with the end of the left suprahepatic vein. Preoperative work-up included liver MRI, thoracic CT-scan, and blood exams. Findings were as follows: Child-Pugh score A5, MELD score 8, normal platelet count, and AFP within normal values. After a multidisciplinary discussion, a left lateral sectionectomy was indicated using a robotic minimally invasive approach. Intraoperative ultrasound is performed to rule out other missed lesions. Parenchymal transection is then performed with a Kelly clamp crushing technique using intermittent vascular clamping. There were no intraoperative complications. The postoperative course was uneventful and the patient was discharged on postoperative day (POD) 1. 

Robotic atypical resection of liver segment II for hepatocellular carcinoma (HCC) on fibrotic (F3) liver 

Background: Solid pseudopapillary tumors (SPT) are unusual pancreatic neoplasms, accounting for 4% of all cystic pancreatic lesions. Frequently asymptomatic and found in young women, they have and excellent prognosis, although 10 to 15% of the patients show metastasis at the time of surgery. Aims: In this video, authors demonstrate a laparoscopic distal pancreatectomy with preservation of the spleen and its blood supply (Kimura procedure).

Material and methods: This is the case of a 61-year-old female patient, referred to a general surgery consultation due to a pancreatic incidentaloma detected on abdominal ultrasound. CT-scan and MRI showed an 18mm lesion on the anterior surface of the pancreatic body. 68Ga-DOTANOC PET was normal. Endoscopic ultrasound with biopsy was consistent with an SPT. Serologic tumor markers were normal. 

Results: The patient underwent a laparoscopic distal pancreatectomy with preservation of the spleen and its blood vessels (Kimura procedure). Postoperative outcomes were uneventful and the patient was discharged on postoperative day 6. The histopathological analysis showed a solid pseudopapillary pancreatic neoplasia (pTMN: pT1c Nx ILV0 IPN0 R0). The patient was proposed for surveillance. 

Conclusion: The SPT has an indolent behavior and a surgical resection is considered curative in most patients, with an overall 5-year survival as high as 97%. Pancreatic parenchyma preserving resections seems to be associated with a higher risk of recurrence. Lifelong follow-up should be performed as recurrence may occur late.

Solid pseudopapillary tumors of the pancreas: Kimura laparoscopic approach

Tumeurs pseudo-papillaires solides du pancréas : technique de Kimura laparoscopique

In this key lecture, Dr. Asbun outlines the management of intraoperative complications after laparoscopic pancreatectomy.

Management of intraoperative complications after laparoscopic pancreatectomy (stopping bleeding during MIS HPB)

Prise en charge des complications peropératoires après une pancréatectomie laparoscopique (arrêter les saignements pendant une chirurgie hépatopancréatobiliaire mini-invasive)

Focus on laparoscopic and robotic hepatopancreatic surgery