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Introduction: 

A left paraduodenal hernia (LPDH) is a rare type of congenital internal hernia caused by an abnormal rotation and fixation of the midgut during embryonic development (1). The small bowel is herniated in the left mesocolon through a congenital opening in the mesenteries known as the fossa of Landzert. The preoperative diagnosis of LPDH is difficult because of its non-specific clinical manifestations (2-3). The laparoscopic repair of paraduodenal hernia is recommended for its minimal invasiveness and postoperative advantages. 

Clinical case presentation: 

We report the case of a 68 year-old woman who was admitted to the emergency room with a history of subacute recurrent abdominal pain that appeared ten days before the admission and suddenly worsened the night before the evaluation in the emergency room. No previous surgery was reported. 

A contrast CT revealed an encapsulated cluster of jejunal loops in the left anterior pararenal space, near the ligament of Treitz, behind the inferior mesenteric vein (IMV), and behind the ascending left colic artery. An emergency laparoscopic surgery was performed. The herniated jejunal loops were replaced and the hernial defect was repaired with 3 stitches of a non-readsorbable suture. The postoperative period was uneventful, without any complications, and the patient was discharged on postoperative day 4. 

Discussion: 

Paraduodenal hernias (PDHs) often occur between the age of 40 and 60 years. Acquired holes are mainly the result of surgery and are often seen in patients undergoing bariatric surgery (4). In the absence of a surgical history and in the presence of radiological findings of small bowel loops in the left anterior pararenal space behind the IMV, a PDH should be considered (5). The laparoscopic treatment of a PHD can reduce hospital stay, promote early feeding, and reduce the incidence of perioperative complications. 

Conclusion: 

The preoperative diagnosis of PDHs is difficult (6). A retrospective study showed that the mortality rate of PHDs is >20%. A contrast CT is mandatory for the diagnosis (7). The surgical strategy to repair the hernial defect depends on several factors such as the size of the hernia sac, the location of the mesenteric vessels, and the presence of intestinal obstruction. Laparoscopic surgery is considered to be a safe surgical approach (8).

References: 

(1). Aga RA, Fowler AJ, Saetta A, Barai I, Rajmohan S et al. Consensus-based surgical case report guidelines. Int J Surg 2016;34:180-6. 

(2). Fukunaga M, Kidokoro A, Iba T. Laparoscopic surgery for left paraduodenal hernia. J Laparoendoscopic Adv Surg Tech A 2004;14:111-5. 

(3). Rollins MD, Glasgow RE. Left paraduodenal hernia. J Am Coll Surg 2004;198:492-3.

(4). Schizas D, Apostolou K, Krivan S et al. Paraduodenal hernias: a systematic review of the literature. Hernia 2019;23:1187-97. 

(5). Blachar A, Federle MP. Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteria. Radiology 2001;218:68-74. 

(6). Blachar A, Federlee MP. Internal hernia: an increasingly common cause of small bowel obstruction. Semin Ultrasound CT MR 2002;23:174-83.

(7). Liu TH. Timing of abdominal CT evaluation impacts diagnosis of paraduodenal hernia. Am Surg 2016;82:546-549. 

(8). Palanivelu C, Rangarajan M, Jategaonkar PA et al. Laparoscopic management of PDHs: mesh and mesh less repairs. A report of four cases. J Gastrointestinal Surg 2007;11:291-5. 

Laparoscopic repair of small bowel obstruction due to left paraduodenal hernia

Prise en charge laparoscopique d'une obstruction de l'intestin grêle due à une hernie paraduodénale gauche

This is the case of a 39-year-old woman with a known medical history of pectus excavatum. She presented with unresolving left-sided pleuritic pain, dry cough, fever, and mild shortness of breath after completing a full course of antibiotics for a suspected pulmonary infection. On physical examination, no abnormal findings were noted. Laboratory results and chest X-ray were unremarkable. A thoracic CT-scan with contrast revealed the presence of an aberrant arterial branch of the distal thoracic aorta connected to lateral and posterior segments of the lower left lobe, suggestive of intralobar pulmonary sequestration. A lower lobectomy performed via video-assisted thoracoscopic surgery was decided upon. The procedure was uneventful and the patient was discharged on postoperative day 8. Pathological findings revealed the presence of an intralobar pulmonary sequestration with bronchiectasis, fibrosis, and chronic inflammatory infiltration. 

References:

1. Nomori H, Shiraishi A, Cong Y, Sugimura H, Mishima S. Differences in postoperative changes in pulmonary functions following segmentectomy compared with lobectomy. Eur J Cardiothorac Surg 2018 1;53(3):640. 

2. Butler JP, Loring SH, Patz S, et al. Evidence for adult lung growth in humans. N Engl J Med 2012; 367: 244–247. 

3. Mizobuchi T, Wada H, Sakairi Y, et al. Spirometric and radiological evaluation of the remnant lung long after major pulmonary resection: can compensatory phenomena be recognized in clinical cases? Surg Today 2014; 44: 1735–1743. 

4. Wang X, Guo H, Hu Q, Ying Y, Chen B. Pulmonary function after segmentectomy versus lobectomy in patients with early-stage non-small-cell lung cancer: a meta-analysis. Journal of International Medical Research. September 2021. doi:10.1177/03000605211044204. 

5. Charloux A, Quoix E. Lung segmentectomy: does it offer a real functional benefit over lobectomy? Eur Respir Rev. 2017 Oct 25;26(146):170079. doi: 10.1183/16000617.0079-2017. PMID: 29070582. 

6. Bédat B, Abdelnour-Berchtold E, Krueger T, et al. Impact of complex segmentectomies by video-assisted thoracic surgery on peri-operative outcomes. J Thorac Dis. 2019;11(10):4109-4118. doi:10.21037/jtd.2019.10.07. 

7. Suzuki K, Saji H, Aokage K, Watanabe SI, Okada M, Mizusawa J, Nakajima R, Tsuboi M, Nakamura S, Nakamura K, Mitsudomi T, Asamura H; West Japan Oncology Group; Japan Clinical Oncology Group. Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial. J Thorac Cardiovasc Surg. 2019 Sep;158(3):895-907. doi: 10.1016/j.jtcvs.2019.03.090. Epub 2019 Apr 9. PMID: 31078312.

8. Saji, Hisashi and Okada, Morihito and Tsuboi, Masahiro and Nakajima, Ryu and Suzuki, Kenji and Aokage, Keiju and Aoki, Tadashi and Okami, Jiro and Yoshino, Ichiro and Ito, Hiroyuki and Okumura, Norihito and Yamaguchi, Masafumi and Ikeda, Norihiko and Wakabayashi, Masashi and Nakamura, Kenichi and Fukuda, Haruhiko and Nakamura, Shinichiro and Mitsudomi, Tetsuya and Watanabe, Shun-ichi and Asamura, Hisao and Group, West Japan Oncology and Group, Japan Clinical Oncology, Segmentectomy Versus Lobectomy in Small-Sized Peripheral Non-Small Cell Lung Cancer (JCOG0802/WJOG4607L): A Multicentre, Randomised, Controlled, Phase 3 Trial. 

9. Wentao Fang, Commentary: Is segmentectomy ready to be accepted as the standard of care?, The Journal of Thoracic and Cardiovascular Surgery, Volume 161, Issue 1, 2021, Pages 292-293, ISSN 0022-5223, https://doi.org/10.1016/j.jtcvs.2020.01.037.

Video-assisted thoracoscopic left lower lobectomy in the treatment of intralobar pulmonary sequestration

Lobectomie inférieure gauche par thoracoscopie vidéo-assistée dans le traitement de la séquestration pulmonaire intralobaire

Authors present the case of a laparoscopic pancreatic enucleation of a clear cell renal cell carcinoma metastatic lesion of the uncinate process. A 43-year-old female patient was admitted with a lesion in the uncinate process. This lesion was detected via 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 a right nephrectomy performed 9 years ago for a clear cell renal cell carcinoma, which was confirmed by the histopathology report. A multidisciplinary investigation was performed. A pancreatic protocol CT-scan revealed a 2.5cm hyper-enhancing round-shaped tumor, located within the uncinate process with no interference with the main pancreatic duct (MPD). Considering the CT-scan characteristics of the lesion and the past medical history of the patient, a clear cell renal cell metastasis was suspected. Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) was performed. Immunohistochemical examination using CD10 confirmed the diagnosis. 

A laparoscopic pancreatic enucleation was planned with a possible Whipple procedure in case the enucleation would turn out to be unfeasible due to such factors as intensive bleeding from an intrapancreatic vessel, unclear borders of the tumor, and high risk of postoperative pancreatic fistula formation. Nevertheless, the attempt to perform enucleation succeeded. 

The postoperative course was uneventful. The drain was removed on postoperative day 3 after amylase level control. Final histopathological examination revealed a clear cell renal cell carcinoma (RCC) metastatic lesion to the pancreas with clear surgical margins. 

The purpose of the video is to demonstrate the feasibility of laparoscopic pancreatic enucleation, which is an organ-preserving procedure and is accompanied by better long-term results. 

Laparoscopic pancreatic enucleation of a clear cell renal cell carcinoma metastasis

Enucléation pancréatique laparoscopique d'une métastase d'un carcinome rénal à cellules claires

Authors present the case of a laparoscopic spleen-preserving distal pancreatectomy with preservation of the splenic artery and vein (Kimura’s procedure). A 26-year-old female patient was admitted to hospital with a neoplasm of the pancreatic tail detected via abdominal ultrasound. A pancreatic protocol CT-scan revealed a 7cm round-shaped tumor in the pancreatic tail. The CT features of the lesion were highly suggestive for a mucinous cystadenoma. A spleen-preserving laparoscopic distal pancreatectomy is considered as the first choice procedure for benign lesions located at the body or tail of the pancreas. It is performed very frequently worldwide. The advantages of splenic preservation are related to the preserved immune function of the organ. The two main surgical techniques, which have been proposed and widely adopted for spleen-preserving laparoscopic distal pancreatectomy include the Warshaw (splenic vessel ligation) and Kimura (splenic vessel preservation) techniques. 

The procedure was complicated due to the large size of the lesion and firm adhesions between the vessels and the tumor. However, splenic vessels were successfully preserved after clipping all branches of the splenic vein and artery. No significant bleeding occurred. The estimated blood loss was 50mL. The operation time was 210 minutes. 

The purpose of the video is to demonstrate the authors' experience in performing Kimura's procedure. 

Laparoscopic spleen-preserving distal pancreatectomy with preservation of the splenic artery and vein (Kimura’s procedure) for a mucinous cystadenoma of the pancreatic tail 

Pancréatectomie distale laparoscopique avec préservation splénique et conservation de l'artère et de la veine spléniques (technique de Kimura) pour cystadénome mucineux de la queue du pancréas

The authors present the case of a 25-year-old female patient who consulted for abdominal pain. Magnetic resonance imaging with contrast showed a 4cm cystic tumor with a calcified capsule, heterogeneous with irregular membranes compatible with a hydatid cyst. The surgical team decided to perform a laparoscopic approach to treat the splenic tumor secondary to a hydatid cyst. The objective of the authors was to demonstrate the advantage of a laparoscopic approach in the treatment of spleen tumors secondary to a hydatid cyst. 

Laparoscopic splenectomy for primary hydatid cyst of the spleen: lateral approach

Splénectomie laparoscopique pour kyste hydatique de la rate : approche latérale

In this educational video, authors present the case of a 40-year-old female patient who underwent a laparoscopic resection of a large retropancreaticoduodenal enlarged lymh node. Her past medical history included a gastric bypass for morbid obesity, asthma, SARS-COV2 disease, and pericarditis. The patient presented with a general deterioration since a few months. Blood tests revealed a persistent inflammatory syndrome and positive antinuclear antibodies. Preoperative work-up included MRI and PET-scan, which revealed hypermetabolic multilocalized adenomegalies above and underneath the diaphragm. The largest one was in a retroduodenopancreatic position. Endoscopic and percutaneous biopsies showed no malignancy. After a multidisciplinary discussion, a minimally invasive lymph node resection was considered. Exploration of the abdominal cavity confirmed the presence of a voluminous 4cm retroduodenopancreatic lymph node. Once a Kocher maneuver was performed, the dissection of the adenomegaly was achieved with bipolar cautery and scissors. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. Pathological findings showed a HHV-8-negative idiopathic multicentric Castleman disease. 

Laparoscopic resection of a pancreaticoduodenal enlarged lymph node

Résection laparoscopique d'un ganglion pancréaticoduodénal hypertrophié

Préservation de l'artère colique gauche lors de la résection du côlon sigmoïde par approche laparoscopique

Preservation of the left colic artery may result in an improved blood supply to the proximal cut end of the sigmoid colon. Lymph node metastasis is one of the most important prognostic factors in patients with colorectal cancer. Lymph node dissection with preservation of the left colic artery has good oncological results, since meta-analyses of clinical studies show no difference in the number of harvested lymph nodes. This ensures the adequacy of staging and the choice of subsequent treatments, thereby ensuring good overall and disease-free survival. Overall and disease-free survival may improve due to a decrease in the incidence of anastomotic leakage. 

Medley of general, digestive, and thoracic surgical procedures