monthly focus

surgical intervention video

Obesity is a worldwide problem. The Roux-en-Y gastric bypass (RYGB) is highly effective in reducing excess body weight and in the management of obesity-related comorbidities. It is a well-tolerated procedure, with excellent results but not exempt from complications. Internal hernias are probably the most feared late complications of RYGB. Petersen’s defect is described as the space between the transverse mesocolon and Roux limb mesentery, and hernias might present as an acute intestinal obstruction or as mild chronic symptoms such as intermittent abdominal cramping, early satiety, and loss of appetite. A hernia through the mesenteric defect at the jejunojejunostomy is also possible and its symptoms can also present in an acute or chronic fashion. The incidence of these hernias can be reduced by closing the mentioned defects during RYGB, but this does not prevent 100% of hernias. 

Resolution is possible, in both cases, by reducing the herniated intestine and closing the defect laparoscopically, but this is usually technically challenging, especially for inexperienced surgeons.

Total herniation of small bowel through Petersen’s and mesenteric defects in the same patient

Hernie totale de l'intestin grêle à travers l'espace de Petersen et la brèche mésentérique chez un même patient

Radical esophagectomy with lymphadenectomy remains the mainstay of curative therapy for esophageal carcinoma. Complete resection of esophagus and regional lymph node (R0) resection are key to improve long-term survival. For carcinomas of the lower third of the esophagus, different tumor characteristics between Western and Eastern countries cause their surgical management to vary. Controversy continues over the optimal extent of lymphadenectomy to be performed with esophagectomy. A total lymphadenectomy is proposed to obtain accurate staging, control locoregional recurrence, and improve long-term survival although it could be technically demanding. We present a case of a minimally invasive Ivor-Lewis resection with total lymphadenectomy and robotic anastomosis. 

Ivor-Lewis total lymphadenectomy with robotic anastomosis for esophageal carcinoma

Lymphadénectomie totale selon Ivor-Lewis avec anastomose robotique pour le carcinome œsophagien

Laparoscopic total gastrectomy is technically feasible, safe, and may offer advantages over open gastrectomy in short-term outcomes for the treatment of gastric cancer. In fact, it is associated with decreased blood loss, less postoperative pain, a faster return of bowel function, a shorter hospital stay, a lower postoperative morbidity, and longer operative times. 

This is the case of a 48-year-old woman who was evaluated for dyspepsia, epigastric pain and asthenia. Upper endoscopy found a gastric lesion on the lesser curvature. The biopsy study confirmed the presence of a poorly cohesive carcinoma with signet ring cells. The CT-scan showed no evidence of the gastric lesion, nor metastasis or lymph nodes affected. 

Surgical treatment was decided upon along with a laparoscopic radical total gastrectomy. An aberrant left hepatic artery arising from the left gastric artery was encountered during the procedure and preserved. 

The procedure was uneventful, and the patient was discharged on postoperative day 7. Pathological findings revealed the presence of a poorly cohesive carcinoma (WHO classification) / diffuse-type adenocarcinoma (Lauren classification) with the following TMN staging: pT1b N0 R0. 



Abbreviations: PHA – Proper Hepatic Artery, CHA – Common Hepatic Artery, GDA – Gastroduodenal Artery, RGA – Right Gastric Artery, LGA – Left Gastric Artery, SA – Splenic Artery, ALHA - Aberrant Left Hepatic Artery

Laparoscopic total gastrectomy with D2 lymphadenectomy in a patient with an aberrant left hepatic artery

Gastrectomie totale laparoscopique avec lymphadénectomie D2 chez une patiente présentant une artère hépatique gauche aberrante

This video shows the case of a patient with a gastric tumor which required a total gastrectomy with D2 lymphadenectomy using a robotic approach, with the particularity that the patient had an accessory left hepatic artery. The objective of the video is to show the technique in a stepwise fashion, with special importance attached to lymphadenectomy. Robotic surgery is increasingly implemented and videos are required to try standardize the technique so that it will become more reproducible. 

Robotic total gastrectomy + D2 lymphadenectomy with preservation of an accessory left hepatic artery

Gastrectomie totale robotisée + lymphadénectomie D2 avec préservation de l'artère hépatique gauche accessoire

Educational objective: The objective of this video is to present the laparoscopic repair of an acutely perforated duodenal bulb ulcer. 

Case presentation: This is the case of a 55-year-old man who was admitted to the emergency department with a 4-hour history of generalized abdominal pain of abrupt onset. Clinical examination findings included a diffusely tender abdomen with involuntary guarding, particularly in the right abdomen. An abdominal CT-scan was performed and the presence of a significant pneumoperitoneum in conjunction with air bubbles, free fluid, gastroduodenal wall edema and associated fat stranding in the periduodenal region were noted, suggestive of a perforated peptic ulcer. The patient underwent an emergent exploratory laparoscopy with the aim of peritoneal lavage and perforation repair. Since the defect was not prohibitively large, it was decided to include a primary suturing in the repair. To augment our repair, an omental patch was constructed over the suture line. The patient had an uneventful postoperative course. 

Discussion: Perforation is a common complication of peptic ulcers, most commonly occurring in the duodenal bulb with a prior history of Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs). Early diagnosis and surgical management of perforated peptic ulcers is associated with an excellent prognosis. The mainstay of surgical treatment is the elimination of the source of the infection, typically with an omentopexy, in conjunction with a thorough peritoneal lavage. 

Conclusions: Laparoscopic repair of acutely perforated duodenal ulcers is feasible and safe in stable patients with simple anterior perforations, even though it requires advanced laparoscopic skills. 

Note from WebSurg reviewers: It is not an advanced procedure, but the first procedure left to young surgeons. The patient can be fed on postoperative day 1 and can be discharged on postoperative day 2. Of note, the use of the nasogastric tube and drain are not validated in the literature and general practice. 

Focus on upper GI surgery

Total herniation of small bowel through Petersen’s and mesenteric defects in the same patient

Ivor-Lewis total lymphadenectomy with robotic anastomosis for esophageal carcinoma

Robotic total gastrectomy + D2 lymphadenectomy with preservation of an accessory left hepatic artery

Laparoscopic total gastrectomy with D2 lymphadenectomy in a patient with an aberrant left hepatic artery

Laparoscopic repair of an acutely perforated duodenal ulcer