monthly focus

surgical intervention video

In this educational video, the authors present the case of a 50-year-old female patient presenting with a suspicion of alveolar echinococcosis. Her past medical history included epilepsy and resection of a left parietal oligodendroglioma. The patient initially reported abdominal discomfort. A systematic blood exam control showed anicteric cholestasis, and further investigations led to the diagnosis of a 3cm subcapsular cystic lesion in liver segment 8 with intracystic calcifications. MRI and CT-scan confirmed the presence of the cystic lesion at the junction of segment 5 and segment 8 without enhancement, which led to suspect a parasitic cyst. Serological tests for alveolar and cystic echinococcosis were negative, as well as HBV and HCV testing. After a multidisciplinary discussion and imaging analysis, a parasitic cyst was suspected and a robotic surgical resection was proposed. Exploration of the abdominal cavity confirmed the presence of a 3cm subcapsular cystic lesion without any other lesions. Parenchymal transection was then performed with a Kelly clamp crushing technique using intermittent vascular clamping. When dissection had to be more precise, a cavitron ultrasonic surgical aspirator (CUSA) was used and introduced into the assistant trocar and guided via the robotic arm. The postoperative course was uneventful. The patient was discharged on postoperative day 3. Histological findings confirmed the diagnosis of a necrotic cystic lesion without any specified origin.

Robotic atypical resection of liver segments 5-8 for suspected alveolar echinoccocosis

Résection robotique atypique des segments 5-8 du foie pour suspicion d'échinococcose alvéolaire

Pancréatosplénectomie modulaire antérograde radicale (technique RAMPS) avec reconstruction de la veine mésentérique supérieure 

The von Hippel-Lindau disease (VHL) is an autosomal dominant hereditary genetic disease, with a high penetrance, affecting 1 out of 36,000 live births, hence becoming one of the most frequent multisystemic familial cancer syndromes. In this educational video, the authors present the case of a patient with a family history of VHL and with a pancreatic tumor with superior mesenteric vein involvement. A radical antegrade modular pancreatosplenectomy (RAMPS) was proposed with superior mesenteric vein reconstruction to attempt a complete oncological resection as well as an improved lymph node harvesting. 

Radical antegrade modular pancreatosplenectomy (RAMPS) with superior mesenteric vein reconstruction

The laparoscopic Whipple procedure is feasible and adequate in terms of oncological outcomes. It can be performed in selected patients by highly trained laparoscopic teams with an extensive experience in pancreatic and laparoscopic surgery. 

Laparoscopic Whipple procedure with double hepaticojejunostomy after distal pancreatectomy

Procédure de Whipple par laparoscopie avec double hépaticojéjunostomie après pancréatectomie distale

Laparoscopic right hepatectomy is an alternative to open surgery offering not only equivalent oncological results but also a faster recovery associated with an improved pain management among other benefits, even involving complex procedures as a two-step hepatectomy or vascular replacement. However, surgeons need to have an expertise in laparoscopic surgery and open liver surgery. This video shows the case of a 64-year-old man who was evaluated for a cholestatic syndrome. MRI found a lesion in the biliary confluence extending towards the right hepatic duct (Bismuth IIIa type). The CA 19-9 value was 344. After discussion at the institutional interdisciplinary committee, a two-step laparoscopic right hepatectomy with vessel replacement was decided upon due to the portal compromise. 

Laparoscopic two-stage hepatectomy procedure combined with portal vein replacement

Hépatectomie laparoscopique en deux étapes associée à un remplacement de la veine porte

Authors present the case of a young lady presenting with acute abdominal pain after a fatty meal. Investigations revealed a bulky pancreas on ultrasound imaging and acute pancreatitis on CT-scan. The patient was managed with nasojejunal feeds and parenteral nutrition for 6 weeks. She later started to develop a lump in the abdomen and vomiting after oral feeds. CT-scan showed a large pseudocyst of the pancreas approximately 15 by 18cm in size, with necrotic debris at the base. In view of such symptoms, she was planned for internal drainage by performing a stapled laparoscopic cystogastrostomy. She had an uneventful recovery and was discharged on postoperative day 5 after starting a liquid diet. 

Laparoscopic stapled cystogastrostomy for a pseudocyst of the pancreas

Cystogastrostomie laparoscopique par agrafage pour un pseudokyste du pancréas

Choosing the appropriate surgical treatment for pancreatic neuroendocrine tumors (PanNETs) should follow specific criteria based on tumor functionality, histological grade and stage. 

In this video, the authors demonstrate the technique to perform a distal pancreatectomy with splenic preservation, as the patient has a well-differentiated 22 by 18mm pancreatic neuroendocrine tumor, which is an indication for this type of surgical approach. 

Laparoscopic distal pancreatectomy for pancreatic neuroendocrine tumors (PanNETs)

This educational video presents the case of a 60-year-old male patient with no history of morbidity. He consulted for jaundice without associated pain. Lab findings demonstrated a direct predominant hyperbilirubinemia pinpointing a cholestatic profile. Duodenoscopy revealed a papillary tumor positive for adenocarcinoma. An imaging study reported the dilation of intrahepatic and extrahepatic bile ducts with a change in caliber at the level of the duodenal papilla, without compromising mesenteric vessels or the celiac trunk, without any evidence of a systemic disease. The multidisciplinary medical team decided upon a surgical resection of the lesion with curative intent, using a minimally invasive approach, namely a laparoscopic pancreatoduodenectomy. There were no intraoperative complications. Pathological findings reported a moderately differentiated intestinal-type adenocarcinoma, located in the duodenal papilla, with resection margins far from the neoplasm (proximal, distal, pancreatic resection margin, retroperitoneal margin, and bile duct margin). The patient was discharged on postoperative day 7 and tolerated oral feeding. His outcome was uneventful, and he received adjuvant chemotherapy with Folfirinox. Authors describe a laparoscopic pancreatoduodenectomy, emphasizing the anatomical references that must be considered and showing a gastropancreatic anastomosis that uses a purse-string suture, as well as hemostatic sutures between the gastric mucosa and the pancreas. This technique has allowed the authors to reduce the complications related to a postoperative pancreatic fistula, postoperative pain, and to shorten the patient's hospital stay. 

The video learning objectives are the following: 

- To learn the steps of laparoscopic pancreatectomy in a stepwise fashion,

- To expose anatomical landmarks in a clear and educational manner emphasizing the critical steps of the surgery,

- To encourage other surgical teams and serve as a guide when planning this type of procedure, showing potential outcomes and maintaining a culture of safety at all times. 

Focus on liver and pancreatic surgery