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surgical intervention video

Hépatectomie atypique du segment 8 pour carcinome hépatocellulaire

Hepatocellular carcinoma (HCC) is an aggressive tumor, which often occurs in the context of chronic liver disease and cirrhosis. Up to one-third of cirrhotic patients will develop HCC during their lifetime. The mainstay of therapy for HCCs is surgical resection. 



This video presents the case of a 61-year-old male patient with a BMI of 29 and a past medical history of laparoscopic cholecystectomy and alcoholic cirrhosis, Child Pugh score of A5 and MELD 6, he was diagnosed with a hepatocellular carcinoma. The patient had compensated cirrhosis and had been abstinent for 24 months. While attending a gastroenterology consultation for liver cirrhosis, a CT-scan detected a 2cm mass in hepatic segment 8, LI-RADS 5. It was compatible with hepatocellular carcinoma stage A according to the Barcelona Clinic Liver Cancer (BCLC) staging system and a cT1aN0M0 according to TNM classification. Alphafetoprotein was 4.3 IU/mL and staging with thoraco-abdominal CT revealed no lymph node or distant metastasis. The patient was offered an atypical segmentectomy of hepatic segment 8.



The surgical procedure was guided by means of ultrasound, which allowed the surgeon to more accurately determine the dimensions of the tumor, as well as the anatomical relationships with the hepatic veins and portal system. Before starting liver mobilization or resection, the equipment for a Pringle maneuver was prepared, although this maneuver was unnecessary. The surgery lasted 220 minutes and a total blood loss of 100mL was noted. 



The postoperative period was uneventful, and the patient was discharged on postoperative day 3. The pathological findings confirmed the presence of a 21mm hepatocellular carcinoma, grade 2, and with free margins ≥1mm - pT1bNxMxF1.



At the patient’s one-month follow-up, the patient had no surgical or liver-related complications.

Atypical segment 8 laparoscopic hepatectomy for hepatocellular carcinoma

A superior bisegmentectomy, in essence a laparoscopic anatomical segment 7/8 liver resection, is a hepatic surgery made possible through the presence of an accessory inferior right hepatic vein (IRHV). We present and compare 2 patients with an accessory IRHV who underwent the same surgery, the first for suspected colorectal metastasis and incorporating a Pringle maneuver (PM), and the second for suspected hepatocellular carcinoma and without PM. In both cases, intraoperative ultrasound was used to mark a transection line between the right hepatic vein (RHV) and middle hepatic vein (MHV), with preservation of the MHV. The transection also involved a lateral extension between segment 8 and segment 5. Parenchymal transection was performed with a Cavitron Ultrasonic Surgical Aspirator (CUSA). For both patients, the postoperative course was uneventful, with histology confirming a diagnosis of bile duct adenoma for the first case, and hepatocellular carcinoma for the second case with R0 resection. 

IRHV-preserving laparoscopic superior bisegmentectomy for segment 7/8 tumors: dual comparison

Bisegmentectomie supérieure laparoscopique, préservant la veine hépatique droite inférieure, pour les tumeurs hépatiques (segments 7/8) : double comparaison

This is the case of a 37–year-old male patient who was referred to our unit for altered hepatic enzymes without any specific abdominal symptoms. The patient reported no previous medical history with the exception of a laparoscopic cholecystectomy ten years prior. Blood tests showed elevated cholestasis markers (GGT: 156 IU, NV: 12-68 and ALP: 128 IU, NV: 41-117) with normal bilirubin and transaminases values. A complete cross-sectional imaging work-up was performed (CT-scan and MRI) showing a dilatation of the common bile duct from the biliary confluence up to the papilla of Vater. No suspected duodenal, peri-ampullary or biliary lesion was noted. Cholangiography sequences did not reveal any intraluminal obstruction which could cause this dilatation. Pancreatic parenchyma and Wirsung’s duct were normal. An endoscopic ultrasound was thus performed which showed a dilated common bile duct up to 23mm without any lesion or sign of lithiasis. CPRE confirmed the caliber of the duct associated with a type I pancreatobiliary maljunction according to Kimura (pancreatic duct junction type) and a back flow of the contrast product in the Wirsung’s duct. The diagnosis of a Todani type I bile duct cyst was established and a surgical treatment was proposed for the potential risk of cancer development. 

Robotic common bile duct resection and bilio-enteric anastomosis for Todani type I congenital bile duct cyst

Résection robotique du canal cholédoque et anastomose bilio-entérique pour kyste congénital du canal cholédoque

Background: Intraductal papillary mucinous neoplasm (IPMN) is a benign lesion of the pancreas arising from its own ductal system both in the form of single and multiple lesions. It is generally a benign lesion, but sometimes it may spontaneously become malignant and the diagnosis of neoplastic transformation, when it occurs, is difficult to obtain. Observation is thus warranted for IPMN with a low risk of malignant evolution. Main pancreatic duct (MPD) IPMN or mixed type (MT) IPMN cyst size of greater than 3cm or a dimensional increase >5mm/2 years, enhancing mural nodes and MPD dilatation (5-9mm) are features, which significantly correlate with the risk of malignancy. In these cases, pancreatic resection is appropriated when feasible. Survival after surgery for non-invasive IPMN is excellent. 

Methods: A 75-year-old woman underwent left upper lobectomy for lung cancer. Staging exams revealed a MT IPMN of the pancreatic body with no signs of malignancy. Observation was recommended. A follow-up EUS was performed and showed an increase in size at which time the main cyst was associated with a dilatation of the MPD. Fine needle aspiration (FNA) samples were non-diagnostic. The multidisciplinary board recommended a pancreatic resection. 



Results: Robotic distal pancreatectomy with splenectomy was performed. Pancreatic cysts were removed intact, operative time was 250 minutes, with an estimated blood loss of 150mL. Recovery was uneventful. The patient was discharged on postoperative day 7. Pathological examination revealed IPMN with low-grade dysplasia.



Conclusions: Robotic distal pancreatectomy with splenectomy is safe, feasible, and oncologically appropriate, if performed in specialized centers with experience in pancreatic minimally invasive and advanced surgery. 

Robotic distal pancreatectomy with splenectomy for intraductal papillary mucinous neoplasm (IPMN) of the pancreatic body

Pancréatectomie distale robotisée avec splénectomie pour tumeur intracanalaire papillaire et mucineuse du pancréas (TIPMP)

Colorectal cancer is the second most common cancer in the world and around 50% of patients will develop liver metastasis at some point. Of those, 20% will be candidates for potentially curative liver resection, which dramatically improves long-term survival. Patients must be carefully selected, taking into account clinical, tumor and anatomical factors. The resection could be anatomical or parenchymal-sparing: the key is obtaining clear margins. Minimally invasive resection, in carefully selected patients, has been shown to have superior short-term outcomes and comparable long-term oncologic outcomes.



The authors present a case report of an atypical hepatectomy with wedge gastric resection performed laparoscopically in a patient with hepatic metastasis from colorretal cancer.



A 48-year-old woman with hepatitis B and surgical history of Roux-en-Y gastric bypass was managed by surgery and oncology teams for colorectal cancer since April 2018: the patient underwent left hemicolectomy (pathological report stage was pT3 N1b M0 (IIIB)). The patient underwent adjuvant chemotherapy until November 2018 and was in a follow-up program since. In March 2022, a routine abdominal CT showed a liver lesion in segment II which was not present in previous exams, with suspicion of metastasis. An MRI confirmed the nodule, CEA showed a slight increase and CA 19.9 was negative. The patient was offered systemic chemotherapy, after which the lesion was unchanged. Surgery was proposed in a multidisciplinary oncology setting.



The patient was submitted to laparoscopic metastasectomy of segment II. During the surgery, the gastric pouch from the previous gastric bypass was closely adherent to the metastasis. Therefore, a gastric wedge resection was performed to ensure clear margins. The lesion was identified intraoperatively with laparoscopic ultrasound and indocyanine green fluorescence, administered 24 hours before. The procedure was uneventful, and the patient was discharged on postoperative day 4. Pathological report confirmed a liver metastasis compatible with colon origin with clear margins (the gastric adhesions shows no neoplasia). The patient was offered adjuvant chemotherapy.





A challenging laparoscopic liver resection

Une hépatectomie laparoscopique difficile

We present the case of a 74-year-old Chinese man who underwent a laparoscopic Whipple’s procedure for a 4.4 by 3.0 by 6.2cm multiseptated cystic lesion in the pancreatic uncinate process with enhancing solid components worrisome for malignant transformation. The lesion was noted incidentally on a computed tomography imaging of the thorax, abdomen, and pelvis conducted for prostate cancer staging. In this video, an end-to-end intussuscepting pancreaticojejunostomy performed laparoscopically is demonstrated on a patient with a soft pancreas that does not hold sutures well, and a narrow main pancreatic duct (3 mm). The hepaticojejunostomy was also technically challenging in this patient with a non-dilated, 2 mm common bile duct. Our patient recovered well postoperatively – drain amylase was on a downward trend, and a CT-scan 3 weeks postoperatively showed no anastomotic leak or fluid collection. 

Laparoscopic Whipple procedure with an intussuscepting pancreaticojejunostomy

Intervention laparoscopique de Whipple avec anastomose pancréaticojéjunale invaginante

Recurrent pyogenic cholangitis is a condition characterized by recurrent infections, intraductal calculi, and biliary strictures. The patient was a 70-year-old woman with a background history of open cholecystectomy. She presented with fever, epigastric pain, and abdominal bloating. She was diagnosed with recurrent pyogenic cholangitis. She underwent a laparoscopic adhesiolysis, left hemihepatectomy, total choledochectomy, and Roux-en-Y hepaticojejunostomy. Traditionally, an open approach has been undertaken due to the complexity and potential technical difficulties in performing it laparoscopically. This case illustrates that the laparoscopic approach can be a safe and feasible alternative to open surgery in the definitive management of recurrent pyogenic cholangitis. 

Focus on hepatobiliary and pancreatic surgery