monthly focus

surgical intervention video

The author presents the case of a 35-year-old male patient who underwent a laparoscopic re-exploration after a laparoscopic subtotal cholecystectomy. Initially, the patient had an acute cholecystitis and a high suspicion of common bile duct lithiasis. He had been managed in another facility with endoscopic retrograde cholangiopancreatography (ERCP). He had a sphincterotomy and 2 stones extracted. He underwent a laparoscopic subtotal cholecystectomy. Following this, the patient complained of right upper quadrant pain. Six weeks later, as an outpatient he was diagnosed with remnant cholecystitis after subtotal reconstituting cholecystectomy.



Take-home messages:

Subtotal cholecystectomy is an appropriate exit strategy to resolve acute biliary pathology and prevent bile duct injury. Although reconstructive subtotal cholecystectomy has a lower rate of bile leak, it has a higher incidence of cholecystitis recurrence. Given the persistence or recurrence of digestive symptoms after a subtotal cholecystectomy, the possibility of recurrence of cholecystitis and the feasibility of cholecystectomy of the gallbladder remnant must be evaluated. 



Bibliography:

1. Jayant M, Kaushik R. Presentation and management of gallbladder remnant after partial cholecystectomy. Trop Gastroenterol. 2013 Apr-Jun;34(2):99-103. doi: 10.7869/tg.2012.106. PMID: 24377158.

2. Henneman, D., da Costa, D.W., Vrouenraets, B.C. et al. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc 27, 351–358 (2013). https://doi.org/10.1007/s00464-012-2458-2

3. Teshima, T., Nitta, H., Mitsuura, C. et al. How to treat remnant cholecystitis after subtotal cholecystectomy: two case reports. surg case rep 7, 109 (2021). https://doi.org/10.1186/s40792-021-01183-x

4. Parkland 4 acute cholecystitis: PAECIF/PAECOF systematic dissection technique, a new proposal for a 100% safe cholecystectomy. N Zaragoza Arias, MD, FJ Martínez Jiménez, MD. Epublication WebSurg.com, Jun 2022;22(06). URL: http://websurg.com/doi/vd01en6684



Gallbladder remnant acute cholecystitis after subtotal reconstituting cholecystectomy

Cholécystite aiguë avec moignon de vésicule biliaire restant après cholécystectomie subtotale reconstituante 

This video presents the case of a 50-year-old woman who underwent a laparoscopic pylorus-preserving pancreaticoduodenectomy (PPPD) for a 4cm mucinous cystic pancreatic neoplasm (MCPN). The authors demonstrate the key steps of this operation using a 3D laparoscopic technique. The pancreaticojejunostomy (PJ) was performed using a duct-to-mucosa technique in the setting of a soft pancreas and small 2mm pancreatic duct. The video shows that the duct-to-mucosa technique for PJ is technically feasible and safe, even in the setting of a soft pancreas and small pancreatic duct – traditionally known as risk factors for post-operative pancreatic fistulae (1). 



Take-home messages:

Our video shows that the duct-to-mucosa technique for pancreaticojejunostomy is technically feasible and safe, even in the setting of a soft pancreas and small pancreatic duct. 



Bibliography:

1. Hassan, R. A., Zidan, A. M., Jabir, M. A., Abdelshafy, M., Abdallah, M., & Taha, A. (2022, August 1). Risk factors predicting the development of a pancreatic fistula following pancreaticoduodenectomy: A retrospective cohort study. International Journal of Surgery Open. https://doi.org/10.1016/j.ijso.2022.100509

Laparoscopic pylorus-preserving pancreaticoduodenectomy for mucinous cystic neoplasm

This video presents the case of a 48-year-old male patient who presented with diarrhea. Colonoscopy showed two ulcerative adenocarcinomas in the descending colon and splenic flexure. CT-scan revealed two liver metastases. It was decided to perform a preoperative chemotherapy to reduce the liver metastases. A hepatectomy and a left colectomy were also performed simultaneously. 



Bibliographic references: 

1. Krell, R. W., & D’Angelica, M. I. (2019). Treatment sequencing for simultaneous colorectal liver metastases. Journal of Surgical Oncology, 119(5), 583‑593. https://doi.org/10.1002/jso.25424 

2. Avella, P., Vaschetti, R., Cappuccio, M., Gambale, F., DE Meis, L., Rafanelli, F., Brunese, M. C., Guerra, G., Scacchi, A., & Rocca, A. (2022). The role of liver surgery in simultaneous synchronous colorectal liver metastases and colorectal cancer resections: A literature review of 1730 patients underwent open and minimally invasive surgery. Minerva Surgery, 77(6), 582 590. https://doi.org/10.23736/S2724-5691.22.09716-7 

3. Reddy, S. K., Pawlik, T. M., Zorzi, D., Gleisner, A. L., Ribero, D., Assumpcao, L., Barbas, A. S., Abdalla, E. K., Choti, M. A., Vauthey, J.-N., Ludwig, K. A., Mantyh, C. R., Morse, M. A., & Clary, B. M. (2007). Simultaneous resections of colorectal cancer and synchronous liver metastases: A multi-institutional analysis. Annals of Surgical Oncology, 14(12), 3481‑3491. https://doi.org/10.1245/s10434-007-9522-5 



Laparoscopic left colectomy and lateral left hepatectomy for colorectal cancer and liver metastasis

Colectomie gauche laparoscopique et hépatectomie latérale gauche pour le traitement d’un cancer colorectal et de métastases hépatiques

Segmentectomie hépatique laparoscopique (segment 1) pour métastase hépatique colorectale en contact avec la veine cave inférieure



This video presents the case of a 67-year-old man who was referred for surgical resection of a metachronous colorectal liver metastasis in liver segment 1, in contact with the inferior vena cava. The diagnosis of a 50mm mass was established after a 20-month oncological follow-up. The patient was asymptomatic. His CEA level was 6.9µg/L. Neoadjuvant chemotherapy with FOLFIRI-bevacizumab was administered but no downsizing was observed after six cycles. As a result, a surgical resection was decided upon. 

The first step of the procedure was a laparoscopic ultrasonographic assessment of the extension of vascular invasion. The evaluation revealed a preserved surface between the tumor and the inferior vena cava. Consequently, the procedure was continued laparoscopically. Liver segment 1 was resected and the inferior vena cava was completely exposed. No vascular resection was required. The postoperative period was uneventful, and the patient was discharged on postoperative day 3. 

Laparoscopic liver surgery offers many advantages when compared to open liver surgery. However, laparoscopy has still not proven its added value in vascular invasion and vascular reconstruction settings. This video aims to show how a stepwise approach with detailed perioperative ultrasonographic evaluation helps to refine the preoperative iconography and tailor the surgical strategy. The value of a meticulous anatomical dissection in laparoscopic liver surgery becomes more evident in cases of possible vascular invasion when precision surgery is vital. 



Bibliography:

1. Ferrero A, Russolillo N, Langella S, Forchino F, Stasi M, Fazio F, Lo Tesoriere R. Ultrasound liver map technique for laparoscopic liver resections: perioperative outcomes are not impaired by technical complexity. Updates Surg. 2019 Mar;71(1):49-56. doi: 10.1007/s13304-019-00646-z. Epub 2019 Mar 27. PMID: 30919242.

2. Kumon M, Kumon T, Tsutsui E, Ebashi C, Namikawa T, Ito K, Sakamoto Y. Definition of the caudate lobe of the liver based on portal segmentation. Glob Health Med. 2020 Oct 31;2(5):328-336. doi: 10.35772/ghm.2020.01088. PMID: 33330828; PMCID: PMC7731356.

Laparoscopic liver segment I resection of colorectal liver metastasis in contact with the inferior vena cava

Laparoscopic left lobectomy for liver perivascular epithelioid cell neoplasm (PEComa) 

Lobectomie gauche laparoscopique pour la prise en charge d’une tumeur des cellules épithélioïdes périvasculaires (PECome) 

Résection laparoscopique du duodénum distal avec préservation du pancréas pour adénome duodénal

Introduction

Small bowel (SB) malignant tumors are rare and cause non-specific symptoms, often leading to a late diagnosis. Most SB adenocarcinomas are found in the duodenum and arise from adenomas. Surgery is usually reserved for endoscopically non-excisable adenomas.



Materials and methods

It is the case of a patient with a D3 duodenal adenoma who underwent a laparoscopic duodenectomy.



Results

This is the case of a 58-year-old woman without any relevant personal medical history. Due to dyspepsia and heartburn, an endoscopy was performed and showed an irregular sessile polyp in the duodenum (D3) located 5cm away from the ampulla of Vater and not excisable endoscopically. A tattoo was performed. Biopsies revealed an adenomatous polyp with low-grade dysplasia (LGD). CT-scan showed a 15 by 13mm polypoid focal parietal thickening in D3, without extraparietal extension. No other changes were noted.

MRI revealed a 19 by 13 by 28mm polypoid lesion in D3 to the right and anteriorly to the abdominal aorta, without invasion of adjacent structures.

A laparoscopic D3-D4 duodenectomy with a mechanical intracorporeal side-to-side duodenojejunostomy were performed uneventfully. Preservation of the ampulla of Vater was confirmed via intraoperative endoscopy. An intraoperative methylene blue test was performed and did not reveal any leaks. The postoperative period was uneventful, and the patient was discharged on postoperative day 5. Histological exam revealed a 45 by 15mm tubulovillous adenoma with low-grade dysplasia. The patient was asymptomatic and was followed up.



Conclusion

SB adenomas are benign lesions with a significant potential to become malignant and develop into villous adenomas. Duodenal adenomas larger than 2cm and with ampullary location carry a higher risk of malignancy. Upper endoscopy is performed either for diagnostic or therapeutic purposes. Endoscopic resection must be performed in experienced centers. Surgery is indicated in cases of endoscopic unresectability. The laparoscopic approach offers the best outcomes.



Bibliography

1. Chathadi K., et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2015 Nov;82(5):773-81.

2. Kemp C., et al. Resection of benign duodenal neoplasms. Am Surg. 2007 Nov;73(11):1086-91.

3. Talamonti MS., et al. Primary cancers of the small bowel: analysis of prognostic factors and results of surgical management. Arch Surg. 2002;137(5):564. 

4. Amitabh Yadav, Samiran Nundy. Case series of non-ampullary duodenal adenomas. Annals of Medicine and Surgery, Volume 69, 2021, 102730, ISSN 2049-0801.

Laparoscopic distal duodenal resection with pancreatic preservation for duodenal adenoma

Polycystic liver disease (PLD) is a rare genetic disease. It is caused by mutations in genes that encode proteins involved in the transport of fluid and growth of hepatic epithelial cells. Such mutations lead to the replacement of normal liver tissue by fluid-filled liver cysts (1). Most patients with PLD are asymptomatic and diagnosed incidentally on imaging (3). Symptomatic patients with PLD that are good surgical candidates should be treated surgically (2) (4). The main goal in such patients is to reduce the intracystic pressure. This can be achieved with unroofing and fenestration of the cysts where possible or with excision of the entire involved liver part (1). Both procedures have a high risk of recurrence, since new cysts could be induced, and some patients may even need liver transplantation (1). 

During surgery, the first step involves the marking of the unroofing line. The excision of the entire cyst’s wall is not the main goal of the procedure, due to a high risk for portal or hepatic vessel injury. When the cyst wall is excised, the omentum should be placed within the cyst’s cavity to prevent recurrence, a technique called omentoplasty. Although uncommon, complications of this procedure include trocar-site infection, bile leakage from cut edges of the cyst, and vascular injuries (2). 



Bibliography: 

1. Kothadia JP, Kreitman K, Shah JM. Polycystic Liver Disease. 2023 Feb 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31751072. 

2. Tanaka M, Inoue Y, Mise Y, Ishizawa T, Arita J, Takahashi Y, Saiura A. Laparoscopic deroofing for polycystic liver disease using laparoscopic fusion indocyanine green fluorescence imaging. Surg Endosc. 2016 Jun;30(6):2620-3. doi: 10.1007/s00464-015-4526-x. Epub 2015 Sep 28. PMID: 26416378. 

3. Kaul V V, Friedenberg F, Rothstein KD. Hepatic Cysts. Curr Treat Options Gastroenterol. 2000 Dec;3(6):439-444. doi: 10.1007/s11938-000-0031-x. PMID: 11096603. 

4. Robert E Glasgow, M. (2022a) Hepatic cysts guidelines, EASL Guidelines on Cystic Liver Disease. Available at: https://emedicine.medscape.com/article/190818-guidelines (Accessed: 24 September 2023). 

Laparoscopic liver cyst unroofing in a patient with polycystic liver disease

Résection d'un kyste hépatique par laparoscopie chez un patient atteint d'une maladie polykystique du foie

This video demonstrates a laparoscopic extrahepatic bile duct resection and a Roux-en-Y hepaticojejunostomy technique in a 48-year-old female patient for a choledochal cyst. Diagnostic imaging performed for abdominal pain was consistent with a Todani type Ic choledochal cyst. She had a surgical history of cholecystectomy for cholecystolithiasis and sleeve gastrectomy for morbid obesity. During the hepaticojejunostomy, tearing of the bile duct and its management are outlined in the video.



Bibliography:

1. Xiao J, Chen M, Hong T, Qu Q, Li B, Liu W, He X. Surgical Management and Prognosis of Congenital Choledochal Cysts in Adults: A Single Asian Center Cohort of 69 Cases. J Oncol. 2022 Jan 21;2022:9930710. doi: 10.1155/2022/9930710. PMID: 35096065

2. Zhang K, Zhao D, Xie X, Wang W, Xiang B. Laparoscopic surgery versus robot-assisted surgery for choledochal cyst excision: A systematic review and meta-analysis. Front Pediatr. 2022 Oct 26;10:987789. doi: 10.3389/fped.2022.987789. PMID: 36389347

3. Yin T, Chen S, Li Q, Huang T, Li L, Diao M. Comparison of outcomes and safety of laparoscopic and robotic-assisted cyst excision and hepaticojejunostomy for choledochal cysts: A systematic review and meta-analysis. Ann Med Surg (Lond). 2022 Feb 26;75:103412. doi: 10.1016/j.amsu.2022.103412. PMID: 35386800



Laparoscopic extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy for choledochal cyst

Résection extrahépatique de la voie biliaire principale par laparoscopie et hépaticojéjunostomie selon Roux pour kyste du cholédoque

A good knowledge of hepatic vascular distribution, both classical and its variations, is essential to plan and perform all surgical and radiological procedures in the upper abdomen. Total replaced hepatic arteries coming from the superior mesenteric artery represent 3 to 5% of all patients and this must be taken into consideration for an adequate periarterial lymphatic adipose tissue dissection and to avoid complications. 



Bibliography:

1. Japanese Gastric Cancer Association. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer 26, 1–25 (2023). https://pubmed.ncbi.nlm.nih.gov/36342574/.

2. Staśkiewicz, G., Torres, K., Denisow, M. et al. Clinically relevant anatomical parameters of the replaced right hepatic artery (RRHA). Surg Radiol Anat 37, 1225–1231 (2015). https://pubmed.ncbi.nlm.nih.gov/25982897/.

3. Huang CM, Chen RF, Chen QY, Wei J, Zheng CH, Li P, Xie JW, Wang JB, Lin JX, Lu J, Cao LL, Lin M. Application Value of a 6-Type Classification System for Common Hepatic Artery Absence During Laparoscopic Radical Resections for Gastric Cancer: A Large-Scale Single-Center Study. Medicine (Baltimore). 2015 https://pubmed.ncbi.nlm.nih.gov/26266363/.

Focus on HPB surgery