Виртуальный университет

Thoracoscopic thymectomy is currently considered the approach of choice for the treatment of thymic conditions, including myasthenia gravis (MG). It has demonstrated advantages over open approaches, because it reduces postoperative pain, hospital stay, blood loss, promotes early patient discharge, and provides cosmetic improvement. The use of a subxiphoid access, either as a single port or camera-assistant port, grants even greater benefits as it allows the following: visualization of the phrenic nerve to the contralateral phrenic nerve, reaching all the thymus poles and the lower limit of the thyroid gland, peritracheal fat and aortopulmonary window, pericardial dissection and bilateral epiphrenic fat removal. In addition, it facilitates bilateral exploration through a pleural opening without the need to place another trocar on the left, and the use of carbon dioxide throughout the surgery, thereby avoiding sternal retraction. The dissection through the correct planes, and the systematization of the operative technique might reduce time and improve outcomes.

Authors present the case of a laparoscopic central pancreatectomy in a patient with a clear cell renal cell carcinoma metastatic lesion to the pancreatic neck.
A 71-year old female patient was admitted with a pancreatic neck lesion detected by 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 right nephrectomy performed 25 years ago. The patient stated that she had an acquired cystic kidney disease, but no medical records were available to confirm that. A multidisciplinary investigation was performed. Pancreatic protocol CT-scan revealed a 2.5cm hyper-enhancing round-shaped tumor, located within the pancreatic neck. The patient had no carcinoid syndrome, and levels of PNET specific markers (Chromogranin A, NSE, Insulin, 5-HIIA) were not elevated. CA 19-9 and CEA levels were also normal. The tumor was [111In]-octreotide negative on octreotide scan. As a result, a non-functioning pancreatic neuroendocrine tumor was suspected considering its CT-scan characteristics.
A laparoscopic pancreatic enucleation was planned with possible central pancreatectomy in case the enucleation would turn out to be unfeasible. The attempt to perform enucleation failed due to intensive bleeding from an intrapancreatic vessel, unclear borders of the tumor, and high risk of postoperative pancreatic fistula formation. It was decided to continue the surgery with central pancreatectomy.
The postoperative course was complicated by a postoperative pancreatic fistula (POPF) grade B (according to the ISGPF classification), which was managed successfully using interventional percutaneous drainage. Final histopathological examination revealed a clear cell renal cell carcinoma (RCC) metastatic lesion to the pancreas. A CT-scan performed 2 years after the surgery revealed no signs of disease progression. The pancreaticojejunostomy shows no signs of obstruction. The patient has neither exocrine nor endocrine pancreatic insufficiency.
The purpose of the video is to demonstrate the feasibility of laparoscopic central pancreatectomy, which is an organ-preserving procedure and is accompanied with better long-term results.

In this video, authors demonstrate a laparoscopic Sugarbaker technique for parastomal hernia repair using a Gore-Tex mesh in an 18-year-old man with a history of anal cancer status post-abdominoperineal resection with an end colostomy and known chronic parastomal hernia. His history also includes hypoplastic left heart syndrome status post-orthotopic cardiac transplant, DiGeorge syndrome, Hodgkin’s disease type post-transplant lymphoproliferative disease, and immune deficiency. He presented with abdominal pain, nausea, and vomiting secondary to small bowel obstruction at the site of his previous parastomal hernia. CT-scan showed a mesenteric swirl with a transition point. Upon laparoscopy, the parastomal hernia was identified. The bowel was reduced and hernia edges cauterized. Primary repair of the hernia defect was performed using a percutaneous technique. A Jackson-Pratt (JP) drain was left inside the hernia area and exited through a separate part of the abdomen. Following the Sugarbaker technique, a 16 by 20cm Gore-Tex dual mesh plus was used to reinforce the defect. Percutaneous sutures in the four corners secured the mesh. Once the mesh was in the desired location, absorbable tackers were used to attach the mesh to the anterior abdominal wall. Additional percutaneous sutures were added to the medial mesh. The patient recovered well. His nasogastric tube was removed on postoperative day (POD) 4. He was advanced to a regular diet and discharged on POD 7. Surveillance CT showed an intact repair with no recurrence a year after surgery. This case demonstrates a Sugarbaker technique for the closure of parastomal hernias using a Gore-Tex graft for parastomal hernias. The laparoscopic Sugarbaker technique is a safe procedure for the repair of parastomal hernias.

An 89-year-old man was admitted to hospital because of complaints of abdominal pain and diarrhea with a one-month evolution. His medical history included atrial fibrillation for which he was on anticoagulants, type 2 diabetes mellitus, and recurrent syncopes. The patient’s surgical history included cholecystectomy, right inguinal hernioplasty, and prostatectomy. During the performance of a colonoscopy, the patient had an onset of intense and widespread abdominal pain. Colonoscopy showed a suspicion of perforation at the level of the sigmoid colon, without any evidence of tumor-like lesions. CT-scan showed a pneumoperitoneum and perforation at the level of the distal sigmoid colon. It was decided to perform a laparoscopic approach. A perforation was identified in the rectosigmoid junction. The perforation was sutured.
The patient presented with an acute coronary syndrome in the immediate postoperative period, which was managed with medical treatment. Subsequently, the patient had symptoms of paralytic ileus, which were managed conservatively with subsequent recovery of bowel transit. The patient was discharged on postoperative day 10.

In the minimally invasive approach to a gastric pathology, the association of laparoscopy with endoscopy (also called hybrid or collaborative surgery) emerges as an advanced therapeutic option for the surgical treatment of both benign and malignant intragastric lesions in selected patients.
We present the case of an elderly patient aged 86 with a serious medical history. She is endoscopically diagnosed with a gastric lesion located in the incisura angularis with a biopsy of high-grade dysplasia/carcinoma “in situ”.
Given the patient's age and her medical history, the multidisciplinary committee decided to perform a minimally invasive surgery. Submucosal dissection of the lesion using a hybrid approach (intragastric endoscopy/laparoscopy) was proposed.
The pathological area was marked and stained by endoscopy, followed by intragastric submucosal dissection with laparoscopic instruments assisted by means of endoscopy.
The surgery went smoothly and the patient could be discharged 48 hours after surgery.
Final pathological findings reported a well-differentiated tubular adenocarcinoma infiltrating the lamina propria and surgical resection margins free of tumor infiltration (pT1a Nx Mx (TNM 8th Ed. 2017)).

This patient previously underwent a right ovarian cystectomy for endometrioma with final histopathology confirming an endometrioid adenocarcinoma in association with endometriosis (at least FIGO 1C1). Preoperative MRI and CT-scan suggested endometriosis/disease in the rectouterine pouch, with no evidence of disease outside the pelvis. Completion surgery with a Hudson’s procedure and comprehensive surgical staging was planned as a laparoscopic intervention. On initial inspection, intravenous indocyanine green (ICG) was used to facilitate the identification of endometriosis disease in the pelvis. Following surgical staging, including ‘en bloc’ dissection of the uterus, tubes, ovaries, and rectosigmoid, the specimen was removed via the vagina with the aid of an Alexis wound retractor. For re-anastomosis, the distal descending colon was delivered through the vagina, the anvil applied, and the anastomosis completed laparoscopically. This anastomosis was then defunctioned via a loop ileostomy. ICG was used to confirm anastomotic perfusion. The ileostomy was successfully reversed after 10 days facilitating postoperative treatment with chemotherapy.

In this video, we describe the anatomic thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula (ATREA) in patients with different anatomic presentations (newborn with typical anatomy, newborn with azygos lobe, newborn with major vascular malformation) in a stepwise fashion. For detailed information, please consult our paper “Anatomic thoracoscopic repair of esophageal atresia”, by Fonte et al. (2017).

The objective is to demonstrate our technique for thoracoscopic mediastinal mass excision with concomitant bronchial injury repair.
A 13-year-old boy presented with one-month of dysphagia and a history of a recent tick bite prophylactically treated. Esophagram showed a mid-esophageal externally compressing mass confirmed by endoscopy. Chest MRI showed a 5cm mediastinal mass. Differential diagnosis included infected esophageal duplication cyst versus histoplasmoma. A thoracoscopic mass resection was scheduled.
Upon accessing the right chest, a mid-thoracic lesion next to the esophagus was noted. The mass was adherent to the esophageal wall during dissection. Intraoperative biopsy revealed a cottage cheese-like substance in the mass. Frozen section suspected a duplication cyst in the esophageal musculature. As a result, we proceeded with the resection. The cavity was then irrigated and some fluid was noted at the endotracheal tube. A 5mm right mainstem bronchus tear was found. Flexible bronchoscopy was used to repair the injury with absorbable sutures. The mass was removed from the esophageal wall and repaired with absorbable sutures. A small pleural flap was created to prevent the sutures from communicating. The patient had a small persistent pneumothorax several days postoperatively. Repeat flexible bronchoscopy showed no leak or narrowing on postoperative day (POD) 7. The patient was discharged home on POD 8. Final pathology showed a mediastinal lymph node with a non-caseating granuloma. He had positive antibodies to Francisella tularensis (tularemia Ab). His final diagnosis was mediastinal tularemia.
This video demonstrates mediastinal mass diagnostic and treatment challenges. It also shows that concomitant bronchial injuries are safe and effective to repair thoracoscopically.