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Monthly publications

#May 2017
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Intraglissonian approach to the round ligament for left lateral segmentectomy in a large hemangioma
In this video, we present the clinical case of a 65-year-old woman with a large hemangioma involving liver segments II and III. The patient consulted because of epigastric pain and dyspepsia. A laparoscopic approach was performed. Instead of using the conventional extraglissonian approach for left lateral segmentectomy, in this video, we described a new approach which consisted in dissecting and dividing the portal and arterial branches for segments II and III selectively.
The CT-scan shows a large hemangioma occupying almost entirely the left lateral segments. Under general anesthesia, the laparoscopic approach was performed with 4 trocars. By selectively dividing the inflow for these left lateral segments (segments II and III), the parenchymal transection was performed safely, without bleeding, and the left suprahepatic vein could be transected with a stapler very easily. The extraction of the specimen was carried out increasing the incision for the 12mm trocar in the midline. The patient was discharged on postoperative day 4 without complications.
J Aguirrezabalaga, JF Noguera, MD, PhD, M Gomez, I Rey, JI Rivas
Surgical intervention
1 year ago
1478 views
113 likes
0 comments
16:09
Intraglissonian approach to the round ligament for left lateral segmentectomy in a large hemangioma
In this video, we present the clinical case of a 65-year-old woman with a large hemangioma involving liver segments II and III. The patient consulted because of epigastric pain and dyspepsia. A laparoscopic approach was performed. Instead of using the conventional extraglissonian approach for left lateral segmentectomy, in this video, we described a new approach which consisted in dissecting and dividing the portal and arterial branches for segments II and III selectively.
The CT-scan shows a large hemangioma occupying almost entirely the left lateral segments. Under general anesthesia, the laparoscopic approach was performed with 4 trocars. By selectively dividing the inflow for these left lateral segments (segments II and III), the parenchymal transection was performed safely, without bleeding, and the left suprahepatic vein could be transected with a stapler very easily. The extraction of the specimen was carried out increasing the incision for the 12mm trocar in the midline. The patient was discharged on postoperative day 4 without complications.
Basic principles and technical tips for laparoscopic pancreatectomy
With the improved laparoscopic instruments and energy devices, laparoscopy has become increasingly popular among surgeons. In this video, Professor Asbun outlines principles and tips for laparoscopic pancreatectomy. Beginners and young surgeons have to fully commit themselves in the training as there is no shortcut in the learning of laparoscopic surgery. Patient position plays a key role in laparoscopic solid organ surgery. The surgeons are using gravity to make the surgery easier. Placement of ports for pancreaticoduodenectomy in Kocher’s maneuver is as essential as the exposure of the operative field. Camera, laparoscope and instrumentation also play a key role. As energy devices are diverse and since the learning curve is different for each surgeon, the importance of technical tips cannot be neglected. In advanced techniques, HPB training is essential and suturing is the basic and most important part. Exposure, division of the duodenum and hepatoduodenal ligament, SMV-PV trunk exposure, Kocher’s maneuver, pancreatic neck division, identification of the pancreatic duct, uncinate process dissection, SMA dissection, lymph node dissection, and specimen removal represent the steps of the procedure. Laparoscopic surgery should be a standard for distal pancreatectomy. The superiority of laparoscopy over open surgery still needs to be proven as laparoscopy requires a high level of skills.
HJ Asbun
Lecture
1 year ago
4087 views
160 likes
0 comments
33:33
Basic principles and technical tips for laparoscopic pancreatectomy
With the improved laparoscopic instruments and energy devices, laparoscopy has become increasingly popular among surgeons. In this video, Professor Asbun outlines principles and tips for laparoscopic pancreatectomy. Beginners and young surgeons have to fully commit themselves in the training as there is no shortcut in the learning of laparoscopic surgery. Patient position plays a key role in laparoscopic solid organ surgery. The surgeons are using gravity to make the surgery easier. Placement of ports for pancreaticoduodenectomy in Kocher’s maneuver is as essential as the exposure of the operative field. Camera, laparoscope and instrumentation also play a key role. As energy devices are diverse and since the learning curve is different for each surgeon, the importance of technical tips cannot be neglected. In advanced techniques, HPB training is essential and suturing is the basic and most important part. Exposure, division of the duodenum and hepatoduodenal ligament, SMV-PV trunk exposure, Kocher’s maneuver, pancreatic neck division, identification of the pancreatic duct, uncinate process dissection, SMA dissection, lymph node dissection, and specimen removal represent the steps of the procedure. Laparoscopic surgery should be a standard for distal pancreatectomy. The superiority of laparoscopy over open surgery still needs to be proven as laparoscopy requires a high level of skills.
Reduced port laparoscopic pyloroduodenectomy with handsewn Roux-en-Y reconstruction
Background: Reduced port laparoscopic surgery (RPLS) is an evolution of conventional laparoscopic surgery, allowing for enhanced cosmetic outcomes, in addition to a reduced abdominal wall trauma. Tips and tricks are required to complete a procedure using a RPLS.

Video: This video shows a 55-year-old lady who underwent a laparoscopic pyloro-duodenectomy for a duodenal bulb lesion increased in size at endoscopic follow-up. Three trocars were used (a 12mm one in the umbilicus, a 5mm one in the right flank, a 5mm one in the left flank). The exposure of the operative field was enhanced thanks to a temporary percutaneous suture placed into the hepatic round ligament. Perioperative gastroscopy allowed for an adequate resection without too much distance from the margins, and preservation of the entire gastric antrum. The reconstruction was performed through a handsewn end-to-end gastrojejunostomy, with a 50cm alimentary limb, and a semi-mechanical side-to-side jejunojejunostomy. Finally, a gastroscopy was used to test the gastrojejunostomy.

Results: Total operative time was 190 minutes. Perioperative bleeding was 50cc. Postoperative course was uneventful, and the patient was discharged on postoperative day 7. Pathological findings demonstrated a Brunner’s gland hamartoma, with safe distance from the margins.

Conclusions: RPLS is a step forward of conventional laparoscopy. Perioperative gastroscopy is essential to perform safe upper GI resections. br>
G Dapri, NA Bascombe, S Targa
Surgical intervention
1 year ago
726 views
25 likes
0 comments
09:01
Reduced port laparoscopic pyloroduodenectomy with handsewn Roux-en-Y reconstruction
Background: Reduced port laparoscopic surgery (RPLS) is an evolution of conventional laparoscopic surgery, allowing for enhanced cosmetic outcomes, in addition to a reduced abdominal wall trauma. Tips and tricks are required to complete a procedure using a RPLS.

Video: This video shows a 55-year-old lady who underwent a laparoscopic pyloro-duodenectomy for a duodenal bulb lesion increased in size at endoscopic follow-up. Three trocars were used (a 12mm one in the umbilicus, a 5mm one in the right flank, a 5mm one in the left flank). The exposure of the operative field was enhanced thanks to a temporary percutaneous suture placed into the hepatic round ligament. Perioperative gastroscopy allowed for an adequate resection without too much distance from the margins, and preservation of the entire gastric antrum. The reconstruction was performed through a handsewn end-to-end gastrojejunostomy, with a 50cm alimentary limb, and a semi-mechanical side-to-side jejunojejunostomy. Finally, a gastroscopy was used to test the gastrojejunostomy.

Results: Total operative time was 190 minutes. Perioperative bleeding was 50cc. Postoperative course was uneventful, and the patient was discharged on postoperative day 7. Pathological findings demonstrated a Brunner’s gland hamartoma, with safe distance from the margins.

Conclusions: RPLS is a step forward of conventional laparoscopy. Perioperative gastroscopy is essential to perform safe upper GI resections. br>
ERAS, fast track perioperative management in HPB surgery
In this key lecture, Dr. DeJong describes the concept of the enhanced recovery after surgery (ERAS) project with the objectives of fast-track preoperative, intraoperative, and postoperative management in HPB surgery. He highlights a breakthrough project run in the Netherlands with discharge criteria along with other national initiatives in the UK, Sweden, France, and worldwide with examples of randomized clinical trials. He describes the guidelines and initial experience of fast-track liver surgery with the ERAS pancreas program and compares it to the ORANGE-II trial. He outlines the PANDA trial with or without drain, and puts forward the recommendations for perioperative management.
CHC DeJong
Lecture
1 year ago
746 views
49 likes
0 comments
24:01
ERAS, fast track perioperative management in HPB surgery
In this key lecture, Dr. DeJong describes the concept of the enhanced recovery after surgery (ERAS) project with the objectives of fast-track preoperative, intraoperative, and postoperative management in HPB surgery. He highlights a breakthrough project run in the Netherlands with discharge criteria along with other national initiatives in the UK, Sweden, France, and worldwide with examples of randomized clinical trials. He describes the guidelines and initial experience of fast-track liver surgery with the ERAS pancreas program and compares it to the ORANGE-II trial. He outlines the PANDA trial with or without drain, and puts forward the recommendations for perioperative management.
Laparoscopic distal pancreatectomy with splenectomy
In this video, a laparoscopic distal pancreatectomy with a splenectomy is demonstrated. The colon is mobilized from the omentum and the splenic flexure is lowered completely. The dissection is completed towards the right side in order to access the pancreatic isthmus. The dissection is initiated at the level of the inferior pancreatic port in order to identify the mesentericoportal axis. The retropancreatic dissection is performed. The splenic vein and the splenic artery are dissected and taped. A tape is placed around the pancreas in order to facilitate the dissection thanks to the traction exerted. The pancreas is divided by means of a stapler, tan cartridge. The splenic vessels were divided through Hem-o-lok™ Polymer Locking Ligation Systems. The dissection is performed from the right to the left side of the retropancreatic region. The greater omentum is dissected in close contact with the greater curvature of the stomach. The short gastric vessels are progressively divided. The division of the posterior mesogastrium allows to completely free the specimen, which is then placed in a bag. The specimen is removed through a suprapubic Pfannenstiel’s incision.
P Pessaux, R Memeo, V De Blasi, D Mutter, J Marescaux
Surgical intervention
1 year ago
1897 views
160 likes
0 comments
21:51
Laparoscopic distal pancreatectomy with splenectomy
In this video, a laparoscopic distal pancreatectomy with a splenectomy is demonstrated. The colon is mobilized from the omentum and the splenic flexure is lowered completely. The dissection is completed towards the right side in order to access the pancreatic isthmus. The dissection is initiated at the level of the inferior pancreatic port in order to identify the mesentericoportal axis. The retropancreatic dissection is performed. The splenic vein and the splenic artery are dissected and taped. A tape is placed around the pancreas in order to facilitate the dissection thanks to the traction exerted. The pancreas is divided by means of a stapler, tan cartridge. The splenic vessels were divided through Hem-o-lok™ Polymer Locking Ligation Systems. The dissection is performed from the right to the left side of the retropancreatic region. The greater omentum is dissected in close contact with the greater curvature of the stomach. The short gastric vessels are progressively divided. The division of the posterior mesogastrium allows to completely free the specimen, which is then placed in a bag. The specimen is removed through a suprapubic Pfannenstiel’s incision.
Spleen and splenic vessel preserving distal pancreatectomy for bifocal PNET in a young patient with MEN1
In this key lecture, Dr. Conrad outlines key steps related to spleen and splenic vessel preserving distal pancreatectomy, laparoscopic insulinoma enucleation of the posterior pancreatic neck, and laparoscopic partial splenectomy. He stresses the technical aspects of intraoperative ultrasonography, celiac trunk dissection, and gives some recommendations with regards to leak reduction, vascular dissection, and energy device use. He provides tips and tricks for insulinoma dissection and emphasizes key concepts and technical points for main pancreatic duct preservation, hilum dissection, and spleen transection.
C Conrad
Lecture
1 year ago
826 views
65 likes
0 comments
15:24
Spleen and splenic vessel preserving distal pancreatectomy for bifocal PNET in a young patient with MEN1
In this key lecture, Dr. Conrad outlines key steps related to spleen and splenic vessel preserving distal pancreatectomy, laparoscopic insulinoma enucleation of the posterior pancreatic neck, and laparoscopic partial splenectomy. He stresses the technical aspects of intraoperative ultrasonography, celiac trunk dissection, and gives some recommendations with regards to leak reduction, vascular dissection, and energy device use. He provides tips and tricks for insulinoma dissection and emphasizes key concepts and technical points for main pancreatic duct preservation, hilum dissection, and spleen transection.
Robotic pancreaticoduodenectomy for vaterian ampulloma
We report the case of a robot-assisted pancreaticoduodenectomy for vaterian ampulloma. The patient is positioned in the French position with the assistant between the legs and the robot at the head. Five trocars are used: the camera is introduced through the umbilical trocar. The operation begins with the exploration of the peritoneum and of the liver. The gastric antrum is divided. Each structure of the hepatic pedicle is skeletonized. The superior border of the pancreas is dissected, hence allowing to approach the mesentericoportal axis.
The surgeon proceeds to the inferior border of the pancreas in order to find the mesentericoportal axis and to achieve a retropancreatic passage, which is where the pancreas will be divided. The pancreas is divided using the Sonicision™ cordless ultrasonic dissection device. The first jejunal loop is divided with a stapler. The specimen is totally mobilized ‘en bloc’, and freed from the portal vascular axis with a dissection of the right border of the coeliac trunk. At the end of the dissection, the different arterial and venous structures are skeletonized with a lymph node resection. The reconstruction is performed with a pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy.
P Pessaux, R Memeo, V De Blasi, D Mutter, J Marescaux
Surgical intervention
1 year ago
1957 views
233 likes
0 comments
28:02
Robotic pancreaticoduodenectomy for vaterian ampulloma
We report the case of a robot-assisted pancreaticoduodenectomy for vaterian ampulloma. The patient is positioned in the French position with the assistant between the legs and the robot at the head. Five trocars are used: the camera is introduced through the umbilical trocar. The operation begins with the exploration of the peritoneum and of the liver. The gastric antrum is divided. Each structure of the hepatic pedicle is skeletonized. The superior border of the pancreas is dissected, hence allowing to approach the mesentericoportal axis.
The surgeon proceeds to the inferior border of the pancreas in order to find the mesentericoportal axis and to achieve a retropancreatic passage, which is where the pancreas will be divided. The pancreas is divided using the Sonicision™ cordless ultrasonic dissection device. The first jejunal loop is divided with a stapler. The specimen is totally mobilized ‘en bloc’, and freed from the portal vascular axis with a dissection of the right border of the coeliac trunk. At the end of the dissection, the different arterial and venous structures are skeletonized with a lymph node resection. The reconstruction is performed with a pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy.
Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.
G Dapri, NA Bascombe, L Gerard, C Samaniego Ballar, C Jiménez Viñas
Surgical intervention
1 year ago
2220 views
215 likes
0 comments
10:22
Completely intracorporeal handsewn laparoscopic anastomoses during Whipple procedure
Background: Since 1935, the Whipple procedure was described, using conventional open surgery. With the advent of minimally invasive surgery (MIS), it was reported to be feasible also using the latest technology. In this video, the authors demonstrate a full laparoscopic Whipple procedure, performing the three anastomoses using an intracorporeal handsewn method.

Video: A 70-year-old man presenting with an adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma, underwent a laparoscop ic Whipple procedure. Preoperative work-up showed a T3N1M0 tumor.

Results: Total operative time was 8 hours 20minutes; time for the dissection was 6 hours 20 minutes; time for specimen extraction was 20 minutes, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 hour 40 minutes. Operative bleeding was 350cc. The patient was discharged on postoperative day 9. Pathological findings confirmed a moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymph nodes on 23 isolated; 7 edition UICC stage: pT4N1.

Conclusions: The laparoscopic Whipple procedure remains an advanced procedure to be performed laparoscopically and/or using open surgery. All the advantages of MIS such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient’s comfort, and enhanced cosmesis are offered using laparoscopy.