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General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Laparoscopic left lateral sectionectomy for hepatocarcinoma in a cirrhotic patient
This video demonstrates a laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC) in a cirrhotic liver with hemochromatosis. This is the case of a 77-year-old patient who presented with a 40mm HCC located in Couinaud’s liver segment II and III. After left liver mobilization, parenchymal transection was initiated along the left side of the falciform ligament, mainly using the cavitron ultrasonic surgical aspirator (CUSA®). Tissue Select mode was used during the exposure of the vascular structure. The Glissonian pedicles of segments III and II were encircled and transected, and finally the suprahepatic vein was divided using an Endo GIA™ linear stapler. The specimen was extracted with a short suprapubic incision. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of a well-differentiated HCC.
P Pessaux, T Urade, T Wakabayashi, E Felli, A Mazzotta, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
2 months ago
1653 views
7 likes
0 comments
07:22
Laparoscopic left lateral sectionectomy for hepatocarcinoma in a cirrhotic patient
This video demonstrates a laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC) in a cirrhotic liver with hemochromatosis. This is the case of a 77-year-old patient who presented with a 40mm HCC located in Couinaud’s liver segment II and III. After left liver mobilization, parenchymal transection was initiated along the left side of the falciform ligament, mainly using the cavitron ultrasonic surgical aspirator (CUSA®). Tissue Select mode was used during the exposure of the vascular structure. The Glissonian pedicles of segments III and II were encircled and transected, and finally the suprahepatic vein was divided using an Endo GIA™ linear stapler. The specimen was extracted with a short suprapubic incision. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of a well-differentiated HCC.
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
This is the case of a 69-year-old male patient presenting to the emergency department for abdominal pain and fever. After CT-scan and liver MRI, a biliary cystadenoma was suspected. CEA and CA 19-9 were normal. Hydatid cyst serology was negative. Considering the localization and the size of the tumor, a left laparoscopic hepatectomy was indicated. The patient’s surgical history included laparoscopic sigmoidectomy, intestinal occlusion for internal hernia, appendectomy, and bilateral inguinal hernia repair. Dissection of adhesions and cholecystectomy were performed first. After transection of the left hepatic artery and the left portal vein, parenchymal transection was performed by exposing the middle hepatic vein under intermittent clamping using blood flow occlusion. During parenchymal transection, the left hepatic duct and the left hepatic vein were divided. The specimen was extracted through a suprapubic incision. The postoperative outcome was uneventful. Pathological findings showed the presence of a biliary cyst communicating with the biliary system, without any malignant characteristics.
O Soubrane, P Pessaux, E Felli, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
2 months ago
1427 views
2 likes
0 comments
34:11
Laparoscopic left hepatectomy for a suspected biliary cystadenoma
This is the case of a 69-year-old male patient presenting to the emergency department for abdominal pain and fever. After CT-scan and liver MRI, a biliary cystadenoma was suspected. CEA and CA 19-9 were normal. Hydatid cyst serology was negative. Considering the localization and the size of the tumor, a left laparoscopic hepatectomy was indicated. The patient’s surgical history included laparoscopic sigmoidectomy, intestinal occlusion for internal hernia, appendectomy, and bilateral inguinal hernia repair. Dissection of adhesions and cholecystectomy were performed first. After transection of the left hepatic artery and the left portal vein, parenchymal transection was performed by exposing the middle hepatic vein under intermittent clamping using blood flow occlusion. During parenchymal transection, the left hepatic duct and the left hepatic vein were divided. The specimen was extracted through a suprapubic incision. The postoperative outcome was uneventful. Pathological findings showed the presence of a biliary cyst communicating with the biliary system, without any malignant characteristics.
Laparoscopic central hepatectomy using a Glissonian approach for hepatocellular adenoma
A 32-year-old asymptomatic female patient presented an incidental finding of a liver mass during pregnancy. The mass grew during pregnancy, and a biopsy confirmed the diagnosis of hepatocellular adenoma. On MRI, a hypodense 7 by 6.1cm mass with adipose infiltration was identified. Previously, it was a 5.8 by 5.1cm mass, located in liver segments IV, V, and VIII inferiorly.
The cystic duct and its artery were ligated. However, the gallbladder was kept in place for traction. After dissection of the anterior pedicle, a linear stapler was applied. The right lobe was mobilized and the right transection line was made according to the ischemia line of the anterior sector.
During the liver transection of segment IVB, the pedicle was identified, and linear stapling helped to control it. The parenchymal transection was performed with an ultrasonic scalpel and bipolar cautery. The liver surface of the anterior sector was demarcated and transected. Both the left and the right plane of transection were inferiorly joined. The middle and right hepatic vein branches were stapled.
The specimen was mobilized. Argon beam and bipolar forceps provided the hemostasis. The specimen was removed via a Pfannenstiel’s incision and a drain was placed. The duration of the procedure was 345 minutes. The estimated blood loss was 1200mL.
The patient was discharged from the intensive care unit on postoperative day 1 and from hospital on postoperative day 4. No complication was noted in 90 days. Pathological findings showed a mass of 10.7 by 8.4 by 4.8cm. The lesion represented a hepatocellular adenoma with negative margins.
R Araujo, D Burgardt, V Vazquez, F Felippe, MA Sanctis, D Wohnrath
Surgical intervention
2 months ago
498 views
3 likes
0 comments
09:00
Laparoscopic central hepatectomy using a Glissonian approach for hepatocellular adenoma
A 32-year-old asymptomatic female patient presented an incidental finding of a liver mass during pregnancy. The mass grew during pregnancy, and a biopsy confirmed the diagnosis of hepatocellular adenoma. On MRI, a hypodense 7 by 6.1cm mass with adipose infiltration was identified. Previously, it was a 5.8 by 5.1cm mass, located in liver segments IV, V, and VIII inferiorly.
The cystic duct and its artery were ligated. However, the gallbladder was kept in place for traction. After dissection of the anterior pedicle, a linear stapler was applied. The right lobe was mobilized and the right transection line was made according to the ischemia line of the anterior sector.
During the liver transection of segment IVB, the pedicle was identified, and linear stapling helped to control it. The parenchymal transection was performed with an ultrasonic scalpel and bipolar cautery. The liver surface of the anterior sector was demarcated and transected. Both the left and the right plane of transection were inferiorly joined. The middle and right hepatic vein branches were stapled.
The specimen was mobilized. Argon beam and bipolar forceps provided the hemostasis. The specimen was removed via a Pfannenstiel’s incision and a drain was placed. The duration of the procedure was 345 minutes. The estimated blood loss was 1200mL.
The patient was discharged from the intensive care unit on postoperative day 1 and from hospital on postoperative day 4. No complication was noted in 90 days. Pathological findings showed a mass of 10.7 by 8.4 by 4.8cm. The lesion represented a hepatocellular adenoma with negative margins.
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
P Pessaux, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
2 months ago
1271 views
2 likes
0 comments
05:51
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
C Sposito, D Citterio, C Battiston, V Mazzaferro
Surgical intervention
8 months ago
2415 views
8 likes
0 comments
10:57
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
P Pessaux, R Memeo, J Hallet, Z Cherkaoui, D Mutter, J Marescaux
Surgical intervention
1 year ago
6904 views
939 likes
0 comments
32:12
Laparoscopic right hemihepatectomy
A laparoscopic right hemihepatectomy was performed for a gastric liver metastasis. After the dissection of the anatomical structure of the hepatic pedicle and an ultrasound examination, the right portal vein and the right branch of the hepatic artery were clamped, hence allowing to skeletonize the demarcation between the right liver and the left liver. The devascularization line was subsequently marked by means of electrocautery. The right hepatic branch and the right branch of the portal vein were divided between locked clips. The hepatotomy was started. The first very superficial centimeters were dissected using the Sonicision® Cordless Ultrasonic Dissection Device. No pedicular clamping was performed. The dissection followed the ischemic demarcation line between the right liver and the left liver. Hemostasis and biliostasis were completed using the Aquamantys® Bipolar Sealers. Once the first centimeters had been dissected, dissection was carried on using the CUSA™ ultrasonic dissector (Cavitron Ultrasonic Surgical Aspirator). Liver segment I was divided in order to open the posterior aspect of the hilar plate. The dissection was performed on the right border of the vena cava. The hilar plate was dissected, making it possible to control the right branch of the biliary tract intraparenchymally. The right hepatic vein was dissected and divided with an Endo GIA™ linear stapler. Makuuchi’s ligament was subsequently dissected and divided by means of a firing of the Endo GIA™ linear stapler, white cartridge. Mobilization of the right liver was completed by dividing the triangular ligament’s attachments at the level of the diaphragm. The right hepatectomy specimen was introduced into a bag, which was extracted through a suprapubic Pfannenstiel’s incision. Pneumoperitoneum pressure was diminished in order to control hemostasis and biliostasis.
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
O Soubrane, P Pessaux, R Memeo, L Soler, D Mutter, J Marescaux
Surgical intervention
1 year ago
4283 views
568 likes
0 comments
51:19
LIVE INTERACTIVE SURGERY: laparoscopic right hepatectomy in a patient with hepatocellular carcinoma (HCC) and metabolic syndrome
In this live interactive video, Professor Luc Soler provided a brief introduction of 3D reconstruction and modeling for precise tumor localization and future liver remnant before and after chemoembolization and right portal vein embolization. Dr. Soubrane briefly described the main principles, key steps, and preoperative planning in a 62-year-old male patient with hepatocellular carcinoma (HCC) and metabolic syndrome. He demonstrated the main technical aspects of port placement, hepatic pedicle dissection, exploration and dissection of vessels, and transection of liver parenchyma.
Pure laparoscopic Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
J Pekolj, F Alvarez, P Huespe, J Montagné, M Palavecino
Surgical intervention
1 year ago
1231 views
79 likes
0 comments
08:17
Pure laparoscopic Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
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
2 years ago
1626 views
114 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.
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
2 years ago
786 views
50 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.
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
P Pessaux, R Memeo, V De Blasi, D Mutter, T Piardi, J Marescaux
Surgical intervention
3 years ago
682 views
18 likes
0 comments
16:09
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
P Pessaux, J Hallet, R Memeo, S Tzedakis, V De Blasi, D Mutter, J Marescaux, L Soler
Surgical intervention
3 years ago
1686 views
58 likes
0 comments
13:06
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
P Pessaux, R Memeo, J Hargat, S Tzedakis, D Mutter, J Marescaux, L Soler
Surgical intervention
3 years ago
2045 views
42 likes
0 comments
08:07
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
A Prado de Resende
Surgical intervention
3 years ago
1597 views
65 likes
0 comments
26:34
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
Totally laparoscopic liver resection, very low anterior resection and excision of common iliac artery lymph nodes in a patient with rectal cancer and synchronous liver metastases
This is the case of a 62-year-old lady who presented with rectal bleeding four months earlier. Rectosigmoidoscopy, contrast enhanced thoraco-abdominal CT-scan, and pelvic MRI were obtained. A T3 N2 rectal adenocarcinoma 6cm proximal to the dentate line was detected. CT-scan showed that the patient had two liver metastases: one was a 4cm mass located in liver segment II and the other one 1.5cm in liver segment V. Due to the presence of suspected common iliac artery lymph nodes as determined by CT-scan, PET-CT was also obtained, which demonstrated an 18F FDG uptake in the corresponding lymph nodes. A simultaneous resection of all malignant structures was decided upon. With the patient placed in a modified lithotomy position, five trocars were inserted in the upper quadrants to start with liver resection. Left lateral sectionectomy was performed first. After resection of the lesion situated in liver segment V, which was completed without a cholecystectomy, attention was turned towards the rectal procedure. The patient was placed in a Trendelenburg position with the left side tilted upwards. Two additional trocars were placed to facilitate handling. After IMA and IMV division, a standard total mesorectal excision procedure was completed. Common iliac artery lymph nodes were then harvested. The anastomosis was performed using a double-stapling technique. A diverting ileostomy was also fashioned.
MF Can
Surgical intervention
3 years ago
1248 views
38 likes
0 comments
16:08
Totally laparoscopic liver resection, very low anterior resection and excision of common iliac artery lymph nodes in a patient with rectal cancer and synchronous liver metastases
This is the case of a 62-year-old lady who presented with rectal bleeding four months earlier. Rectosigmoidoscopy, contrast enhanced thoraco-abdominal CT-scan, and pelvic MRI were obtained. A T3 N2 rectal adenocarcinoma 6cm proximal to the dentate line was detected. CT-scan showed that the patient had two liver metastases: one was a 4cm mass located in liver segment II and the other one 1.5cm in liver segment V. Due to the presence of suspected common iliac artery lymph nodes as determined by CT-scan, PET-CT was also obtained, which demonstrated an 18F FDG uptake in the corresponding lymph nodes. A simultaneous resection of all malignant structures was decided upon. With the patient placed in a modified lithotomy position, five trocars were inserted in the upper quadrants to start with liver resection. Left lateral sectionectomy was performed first. After resection of the lesion situated in liver segment V, which was completed without a cholecystectomy, attention was turned towards the rectal procedure. The patient was placed in a Trendelenburg position with the left side tilted upwards. Two additional trocars were placed to facilitate handling. After IMA and IMV division, a standard total mesorectal excision procedure was completed. Common iliac artery lymph nodes were then harvested. The anastomosis was performed using a double-stapling technique. A diverting ileostomy was also fashioned.
Laparoscopic right hemihepatectomy with augmented reality
We report the case of a 42-year-old woman who underwent a laparoscopic right hemihepatectomy for a hepatic metastasis. The intervention is begun with the exploration of the entire peritoneal cavity and an intraoperative ultrasound exam of the liver. The lesion is identified by means of augmented reality. Dissection of the different vascular structures is then performed at the level of the hepatic pedicle. A clamping test of the right branches is achieved. The right branch of the hepatic artery and the right portal vein are clamped, hence creating the demarcation area, which is identified by means of the coagulating hook. Declamping of portal and arterial structures coursing towards the right liver is achieved. The right branch of the portal vein is divided between two clips. The right branch of the hepatic vein is also divided between two clips. After mobilization of the right liver, the hepatotomy is begun. The first superficial centimeters are divided using an ultrasonic dissector (Ultracision®). Dissection is then carried on by means of a Cusa® Dissectron® Ultrasonic Surgical Aspirator. The largest structures are subsequently dissected intraparenchymally, and then clipped and divided. Hemostasis is completed using a radiofrequency instrument. The right biliary tract is dissected intraparenchymally, clipped and divided. The right hepatic vein is divided by means of a stapler. The specimen is placed in a bag, which is extracted by means of a small Pfannenstiel incision. Hemostasis is controlled as the pneumoperitoneum is reduced. A blade is positioned in the hepatectomy area.
P Pessaux, J Hallet, R Memeo, X Untereiner, L Soler, D Mutter, J Marescaux
Surgical intervention
4 years ago
2477 views
68 likes
0 comments
12:53
Laparoscopic right hemihepatectomy with augmented reality
We report the case of a 42-year-old woman who underwent a laparoscopic right hemihepatectomy for a hepatic metastasis. The intervention is begun with the exploration of the entire peritoneal cavity and an intraoperative ultrasound exam of the liver. The lesion is identified by means of augmented reality. Dissection of the different vascular structures is then performed at the level of the hepatic pedicle. A clamping test of the right branches is achieved. The right branch of the hepatic artery and the right portal vein are clamped, hence creating the demarcation area, which is identified by means of the coagulating hook. Declamping of portal and arterial structures coursing towards the right liver is achieved. The right branch of the portal vein is divided between two clips. The right branch of the hepatic vein is also divided between two clips. After mobilization of the right liver, the hepatotomy is begun. The first superficial centimeters are divided using an ultrasonic dissector (Ultracision®). Dissection is then carried on by means of a Cusa® Dissectron® Ultrasonic Surgical Aspirator. The largest structures are subsequently dissected intraparenchymally, and then clipped and divided. Hemostasis is completed using a radiofrequency instrument. The right biliary tract is dissected intraparenchymally, clipped and divided. The right hepatic vein is divided by means of a stapler. The specimen is placed in a bag, which is extracted by means of a small Pfannenstiel incision. Hemostasis is controlled as the pneumoperitoneum is reduced. A blade is positioned in the hepatectomy area.
Pure laparoscopic posterior sectionectomy and wedge resections for bilobar colorectal liver metastases
We report the case of a 74-year-old gentleman who underwent a laparoscopic liver resection for bilobar colorectal liver metastases. The patient presented with newly diagnosed liver metastases one year after undergoing a right hemi-colectomy followed by six cycles of adjuvant chemotherapy for a T3N1 adenocarcinoma. After six cycles of preoperative systemic therapy, a 30 percent reduction in the volume of the liver lesions is obtained. Preoperative three-dimensional reconstruction of the cross-sectional imaging is obtained to plan a laparoscopic liver resection. Virtual hepatectomy is then performed using the virtual three-dimensional model. Five trocars are used as depicted. The camera is initially positioned in a 10mm umbilical port. It will be placed in a 12mm port during parenchymal transection. The subxiphoid port is used by the assistant for liver traction and suctioning. The procedure is initiated by lyzing adhesions that resulted from the previous cholecystectomy and right hemi-colectomy. An umbilical tape is placed around the portal pedicle for eventual intermittent clamping during the resection. An intraoperative ultrasound confirms that no additional lesions are present. The transection line is drawn on the liver surface under ultrasound guidance.
The portal pedicle is clamped to begin the parenchymal transection. The liver capsule is first divided using an energy device. Deeper parenchymal transection is performed with an ultrasonic dissector. After 15 minutes, the pedicle clamping is taken down by melting and extracting the proximal clip previously placed. This procedure will be repeated throughout the parenchymal transection to obtain a posterior sectionectomy. Hemostasis of the transected liver is obtained. A non-anatomical segment III resection is then performed. Finally, the fourth lesion is resected with a non-anatomical segment IV resection. These specimens are placed in a bag and extracted through a small extension of the umbilical port.
P Pessaux, J Hallet, R Memeo, D Mutter, J Marescaux
Surgical intervention
4 years ago
1787 views
54 likes
0 comments
10:01
Pure laparoscopic posterior sectionectomy and wedge resections for bilobar colorectal liver metastases
We report the case of a 74-year-old gentleman who underwent a laparoscopic liver resection for bilobar colorectal liver metastases. The patient presented with newly diagnosed liver metastases one year after undergoing a right hemi-colectomy followed by six cycles of adjuvant chemotherapy for a T3N1 adenocarcinoma. After six cycles of preoperative systemic therapy, a 30 percent reduction in the volume of the liver lesions is obtained. Preoperative three-dimensional reconstruction of the cross-sectional imaging is obtained to plan a laparoscopic liver resection. Virtual hepatectomy is then performed using the virtual three-dimensional model. Five trocars are used as depicted. The camera is initially positioned in a 10mm umbilical port. It will be placed in a 12mm port during parenchymal transection. The subxiphoid port is used by the assistant for liver traction and suctioning. The procedure is initiated by lyzing adhesions that resulted from the previous cholecystectomy and right hemi-colectomy. An umbilical tape is placed around the portal pedicle for eventual intermittent clamping during the resection. An intraoperative ultrasound confirms that no additional lesions are present. The transection line is drawn on the liver surface under ultrasound guidance.
The portal pedicle is clamped to begin the parenchymal transection. The liver capsule is first divided using an energy device. Deeper parenchymal transection is performed with an ultrasonic dissector. After 15 minutes, the pedicle clamping is taken down by melting and extracting the proximal clip previously placed. This procedure will be repeated throughout the parenchymal transection to obtain a posterior sectionectomy. Hemostasis of the transected liver is obtained. A non-anatomical segment III resection is then performed. Finally, the fourth lesion is resected with a non-anatomical segment IV resection. These specimens are placed in a bag and extracted through a small extension of the umbilical port.
Laparoscopic right hepatectomy using hanging maneuver and Glissonian approach
Background: In open surgery for major hepatectomies, the Glissonian approach and liver hanging maneuver have proven useful. However, these techniques are not routinely applied in a laparoscopic context due to some intrinsic difficulty. Published techniques for laparoscopic major hepatectomy generally involve hilar dissection with separate transection of vasculo-biliary elements and anatomical parenchymal transection along the demarcation line. This video demonstrates the feasibility of the Glissonian approach and liver hanging maneuver that were performed for total laparoscopic right hepatectomy.
Methods: A 57-year-old woman suffering from huge liver mass was referred for surgical treatment. A total laparoscopic right hepatectomy was performed for this lesion. The operation followed 5 distinct phases: early hanging maneuver, extrahepatic extrafascial access to the right portal pedicle, parenchymal transection, control and division of the right hepatic vein, and complete mobilization of the right liver.
Results: Operative time was 400 min. The estimated blood loss was 150mL and no need for blood transfusion. The pathological examination confirmed an 8 by 6 by 7cm HCC with clear surgical margins. Patient recovery was uneventful, and the patient was discharged on postoperative day 6.
Conclusions Glissonian approach and hanging maneuver have proven to be safe and useful procedures for performing precise laparoscopic right hepatectomy.
R Chanwat, C Bunchaliew
Surgical intervention
4 years ago
3027 views
67 likes
0 comments
07:27
Laparoscopic right hepatectomy using hanging maneuver and Glissonian approach
Background: In open surgery for major hepatectomies, the Glissonian approach and liver hanging maneuver have proven useful. However, these techniques are not routinely applied in a laparoscopic context due to some intrinsic difficulty. Published techniques for laparoscopic major hepatectomy generally involve hilar dissection with separate transection of vasculo-biliary elements and anatomical parenchymal transection along the demarcation line. This video demonstrates the feasibility of the Glissonian approach and liver hanging maneuver that were performed for total laparoscopic right hepatectomy.
Methods: A 57-year-old woman suffering from huge liver mass was referred for surgical treatment. A total laparoscopic right hepatectomy was performed for this lesion. The operation followed 5 distinct phases: early hanging maneuver, extrahepatic extrafascial access to the right portal pedicle, parenchymal transection, control and division of the right hepatic vein, and complete mobilization of the right liver.
Results: Operative time was 400 min. The estimated blood loss was 150mL and no need for blood transfusion. The pathological examination confirmed an 8 by 6 by 7cm HCC with clear surgical margins. Patient recovery was uneventful, and the patient was discharged on postoperative day 6.
Conclusions Glissonian approach and hanging maneuver have proven to be safe and useful procedures for performing precise laparoscopic right hepatectomy.
Laparoscopic resection and radiofrequency thermal ablation for colorectal liver metastasis
We report a case of laparoscopic hepatic resection combined with radiofrequency thermoablation for colonic liver metastases. A 55-year old female patient underwent a laparoscopic right colectomy for a pT2N0 right colon adenocarcinoma and she presented 18 months after liver metastases. The procedure begins with the exploration of the entire peritoneal cavity and an intraoperative ultrasonography was performed. At the left liver lobe, the lesion situated at the upper part of segment 2 is identified, allowing for the placement of a 3cm radiofrequency needle within the lesion treated for 20 minutes. A clamping of the hepatic pedicle is then performed. An atypical resection of the liver’s 5th segment is decided upon. No drainage was used and the patient was discharged on postoperative day 5. The postoperative CT-scan confirmed the correct thermoablation of the lesion in segment 2 of the liver.
P Pessaux, D Ntourakis, S Varatharajah, D Mutter, J Marescaux
Surgical intervention
4 years ago
2100 views
7 likes
0 comments
06:29
Laparoscopic resection and radiofrequency thermal ablation for colorectal liver metastasis
We report a case of laparoscopic hepatic resection combined with radiofrequency thermoablation for colonic liver metastases. A 55-year old female patient underwent a laparoscopic right colectomy for a pT2N0 right colon adenocarcinoma and she presented 18 months after liver metastases. The procedure begins with the exploration of the entire peritoneal cavity and an intraoperative ultrasonography was performed. At the left liver lobe, the lesion situated at the upper part of segment 2 is identified, allowing for the placement of a 3cm radiofrequency needle within the lesion treated for 20 minutes. A clamping of the hepatic pedicle is then performed. An atypical resection of the liver’s 5th segment is decided upon. No drainage was used and the patient was discharged on postoperative day 5. The postoperative CT-scan confirmed the correct thermoablation of the lesion in segment 2 of the liver.
Laparoscopic left lateral sectionectomy for hepatocarcinoma on cirrhotic liver
We report the case of a 73-year old patient presenting with a Child-Pugh class A5, post-viral B cirrhosis, with no portal hypertension in which a laparoscopic left lateral sectionectomy is performed for hepatocarcinoma. Four ports are placed. Parenchymal transection is marked approximately 1cm to the left of the falciform ligament and parenchymal transection is initiated. With intermittent clamping, hepatotomy is performed painstakingly and progressively, and every vascular or biliary structure that one comes across is either clipped, or coagulated. The specimen is extracted using a suprapubic Pfannenstiel’s incision. Pathological findings confirm the presence of a hepatocarcinoma on a cirrhotic liver. No drainage was used. The postoperative outcome was uneventful. The patient was discharged on postoperative day 6.
P Pessaux, D Ntourakis, M Shen, J Marescaux
Surgical intervention
4 years ago
2132 views
54 likes
0 comments
10:24
Laparoscopic left lateral sectionectomy for hepatocarcinoma on cirrhotic liver
We report the case of a 73-year old patient presenting with a Child-Pugh class A5, post-viral B cirrhosis, with no portal hypertension in which a laparoscopic left lateral sectionectomy is performed for hepatocarcinoma. Four ports are placed. Parenchymal transection is marked approximately 1cm to the left of the falciform ligament and parenchymal transection is initiated. With intermittent clamping, hepatotomy is performed painstakingly and progressively, and every vascular or biliary structure that one comes across is either clipped, or coagulated. The specimen is extracted using a suprapubic Pfannenstiel’s incision. Pathological findings confirm the presence of a hepatocarcinoma on a cirrhotic liver. No drainage was used. The postoperative outcome was uneventful. The patient was discharged on postoperative day 6.
Transumbilical single incision laparoscopic pericystectomy of liver segment 7
Background: Transumbilical single incision laparoscopy has recently sparked interest mainly to improve cosmetic outcomes, while other potential advantages are currently under evaluation. This video presents a pericystectomy of liver segment 7 performed in a patient with a hydatic cyst.

Clinical case: A 26-year-old female, without any surgical history but with a body mass index of 20.6 kg/m2 consulted for a hepatic lesion. Preoperative work-up showed a hydatic cyst of liver segment 7 with renal adhesions. The procedure was performed using an 11mm reusable port to accommodate a 10mm, 30-degree standard length scope, reusable curved instruments according to Dapri (Karl Storz Endoskope), and a straight Ligasure™ V (Covidien). Intraoperative ultrasonography allowed to identify the edges of pericystectomy. The specimen was retrieved through the umbilicus in a custom-made plastic bag, and morcellated at that level.

Results: No conversion to open surgery nor insertion of additional ports were necessary. Laparoscopy took 160 minutes, and the final umbilical incision length was 16mm. Pathologic data confirmed the presence of a hydatic cyst. The patient was discharged on postoperative day 5.

Conclusions: Transumbilical single incision laparoscopy is beneficial in liver surgery for benign lesions, due to minimal final scar length, which has cosmetic as well as additional potential advantages that need to be further investigated.
G Dapri, V Donckier
Surgical intervention
6 years ago
2801 views
66 likes
0 comments
05:40
Transumbilical single incision laparoscopic pericystectomy of liver segment 7
Background: Transumbilical single incision laparoscopy has recently sparked interest mainly to improve cosmetic outcomes, while other potential advantages are currently under evaluation. This video presents a pericystectomy of liver segment 7 performed in a patient with a hydatic cyst.

Clinical case: A 26-year-old female, without any surgical history but with a body mass index of 20.6 kg/m2 consulted for a hepatic lesion. Preoperative work-up showed a hydatic cyst of liver segment 7 with renal adhesions. The procedure was performed using an 11mm reusable port to accommodate a 10mm, 30-degree standard length scope, reusable curved instruments according to Dapri (Karl Storz Endoskope), and a straight Ligasure™ V (Covidien). Intraoperative ultrasonography allowed to identify the edges of pericystectomy. The specimen was retrieved through the umbilicus in a custom-made plastic bag, and morcellated at that level.

Results: No conversion to open surgery nor insertion of additional ports were necessary. Laparoscopy took 160 minutes, and the final umbilical incision length was 16mm. Pathologic data confirmed the presence of a hydatic cyst. The patient was discharged on postoperative day 5.

Conclusions: Transumbilical single incision laparoscopy is beneficial in liver surgery for benign lesions, due to minimal final scar length, which has cosmetic as well as additional potential advantages that need to be further investigated.
Total laparoscopic right hepatectomy for large hepatoma using the Glissonian pedicle control with anterior approach
Background: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic right hepatectomy remains a challenging procedure, especially in patients with large tumor. This video illustrates a useful technique for total laparoscopic right hepatectomy which was successfully performed in patient with large hepatoma.

Methods: We demonstrate the case of a patient with a large tumor located in the right liver who underwent a total laparoscopic right hepatectomy. An anterior approach technique combined with Glissonian approach were used. The main steps of this technique are extraparenchymal control of right Glissonian pedicle en masse without liver dissection, parenchymal transection along the demarcation line, transection of right Glissonian pedicle, separation of whole right liver parenchyma, control and division of right hepatic vein and mobilization of the right liver from surrounding ligaments. No Pringle's maneuver was used.

Results: The technique was successfully performed without complication. Operative time was 560 min. Intraoperative blood loss was 1.100mL. The length of hospital stay was 6 days. The pathological report was well-differentiated HCC and free surgical margin.

Conclusion: Total laparoscopic right hepatectomy for large hepatoma by using the Glissonian pedicle control with anterior approach is feasible and safe.
R Chanwat, C Bunchaliew, T Khuhaprema
Surgical intervention
6 years ago
6208 views
40 likes
4 comments
09:19
Total laparoscopic right hepatectomy for large hepatoma using the Glissonian pedicle control with anterior approach
Background: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic right hepatectomy remains a challenging procedure, especially in patients with large tumor. This video illustrates a useful technique for total laparoscopic right hepatectomy which was successfully performed in patient with large hepatoma.

Methods: We demonstrate the case of a patient with a large tumor located in the right liver who underwent a total laparoscopic right hepatectomy. An anterior approach technique combined with Glissonian approach were used. The main steps of this technique are extraparenchymal control of right Glissonian pedicle en masse without liver dissection, parenchymal transection along the demarcation line, transection of right Glissonian pedicle, separation of whole right liver parenchyma, control and division of right hepatic vein and mobilization of the right liver from surrounding ligaments. No Pringle's maneuver was used.

Results: The technique was successfully performed without complication. Operative time was 560 min. Intraoperative blood loss was 1.100mL. The length of hospital stay was 6 days. The pathological report was well-differentiated HCC and free surgical margin.

Conclusion: Total laparoscopic right hepatectomy for large hepatoma by using the Glissonian pedicle control with anterior approach is feasible and safe.
Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
U Cillo, E Gringeri, R Boetto, G Zanus
Surgical intervention
6 years ago
3909 views
30 likes
1 comment
05:20
Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
Laparoscopic right hemihepatectomy for polyadenomatosis
Hepatic adenomatosis was first described in 1985 by Flejou et al. as multiple adenomas (arbitrarily more than 10), in an otherwise normal liver parenchyma. Several authors have suggested that it is a distinct entity from hepatic adenoma, which is predominantly seen in young women taking oral contraceptives. Although considered a benign disease, it can be associated with potentially fatal complications such as malignant transformation and intraperitoneal hemorrhage due to rupture. Currently, there is no consensus on patient management. However, surgical removal of large lesions may significantly improve symptoms and reduce the risk of complications. Genetic counselling may now play an important role in case management.
We report the case of a 33-year-old woman who underwent a laparoscopic right liver resection for multiple liver adenomatosis. This patient had already had a right liver-appended adenoma resected as well as a cholecystectomy. Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. Hepatic inflow is taken extraparenchymally before the transection of the hepatic parenchyma in an anterior to posterior fashion.
P Pessaux, A Sa Cunha, E Marzano, T Piardi, J Marescaux
Surgical intervention
6 years ago
2726 views
15 likes
0 comments
20:21
Laparoscopic right hemihepatectomy for polyadenomatosis
Hepatic adenomatosis was first described in 1985 by Flejou et al. as multiple adenomas (arbitrarily more than 10), in an otherwise normal liver parenchyma. Several authors have suggested that it is a distinct entity from hepatic adenoma, which is predominantly seen in young women taking oral contraceptives. Although considered a benign disease, it can be associated with potentially fatal complications such as malignant transformation and intraperitoneal hemorrhage due to rupture. Currently, there is no consensus on patient management. However, surgical removal of large lesions may significantly improve symptoms and reduce the risk of complications. Genetic counselling may now play an important role in case management.
We report the case of a 33-year-old woman who underwent a laparoscopic right liver resection for multiple liver adenomatosis. This patient had already had a right liver-appended adenoma resected as well as a cholecystectomy. Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. Hepatic inflow is taken extraparenchymally before the transection of the hepatic parenchyma in an anterior to posterior fashion.
Single incision transumbilical laparoscopic left hepatic lobectomy
Background: Single-incision laparoscopy (SIL) recently gained interest mainly to improve the cosmetic outcomes. This video shows a patient submitted to left hepatic lobectomy by transumbilical SIL.

Video: A 24 year-old woman with a BMI of 24.4 kg/m2 consulted for a hydatid cyst of the II-III hepatic segments. Preoperative work-up showed a hepatic hydatid cyst of the segment III, partially involving the segment II. A transumbilical SIL was performed using an 11mm trocar for a 10mm, standard length, 30-degree scope, and a curved grasping forceps, and Ligasure V. At the end of the resection, a custom-made plastic bag was inserted in the abdomen through the 11mm trocar, and the specimen was morcellated at the umbilicus inside it without tearing.

Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 114 minutes and laparoscopic time 96 minutes. Final umbilical incision length was 20mm. The patient’s pain medication could be kept low and the patient was discharged on the 5th postoperative day. After 6 months, the patient was well with no visible scar.

Conclusion: Left hepatic lobectomy for benign lesions can safely be performed through transumbilical SIL. In the absence of malignancy, the final incision length can be kept minimal.
G Dapri, V Donckier, J Himpens, GB Cadière
Surgical intervention
7 years ago
2699 views
25 likes
2 comments
05:12
Single incision transumbilical laparoscopic left hepatic lobectomy
Background: Single-incision laparoscopy (SIL) recently gained interest mainly to improve the cosmetic outcomes. This video shows a patient submitted to left hepatic lobectomy by transumbilical SIL.

Video: A 24 year-old woman with a BMI of 24.4 kg/m2 consulted for a hydatid cyst of the II-III hepatic segments. Preoperative work-up showed a hepatic hydatid cyst of the segment III, partially involving the segment II. A transumbilical SIL was performed using an 11mm trocar for a 10mm, standard length, 30-degree scope, and a curved grasping forceps, and Ligasure V. At the end of the resection, a custom-made plastic bag was inserted in the abdomen through the 11mm trocar, and the specimen was morcellated at the umbilicus inside it without tearing.

Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 114 minutes and laparoscopic time 96 minutes. Final umbilical incision length was 20mm. The patient’s pain medication could be kept low and the patient was discharged on the 5th postoperative day. After 6 months, the patient was well with no visible scar.

Conclusion: Left hepatic lobectomy for benign lesions can safely be performed through transumbilical SIL. In the absence of malignancy, the final incision length can be kept minimal.
En bloc laparoscopic right hemicolectomy associated to atypical hepatectomy for advanced cancer of the hepatic flexure
Background: An adenocarcinoma of the hepatic colic flexure associated to liver invasion was diagnosed in a 55 year-old woman, who consulted for weight loss and anemia. The patient was submitted to neoadjuvant chemotherapy and, after 4 cycles, an en bloc laparoscopic right hemicolectomy and atypical hepatectomy of segment VI was proposed.
Video: The surgeon stood between the patient’s legs, and the cameraman to the patient’s left. Four trocars were placed in the abdomen. The right mesocolon was opened at the root of the ileocaecal vessels, which were meticulously dissected and clipped. The arterial and venous branch of the middle colic vessels were sectioned as well. The right mesocolon was freed from the duodenum respecting Toldt’s fascia. The proximal transverse colon and the distal ileum were divided by firing of a linear stapler (purple and white loads). Peroperative ultrasonography permitted exclusion of other hepatic lesions and the delimitation of the en bloc resection of segment VI. The hepatic parenchyma was transected using the coagulating hook. A laparoscopic manual side-to-side ileocolic anastomosis by 2 runnings sutures was performed. The mesocolic defect was closed, and the specimen was retrieved through a protected suprapubic incision.
Results: Operative time was 180 minutes and estimated blood loss 150 mL. The patient was discharged on the 5th postoperative day. Pathology evidenced a pT4N1 colic adenocarcinoma. She underwent additional adjuvant chemotherapy, and was doing well at the time of the last office visit.
Conclusion: Advanced colic cancer associated to hepatic invasion can be safely treated by laparoscopy.
G Dapri, J Himpens, GB Cadière
Surgical intervention
7 years ago
7069 views
41 likes
18 comments
10:17
En bloc laparoscopic right hemicolectomy associated to atypical hepatectomy for advanced cancer of the hepatic flexure
Background: An adenocarcinoma of the hepatic colic flexure associated to liver invasion was diagnosed in a 55 year-old woman, who consulted for weight loss and anemia. The patient was submitted to neoadjuvant chemotherapy and, after 4 cycles, an en bloc laparoscopic right hemicolectomy and atypical hepatectomy of segment VI was proposed.
Video: The surgeon stood between the patient’s legs, and the cameraman to the patient’s left. Four trocars were placed in the abdomen. The right mesocolon was opened at the root of the ileocaecal vessels, which were meticulously dissected and clipped. The arterial and venous branch of the middle colic vessels were sectioned as well. The right mesocolon was freed from the duodenum respecting Toldt’s fascia. The proximal transverse colon and the distal ileum were divided by firing of a linear stapler (purple and white loads). Peroperative ultrasonography permitted exclusion of other hepatic lesions and the delimitation of the en bloc resection of segment VI. The hepatic parenchyma was transected using the coagulating hook. A laparoscopic manual side-to-side ileocolic anastomosis by 2 runnings sutures was performed. The mesocolic defect was closed, and the specimen was retrieved through a protected suprapubic incision.
Results: Operative time was 180 minutes and estimated blood loss 150 mL. The patient was discharged on the 5th postoperative day. Pathology evidenced a pT4N1 colic adenocarcinoma. She underwent additional adjuvant chemotherapy, and was doing well at the time of the last office visit.
Conclusion: Advanced colic cancer associated to hepatic invasion can be safely treated by laparoscopy.
Laparoscopic closed cystopericystectomy in liver hydatidosis
A 54-year-old woman presented to our Department with epigastric pain. Abdominal ultrasound and MRI showed a cystic lesion of 30 x 36 x 37mm located in segment III of the liver. The left portal trunk, which divides into branches, can be found close to the lesion. Serological test of hydatidosis was positive (1/2560). The surgical intervention was decided upon. In our opinion, radical surgery (total cystectomy or liver resection) should be the technique of choice in liver hydatidosis, since better results are obtained, especially in terms of morbidity, relapse and hospital stay. Totally laparoscopic closed cystopericystectomy, when feasible, could be done, but it is more technically demanding than conservative techniques.
JM Ramia, JE Quiñones, R de la Plaza, J García-Parreño
Surgical intervention
8 years ago
2764 views
88 likes
0 comments
10:03
Laparoscopic closed cystopericystectomy in liver hydatidosis
A 54-year-old woman presented to our Department with epigastric pain. Abdominal ultrasound and MRI showed a cystic lesion of 30 x 36 x 37mm located in segment III of the liver. The left portal trunk, which divides into branches, can be found close to the lesion. Serological test of hydatidosis was positive (1/2560). The surgical intervention was decided upon. In our opinion, radical surgery (total cystectomy or liver resection) should be the technique of choice in liver hydatidosis, since better results are obtained, especially in terms of morbidity, relapse and hospital stay. Totally laparoscopic closed cystopericystectomy, when feasible, could be done, but it is more technically demanding than conservative techniques.
Laparoscopic right hepatectomy for colorectal liver metastases
Major anatomical liver resections, initially considered to be unsuitable for laparoscopy, are increasingly reported by several centers worldwide. It is widely accepted that standards of open liver surgery should not be compromised during laparoscopic interventions. The video describes a totally laparoscopic right hepatectomy in an adipose patient (BMI of 44) for metastases of a rectal carcinoma.
24 months after sphincter-preserving radical rectal resection with TME (ypT3, ypN 0 (0/20), M0), metastases of the right liver were diagnosed during routine follow-up. According to MRI, endoscopy and PET-scan, metastases were limited to the right liver.
The procedure includes the following steps: positioning of the adipose patient, intermittent pneumatic calf compression for prevention of deep vein thrombosis, trocar placement, explorative laparoscopy, intraoperative diagnostic ultrasound, cholecystectomy, mobilization of the right liver, preparation of the hepatoduodenal ligament without Pringle’s maneuver, dissection and ligation of the right hepatic artery, right portal branch, and right hepatic duct, parenchymal dissection with ultrasonic surgical aspirator, a bipolar vessel-sealing device, vascular stapler only for larger vessels, ligation of right hepatic vein, sealing of the resection surface with bipolar coagulation, Argon beamer and fibrin glue, extraction of the resected specimen.
During surgery, the central venous pressure was kept low, no blood transfusions were performed and the postoperative course was uneventful. The pathological findings confirmed metastases of an adenocarcinoma with a maximal diameter of 6cm and clear resection margins. The patient was discharged 8 days after resection.
Laparoscopic right hepatectomy was carried out without compromising surgical principles established for open surgery. It is demonstrated that laparoscopic equipment such as intraoperative ultrasound, ultrasonic surgical aspirator, bipolar and Argon beamer coagulation and fibrin glue sealing can be used to their fullest extent. However, proficiency in both open liver surgery and advanced laparoscopy is compulsory.
M Schön
Surgical intervention
8 years ago
8749 views
31 likes
2 comments
16:10
Laparoscopic right hepatectomy for colorectal liver metastases
Major anatomical liver resections, initially considered to be unsuitable for laparoscopy, are increasingly reported by several centers worldwide. It is widely accepted that standards of open liver surgery should not be compromised during laparoscopic interventions. The video describes a totally laparoscopic right hepatectomy in an adipose patient (BMI of 44) for metastases of a rectal carcinoma.
24 months after sphincter-preserving radical rectal resection with TME (ypT3, ypN 0 (0/20), M0), metastases of the right liver were diagnosed during routine follow-up. According to MRI, endoscopy and PET-scan, metastases were limited to the right liver.
The procedure includes the following steps: positioning of the adipose patient, intermittent pneumatic calf compression for prevention of deep vein thrombosis, trocar placement, explorative laparoscopy, intraoperative diagnostic ultrasound, cholecystectomy, mobilization of the right liver, preparation of the hepatoduodenal ligament without Pringle’s maneuver, dissection and ligation of the right hepatic artery, right portal branch, and right hepatic duct, parenchymal dissection with ultrasonic surgical aspirator, a bipolar vessel-sealing device, vascular stapler only for larger vessels, ligation of right hepatic vein, sealing of the resection surface with bipolar coagulation, Argon beamer and fibrin glue, extraction of the resected specimen.
During surgery, the central venous pressure was kept low, no blood transfusions were performed and the postoperative course was uneventful. The pathological findings confirmed metastases of an adenocarcinoma with a maximal diameter of 6cm and clear resection margins. The patient was discharged 8 days after resection.
Laparoscopic right hepatectomy was carried out without compromising surgical principles established for open surgery. It is demonstrated that laparoscopic equipment such as intraoperative ultrasound, ultrasonic surgical aspirator, bipolar and Argon beamer coagulation and fibrin glue sealing can be used to their fullest extent. However, proficiency in both open liver surgery and advanced laparoscopy is compulsory.