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Dimitrios NTOURAKIS


Attiki, Greece
MD, PhD
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Laparoscopic enucleation of a pancreatic tumor: posterior approach
We report the case of a 55-year-old woman with a hypervascularized lesion at the posterior aspect of the pancreatic tail, which is evocative of an endocrine tumor of the pancreas. We decided to perform a laparoscopic enucleation of this tumor using a posterior approach. The patient is positioned in a right lateral decubitus. The intervention begins with the opening of the posterior mesogastrium, which allows to tilt the entire splenopancreatic block to the right. The tumor located on the posterior aspect clearly appears. An enucleation of the tumor is then performed using the monopolar cautery hook. In order to facilitate the lesion's exposure, a traction suture will be placed. This helps to expose the tumor. The inferior border of the tumor is freed from the splenic vein and the monopolar hook allows to perform a step-by-step enucleation. An intrapancreatic freeing of the lesion's deep plane is achieved using the Sonicision™ device. The tumor is placed into a bag and extracted through a port. The extemporaneous exam confirms the diagnosis of an endocrine tumor. Hemostasis is controlled. The splenopancreatic block is put back in its original anatomical position. There is no pancreatic fistula. The patient is discharged on postoperative day 5. The final diagnosis confirms a G1 endocrine tumor.
Surgical intervention
3 years ago
1255 views
46 likes
0 comments
11:04
Laparoscopic enucleation of a pancreatic tumor: posterior approach
We report the case of a 55-year-old woman with a hypervascularized lesion at the posterior aspect of the pancreatic tail, which is evocative of an endocrine tumor of the pancreas. We decided to perform a laparoscopic enucleation of this tumor using a posterior approach. The patient is positioned in a right lateral decubitus. The intervention begins with the opening of the posterior mesogastrium, which allows to tilt the entire splenopancreatic block to the right. The tumor located on the posterior aspect clearly appears. An enucleation of the tumor is then performed using the monopolar cautery hook. In order to facilitate the lesion's exposure, a traction suture will be placed. This helps to expose the tumor. The inferior border of the tumor is freed from the splenic vein and the monopolar hook allows to perform a step-by-step enucleation. An intrapancreatic freeing of the lesion's deep plane is achieved using the Sonicision™ device. The tumor is placed into a bag and extracted through a port. The extemporaneous exam confirms the diagnosis of an endocrine tumor. Hemostasis is controlled. The splenopancreatic block is put back in its original anatomical position. There is no pancreatic fistula. The patient is discharged on postoperative day 5. The final diagnosis confirms a G1 endocrine tumor.
Perforated gastric pouch ulcer 4 years after gastric bypass surgery: laparoscopic diagnosis and treatment
The frequency of marginal ulcers is reported to range between 0.6% and 16% after laparoscopic Roux-en-Y gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H pylori infection, non-steroidal anti-inflammatory drugs use, and smoking [1, 2]. We present a rare case of a gastric pouch ulcer perforation occurring 4 years after a laparoscopic gastric bypass.
Bibliographic references:
1. Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Bramkamp M, Muller MK, Wildi S, Clavien PA, Weber M. Obes Surg 2006;16:1545-7.
2. Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Chin EH, Hazzan D, Sarpel U, Herron DM. Surg Endosc 2007;21:2110.
Surgical intervention
4 years ago
1344 views
28 likes
0 comments
10:13
Perforated gastric pouch ulcer 4 years after gastric bypass surgery: laparoscopic diagnosis and treatment
The frequency of marginal ulcers is reported to range between 0.6% and 16% after laparoscopic Roux-en-Y gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H pylori infection, non-steroidal anti-inflammatory drugs use, and smoking [1, 2]. We present a rare case of a gastric pouch ulcer perforation occurring 4 years after a laparoscopic gastric bypass.
Bibliographic references:
1. Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Bramkamp M, Muller MK, Wildi S, Clavien PA, Weber M. Obes Surg 2006;16:1545-7.
2. Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Chin EH, Hazzan D, Sarpel U, Herron DM. Surg Endosc 2007;21:2110.
Acute small bowel ischemia: laparoscopic exploration and treatment
We present the case of a 63-year-old male patient admitted to the emergency department with severe acute abdominal pain unresponsive to symptomatic treatment. The clinical examination revealed a generalized peritoneal reaction. The diagnosis of small bowel ischemia with free peritoneal fluid without occlusion of the superior mesenteric artery (SMA) or the superior mesenteric vein (SMV) was established by means of a contrast injected CT-scan.
A laparoscopic exploration allowed to discover a segmental small bowel ischemic necrosis with severe hemorrhagic congestion of the bowel wall. After verifying that the rest of the small bowel and the colon were viable, a laparoscopic resection was performed with an intracorporeal side-to-side anastomosis. The postoperative course was uneventful with patient discharge on day 4.
Pathological examination confirmed that the resected segment of 92cm had ischemia of the mucosa and of the serosa with intensive congestion and hemorrhagic effusion. The patient’s one-month follow-up was uneventful. A programmed cardiological, hematological and immunological consultation and work-up to look for thrombotic risk factors was negative.
Acute small bowel ischemia is an unusual cause of acute abdomen that is difficult to diagnose due to its non-specific clinical signs. Clinical suspicion is warranted in patients with a past history of cardiovascular thrombotic conditions or hypercoagulable states. In 50% of cases, it is caused by arterial obstruction, in 20 to 30% of cases by non-occlusive arterial ischemia, and by venous occlusion [1] in 5 to 15% of cases. It has a high mortality rate of 59 to 93% and patient survival is highly dependent on a timely diagnosis and treatment. The European Association for Endoscopic Surgery (EAES) consensus for the laparoscopic approach to the acute abdomen states that there is no published data demonstrating advantages in the diagnosis and treatment of acute bowel ischemia by laparoscopy [2]. However, laparoscopy may prove beneficial in confirming the diagnosis in doubtful cases, calculate the extension of the ischemic small bowel segment, and offer a treatment option in cases of segmental necrosis.
1. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology 2000;118:954-68.
2. Agresta F, Ansaloni L, Baiocchi GL, Bergamini C, Campanile FC, Carlucci M, Cocorullo G, Corradi A, Franzato B, Lupo M, Mandalà V, Mirabella A, Pernazza G, Piccoli M, Staudacher C, Vettoretto N, Zago M, Lettieri E, Levati A, Pietrini D, Scaglione M, De Masi S, De Placido G, Francucci M, Rasi M, Fingerhut A, Uranüs S, Garattini S. Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES). Surg Endosc 2012;26:2134-64.
Surgical intervention
4 years ago
2280 views
68 likes
0 comments
19:57
Acute small bowel ischemia: laparoscopic exploration and treatment
We present the case of a 63-year-old male patient admitted to the emergency department with severe acute abdominal pain unresponsive to symptomatic treatment. The clinical examination revealed a generalized peritoneal reaction. The diagnosis of small bowel ischemia with free peritoneal fluid without occlusion of the superior mesenteric artery (SMA) or the superior mesenteric vein (SMV) was established by means of a contrast injected CT-scan.
A laparoscopic exploration allowed to discover a segmental small bowel ischemic necrosis with severe hemorrhagic congestion of the bowel wall. After verifying that the rest of the small bowel and the colon were viable, a laparoscopic resection was performed with an intracorporeal side-to-side anastomosis. The postoperative course was uneventful with patient discharge on day 4.
Pathological examination confirmed that the resected segment of 92cm had ischemia of the mucosa and of the serosa with intensive congestion and hemorrhagic effusion. The patient’s one-month follow-up was uneventful. A programmed cardiological, hematological and immunological consultation and work-up to look for thrombotic risk factors was negative.
Acute small bowel ischemia is an unusual cause of acute abdomen that is difficult to diagnose due to its non-specific clinical signs. Clinical suspicion is warranted in patients with a past history of cardiovascular thrombotic conditions or hypercoagulable states. In 50% of cases, it is caused by arterial obstruction, in 20 to 30% of cases by non-occlusive arterial ischemia, and by venous occlusion [1] in 5 to 15% of cases. It has a high mortality rate of 59 to 93% and patient survival is highly dependent on a timely diagnosis and treatment. The European Association for Endoscopic Surgery (EAES) consensus for the laparoscopic approach to the acute abdomen states that there is no published data demonstrating advantages in the diagnosis and treatment of acute bowel ischemia by laparoscopy [2]. However, laparoscopy may prove beneficial in confirming the diagnosis in doubtful cases, calculate the extension of the ischemic small bowel segment, and offer a treatment option in cases of segmental necrosis.
1. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology 2000;118:954-68.
2. Agresta F, Ansaloni L, Baiocchi GL, Bergamini C, Campanile FC, Carlucci M, Cocorullo G, Corradi A, Franzato B, Lupo M, Mandalà V, Mirabella A, Pernazza G, Piccoli M, Staudacher C, Vettoretto N, Zago M, Lettieri E, Levati A, Pietrini D, Scaglione M, De Masi S, De Placido G, Francucci M, Rasi M, Fingerhut A, Uranüs S, Garattini S. Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES). Surg Endosc 2012;26:2134-64.
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
Surgical intervention
4 years ago
3065 views
123 likes
0 comments
20:03
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
Laparoscopic interval appendectomy after conservative treatment of an appendiceal abscess
Appendectomy is the standard treatment for acute appendicitis in adults and children. However, more and more studies demonstrate that a conservative treatment with antibiotics and radiological drainage, if required, is effective and may be of importance in complicated cases and in older frail patients [1].
In the absence of randomized controlled trials, there is no consensus on whether an appendectomy at distance from the acute phase (interval appendectomy) is necessary for conservatively treated patients. A large observational study has shown that about 10% of these patients will require an appendectomy [2] over a period of several years. However, a histopathological study of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess concluded that more than half of the patients had strong histopathological changes in the appendix, thereby suggesting a high possibility of recurrence [3].
This is the case of a 58-year-old female patient presenting with a perforated appendix with an appendiceal abscess, treated by antibiotherapy and radiological drainage. She has a past history of uterine cancer treated by radiochemotherapy and total hysterectomy, complicated by bilateral ureteral stenoses after radiotherapy, treated by long-term pig-tail urinary catheters, as well as a postoperative abdominal hernia treated by means of an abdominal underlay mesh. Even though the initial non-surgical treatment of her complicated acute appendicitis was successful, an interval appendectomy was indicated because of persistent abdominal pain in the right lower quadrant (RLQ). The operation was performed laparoscopically with a simple postoperative course.
References:
1. Tannoury J. Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013;19:3942-50.
2. McCutcheon BA, Chang DC, Marcus LP, Inui T, Noorbakhsh A, Schallhorn C, Parina R, Salazar FR, Talamini MA. Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis. J Am Coll Surg 2014;218:905-13.
3. Otake S, Suzuki N, Takahashi A, Toki F, Nishi A, Yamamoto H, Kuroiwa M, Kuwano H. Histological analysis of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess. Surg Today 2014;44:1400-5.
Surgical intervention
4 years ago
5259 views
168 likes
0 comments
12:12
Laparoscopic interval appendectomy after conservative treatment of an appendiceal abscess
Appendectomy is the standard treatment for acute appendicitis in adults and children. However, more and more studies demonstrate that a conservative treatment with antibiotics and radiological drainage, if required, is effective and may be of importance in complicated cases and in older frail patients [1].
In the absence of randomized controlled trials, there is no consensus on whether an appendectomy at distance from the acute phase (interval appendectomy) is necessary for conservatively treated patients. A large observational study has shown that about 10% of these patients will require an appendectomy [2] over a period of several years. However, a histopathological study of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess concluded that more than half of the patients had strong histopathological changes in the appendix, thereby suggesting a high possibility of recurrence [3].
This is the case of a 58-year-old female patient presenting with a perforated appendix with an appendiceal abscess, treated by antibiotherapy and radiological drainage. She has a past history of uterine cancer treated by radiochemotherapy and total hysterectomy, complicated by bilateral ureteral stenoses after radiotherapy, treated by long-term pig-tail urinary catheters, as well as a postoperative abdominal hernia treated by means of an abdominal underlay mesh. Even though the initial non-surgical treatment of her complicated acute appendicitis was successful, an interval appendectomy was indicated because of persistent abdominal pain in the right lower quadrant (RLQ). The operation was performed laparoscopically with a simple postoperative course.
References:
1. Tannoury J. Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013;19:3942-50.
2. McCutcheon BA, Chang DC, Marcus LP, Inui T, Noorbakhsh A, Schallhorn C, Parina R, Salazar FR, Talamini MA. Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis. J Am Coll Surg 2014;218:905-13.
3. Otake S, Suzuki N, Takahashi A, Toki F, Nishi A, Yamamoto H, Kuroiwa M, Kuwano H. Histological analysis of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess. Surg Today 2014;44:1400-5.
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
Surgical intervention
4 years ago
1887 views
54 likes
0 comments
06:43
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
Laparoscopic central pancreatectomy for insulinoma
We report the case of a 43-year-old male patient who was diagnosed with insulinoma and had a robotic enucleation of an isthmic pancreatic tumor in November 2012. However, the patient presents with clinical recurrences of hypoglycemia 18 months later. Re-evaluation studies demonstrated a local recurrence. A laparoscopic central pancreatectomy was indicated. The procedure started with the opening of the lesser sac. The splenic vessels were dissected and controlled. A retropancreatic passage along the venous mesenterico-portal axis was performed. Ultrasonography was carried out to assess the pancreatic recurrence area. The pancreas isthmus was transected. A pancreaticogastric anastomosis was performed at the posterior aspect of the stomach. The resected specimen confirms the recurrence of an insulinoma, which has been entirely removed.
Surgical intervention
4 years ago
1280 views
30 likes
0 comments
09:21
Laparoscopic central pancreatectomy for insulinoma
We report the case of a 43-year-old male patient who was diagnosed with insulinoma and had a robotic enucleation of an isthmic pancreatic tumor in November 2012. However, the patient presents with clinical recurrences of hypoglycemia 18 months later. Re-evaluation studies demonstrated a local recurrence. A laparoscopic central pancreatectomy was indicated. The procedure started with the opening of the lesser sac. The splenic vessels were dissected and controlled. A retropancreatic passage along the venous mesenterico-portal axis was performed. Ultrasonography was carried out to assess the pancreatic recurrence area. The pancreas isthmus was transected. A pancreaticogastric anastomosis was performed at the posterior aspect of the stomach. The resected specimen confirms the recurrence of an insulinoma, which has been entirely removed.
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.
Surgical intervention
4 years ago
2101 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.
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.
Laparoscopic transgastric sphincterotomy for common bile duct stones
We report the case of a transgastric sphincterotomy. This is the case of a 67-year-old woman presenting with cholangitis with a past history of an esophageal peptic stenosis. After dilatation, the duodenoscopy does not make it possible to cross this stenosis. A transgastric laparoscopy is decided upon in order to introduce the duodenoscope through a 15mm port. The duodenoscope is then introduced through the port into the anterior gastric wall allowing for a successful sphincterotomy and stone extraction. The duodenoscope is withdrawn and the gastrotomy is closed. A laparoscopic cholecystectomy is performed. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6.
Surgical intervention
5 years ago
2859 views
41 likes
0 comments
09:04
Laparoscopic transgastric sphincterotomy for common bile duct stones
We report the case of a transgastric sphincterotomy. This is the case of a 67-year-old woman presenting with cholangitis with a past history of an esophageal peptic stenosis. After dilatation, the duodenoscopy does not make it possible to cross this stenosis. A transgastric laparoscopy is decided upon in order to introduce the duodenoscope through a 15mm port. The duodenoscope is then introduced through the port into the anterior gastric wall allowing for a successful sphincterotomy and stone extraction. The duodenoscope is withdrawn and the gastrotomy is closed. A laparoscopic cholecystectomy is performed. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6.
PROGRESS - Transanal TME with colo-anal anastomosis without trans-abdominal assistance for rectal cancer in a male patient
The authors put forward an original oncologic Total Mesorectal Excision (TME) technique combined with distal sigmoidectomy followed by a mechanical colo-anal side-to-end anastomosis using a purely transanal route.
The originality of this technique lies in the strictly transanal approach without any laparoscopic assistance as well as in the oncologic dissection of the rectum around its fascia propria. In addition, the technique is outstanding in the mobilization of the sigmoid mesocolon’s root as well as in the retroperitoneal mobilization of the vascular inferior mesenteric axis, hence avoiding contact with intra-abdominal organs.
This technique is called PROGRESS (Peri Rectal Oncologic Gateway for Retroperitoneal EndoScopic Surgery) due to the retroperitoneal endoscopic dissection using a perirectal access.
The video shows images of remarkable quality, especially of anatomical nerve structures, due to the use of a 4mm, 30-degree scope and a Karl Storz High-Definition camera introduced through the TEO™ device.
Surgical intervention
6 years ago
5924 views
34 likes
0 comments
18:55
PROGRESS - Transanal TME with colo-anal anastomosis without trans-abdominal assistance for rectal cancer in a male patient
The authors put forward an original oncologic Total Mesorectal Excision (TME) technique combined with distal sigmoidectomy followed by a mechanical colo-anal side-to-end anastomosis using a purely transanal route.
The originality of this technique lies in the strictly transanal approach without any laparoscopic assistance as well as in the oncologic dissection of the rectum around its fascia propria. In addition, the technique is outstanding in the mobilization of the sigmoid mesocolon’s root as well as in the retroperitoneal mobilization of the vascular inferior mesenteric axis, hence avoiding contact with intra-abdominal organs.
This technique is called PROGRESS (Peri Rectal Oncologic Gateway for Retroperitoneal EndoScopic Surgery) due to the retroperitoneal endoscopic dissection using a perirectal access.
The video shows images of remarkable quality, especially of anatomical nerve structures, due to the use of a 4mm, 30-degree scope and a Karl Storz High-Definition camera introduced through the TEO™ device.