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Focus on Solid Organs Surgery - First Part

Epublication, Jun 2016;16(06). URL: http://websurg.com/doi/fc01en4
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LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy for pheochromocytoma
Laparoscopic adrenalectomy was first described by Gagner et al. in 1992. It has become the procedure of choice for most benign adrenal lesions since then because of decreased blood loss, shorter hospital stay, faster recovery, and lower morbidity as compared to open surgery.
The indications for laparoscopic adrenalectomy are the same as for open surgery, except in cases of confirmed adrenocortical carcinomas.
Absolute contraindications for laparoscopic adrenalectomy are as follows: severe cardiopulmonary disease, locally advanced tumors, medically untreated pheochromocytoma, and uncontrolled coagulopathies. This is a live demonstration of a left adrenalectomy recorded during the Minimally Invasive Endocrine Surgery Course, which was held at IRCAD in May 2016.
D Mutter, P Donepudi, J Marescaux
Surgical intervention
2 years ago
3570 views
331 likes
0 comments
28:17
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy for pheochromocytoma
Laparoscopic adrenalectomy was first described by Gagner et al. in 1992. It has become the procedure of choice for most benign adrenal lesions since then because of decreased blood loss, shorter hospital stay, faster recovery, and lower morbidity as compared to open surgery.
The indications for laparoscopic adrenalectomy are the same as for open surgery, except in cases of confirmed adrenocortical carcinomas.
Absolute contraindications for laparoscopic adrenalectomy are as follows: severe cardiopulmonary disease, locally advanced tumors, medically untreated pheochromocytoma, and uncontrolled coagulopathies. This is a live demonstration of a left adrenalectomy recorded during the Minimally Invasive Endocrine Surgery Course, which was held at IRCAD in May 2016.
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy: retroperitoneal access
Retroperitoneal adrenalectomy (posterior approach) provides a direct access to the adrenal gland, hence preventing the risk of injury to intraperitoneal organs. The retroperitoneoscopic approach shortens the mean operative time and it is critical in cases of pheochromocytoma. Consequently, it is the recommended treatment for pheochromocytoma. Blood loss and the convalescence period are also shortened with this approach. The surgical principles of retroperitoneal adrenalectomy according to Professor Martin Walz are as follows: ‘en bloc’ resection, start of dissection with the upper pole of kidney, lower pole of the adrenal gland next, control of the main adrenal vein without clips, and morcellation of the gland if necessary in a bag.
M Walz, P Donepudi, L Soler
Surgical intervention
2 years ago
1742 views
171 likes
0 comments
39:46
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy: retroperitoneal access
Retroperitoneal adrenalectomy (posterior approach) provides a direct access to the adrenal gland, hence preventing the risk of injury to intraperitoneal organs. The retroperitoneoscopic approach shortens the mean operative time and it is critical in cases of pheochromocytoma. Consequently, it is the recommended treatment for pheochromocytoma. Blood loss and the convalescence period are also shortened with this approach. The surgical principles of retroperitoneal adrenalectomy according to Professor Martin Walz are as follows: ‘en bloc’ resection, start of dissection with the upper pole of kidney, lower pole of the adrenal gland next, control of the main adrenal vein without clips, and morcellation of the gland if necessary in a bag.
Total laparoscopic pancreaticoduodenectomy with pancreaticogastric anastomosis
The safe feasibility of total laparoscopic pancreaticoduodenectomy has been demonstrated by several authors. In order to achieve it, a 5-port approach is used. Kocher’s maneuver allows to access the inferior vena cava, the subrenal aorta, the posterior plate of the unciform process, and the superior mesenteric artery. Lymph node resection of the region may be performed completely, namely an interaorticocaval lymphadenectomy around the hepatoduodenal ligament and around the coeliac trunk and its branches. After portal vein dissection, the pancreas must be divided distally from the tumor, and its right part must be separated from the portal vein. The duodenal bulb and the first jejunal loop are divided using a linear stapler. After cholecystectomy, the hepatic duct is cut proximally to the cystic duct. Reconstruction will include three anastomoses, a telescoping posterior end-to-side pancreaticogastrostomy, an end-to-side duodenojejunostomy, and an end-to-side hepaticojejunostomy.
B Ghavami
Surgical intervention
2 years ago
1631 views
57 likes
0 comments
13:35
Total laparoscopic pancreaticoduodenectomy with pancreaticogastric anastomosis
The safe feasibility of total laparoscopic pancreaticoduodenectomy has been demonstrated by several authors. In order to achieve it, a 5-port approach is used. Kocher’s maneuver allows to access the inferior vena cava, the subrenal aorta, the posterior plate of the unciform process, and the superior mesenteric artery. Lymph node resection of the region may be performed completely, namely an interaorticocaval lymphadenectomy around the hepatoduodenal ligament and around the coeliac trunk and its branches. After portal vein dissection, the pancreas must be divided distally from the tumor, and its right part must be separated from the portal vein. The duodenal bulb and the first jejunal loop are divided using a linear stapler. After cholecystectomy, the hepatic duct is cut proximally to the cystic duct. Reconstruction will include three anastomoses, a telescoping posterior end-to-side pancreaticogastrostomy, an end-to-side duodenojejunostomy, and an end-to-side hepaticojejunostomy.
Laparoscopic choledochal cyst excision with intraoperative cholangiogram, hepatic duct cholangioscopy, extracorporeal Roux-en-Y hepaticojejunostomy and closure of mesenteric defects
The laparoscopic treatment of a choledochal cyst begins with a careful preoperative understanding of the anatomy, including bile ducts, as well as the presence of any abnormal pancreatobiliary anatomy. If a hepaticojejunostomy using a Roux-en-Y anastomosis is performed, we prefer an extracorporeal, transumbilical anastomosis, with a retrocolic approach. A series of interrupted or continuous absorbable sutures can be used for the bilioenteric anastomosis. For the last part of the procedure, we emphasize the importance of closure of mesenteric defects with non-absorbable sutures, including both the retrocolic space and Petersen’s defect to prevent future internal herniations.
GA Villalona, D Ozgediz
Surgical intervention
2 years ago
1522 views
72 likes
0 comments
10:31
Laparoscopic choledochal cyst excision with intraoperative cholangiogram, hepatic duct cholangioscopy, extracorporeal Roux-en-Y hepaticojejunostomy and closure of mesenteric defects
The laparoscopic treatment of a choledochal cyst begins with a careful preoperative understanding of the anatomy, including bile ducts, as well as the presence of any abnormal pancreatobiliary anatomy. If a hepaticojejunostomy using a Roux-en-Y anastomosis is performed, we prefer an extracorporeal, transumbilical anastomosis, with a retrocolic approach. A series of interrupted or continuous absorbable sutures can be used for the bilioenteric anastomosis. For the last part of the procedure, we emphasize the importance of closure of mesenteric defects with non-absorbable sutures, including both the retrocolic space and Petersen’s defect to prevent future internal herniations.
Laparoscopic distal pancreatectomy for mucinous cystadenoma
This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.
F Costantino, M Shahbaz, D Mutter, J Marescaux
Surgical intervention
2 years ago
1869 views
94 likes
0 comments
12:01
Laparoscopic distal pancreatectomy for mucinous cystadenoma
This video presents the case of a 39-year-old woman complaining of epigastric and right upper quadrant pain with dorsal irradiation and postprandial pain without nausea or vomiting. Abdominal ultrasound showed the presence of a 21mm cystic mass with multi-lobulated appearance at the tail of the pancreas. MRI confirmed the cystic nature of this tumor lesion of the tail of the pancreas, which was probably compatible with a mucinous cystadenoma (with a 23mm long axis) without communication with Wirsung’s duct. Transgastric echo-endoscopy revealed an ovoid cystic lesion of the pancreatic tail, with clean wall, measuring 19 by 10mm with small septa and a 4mm thick mural nodule without communication with the pancreatic duct. A laparoscopic left pancreatectomy was indicated because of the presence of a mucinous cystadenoma. This video demonstrates a laparoscopic distal pancreatectomy approach. A spleen-preserving distal pancreatectomy by preserving the splenic vessels (Kimura technique) was decided upon.
Complex robotic resection of a large middle mediastinal thymoma
A 62-year-old man had an asymptomatic middle mediastinal tumor with a 4.5cm diameter, opposite to the superior vena cava and the azygos vein in the Barety’s space, which was discovered on thoracic CT-scan performed during an urothelial tumor follow-up.
Past history includes an urothelial carcinoma grade I treated with transurethral cystectomy, an ischemic cardiopathy with a single medical treatment, a prostate hypertrophy, and a sigmoid diverticulosis.
After a multidisciplinary review of the case, a mediastinoscopy was performed. It demonstrated the presence of a thymoma.
The patient was well informed of the operative risks and of the possibility of conversion, but thanks to our experience and national recommendations, we were able to perform a radical robotic assisted thymectomy.
The operation took during 3 hours with less than 100cc of bleeding.
The postoperative course was uneventful and the patient was discharged on postoperative day 3.
Histopathological analysis showed a type AB thymoma according to the OMS 2015 classification. The staging was IIb according to Masaoka. No adjuvant radiotherapy was indicated.
A Boutin, M Sarsam, M Lair, N Piton, C Peillon, JM Baste
Surgical intervention
2 years ago
646 views
64 likes
0 comments
07:38
Complex robotic resection of a large middle mediastinal thymoma
A 62-year-old man had an asymptomatic middle mediastinal tumor with a 4.5cm diameter, opposite to the superior vena cava and the azygos vein in the Barety’s space, which was discovered on thoracic CT-scan performed during an urothelial tumor follow-up.
Past history includes an urothelial carcinoma grade I treated with transurethral cystectomy, an ischemic cardiopathy with a single medical treatment, a prostate hypertrophy, and a sigmoid diverticulosis.
After a multidisciplinary review of the case, a mediastinoscopy was performed. It demonstrated the presence of a thymoma.
The patient was well informed of the operative risks and of the possibility of conversion, but thanks to our experience and national recommendations, we were able to perform a radical robotic assisted thymectomy.
The operation took during 3 hours with less than 100cc of bleeding.
The postoperative course was uneventful and the patient was discharged on postoperative day 3.
Histopathological analysis showed a type AB thymoma according to the OMS 2015 classification. The staging was IIb according to Masaoka. No adjuvant radiotherapy was indicated.
Laparoscopic adrenalectomy (update of September 2014 presentation)
Laparoscopic adrenalectomy is an attractive alternative to open surgery in children as it is associated with less operative pain and a rapid resumption of diet and shorter operative time.
The relative contraindications are patients with malignancies which involve lymph nodes, highly vascular pheochromocytomas, and large tumors.
Neuroblastoma, congenital adrenal hyperplasia, pheochromocytomas and adrenal cortical carcinomas are the main indications in children.
The transabdominal lateral approach is more commonly used in the pediatric population.
The tumors are incidental findings and 31% of them are malignant in children.
The various techniques of adrenalectomy, preoperative work-up, and indications are described in this lecture.
D Patkowski
Lecture
2 years ago
1281 views
89 likes
0 comments
16:05
Laparoscopic adrenalectomy (update of September 2014 presentation)
Laparoscopic adrenalectomy is an attractive alternative to open surgery in children as it is associated with less operative pain and a rapid resumption of diet and shorter operative time.
The relative contraindications are patients with malignancies which involve lymph nodes, highly vascular pheochromocytomas, and large tumors.
Neuroblastoma, congenital adrenal hyperplasia, pheochromocytomas and adrenal cortical carcinomas are the main indications in children.
The transabdominal lateral approach is more commonly used in the pediatric population.
The tumors are incidental findings and 31% of them are malignant in children.
The various techniques of adrenalectomy, preoperative work-up, and indications are described in this lecture.
Laparoscopic adrenalectomy
Retroperitoneoscopic adrenalectomy was developed in 1993, initially only for small benign lesions and recently for lesions superior to 5 cm and even malignancies.
This retroperitoneal technique has gained popularity since it allows for a direct access to the gland and prevents unexpected injuries to the intra-abdominal organs.
In this lecture, Dr. Mushtaq outlines the indications for adrenalectomy in children, patient set-up, trocar placement, and operative technique overview. The importance of resecting the gland ‘en bloc’ has been emphasized.
The retroperitoneal approach begins by placing the child in a prone position. The 12th rib, iliac crest, and paravertebral muscles are then marked on the patient. The first incision is made at the lateral border of the lateral vertebral muscles, halfway between the 12th rib and the iliac crest (Heloury et al., 2011).
This lecture was delivered during the pediatric urology course held at IRCAD in March 2016.
I Mushtaq
Lecture
2 years ago
1628 views
143 likes
0 comments
16:41
Laparoscopic adrenalectomy
Retroperitoneoscopic adrenalectomy was developed in 1993, initially only for small benign lesions and recently for lesions superior to 5 cm and even malignancies.
This retroperitoneal technique has gained popularity since it allows for a direct access to the gland and prevents unexpected injuries to the intra-abdominal organs.
In this lecture, Dr. Mushtaq outlines the indications for adrenalectomy in children, patient set-up, trocar placement, and operative technique overview. The importance of resecting the gland ‘en bloc’ has been emphasized.
The retroperitoneal approach begins by placing the child in a prone position. The 12th rib, iliac crest, and paravertebral muscles are then marked on the patient. The first incision is made at the lateral border of the lateral vertebral muscles, halfway between the 12th rib and the iliac crest (Heloury et al., 2011).
This lecture was delivered during the pediatric urology course held at IRCAD in March 2016.
Basic principles and technical tips for laparoscopic pancreatectomy
With the improved laparoscopic instruments and energy devices, laparoscopy has become increasingly popular among surgeons. In this video, Professor Asbun outlines principles and tips for laparoscopic pancreatectomy. Beginners and young surgeons have to fully commit themselves in the training as there is no shortcut in the learning of laparoscopic surgery. Patient position plays a key role in laparoscopic solid organ surgery. The surgeons are using gravity to make the surgery easier. Placement of ports for pancreaticoduodenectomy in Kocher’s maneuver is as essential as the exposure of the operative field. Camera, laparoscope and instrumentation also play a key role. As energy devices are diverse and since the learning curve is different for each surgeon, the importance of technical tips cannot be neglected. In advanced techniques, HPB training is essential and suturing is the basic and most important part. Exposure, division of the duodenum and hepatoduodenal ligament, SMV-PV trunk exposure, Kocher’s maneuver, pancreatic neck division, identification of the pancreatic duct, uncinate process dissection, SMA dissection, lymph node dissection, and specimen removal represent the steps of the procedure. Laparoscopic surgery should be a standard for distal pancreatectomy. The superiority of laparoscopy over open surgery still needs to be proven as laparoscopy requires a high level of skills.
HJ Asbun
Lecture
1 year ago
4150 views
160 likes
0 comments
33:33
Basic principles and technical tips for laparoscopic pancreatectomy
With the improved laparoscopic instruments and energy devices, laparoscopy has become increasingly popular among surgeons. In this video, Professor Asbun outlines principles and tips for laparoscopic pancreatectomy. Beginners and young surgeons have to fully commit themselves in the training as there is no shortcut in the learning of laparoscopic surgery. Patient position plays a key role in laparoscopic solid organ surgery. The surgeons are using gravity to make the surgery easier. Placement of ports for pancreaticoduodenectomy in Kocher’s maneuver is as essential as the exposure of the operative field. Camera, laparoscope and instrumentation also play a key role. As energy devices are diverse and since the learning curve is different for each surgeon, the importance of technical tips cannot be neglected. In advanced techniques, HPB training is essential and suturing is the basic and most important part. Exposure, division of the duodenum and hepatoduodenal ligament, SMV-PV trunk exposure, Kocher’s maneuver, pancreatic neck division, identification of the pancreatic duct, uncinate process dissection, SMA dissection, lymph node dissection, and specimen removal represent the steps of the procedure. Laparoscopic surgery should be a standard for distal pancreatectomy. The superiority of laparoscopy over open surgery still needs to be proven as laparoscopy requires a high level of skills.
Laparoscopic distal pancreatectomy
Almost all lesions smaller than 7cm, which do not involve the coeliac or mesenteric vessels, should be considered for laparoscopic distal pancreatectomy. Several meta-analyses showed the clear benefits of laparoscopic distal pancreatectomy over open surgery regarding blood loss, hospital stay, morbidity, and wound infection. The comparison of open surgery vs. laparoscopic surgery in patients presenting with adenocarcinoma shows the benefits of laparoscopic surgery. It is much easier to learn this technique. In this lecture, the clockwise technique is briefly demonstrated. Gravity, ports position and instrumentation are essential. The key steps of the clockwise technique are as follows: mobilization of the splenic flexure and of the proximal descending colon, dissection from lateral to medial along the lower edge of the pancreas, determination of the point of division (stapled or hand-sewn), posterior dissection, mobilization of the spleen using gravity along the superior edge of the pancreas, and removal of the specimen.
HJ Asbun
Lecture
2 years ago
1826 views
57 likes
0 comments
13:55
Laparoscopic distal pancreatectomy
Almost all lesions smaller than 7cm, which do not involve the coeliac or mesenteric vessels, should be considered for laparoscopic distal pancreatectomy. Several meta-analyses showed the clear benefits of laparoscopic distal pancreatectomy over open surgery regarding blood loss, hospital stay, morbidity, and wound infection. The comparison of open surgery vs. laparoscopic surgery in patients presenting with adenocarcinoma shows the benefits of laparoscopic surgery. It is much easier to learn this technique. In this lecture, the clockwise technique is briefly demonstrated. Gravity, ports position and instrumentation are essential. The key steps of the clockwise technique are as follows: mobilization of the splenic flexure and of the proximal descending colon, dissection from lateral to medial along the lower edge of the pancreas, determination of the point of division (stapled or hand-sewn), posterior dissection, mobilization of the spleen using gravity along the superior edge of the pancreas, and removal of the specimen.