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General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
F Signorini, S Reimondez, M España, L Obeide, F Moser
Surgical intervention
1 year ago
7886 views
422 likes
6 comments
06:41
Laparoscopic total D2 gastrectomy for cancer
Laparoscopic gastrectomy is accepted as a treatment of choice for gastric cancer due to low postoperative pain, faster recovery, shorter hospital stay, and a better cosmetic outcome as compared to open gastrectomy. Radical gastrectomy, with lymph node dissection, is essential to cure this type of cancer. This technique can be reproduced also in third world countries.
This is the case of a 74-year-old woman who was evaluated for dyspepsia and weight loss. Upper endoscopy found a tumor near the cardia on the lesser curvature. The biopsy study confirmed the presence of an adenocarcinoma. CT-scan showed no metastasis or lymph nodes affected. Surgical treatment was decided upon along with a laparoscopic total D2 gastrectomy.
Subtotal gastrectomy and D1+ lymphadenectomy for distal stage IB gastric cancer with preservation of an accessory left hepatic artery
This video shows a partial gastrectomy in a 63-year-old woman with a stage IB gastric cancer located at the distal third of the stomach. The lesion was located using intraoperatory endoscopy. We found an accessory left hepatic artery originating from the left gastric artery, which was preserved. The gastrojejunostomy was performed in a Roux-en-Y fashion. The alimentary limb was ascended through the transverse mesocolon. The jejunojejunostomy was performed in a latero-lateral fashion with closure of the ostium with simple Ethibond 2/0 stitches. The skin incision used for trocar placement in the upper left abdomen (right hand of the surgeon) was slightly enlarged to allow for specimen extraction.
P Vorwald, R Restrepo, G Salcedo, M Posada
Surgical intervention
1 year ago
2528 views
229 likes
0 comments
11:41
Subtotal gastrectomy and D1+ lymphadenectomy for distal stage IB gastric cancer with preservation of an accessory left hepatic artery
This video shows a partial gastrectomy in a 63-year-old woman with a stage IB gastric cancer located at the distal third of the stomach. The lesion was located using intraoperatory endoscopy. We found an accessory left hepatic artery originating from the left gastric artery, which was preserved. The gastrojejunostomy was performed in a Roux-en-Y fashion. The alimentary limb was ascended through the transverse mesocolon. The jejunojejunostomy was performed in a latero-lateral fashion with closure of the ostium with simple Ethibond 2/0 stitches. The skin incision used for trocar placement in the upper left abdomen (right hand of the surgeon) was slightly enlarged to allow for specimen extraction.
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
HK Yang, SH Kong
Surgical intervention
2 years ago
1644 views
74 likes
0 comments
15:56
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
Laparoscopic total gastrectomy and D2 dissection guided by fluorescence imaging system, followed by esophagojejunostomy using an intracorporeal purse-string suture method
This video demonstrates a case of gastric cancer, which is located at the cardia, and a total gastrectomy was planned. For D2 dissection in a total gastrectomy, lymph node dissection around the splenic artery and splenic hilum is one of the most challenging area. Here, we present an example of complete dissection by following the plane around the splenic vessels.
Fluorescence imaging using indocyanine green (ICG) is a promising technology not only for sentinel node navigation surgery but it is also a guide for extensive lymph node dissection. The laparoscopic fluorescence imaging system was used here as a guidance and assessment tool for complete lymph node dissection. Also, an original method for intracorporeal esophagojejunal anastomosis is introduced, which enables purse-string suture and insertion of the anvil of the circular stapler in a quite stable manner, and reproduces conventional esophagojejunostomy without specialized devices.
HK Yang, SH Kong
Surgical intervention
4 years ago
2712 views
50 likes
1 comment
28:29
Laparoscopic total gastrectomy and D2 dissection guided by fluorescence imaging system, followed by esophagojejunostomy using an intracorporeal purse-string suture method
This video demonstrates a case of gastric cancer, which is located at the cardia, and a total gastrectomy was planned. For D2 dissection in a total gastrectomy, lymph node dissection around the splenic artery and splenic hilum is one of the most challenging area. Here, we present an example of complete dissection by following the plane around the splenic vessels.
Fluorescence imaging using indocyanine green (ICG) is a promising technology not only for sentinel node navigation surgery but it is also a guide for extensive lymph node dissection. The laparoscopic fluorescence imaging system was used here as a guidance and assessment tool for complete lymph node dissection. Also, an original method for intracorporeal esophagojejunal anastomosis is introduced, which enables purse-string suture and insertion of the anvil of the circular stapler in a quite stable manner, and reproduces conventional esophagojejunostomy without specialized devices.
Total gastrectomy for early gastric cancer and giant paraesophageal hernia
This video shows a total gastrectomy in an 83-year-old woman with a giant type III paraesophageal hernia and an early gastric cancer located at the middle third of the stomach. First, type III paraesophageal hernia dissection with complete resection of the hernia sac is shown. A D1 lymphadenectomy is performed.
The esophagus is transected high in the posterior mediastinum and an end-to-side esophago-jejunostomy is performed using the Orvil™ orogastric tube and the EEA™ DST XL 25 circular stapling device. The esophago-jejunostomy is performed in a Roux-en-Y fashion. The alimentary limb is ascended through the transverse mesocolon. The skin incision used for trocar placement in the upper left abdomen (right hand of the surgeon) was slightly enlarged to allow for specimen extraction. Through this incision, the side-to-side jejuno-jejunostomy was performed extracorporeally.
P Vorwald, M de Vega Irañeta, E Bernal, D Cortés, S Ayora González, A Gomez Valdazo
Surgical intervention
5 years ago
3133 views
36 likes
1 comment
16:26
Total gastrectomy for early gastric cancer and giant paraesophageal hernia
This video shows a total gastrectomy in an 83-year-old woman with a giant type III paraesophageal hernia and an early gastric cancer located at the middle third of the stomach. First, type III paraesophageal hernia dissection with complete resection of the hernia sac is shown. A D1 lymphadenectomy is performed.
The esophagus is transected high in the posterior mediastinum and an end-to-side esophago-jejunostomy is performed using the Orvil™ orogastric tube and the EEA™ DST XL 25 circular stapling device. The esophago-jejunostomy is performed in a Roux-en-Y fashion. The alimentary limb is ascended through the transverse mesocolon. The skin incision used for trocar placement in the upper left abdomen (right hand of the surgeon) was slightly enlarged to allow for specimen extraction. Through this incision, the side-to-side jejuno-jejunostomy was performed extracorporeally.
Minimally invasive redo esophagojejunostomy for postoperative dehiscence after laparoscopic total gastrectomy for gastric cancer
This is the case of an 87-year-old man receiving dual antiplatelet therapy, with aortic steno-insufficiency, chronic heart and renal failure, admitted to our service for anemia due to lesser curvature gastric cancer.
The patient underwent an uneventuful laparoscopic total gastrectomy with D1 lymph node dissection with Roux-en-Y reconstruction. Pathological findings were consistent with a poorly differentiated pT4bN2M0 adenocarcinoma (TNM classification, 7th edition).
A fifth postoperative day gastrografin swallow revealed a large anastomotic leak at the esophagojejunostomy.
A conservative approach was considered to treat this complication with a multispecialty approach. However, this approach was rejected for two reasons:
- Firstly, the occurrence of a broad anastomotic leakage in the early postoperative period is often due to necrosis of perianastomotic tissues;
- Secondly, the patient’s age, the poor nutritional status and the early signs of hemodynamic instability - hypertension and tachycardia - called for a more timely and potentially resolutive approach.
Additionally, in our experience, the use of self-expandable metallic stents is associated with a high rate of stent migration in the setting of end-to-side anastomoses.
As a result, a decision was made to perform an emergency explorative laparoscopy with a minimally invasive redo esophagojejunostomy.
The procedure was performed using 5 trocars through the same incisions as the first surgery. Operative time was 180 minutes, with minimal blood loss and no intraoperative transfusion.

Results:
After surgery, the patient required admission to the postoperative intensive care unit for 9 days because of respiratory failure, hemodynamic instability, and the development of a subdiaphragmatic collection, treated by percutaneous drainage.
An upper gastrointestinal gastrografin swallow on postoperative day 10 showed a patent esophagojejunostomy without any leak. The patient was started on a clear fluid diet, and advanced to a solid diet as tolerated, until discharge on postoperative day 14.
I Maruri Chimeno, I Otero Martinez, V Vigorita, M Bertucci Zoccali, H Pardellas Rivera, P Troncoso Pereira , JE Casal Núñez
Surgical intervention
5 years ago
1432 views
16 likes
0 comments
12:54
Minimally invasive redo esophagojejunostomy for postoperative dehiscence after laparoscopic total gastrectomy for gastric cancer
This is the case of an 87-year-old man receiving dual antiplatelet therapy, with aortic steno-insufficiency, chronic heart and renal failure, admitted to our service for anemia due to lesser curvature gastric cancer.
The patient underwent an uneventuful laparoscopic total gastrectomy with D1 lymph node dissection with Roux-en-Y reconstruction. Pathological findings were consistent with a poorly differentiated pT4bN2M0 adenocarcinoma (TNM classification, 7th edition).
A fifth postoperative day gastrografin swallow revealed a large anastomotic leak at the esophagojejunostomy.
A conservative approach was considered to treat this complication with a multispecialty approach. However, this approach was rejected for two reasons:
- Firstly, the occurrence of a broad anastomotic leakage in the early postoperative period is often due to necrosis of perianastomotic tissues;
- Secondly, the patient’s age, the poor nutritional status and the early signs of hemodynamic instability - hypertension and tachycardia - called for a more timely and potentially resolutive approach.
Additionally, in our experience, the use of self-expandable metallic stents is associated with a high rate of stent migration in the setting of end-to-side anastomoses.
As a result, a decision was made to perform an emergency explorative laparoscopy with a minimally invasive redo esophagojejunostomy.
The procedure was performed using 5 trocars through the same incisions as the first surgery. Operative time was 180 minutes, with minimal blood loss and no intraoperative transfusion.

Results:
After surgery, the patient required admission to the postoperative intensive care unit for 9 days because of respiratory failure, hemodynamic instability, and the development of a subdiaphragmatic collection, treated by percutaneous drainage.
An upper gastrointestinal gastrografin swallow on postoperative day 10 showed a patent esophagojejunostomy without any leak. The patient was started on a clear fluid diet, and advanced to a solid diet as tolerated, until discharge on postoperative day 14.
Laparoscopic total gastrectomy with D2 lymphadenectomy for adenocarcinoma
Total gastrectomy with D2 lymphadenectomy is recommended for T1-T2 gastric cancer.
The laparoscopic approach for this procedure has been validated by extensive clinical randomized trials in Asia, leading to fewer postoperative complications and morbidity and identical oncological outcome.
This video presents a laparoscopic total gastrectomy with D2 lymphadenectomy in a 54-year-old woman presenting with a T1-T2 poorly differentiated adenocarcinoma of the lesser curvature of the stomach. Due to the location of the tumor, lymphadenectomy of stations 10 and 11d are not performed. An original technique of circular eso-jejunal anastomosis is described.
A Talvane Torres de Oliveira, C Lacerda, PA Bertulucci
Surgical intervention
5 years ago
5064 views
78 likes
0 comments
25:53
Laparoscopic total gastrectomy with D2 lymphadenectomy for adenocarcinoma
Total gastrectomy with D2 lymphadenectomy is recommended for T1-T2 gastric cancer.
The laparoscopic approach for this procedure has been validated by extensive clinical randomized trials in Asia, leading to fewer postoperative complications and morbidity and identical oncological outcome.
This video presents a laparoscopic total gastrectomy with D2 lymphadenectomy in a 54-year-old woman presenting with a T1-T2 poorly differentiated adenocarcinoma of the lesser curvature of the stomach. Due to the location of the tumor, lymphadenectomy of stations 10 and 11d are not performed. An original technique of circular eso-jejunal anastomosis is described.
Laparoscopic partial gastrectomy with D1 beta lymphadenectomy for early gastric cancer
This is the case of a 75-year-old man, symptom-free, with a cT2N0M0 early cancer of the stomach. The lesion is located between the body and the antrum of the stomach.
The laparoscopic approach allows to carry out a partial gastrectomy with D1 beta lymphadenectomy (lymph nodes number: 1-3-4-5-6-7-8-9) with intraoperative gastroscopy.
A Roux-en-Y gastrojejunal anastomosis is performed (intracorporeal gastrojejunal anastomosis and extracorporeal jejunojejunal anastomosis).
Total surgery time was 5 hours and length of hospital stay was 6 days.
Histology shows pT2N0M0 with 25 lymph nodes.
D1 beta lymphadenectomy is an efficient and less aggressive alternative to treat cases of early gastric cancer.
S Rua, A Pinto, P Moura, C Sousa
Surgical intervention
6 years ago
3283 views
19 likes
0 comments
13:20
Laparoscopic partial gastrectomy with D1 beta lymphadenectomy for early gastric cancer
This is the case of a 75-year-old man, symptom-free, with a cT2N0M0 early cancer of the stomach. The lesion is located between the body and the antrum of the stomach.
The laparoscopic approach allows to carry out a partial gastrectomy with D1 beta lymphadenectomy (lymph nodes number: 1-3-4-5-6-7-8-9) with intraoperative gastroscopy.
A Roux-en-Y gastrojejunal anastomosis is performed (intracorporeal gastrojejunal anastomosis and extracorporeal jejunojejunal anastomosis).
Total surgery time was 5 hours and length of hospital stay was 6 days.
Histology shows pT2N0M0 with 25 lymph nodes.
D1 beta lymphadenectomy is an efficient and less aggressive alternative to treat cases of early gastric cancer.
Totally laparoscopic total gastrectomy for stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma
A 66-year-old man was admitted to our hospital with complaints of epigastric pain. His hemoglobin level was 9.3g/dL. Endoscopy of the upper gastrointestinal tract (EGD) showed an advanced gastric carcinoma that had invaded the middle and lower third of the stomach. A biopsy specimen revealed a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) showed that the tumor had invaded the stomach wall. Enlarged lymph nodes were present only around the lesser curvature (regional lymph nodes No. 3). The patient was diagnosed with stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma according to the Japanese classification of gastric carcinoma1. The patient was then taken to the operating room for exploratory laparoscopy and laparoscopic total gastrectomy with D2 lymphadenectomy. The operation time was 260 minutes. No further evidence of intra-abdominal disease or liver involvement was noted. The patient did well postoperatively and was subsequently discharged home on postoperative day 9. Four metastatic lymph nodes/twenty eight regional lymph nodes were found; so the pathological findings confirmed stage IIIA. The patient is disease-free at 10 months. Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer 1998;1:10-24.
G Pignata, M Barone, U Bracale, E Gianetta, F Badessi
Surgical intervention
8 years ago
5331 views
34 likes
1 comment
26:02
Totally laparoscopic total gastrectomy for stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma
A 66-year-old man was admitted to our hospital with complaints of epigastric pain. His hemoglobin level was 9.3g/dL. Endoscopy of the upper gastrointestinal tract (EGD) showed an advanced gastric carcinoma that had invaded the middle and lower third of the stomach. A biopsy specimen revealed a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) showed that the tumor had invaded the stomach wall. Enlarged lymph nodes were present only around the lesser curvature (regional lymph nodes No. 3). The patient was diagnosed with stage IIIA (cT3 cN1 cM0) advanced gastric carcinoma according to the Japanese classification of gastric carcinoma1. The patient was then taken to the operating room for exploratory laparoscopy and laparoscopic total gastrectomy with D2 lymphadenectomy. The operation time was 260 minutes. No further evidence of intra-abdominal disease or liver involvement was noted. The patient did well postoperatively and was subsequently discharged home on postoperative day 9. Four metastatic lymph nodes/twenty eight regional lymph nodes were found; so the pathological findings confirmed stage IIIA. The patient is disease-free at 10 months. Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer 1998;1:10-24.
Totally laparoscopic subtotal gastrectomy with D2 lymphadenectomy for stage II (cT3 cN0 cM0) advanced gastric carcinoma
A 54-year-old female patient with a past medical history of hypertension presented with abdominal pain and an episode of coffee ground emesis. Symptoms of pain and vomiting started approximately two to three months before admission and began to worsen over the past month. The pain was relieved by food. The patient also admitted to unspecified weight loss over the same period of time. On physical examination, mild distension of the abdomen was observed with a mild to moderate tenderness to palpation involving epigastric tenderness. An endoscopy of the upper gastrointestinal tract (EGD) revealed a gastric ulcer extending to the lower part of the stomach. No active bleeding was observed at the site. Gastric outlet obstruction was also noted with an inflamed edematous pylorus. Biopsy revealed a moderately differentiated gastric carcinoma. Staging CT-scan imaging studies revealed no sites of metastasis. The patient was diagnosed with stage II (cT3 cN0 cM0) advanced gastric carcinoma according to the Japanese classification of gastric carcinoma. The patient was then taken to the operating room for laparoscopic subtotal gastrectomy with D2 lymphadenectomy. The operation time was 220 minutes. No further evidence of intra-abdominal disease or liver involvement was observed. The patient did well postoperatively and was subsequently discharged home on postoperative day 7. No metastatic lymph nodes / twenty-two regional lymph nodes were found; so the pathological findings confirmed stage II. The patient is disease-free at 12 months.
Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer 1998;1:10-24.
G Pignata, U Bracale, M Barone, F Perna, P Becchi
Surgical intervention
9 years ago
6483 views
68 likes
1 comment
25:53
Totally laparoscopic subtotal gastrectomy with D2 lymphadenectomy for stage II (cT3 cN0 cM0) advanced gastric carcinoma
A 54-year-old female patient with a past medical history of hypertension presented with abdominal pain and an episode of coffee ground emesis. Symptoms of pain and vomiting started approximately two to three months before admission and began to worsen over the past month. The pain was relieved by food. The patient also admitted to unspecified weight loss over the same period of time. On physical examination, mild distension of the abdomen was observed with a mild to moderate tenderness to palpation involving epigastric tenderness. An endoscopy of the upper gastrointestinal tract (EGD) revealed a gastric ulcer extending to the lower part of the stomach. No active bleeding was observed at the site. Gastric outlet obstruction was also noted with an inflamed edematous pylorus. Biopsy revealed a moderately differentiated gastric carcinoma. Staging CT-scan imaging studies revealed no sites of metastasis. The patient was diagnosed with stage II (cT3 cN0 cM0) advanced gastric carcinoma according to the Japanese classification of gastric carcinoma. The patient was then taken to the operating room for laparoscopic subtotal gastrectomy with D2 lymphadenectomy. The operation time was 220 minutes. No further evidence of intra-abdominal disease or liver involvement was observed. The patient did well postoperatively and was subsequently discharged home on postoperative day 7. No metastatic lymph nodes / twenty-two regional lymph nodes were found; so the pathological findings confirmed stage II. The patient is disease-free at 12 months.
Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer 1998;1:10-24.
Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach
Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.
B Dallemagne, F Costantino, J Marescaux
Surgical intervention
9 years ago
7549 views
23 likes
0 comments
15:53
Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach
Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.
Combined endoscopic and laparoscopic transgastric single port (TriPort) access for a gastric tumor
Intragastric tumors represent a challenging pathology to treat with a minimally invasive approach because of their position and size. The possibility to combine both endoscopy and intragastric endoscopic surgery is of great value in these cases. This video shows such a combined endoscopic and laparoscopic approach to treat a stromal gastric tumor of the cardia. The endoscopy allows to choose a perfect position of laparoscopic access, depending on the tumor location. Furthermore, it provides the vision at the beginning of the intervention. After ablation of the tumor, a Triport is inserted into the stomach to close the gastric mucosa, allowing multiple transgastric access through a single gastrotomy.
J Leroy, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
10 years ago
348 views
21 likes
0 comments
04:23
Combined endoscopic and laparoscopic transgastric single port (TriPort) access for a gastric tumor
Intragastric tumors represent a challenging pathology to treat with a minimally invasive approach because of their position and size. The possibility to combine both endoscopy and intragastric endoscopic surgery is of great value in these cases. This video shows such a combined endoscopic and laparoscopic approach to treat a stromal gastric tumor of the cardia. The endoscopy allows to choose a perfect position of laparoscopic access, depending on the tumor location. Furthermore, it provides the vision at the beginning of the intervention. After ablation of the tumor, a Triport is inserted into the stomach to close the gastric mucosa, allowing multiple transgastric access through a single gastrotomy.