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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 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
1 month ago
805 views
0 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 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
6809 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
4219 views
567 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.
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
1674 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
2039 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.
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
1236 views
37 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
3 years ago
2471 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
1772 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
3006 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 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
2126 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.
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
6204 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
3899 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 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
8742 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.
Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection
Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.
D Mutter, L Soler, J Marescaux
Surgical intervention
9 years ago
1676 views
45 likes
1 comment
05:42
Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection
Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.
Laparoscopic right hepatectomy: intra-hepatic Glissonian approach
This video demonstrates a totally laparoscopic approach to right hemi-hepatectomy. The right portal pedicle is first divided with an endoscopic stapler. The liver parenchyma is then divided with a combination of ultrasonic scalpel, Cavitron Ultrasound Surgical Aspirator (CUSA), bipolar cautery and clips.

Many surgeons prefer to employ the hand-assisted approach, but in this totally laparoscopic demonstration the author uses the intrahepatic Glissonian approach without the Pringle maneuver. The procedure starts with surgical exploration and laparoscopic evaluation of the liver. The harmonic scalpel divides the hepatic round and falciform ligaments. The author visualizes the suprahepatic inferior vena cava and right hepatic vein, then explores the hepatoduodenal ligament for enlarged lymph nodes. He then mobilizes the right liver as high as possible by transecting the right triangular ligament. Paying attention to the area of the adrenal gland, he dissects the gallbladder hilum, and transects both the cystic artery and duct. He starts the hepatic hilar dissection with an incision of the liver parenchyma, continuing outside the portal pedicle bifurcation toward the right and left sheet. The procedure continues with transection of the right portal pedicle.
B Topal
Surgical intervention
12 years ago
968 views
37 likes
0 comments
05:54
Laparoscopic right hepatectomy: intra-hepatic Glissonian approach
This video demonstrates a totally laparoscopic approach to right hemi-hepatectomy. The right portal pedicle is first divided with an endoscopic stapler. The liver parenchyma is then divided with a combination of ultrasonic scalpel, Cavitron Ultrasound Surgical Aspirator (CUSA), bipolar cautery and clips.

Many surgeons prefer to employ the hand-assisted approach, but in this totally laparoscopic demonstration the author uses the intrahepatic Glissonian approach without the Pringle maneuver. The procedure starts with surgical exploration and laparoscopic evaluation of the liver. The harmonic scalpel divides the hepatic round and falciform ligaments. The author visualizes the suprahepatic inferior vena cava and right hepatic vein, then explores the hepatoduodenal ligament for enlarged lymph nodes. He then mobilizes the right liver as high as possible by transecting the right triangular ligament. Paying attention to the area of the adrenal gland, he dissects the gallbladder hilum, and transects both the cystic artery and duct. He starts the hepatic hilar dissection with an incision of the liver parenchyma, continuing outside the portal pedicle bifurcation toward the right and left sheet. The procedure continues with transection of the right portal pedicle.
Laparoscopic treatment of a hydatid cyst of the liver
This video demonstrates the surgical approach to a large hydatid cyst in the right lobe of the liver. The surgeon uses a 3D reconstruction of the liver and the cyst to create a virtual image of the diseased area and to preplan the surgical approach. The surgeon starts by performing a cholecystectomy to gain better approach to the liver cyst. Then the cyst is aspirated and hypertonic saline is inserted for twenty minutes. Through a small opening in the cyst wall the contents are aspirated. Repeat instillation of hypertonic saline helps aspirate the contents. Once completed the cyst wall is opened wider and the cavity is fully inspected. The cyst is deroofed and the anterior cyst wall removed. The edges of the liver is covered with fibrin glue and a piece of omentum is brought up and sutured to it. A drain is left in place.
J Leroy
Surgical intervention
15 years ago
4112 views
38 likes
1 comment
01:54
Laparoscopic treatment of a hydatid cyst of the liver
This video demonstrates the surgical approach to a large hydatid cyst in the right lobe of the liver. The surgeon uses a 3D reconstruction of the liver and the cyst to create a virtual image of the diseased area and to preplan the surgical approach. The surgeon starts by performing a cholecystectomy to gain better approach to the liver cyst. Then the cyst is aspirated and hypertonic saline is inserted for twenty minutes. Through a small opening in the cyst wall the contents are aspirated. Repeat instillation of hypertonic saline helps aspirate the contents. Once completed the cyst wall is opened wider and the cavity is fully inspected. The cyst is deroofed and the anterior cyst wall removed. The edges of the liver is covered with fibrin glue and a piece of omentum is brought up and sutured to it. A drain is left in place.