Key aspects of vascular isolation and control for en bloc PV resection during laparoscopic whipple. Xenograft vein patch is used for reconstruction
DOI: http://dx.doi.org/10.17797/ee9p182opy
Editor Recruited by: H. Leon Pachter
Specialty: Gastrointestinal Surgery
Laparoscopic Adrenalectomy
Laparoscopic adrenalectomy (LA) was first described by Gagner et al. in the early 1990s, and has since become the gold standard for removal of small and medium sized adrenal tumors.
Most commonly, LA is performed for unilateral benign adrenal lesions, however the minimally invasive technique is also routinely used for bilateral disease, as well as myelolipomas, adrenal cysts, adrenal hemorrhage and androgen-secreting tumors. Compared with the open approach, LA offers shorter hospital stay, improved patient satisfaction, decrease post-operative pain and markedly improved cosmesis. Even more, the difficulty in obtaining adequate open surgical exposure, combined with the diminutive size of the adrenal gland make laparoscopy an especially attractive option. Given this, we decided to proceed with LA approach for our patient who presented with NSCLC metastasis to his right adrenal.
DOI# http://dx.doi.org/10.17797/4ek02iupxd
Mellon MJ, Sethi A, Sundaram CP. Laparoscopic adrenalectomy: Surgical techniques. Indian Journal of Urology : IJU : Journal of the Urological Society of India. 2008;24(4):583-589. doi:10.4103/0970-1591.44277.
Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033.
Irreversible Electroporation for Treatment of Locally Advanced Pancreatic Cancer
Contributors: Robert C.G. Martin, II
Locally advanced pancreatic cancer (Stage 3) is defined by encasement or abutment of vital venous and arterial structures. Irreversible electroporation (IRE) represents an effective local non-thermal ablation modality for treatment of solid tumors involving critical vascular and biliary structures. Electroporation creates pores in the cell membrane and disrupts the ionic gradients while sparing the extracellular matrix, resulting in preservation of blood vessel and biliary scaffolding.
DOI: http://dx.doi.org/10.17797/yonbav6fdz
Editor Recruited by: Jeffrey B. Matthews
Gastric Sleeve Obstruction From Adjustable Gastric Band Capsule
The field of metabolic and bariatric surgery has recently switched from laparoscopic gastric banding (LGB) to laparoscopic sleeve gastrectomy (LSG) as the procedure of choice for weight loss surgery. As LGB has been replaced with LSG many patients who had complications with LGB or failed to loose a satisfactory amount of weight with LGB have had a conversation from their band to a sleeve gastrectomy.
Meticulous dissection takes place when removing a band, as the fibrotic scar capsule that surrounds the band must be resected in its entirety to avoid staple firings across fibrotic tissue rather than healthy gastric tissue. In addition to ensuring a healthy staple line by resecting the fibrotic capsule, we present a case where the band capsule was thought to be removed however was incompletely dissected and caused a postoperative strictured proximal stomach with complete PO intolerance. For this reason, we routinely perform intra-operative endoscopy to ensure the lumen of the stomach is patent prior to staple firing to complete the sleeve gastrectomy in band to sleeve patients.
DOI#: http://dx.doi.org/10.17797/19tn2xjdda
Combined Modality: Laparoscopic Assisted Colonoscopic Polypectomy
Laparoscopic assisted colonoscopic polypectomy aids in the safe excision of otherwise unresectable polyps with colonoscopy alone due to unfavorable locations or polyp charicteristics. A combined procedure allows for laparoscopy to assist in polypectomy by providing traction on the luminal wall, the ability to recognize a full thickness perforation and perform a segmental resection without delay and to spare the patient from multiple exposures to anesthesia.
DOI# http://dx.doi.org/10.17797/d04no64kyu
Laparoscopic Paraesophageal/Hiatal Hernia Repair
Contributor: Ciro Andolfi (University of Chicago), Marco G. Patti (University of Chicago)
We describe our preoperative work-up and the surgical technique of Laparoscopic paraesophageal/hiatal hernia repair.
DOI: http://dx.doi.org/10.17797/56by9lqzf5
Editor Recruited By: Dr. Jeffrey Matthews
Routine Laparoscopic Ultrasound During Laparoscopic Cholecystectomy
Laparoscopic ultrasound (LUS) is a simple and reliable method for evaluating the common bile duct (CBD) during laparoscopic cholecystectomy. It is particularly useful for identifying the location of the CBD and common hepatic duct (CHD) during difficult operative circumstances when the anatomy is obscured. LUS can be performed prior to any potentially hazardous dissection and can easily be repeated as necessary to safely guide dissection. This brief video demonstrates the technique of LUS during routine LC.
A flexible tip probe with a multi-frequency, side viewing, curvilinear transducer is used. Scanning is typically performed at a frequency of 10 MHz. During intraoperative applications, the ability to place the transducer in close contact with the tissue being examined allows use of a higher frequency transducer. Higher frequency ultrasound waves yield better resolution than the lower frequencies that are necessary for adequate depth of penetration during transabdominal imaging.
Fluid is instilled over the hepatoduodenal ligament to improve acoustic coupling. The ultrasound probe, covered by a sterile sheath, is introduced through a 10 mm sub-xiphoid port. The probe is extended to the patients’ right side and then angled to 90 degrees. The bend is maneuvered under the lateral segment of the left liver so that the transducer can be positioned over the hepatoduodenal ligament with light contact.
Scanning is started in a plane transverse to the hepatoduodenal structures. The normal anatomic landmarks are described as depicted in the sonographic image on the video. The junction of the cystic duct with the CBD is identified. The proper hepatic artery (HA) is to the right of the CBD on the screen. The portal vein (PV) is dorsal (“posterior”). The cross sectional image of the PV, HA and CBD together create a “Mickey Mouse” pattern with the cartoon characters’ circular head (PV) below and ears (CBD & HA) on top.
The CBD is traced caudally to the duodenal ampulla which is well seen. This is accomplished by subtle rotation of the operators’ wrist. The internal diameter of the CBD is measured to be 4 mm (normal upper limit 6-7 mm). If present, stones are readily visualized as echogenic structures with posterior acoustic shadowing and sludge as echogenic material without shadowing. The CBD is traced cephalad and the transducer is rotated to yield a longitudinal view of the CBD and PV which appear as parallel tubular structures. In this plane, the right hepatic artery appears as a round structure and is most typically located dorsal to the CHD.
Doppler can demonstrate the characteristic waveforms of the vascular structures, although it is not usually necessary for identification. The PV has a low velocity, continuous forward flow with minor undulations due to cardiac activity. Flow in the inferior vena cava is bi-directional due to the cardiac cycle and respirations. The HA demonstrates features of a low resistance type vessel with a bi-phasic spectral waveform that continues forward during diastole. The CBD has no Doppler signal other than the interference from respiratory excursion. The aorta and right renal artery are also seen at the inferior aspect of the sonographic images.
When the examination has been completed, the flexible probe is straightened and withdrawn under direct vision.
DOI: http://dx.doi.org/10.17797/njy9uc14u2
Editor Recruited By: Jeffrey B. Matthews, MD
Right Hepatic Lobectomy with Intraparenchymal Vascular Control
Contributors: Amy D. Lu and Diego Di Sabato
A right hepatic lobectomy with laparoscopic mobolization and division of the short hepatic veins and intraparenchymal division of the vasculature is depiected in this video.
Editor Recruited By: Jeffrey Matthews, MD
DOI: http://dx.doi.org/10.17797/i04zpfb2x3
A Safe Stepwise Approach to the Critical View of Safety During Laparoscopic Cholecystectomy
Contributors: Eric Zimmerman and Pierre F Saldinger
After the introduction of laparoscopic cholecystectomy bile duct injury rates have increased (3 per 1,000 cholecystectomies). Bile duct injuries after cholecystectomies are unfortunate events that can lead to significant morbidity, high cost and impair in quality of life. The purpose of this video is to demonstrate a safe stepwise approach to the critical view of safety described by Strasberg during laparoscopic cholecystectomy.
DOI: http://dx.doi.org/10.17797/ce9i07jf03
Editor Recruited By: Jeffrey B. Matthews, MD
Laparoscopic Roux-En-Y Gastric Bypass with Circular Stapled Gastrojejunostomy
Contributors: Ranjan Sudan
This video depicts a laparoscopic Roux-en-Y gastric bypass performed with a linear stapled jejunojejunostomy and a circular stapled gastrojejunostomy.
DOI: http://dx.doi.org/10.17797/4mc50uaz8e
Editor Recruited By: Jeffrey B. Matthews, MD