Background: Neuroendocrine tumours of the appendix are rare in the paediatric population, with an incidence of 1 in 10,000. They tend to be diagnosed incidentally following appendicectomy for suspected or confirmed appendicitis. Case Description: A 14-year-old female who presented to the emergency department with a 2-day history of migratory right lower quadrant pain. She had no significant medical or surgical history. She was tender in the right iliac fossa on examination with no classical signs of peritonitis. Mildly raised inflammatory markers along with a non-diagnostic ultrasound lead to the decision to proceed to diagnostic laparoscopy. A torted, injected appendix was identified and removed intraoperatively. The patient had an uncomplicated recovery and was discharged on post operative day one. Histopathology demonstrated a well differentiated grade 2 neuroendocrine tumour with clear margins. The case was discussed at an institutional multidisciplinary team (MDT) with the decision for ongoing surveillance. Conclusions: We describe the first case of a neuroendocrine tumour as the lead point for a torted appendix. Clinicians should be cognisant of the increasing incidence of neuroendocrine tumours and perform adequate resections in any cases where there are unusual findings. Currently management is based on adult management guidelines and these may be too aggressive for paediatric populations. The development of paediatric guidelines should be considered.
Background: Endometriosis is a multifactorial disease which can cause severe pelvic pain that can impact everyday life. In addition, the complex of pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity is a common cause of infertility. The treatment of this disease should be individualized according to the clinical situation and to the level of impairment. This study aims to define the role of surgery in the treatment of deep endometriosis with intestinal localization, particularly whether surgery is capable or not to improve painful symptoms, disease recurrence, and fertility.
The process of creating a pancreatic anastomosis (PA) is a pivotal and challenging part of the reconstruction phase following minimally invasive pancreaticoduodenectomy (PD). This particular step is notably associated with the potential development of postoperative pancreatic fistula, a complication that is more common when dealing with high-risk pancreatic stumps. Currently, there is still lack of consensus on what constitutes the safest method for PA. The best approach might vary depending on the unique intra-operative findings and the surgeons’ individual experience. In our study, we delve into the key challenges and the most relevant features to be considered when choosing the appropriate type of PA. We pay particular attention to complex cases, such as those involving bulky-fatty pancreases or non-visible Wirsung duct, as well as patients with a significant burden of comorbidities. We discuss the primary considerations necessary in these scenarios and suggest ways to overcome their associated challenges, by tailoring known techniques to suit each unique case. While our recommendations are also relevant for open surgery, we emphasize the minimally invasive approach in this study. Our goal is to encourage surgeons to strongly consider the later approach, even in situations that present high levels of complexity and require technical precision. To aid in understanding, we provide specific multimedia educational material to highlight relevant findings and demonstrate the methods we propose. This additional support is designed to enhance the learning experience and offer practical guidance for surgeons.
Background: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ES) is the preferred technique for the management of benign biliary tract pathology. The initial ES performance can lead to long-term complications due to duodenal reflux into the biliary tract. In patients with cholelithiasis, elective cholecystectomy following ERCP is performed to prevent new biliary events and acute cholecystitis. There is no consensus on the indication for cholecystectomy in all cases in elderly patients. The aim of this study is to determine whether cholecystectomy is effective in preventing medium- to long-term biliopancreatic complications in elderly patients who have undergone ERCP-ES for benign conditions.
Background: Candy cane syndrome represents a rarely described complication that presents after gastric bypass surgery. An excessively long blind side of the alimentary limb just below the gastro-jejunal anastomosis configured into a shape that resembles a “candy cane” is the cornerstone of the clinical picture. Upper gastrointestinal symptoms are frequently associated. Suboptimal weight loss has rarely been described in medical literature as a relevant component of the syndrome. Case Description: We present the case of a 34 years old female with a Body Mass Index of 46.7 kg/m2 in which a laparoscopic gastric bypass was performed without any immediate postoperative complications. During follow up unexpected suboptimal weight loss accompanied with gastrointestinal complaints were documented. An intensive workup which included an upper endoscopy and fluoroscopy with oral contrast demonstrated an exceptionally long blind side of the alimentary limb. Increased anastomosis diameter was also identified. The patient was offered surgical revision. A laparoscopic reconfiguration of the gastro jejunal anastomosis accompanied with a proper resection of the excessive length of the blind side of the alimentary limb was performed. The patient experienced improved weight loss and complete resolution of upper gastrointestinal complaints during clinical follow up. Conclusions: Clinical suspicion and diagnosis of this clinical entity accompanied with laparoscopic surgical revision reversed symptoms including suboptimal postoperative weight loss in this patient.
Background: Giant adrenal cysts represent a rare clinical condition. They are usually diagnosed incidentally. The treatment depends on the size, the associated symptoms, and whether it is a functional tumor or not. They are classified in order of frequency as vascular, pseudocyst, epithelial, and parasitic cysts. Case Description: The case report describes a 47-year-old Mexican woman patient who presented to our department with nonspecific symptoms of discomfort and pain in the lumbar region. Preoperative studies were conducted, and laboratory results were within normal parameters. Abdominal ultrasonography showed a giant cyst in the left upper quadrant. Further evaluation with intravenous contrast-enhanced abdominal computed tomography confirmed the presence of a cystic mass originating from the adrenal gland, displacing the spleen, stomach, pancreas, and left kidney. A laparoscopic approach was chosen, and the cyst was carefully dissected from the surrounding structures using precise surgical maneuvers, and the origin of the left adrenal gland was confirmed. Follow-up at 3 weeks showed a favorable recovery, and the patient was discharged without complications. Conclusions: Adrenal cysts should be included in the differential diagnosis of cystic abdominal masses. Laparoscopic surgery is feasible in the hands of experienced surgeons.
Background and Objective: Colorectal cancer (CRC) still remains one of the main causes of tumor-related morbidity and mortality worldwide with liver metastasis occurring in approximately 50% of patients. Surgery is still the “gold standard” and the laparoscopic approach is now performed in every centers. This review aims to provide an overview and summary of the history, current data and new advances on the perioperative and oncologic outcomes of laparoscopic liver resection for colorectal liver metastases (CRLM). Methods: PubMed research has been realized to select articles of interest concerning laparoscopic liver resection in CRC metastases. Only English articles published from January 1990 to June 2022 and for which full text was available have been selected. Key Content and Findings: Surgery is still the “gold standard” and laparoscopic liver resection has proved to be safe and significantly reduce the frequency of complications in liver resection for CRLM. Benefits and limits of new technologies in hepatectomies in CLRM are also considered together with the possible treatment strategies and technical consideration. Conclusions: The laparoscopic approach for CRLM has increased in the last years achieving superior results compared to the traditional approach. Moreover the introduction of augmented reality or new technological tools permit a more precise navigation during complicated surgical procedures. Laparoscopic liver surgery for CLRM has been proved to be safe and effective and it should be considered as the first surgical option.
Background and Objective: Minimally invasive pancreatectomy (MIP) has been increasingly performed in recent years. While the introduction of laparoscopic distal pancreatectomy (LDP) was straightforward, laparoscopic pancreaticoduodenectomy (LPD) was perceived as technically challenging due its complexity. However, robotic surgical innovation made concrete the feasibility of robotic pancreatectomy. These technological reforms have led to surgeons advocating for reduced-port surgery (RPS) for reduced procedure invasiveness. However, there are fewer reports on reduced-port robotic pancreatectomy (RPRP) than on other types of robotic surgery. Minimally invasive surgery (MIS) has lagged behind most in this area due to the complexity of pancreatectomy. In this narrative review, we provide a comprehensive overview of the evolution of RPRP. Methods: Original manuscripts on RPRP, written in English and published before May 30, 2022, were searched for in the PubMed, Embase and Cochrane databases. Keywords included “single-port”, “single-site”, or “single-incision” robotic pancreatectomies. Key Content and Findings: The search revealed seven studies reporting 104 cases of RPRP, including 59 and 45 cases of distal pancreatectomy (DP) and pancreaticoduodenectomy (PD), respectively. Although there were only two studies comparing reduced-port laparoscopic pancreatectomies and open or laparoscopic pancreatectomy, perioperative outcomes were acceptable for both DP and PD. Only five patients in this review required conversion to multi-port or open surgery (4.8%). Although the small number of material papers in this review may not conclusively guide the next steps in this surgery, we found no evidence to disprove the feasibility of RPRP. Conclusions: Based on the results of further comparative studies with conventional robotic pancreatectomy, we hope that RPRP will become more widely used in the future.
In the field of laparoscopic surgery, there has been ongoing discussion regarding the optimal pressure for pneumoperitoneum. Until recently, there was limited data available regarding the effects of low-pressure versus standard-pressure pneumoperitoneum on intraoperative and postoperative outcomes. However, a consensus has been established in most institutions, designating 12 mmHg as the standard pressure for laparoscopy, despite the existence of data on the beneficial effects of lower pressure levels without compromising patient safety. In order to achieve the lowest possible pressure for pneumoperitoneum without compromising patient safety, certain approaches have been suggested. Deep neuromuscular blockade has been proposed as a technique to reduce intraabdominal pressure by inducing muscle relaxation, allowing for lower insufflation pressures while maintaining adequate surgical exposure. This approach has shown promising results in terms of improving postoperative outcomes. However, further studies are needed to validate its efficacy and determine the optimal level of neuromuscular blockade required. In conclusion, the optimal pressure for pneumoperitoneum in laparoscopic surgery has been a subject of ongoing debate and research. Recent evidence suggests that low-pressure pneumoperitoneum may offer advantages in terms of reduced postoperative pain, analgesic consumption, and shoulder pain, without significant increases in complications or conversion rates. However, further studies are needed to fully elucidate the effects of low-pressure pneumoperitoneum on various surgical procedures and patient populations. As laparoscopic surgery continues to evolve, a multidisciplinary approach involving surgeons, anesthesiologists, and researchers is essential to refine techniques and optimize patient care.
: Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been increasingly performed for pancreatic ductal adenocarcinoma (PDAC) in the body and tail of the pancreas. However, it is technically demanding, and a lack of experience can lead to serious intraoperative and postoperative complications or local recurrence due to residual tumors at the surgical margins. There are three keys to successful L-RAMPS: understanding anatomical variations; obtaining appropriate operative fields; and familiarity with several approaches. Preoperative evaluation should be focused not only on the tumor characteristics but also on the anatomical variations of major vessels. Surgeons should choose the appropriate approach according to the tumor location and anatomical variations for each patient. Retracting the liver and stomach is crucial for obtaining appropriate operative fields around the pancreas. Optimizing the caudal view of laparoscopy is important for safe approaches to the major vessels. Adequate posterior dissection according to the extent of retropancreatic invasion and en bloc regional lymphadenectomy should be performed for oncological benefits. Additionally, proper pancreatic transection with precompression of the pancreas, adequate selection of the cartridge of stapler, and slow firing technique is crucial for the prevention of postoperative pancreatic fistulas. A review of the literature was performed and our standard L-RAMPS technique was described.
Background and Objective: The indications and evidence base for robotic-assisted pancreaticoduodenectomy have grown exponentially over the last two decades and robotic-assisted resection is now considered a safe and oncologically-equivalent surgical option for patients with pancreaticobiliary cancers. In this narrative review, we outline the published literature regarding technical considerations and operative steps for robotic pancreaticoduodenectomy including techniques for safe vascular resection and reconstruction.
