Kocher Maneuver Research Articles

Radical robot-assisted laparoscopic nephrectomy with thrombectomy in the vena cava

BackgroundRenal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. Material and methodsWe present the technique we employed in the first case performed in our department. After performing renal artery embolization, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher maneuver; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. ResultsThe surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60mg/dl). ConclusionsRadical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centers. We believe that the technique is reproducible and has clear advantages for our patients.

Nefrectomía radical laparoscópica asistida por robot con trombectomía en vena cava

BackgroundRenal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. Material and methodsWe present the technique we employed in the first case performed in our department. After performing renal artery embolisation, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher manoeuvre; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. ResultsThe surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60mg/dl). ConclusionsRadical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centres. We believe that the technique is reproducible and has clear advantages for our patients.

Robotic choledocoduodenostomy

Background: This video documents a robotic choledocoduodenstomy undertaken in a 59-year- old woman. Methods: The patient presented with chronic right upper abdominal visceral pain and elevated bilirubin. Preoperative workup, including a CT scan and MRI, uncovered the existence of a mild to moderate dilation of the common bile duct (11 mm) with debris present in the distal common bile duct. Results: The patient was taken to the operating room and prepared for the procedure. An 8 mm trocar was placed through the umbilicus for the robotic camera and two 8 mm robotic ports were placed at the right and left midclavicular lines on the same level as the umbilicus. The operation began with the lysis of adhesions followed by an extended Kocher maneuver. Next, a small incision was made along the length of the common bile duct on its ventral side. A biliary Fogarty was placed up the common bile duct toward the common hepatic duct, into the left hepatic duct, and then into the right hepatic duct. Then a choledocoscope was a placed up both the left and right hepatic duct and then down into the duodenum. Then the anastomosis was constructed. Conclusion: The patient tolerated the operation well and went home on postop day 1.

Application of intraoperative transluminal core-biopsy for diagnosis of pancreatic head mass: A single center 15-year experience

BackgroundPathology is the gold standard for diagnosis of pancreatic cancer. Preoperative endoscopic ultrasound-guided biopsy is an expensive procedure that is not routine in developing countries, hence a cheap, reliable alternative is required. AimTo evaluate the effectiveness and safety of a new technique of intraoperative biopsy from pancreatic head mass. MethodsPatients undergoing intraoperative transluminal core-biopsy (TLCB) for pancreatic head mass from January 2000 to June 2015 were included in this study. Following Kocher's maneuver, a biopsy was taken from the mass through the duodenum transluminally, using a commercial 16G automatic core-biopsy needle. Multiple tissue specimens were obtained for intraoperative frozen section examination. Depending on the pathological results, a decision was taken to either perform pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, bypass surgery, or to just terminate the operation. The malignancy status of the lesion was confirmed by postoperative pathological examination and/or long-term follow-up of the patients. ResultsA total of 525 patients were included. Intraoperative pathological reports revealed 436 malignant cases and 89 cases without evidence of malignancy. The sensitivity, specificity, false positive rate, and false negative rate were 97.7%, 100%, 0%, and 2.3%, respectively. Complications occurred in 2 patients. ConclusionTLCB is a quick, safe, effective, and accurate method for intraoperative diagnosis method in patients with pancreatic head mass; it can provide reliable evidence for surgical decision-making.

Kocher maneuver to facilitate cytoreduction within the foramen of Winslow.

A potential site for incomplete cytoreduction in patients with peritoneal metastases is the foramen of Winslow, especially the posterior aspect of the hepatoduodenal ligament. The Kocher maneuver can be used to rotate the duodenum, head of pancreas, and portal structures 180°. In so doing, the foramen of Winslow is clearly exposed for peritonectomy. Residual tumor at this site is a prominent cause of unnecessary treatment failure in the management of patients with mucinous appendiceal neoplasms.

Robotic total pancreatectomy with splenectomy for multifocal intraductal papillary mucinous neoplasm

Objective: In this video, we describe a systematic approach to a robotic total pancreatectomy for multifocal intraductal papillary mucinous neoplasm (IPMN) involving the entire pancreas. Methods: The patient is a 61-year-old female with a history of stage I endometrial cancer post robotic assisted total hysterectomy and salpingo-oophorectomy who was diagnosed with multifocal IPMN. Endoscopic ultrasound with fine needle aspiration of a complex cyst at the pancreas neck was significant for a CEA of 2080. She is a type 1 diabetic on an insulin pump. Results: A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed: (i) Diagnostic laparoscopy (ii) Entry into the lessec sac (iii) Division of the short gastric vessels (iv) Exposure and dissection of the inferior pancreas border (v) Dissection and transection of the splenic artery (vi) Mobilization of the spleen (vii) Exposure of the splenic vein-superior mesenteric vein confluence and transection of the splenic vein (viii) Kocher maneuver (ix) Release of the Treitz and transection of proximal jejunum (x) Transection of the distal stomach (xi) Portal lymphadenectomy (xii) Dissection and transection of the gastroduodenal artery (xiii) Hepaticojejunostomy (xiv) Cholecystectomy (xv) Gastrojejunostomy. Conclusion: Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique.

Safe dissection of high paraaortic lymph nodes superior to the renal vein in ovarian, primary peritoneal, or fallopian tube cancer by the “Komiyama's maneuver”, a modification of Kocher's maneuver

ObjectiveHigh paraaortic lymph nodes superior to the renal vein are often involved by metastasis from advanced ovarian cancer, but are difficult to dissect. We developed a novel surgical technique for removing these nodes. MethodsThe ascending colon is displaced from the right paracolic gutter. A retroperitoneal incision is made cranially from the ileocecal region along Monk's white line (fusion fascia) dorsal to the ascending colon. Incising the fusion fascia toward the root of the right renal vein from inside Gerota's fascia allows separation of the right kidney and mobilization of the ascending colon, partly exposing the inferior vena cava. Then the inferior vena cava below the renal vein is exposed by dissecting the right ovarian vein. Next, Kocher's maneuver is performed [1,2]. After mobilizing the duodenum, the inferior vena cava can be fully exposed below the left hepatic lobe. Then the peritoneum is incised from near the aortic bifurcation along the inferior mesenteric vein toward the ligament of Treitz, allowing complete mobilization of the small intestine and right hemicolon. Placing these viscera extra-abdominally in isolation bags provides excellent visualization of the entire aorta from the superior mesenteric artery to common iliac artery. ResultsThis method can completely remove the high paraaortic nodes, followed by the paraaortic nodes inferior to the renal vein, without complications. ConclusionsThis surgical technique for dissection of the high paraaortic lymph nodes is convenient, safe, and easy to learn. It is considered to be advantageous for management of ovarian, primary peritoneal, or fallopian tube cancer.

Navigating the Root of the Mesentery: A Guided Approach to an Artery-First Pancreatoduodenectomy.

In the standard technique of pancreatoduodenectomy (PD), the superior mesenteric artery (SMA) is approached following Kocher maneuver of the duodenum. Alternative approaches include SMA first with no touch approaches. The aim of this article is to report the preoperative planning for and operative techniques of a combined artery first with no touch technique (CTPD) for the performance of PD. The CTPD technique is described with a detailed discussion of the operative anatomy, and of the importance of preoperative mapping using computed tomography to aid dissection of the mesenteric root and identification of the SMA. The use of careful preoperative mapping of arterial anatomy on cross-sectional imaging helps to facilitate identification of the SMA and simplifies the operative approach to PD. By incorporating detailed preoperative planning and a careful anatomical dissection, the CTPD technique provides an earlier assessment of the superior mesenteric vessels and determination of resectability.

Laparoscopic Enucleation of Benign Pancreatic Tumors

Benign pancreatic tumor enucleations have been performed since 1996. Endocrine tumors (ET) are rare yet they represent about 2/3 of the laparoscopic enucleations, a topic still in debate. Preoperative imaging routinely comprises a CT scan but endoscopic ultrasound is mandatory for localizing the tumor and guided biopsy-aspiration. Trocars have to be positioned to avoid “fencing” with the instruments. A Kocher maneuver may be necessary for accessing deep or posterior tumors. Bipolar electrocautery and harmonic scalpel ensure better hemostasis than the monopolar cautery hook. The raw surface can be covered with hemostatics or fibrin glue. The mean operating time is 2 hours. Forced conversions, due mainly to hemorrhage or insufficient exposure, are rare (9%). Pancreatic fistula, the main postoperative complication, affects up to one third of the patients and does not depend on the choice of dissection instruments, management of the remaining cavity or somatostatin use. A risk factor is the location of the tumor at less than 2mm from the main pancreatic duct. Necrotic pancreatitis, pancreatic pseudocyst and duodenal fistula contribute to a surgical morbidity of 60%. Although safe and technically feasible enucleation still has to be considered a low mortality but high morbidity procedure.

Laparoscopic Management of Gallbladder Cancer: A Stepwise Approach

In the era of laparoscopic cholecystectomy, incidentally discovered gallbladder cancer (IGBC) has become a common clinical presentation.1 A consensus exists that radical resection should be performed for IGBC patients with T1b or more advanced tumors.2 Although the oncologic safety of laparoscopic treatment for selected patients with gallbladder cancer (GBC) has been demonstrated, a laparoscopic approach for IGBC remains uncommonly practiced due to the technical challenge of the frequently reoperative cases.3 PATIENT: A 75-year-old man underwent laparoscopic cholecystectomy for the presumed diagnosis of chronic cholecystitis and sludge at an outside institution, and pathology showed a T3 gallbladder carcinoma with a positive margin at the cystic duct stump. Restaging computed tomography at the time of referral showed findings in the hepatoduodenal ligament and gallbladder fossa concerning residual tumor versus postoperative inflammation. After four cycles of gemcitabine and cisplatin, restaging showed interval resolution of the postoperative change, continued low tumor marker carbohydrate antigen 19-9, and no evidence of metastatic disease. Therefore, the decision was made to perform a laparoscopic radical resection TECHNIQUE: With the patient in French position, significant adhesions around the hepatoduodenal ligament had to be dissected. Lymph node stations 12 and 16 were removed after a Kocher maneuver and hepatoduodenal ligament lymphadenectomy, preserving an accessory right hepatic artery. The cystic duct stump was removed at the level of confluence with the common bile duct. The resulting defect was reconstructed with interrupted sutures. Using intraoperative ultrasonography (IOUS) guidance, an anatomic resection of segments 4b and 5 was performed. An alternative approach is a laparoscopic Glissonian approach that can facilitate a safe anatomic resection.4 An air cholangiogram detected no bile leak and confirmed biliary patency.5 The postoperative recovery was uneventful, and pathology showed residual adenocarcinoma in segments 4b, and 5 with 50% tumor viability and negative margins. Because laparoscopic management of IGBC involves a challenging reoperative procedure, a systematic approach using accurate preoperative anatomic assessment, meticulous IOUS-guided surgery, and air cholangiogram is recommended to minimize the morbidity of this operation.

Direct, Duodenum-Guided Access to the Renal Hilum During Laparoscopic Radical Nephrectomy

AIM :To provide a step-by-step description of the surgical technique that allows for a direct, duodenum-guided access to the renal hilar vessels during laparoscopic radical nephrectomy (LRN). MATERIALS AND METHODS : For a right-sided LRN, a Kocher maneuver exposes the underlying vena cava (VC). The cephalad dissection of its lateral margin leads to the right renal vein (RRV). The right renal artery is identified posteriorly between RRV and VC and clip-secured. The access to the left renal hilum is guided by the identification of the fourth portion of the duodenum and the inferior mesenteric vein. The Treitz ligament is incised. The duodenum is medialized exposing the aortic wall and the left renal vein. The lateral surface of the aorta is carefully dissected till the emergence of the left renal artery. CONCLUSIONS : The described approach, although technically challenging represents a feasible, safe and oncologically valid technique to perform LRN in the hands of an experienced laparoscopist.

Laparoscopic Extended Right Hepatectomy with Biliary Reconstruction for Hilar Cholangiocarcinoma

Introduction: Although laparoscopic methods have been widely adopted for hepato-biliary-pancreatic surgeries, laparoscopic resection of hilar cholangiocarcinoma remains uncommon.1 One of the reasons is because it is a complicated procedure, consisting of major hepatectomy, lymph node dissection, and biliary reconstruction. There have been only one report about this procedure.1 From June 2010 through May 2013, 167 cases of laparoscopic hepatectomy (19 cases of lobectomy), 20 cases of laparoscopic distal pancreatectomy, and 10 cases of laparoscopic pancreaticoduodenectomy were performed in our hospital. Laparoscopic surgery for hilar cholangiocarcinoma is possible through the combination of those procedures. Methods: The patient was a 60-year-old man with jaundice. Magnetic resonance cholangiography showed stenosis of both hepatic ducts. After 22 days of biliary drainage, the patient underwent surgery. The patient was placed in the left hemilateral position and five laparoscopic trocars were positioned. First, the right lobe and the caudate lobe were mobilized away from the inferior vena cava. After performing the Kocher maneuver, lymphadenectomy of the hepatoduodenal ligament was initiated from the superior margin of the duodenum and pancreatic head. The lymph nodes were dissected along the vessels using laparoscopic coagulating shears, and the common bile duct, the right hepatic artery, and the right portal vein were divided. After the Arantius ligament was divided, the hanging tape was placed between the right and middle hepatic veins, along the Arantius ligament. The surface of the liver and the small vessels were divided using laparoscopic coagulating shears. Thereafter, a hepatic parenchymal transection was performed using the crash and clamping method, with bipolar coagulation forceps, which are also referred to as BiClamps. The right hepatic vein was divided using a linear stapler. The left hepatic duct was clamped distally using an endovascular clip and divided adjacent to the umbilical portion. The specimen was retrieved through a minimal epigastric incision. Finally, end-to-side endoscopic hepaticojejunostomy was performed with running 4-0 PDS sutures. Two intra-abdominal drains were placed and the operation was completed. Results: The total operative time was 867 minutes and the total blood loss was 100 g. The postoperative course was uneventful, and the patient was discharged on the 16th postoperative day. A histological examination of resected specimens indicated a curative state with clear margins. There was no tumor recurrence 10 months after the operation. Conclusions: Laparoscopic resections for hilar cholangiocarcinomas are safe and feasible in selected patients and when performed by surgeons with expertise in hepatic surgery and minimally invasive techniques. Further studies are still needed to confirm the benefit of this approach over conventional surgery for hilar cholangiocarcinoma. No competing financial interests exist. I have presented this work at the 2013 EAES congress in Vienna (Austria) on June 19–22, 2013. Runtime of video: 5 mins 54 secs

Intraoperative near-infrared fluorescence visualization of the duodenal gastrinoma in a patient with Zollinger–Ellison syndrome

DISEASE AND ESOPHAGITIS, controlled with protonpump inhibitors during the last 5 years, was admitted to our hospital for evaluation with suspected Zollinger–Ellison syndrome (ZES). The basal acid output was 24 mEq/hr and fasting serum gastrin concentration 1874 pg/mL. On abdominal ultrasonography and magnetic resonance imaging a 15-mm juxta-duodenal pathologic lymph node (LN) of the anterior pancreaticoduodenal artery was detected and no liver metastases. The endoscopic ultrasonography with contrast did not find the primary tumor. Endoscopic fineneedle aspiration cytology with Ki67 proliferation index and Chromogranin A immunohistochemistry from the juxta-duodenal LN confirmed the diagnosis of well-differentiated neuroendocrine carcinoma. Somatostatin receptor scintigraphy was not available. Abdominal exploration, inspection, palpation after Kocher maneuver, and intraoperative ultrasonography only identified but the 15-mm juxta-duodenal LN. Indocyanine-green (ICG) 0.1 mg/kg was administered intravenously, with near-infrared fluorescence (NIRF) visualization (NIRF-800 probe, ArteMIS Handheld System, Quest Medical Imaging BV, Wieringerwerf, the Netherlands) of the duodenum and pancreas. The absolute values of

Last's Anatomy: Regional and Applied, 11th Edn

Last's Anatomy: Regional and Applied has long been a favourite with senior medical students and junior doctors studying for the MRCS examination. Most anatomy textbooks take the form of either large reference tomes or short books aimed at rapid pre-examination cramming. In contrast, Last's Anatomy is both comprehensive enough to satisfy postgraduate surgical expectations, and sufficiently focused to make it a realistic exam revision tool. Since its first appearance in 1954, Last's Anatomy has benefited from a relatively low turnover of single editors, all fellows of The Royal College of Surgeons of England. To this extent, the text has succeeded in staying true to its aims of providing a comprehensive, surgically oriented content, logically delivered and clinically relevant. In an academic climate, where anatomy is playing a progressively decreasing role, it is re-assuring to note that the content has remained descriptive and the format rigorously structured. For example, muscle groups continue to have clearly stated origins, insertions, actions, nerves and tests, whilst the course of blood vessels and nerves is fully described. The ‘Surgical Approach’ subsections add clinical relevance to the text by focusing on the anatomical basis of surgical practice (e.g. abdominal incisions on page 240 or Kocher's manoeuvre on page 279). These serve to bridge the gap between basic science and operative anatomy. Most chapters also contain sections on development, which provides a good basic science background for postgraduate surgical exams. Anatomy is par excellence a visual subject. An anatomy textbook with poor illustrations has been likened to a surgeon with poor hands – informative but of little practical relevance. The 11th edition represents a major step forward in the book's evolution. All the images have been coloured, a large number of clinical pictures have been added and new artwork has been used to enrich the text of past editions. Previously, complex images, such as the otic and pterygopalatine ganglia (page 354, 10th edn) have gained remarkable clarity in this edition (page 377) and illustrates the great benefit colour has brought to the visual appeal of the book. Similarly, new clinical photographs manage to integrate concepts of surgical anatomy, pathology and clinical relevance. One example is the identification of the parotid duct. This is achieved by depicting a malignant bloody discharge in a patient with a parotid duct tumour – a potent and memorable image. Also, new radiographic images add further clarity and meaning to the text (e.g. inferior mesenteric arteriogram on page 255). It is important to note, however, that with the exception of certain changes, the actual text of the book has remained very similar to that of the 10th edition even though its layout has been improved. In summary, Last's Anatomy is one of the only remaining descriptive surgically oriented anatomy texts. Its 11th edition has greatly added clarity due to the new colour scheme and updated images. Consequently, it will continue to be popular not only with postgraduates studying for the MRCS examinations but also with all those who appreciate the importance of sound anatomical knowledge in clinical practice.

V12-10 HAND-ASSISTED LAPAROSCOPIC RIGHT COLON MOBILIZATION FOR CONTINENT CUTANEOUS ILEAL CECOCYSTOPLASTY

You have accessJournal of UrologyReconstruction1 Apr 2015V12-10 HAND-ASSISTED LAPAROSCOPIC RIGHT COLON MOBILIZATION FOR CONTINENT CUTANEOUS ILEAL CECOCYSTOPLASTY Travis Pagliara, Daniel Liberman, and Sean Elliott Travis PagliaraTravis Pagliara More articles by this author , Daniel LibermanDaniel Liberman More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2780AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Continent cutaneous ileal cecocystoplasty (CCIC) offers an effective treatment option for patients with a thick-walled neurogenic bladder. To achieve a tension-free ileo-colic anastomosis, the right colon must be mobilized past the hepatic flexure via an extended laparotomy. We introduce hand-assisted laparoscopic right colon mobilization to allow for a tension-free bowel anastomosis through a Pfannenstiel incision. METHODS A 10cm Pfannenstiel incision is used to begin mobilization of the cecum along the line of Toldt. A gel hand port is inserted and pneumoperitoneum is achieved. A 12mm camera port is inserted through the umbilicus under direct vision. A 5mm midline trocar is placed one handbreadth cephalad to the umbilicus. The right colon is grasped through the hand port and is mobilized past the hepatic flexure, using electro-dissection via the 5 mm port. A Kocher maneuver is continued until the inferior vena cava and duodenum are well exposed. The stapled ileo-colic anastomosis, staple-tapering of ileum, and bladder augmentation are performed in the usual open fashion. The stoma is matured through the umbilical port site. RESULTS The hand-assisted laparoscopic modification of the CCIC has been performed on 20 patients at our institution with an average operative time of 4 hours. One case was aborted before bowel harvest when it was apparent that severe morbid obesity (body mass index of 60) and tight mesentery would preclude a tension-free anastomosis. There have been no bowel injuries or ileo-colic anastomotic leaks. CONCLUSIONS CCIC using a hand-assisted laparoscopic mobilization of the right colon allows for a less invasive and more efficient bladder reconstructive procedure. Future research will explore whether there is a difference in hernia rates, wound complications or length of stay. Multiple Choice Question: Q: How far should the right colon be mobilized to ensure a tension-free ileo-colic anastomosis during continent cutaneous ileal cecocystoplasty A) not at all B) to the ileo-colic artery C) to the hepatic flexure D) past the hepatic flexure until the inferior vena cava E) past the gastrocolic ligament Explanation: To allow for a tension-free ileo-colic anastomosis during bladder augmentation surgery it is important mobilize the right colon past the hepatic flexure until the inferior vena cava. This allows for the bowel anastomosis to be done through a pfannenstiel incision without tension and injury to the mesentery. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e979 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Travis Pagliara More articles by this author Daniel Liberman More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic Resection of a Large Functional Paraganglioma of the Organ of Zuckerkandl

Background: Paragangliomas of the organ of Zuckerkandl (PZ) are rare extra-adrenal pheochromocytomas, and according to a recent systematic review,1 only 135 cases have been reported so far. Detection and appropriate treatment of these tumors is important because PZ have a mortality rate of 43% when presenting acutely. While the utility of the laparoscopic approach in adrenal pheochromocytoma is well established, information on the safety and effectiveness of this approach in PZ is still very sparse. Materials and Methods: Here, we describe the successful laparoscopic resection of a large functional PZ in a 20-year-old woman with infrequent, but severe, hypertensive crises. Urinary metanephrines were three to five times higher than the upper limit of the normal range, and a CT scan revealed a large spherical (10 cm in diameter) abdominal mass, overlying the vena cava and the aorta, from the subpancreatic area to iliac bifurcation. We excised the tumor by the transperitoneal laparoscopic approach. The patient has been placed in the flank position, elevated at ~60°. Trocars were placed following the classical right nephrectomy scheme, with the camera in a lower position to allow a better visualization of the interaortocaval groove. Laparoscopy produced excellent exposure, allowing proper identification of the tumor origin and its relation to adjacent organs. Initially, we did a Kocher maneuver to mobilize the whole cefalo-duodenal-pancreatic bloc and the third and fourth part of duodenum to totally free the anterior vena cava and aorta. Next, we begin preparing the tumor, by leaving laterally the right ureter and clipping large vessels arising from the right iliac axis. We freed the interaortocaval groove by clipping and sectioning two or three retrocaval vessels. Then, we resected the inferior mesenteric artery and divided the blood vessels coming, directly, from the aorta and vena cava. At the end, full resection was completed uneventfully, and the tumor was retrieved in a bag through an enlarged incision of the periumbilical port. Results: Postoperative course was uneventful, and the patient was symptom-free and normotensive. After 1 month, urinary metanephrine dosage was in the normal range. Discussion: Available experience, although limited, suggests that laparoscopic exploration of suspected extra-adrenal pheochromocytoma is an appropriate approach to estimate the extension of the tumor and its resectability. Conclusions: The postoperative follow-up showed the success of the described surgical approach. Appropriate patient preparation and intraoperative and postoperative monitoring appear critical for the successful clinical management of Zuckerkandl paragangliomas. No competing financial interests exist. Running time: 6 mins, 29 secs

Evaluation of postgastrectomy symptoms after distal gastrectomy with Billroth-I reconstruction using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45).

Distal gastrectomy with Billroth-I reconstruction (DGBI) is the most commonly used treatment approach for gastric cancer patients in Japan. The aim of this study was to assess and elucidate the effect of different surgical DGBI techniques on postgastrectomy syndrome (PGS) using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45). The newly created PGSAS-45 composed of 45 questions was used in this study. The scale was distributed to 2,922 patients who underwent gastrectomy >1year prior. Completed forms were returned by 2,520 patients (86%), of which 909 underwent DGBI. The effects of performing the Kocher maneuver, differences in the size of the gastric remnant and differences the anastomosis technique had on the main outcome measures of PGSAS-45 were analyzed. Patients for whom the Kocher maneuver was performed experienced significantly worse meal-related distress and poorer quality of ingestion. Additionally, a less satisfactory physical and mental component summary from the SF-8 was reported. Patients with larger gastric remnants showed significantly better scores on the diarrhea subscale, a slightly better trend for the need for additional meals and dissatisfaction with eating. Regarding the anastomosis technique, there was no difference between the hand-sewn, circular stapler (CS) and linear stapler end-to-end anastomosis, and there was also no difference between the end-to-end and side-to-end anastomosis with the CS. The Kocher maneuver may increase meal-related distress, reduce the quality of ingestion and impart a negative effect on quality of life (QOL). The larger gastric remnants may cause reduction in diarrhea and an improvement in meal-related scores.

Renoportal anastomosis for dual-graft living donor liver transplantation using an artificial graft and a left renal vein-connected inferior vena cava cuff

Renoportal anastomosis for dual-graft living donor liver transplantation using an artificial graft and a left renal vein-connected inferior vena cava cuff

Posterior ‘Superior Mesenteric Artery First’ Approach for Resection of Locally Advanced Pancreatic Cancer

En bloc resection of the superior mesenteric vein (SMV), portal vein (PV), and/or splenic vein (SV) with concomitant venous reconstruction is required in 11-65% of cases of locally advanced pancreatic cancer.1 Early retropancreatic dissection of the superior mesenteric artery (SMA) from behind the pancreatic head utilizing an 'artery first' approach has been reported to be an efficient and safe approach to pancreaticoduodenectomy when SMA involvement is suspected.2 Additionally, this technique has been shown to reduce blood loss and result in shorter PV clamp times.3 While there are multiple variations to 'artery first' resection,4 this video will illustrate the critical steps of using the 'posterior approach' in patients with locally advanced pancreatic cancer. This approach has the benefit of early identification of a replaced right hepatic artery, but may be difficult in obese patients or those with extensive peripancreatic inflammation. These difficulties may be overcome by utilizing an 'inferior supracolic (anterior) approach', but this necessitates early division of the pancreatic neck and stomach.5 METHODS: Select video clips were compiled from several pancreatoduodenectomies to demonstrate this technique. A variety of bipolar devices were utilized for dissection depending on surgeon preference. All patients were diagnosed with locally advanced pancreatic cancer by Americas Hepato-Pancreato-Biliary Association/Society of Surgical Oncology (AHPBA/SSO) consensus criteria, confirmed by biopsy, and completed neoadjuvant chemotherapy. Patients were restaged by pancreas protocol computed tomography scan at the end of chemotherapy and offered local resection if the tumor did not progress and they were medically fit. No Institutional Review Board approval was required. The operation begins by dividing the attachment of the transverse mesocolon to the right perinephric area and extending this down to the white line of Toldt, followed by a wide Kocher maneuver. The lateral attachments to the pancreatic head are then divided, thereby exposing the left renal vein. The lesser sac is entered directly over the uncinate, allowing for a full visceral rotation of the pancreatic head, and further facilitating exposure of the left renal vein. In the setting of malignancy, the SMA may now be palpated posterior to the pancreatic head and/or neck to confirm it is free of tumor. If tumor is invading the SMA, the pancreaticoduodenectomy is aborted prior to performing any gastrointestinal or pancreatic transections. If the SMA is free, the dissection is then carried on to the inferior aspect of the pancreatic neck. Here the SMV (jejunal and ileal branches), middle colic vein, and the gastroepiploic vein are identified and the latter is ligated and transected. Following this, dissection of the portal structures (hepatic arteries, gastroduodenal artery, common bile duct, and PV) is performed. The jejunum is then divided, the ligament of Treitz is taken down, and the jejunum is then mobilized to the patient's right side. This allows for clear visualization of the pancreatic head/uncinate/SMV relationship. At this point, proximal and distal control of the PV, SMV, and SV should be obtained using vessel loops or umbilical tape. The dissection then proceeds laterally along the SMA border (posterior to the pancreatic head). This is often facilitated by use of a bipolar sealing device due to a rich lymphovascular network. Once the lateral border of the SMA is clearly exposed, dissection along its longitudinal axis is performed utilizing the jejunum for traction. Following this dissection, larger vessels such as the inferior pancreaticoduodenal artery can be more readily identified and ligated to fully mobilize the pancreatic head. After the head is completely separated from the SMA, the neck is divided. This leaves the specimen attached solely by the PV and SMV, which greatly facilitates venous resection and reconstruction when necessary. The 'artery first' approach has been shown to be safe and feasible in pancreatic resections. This technique should be considered whenever tumor is thought to involve the SMV and/or PVs as a means to facilitate safe venous resection and reconstruction while preserving sound oncologic principles.

Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video)

In previous reports of laparoscopic pancreaticoduodenectomy, the Kocher maneuver with a wide mobilization of the right colonic flexure is carried out in the early phase, and dissection of the superior mesenteric artery is performed in the last phase of resection. This report describes laparoscopic superior mesenteric artery first approach, in which the superior mesenteric artery is dissected in the early phase of resection. Through the ligament of Treitz, the retroperitoneum is widely opened and the superior mesenteric artery is isolated just superior to the left renal vein. The periarterial connective tissue and nerve plexuses surrounding the superior mesenteric artery are dissected longitudinally to identify the inferior pancreaticoduodenal artery, which is then tied and divided. The superior mesenteric artery first approach and early ligation of the inferior pancreaticoduodenal artery is considered to be a feasible, safe, and effective method for performing pure laparoscopic pancreaticoduodenectomy.