Laparoscopic cholecystectomy and exploration of common bile duct in a patient with situs inversus

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients: A technical review

Situs inversus (SI) is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs. Since the 1990s, more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy. In these cases, the major problem is to overcome is the left-right condition for right-handed surgeons. Laparoscopic common bile duct exploration (LCBDE), an alternative to treat patients with bile duct stones, has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography. Recent updated meta-analyses revealed that a shorter postoperative hospital stay, fewer procedural interventions, cost-effectiveness, a higher stone clearance rate, and fewer perioperative complications are additional advantages of LCBDE. However, the technique is technically demanding, even for skilled laparoscopic surgeons. Conducting LCBDE in patients with difficult situations, such as SI, is more complex than usual. We herein review published SI patients with choledocholithiasis treated by LCBDE, including our own experience, and this paper focuses on the technical aspects.

Laparoendoscopic rendezvous procedure in a patient with situs inversus totalis: A case report and review of the literature

Situs inversus totalis patients may be associated with difficulties in the diagnosis and treatment of surgical diseases. This case suggests that laparoendoscopic rendezvous procedure could be associated with a lower morbidity and length of hospital stay.

Laparoscopic Gastric Resection for Gastric Cancer: Is Intracorporeal Anastomosis Necessary?

BACKGROUND AND OBJECTIVE

In surgical dissection, laparoscopic approach and open techniques do not differ significantly, but there is still no consensus on how anastomosis should be performed in both cardia and distal gastric tumors. Anastomosis can be performed by laparoscopy-assisted mini-laparotomy or by intracorporeal suture techniques. In this study, we aim to present our four years of clinical experience and short-term surgical results from 133 cases in order to evaluate the necessity of laparoscopic anastomosis.

METHODS

This study was approved by Ethics Committee (No: 1-8-19, date: 14/01/2019). Patients who underwent curative resection with the diagnosis of gastric adenocarcinoma between January 2014 and January 2018 in the Ankara University Surgical Oncology Department were included in the study.

RESULTS

Of the 133 patients included in the study, 108 (81.2) were male and the mean age was 60.51 ± 12.0 years. The time of anastomosis was significantly longer in patients undergoing intracorporeal anastomosis (p = 0.021). The incidence of anastomotic leakage was significantly higher in the group undergoing intracorporeal anastomosis (p = 0.004).

CONCLUSIONS

We think that esophagojejunostomy and jejunojejunostomy anastomoses in patients undergoing total gastrectomy should be performed with intracorporeal techniques in terms of benefit risk assessment. We believe that it is more feasible to continue the case with mini laparotomy when anastomosis is reached in patients who are planned to have gastrojejunostomy. In addition, in terms of intracorporeal anastomoses and advanced laparoscopic techniques, intracorporeal anastomoses performed in gastric cancer surgery for a laparoscopist who has completed the learning curve do not appear to be very different in terms of anastomosis safety.

Laparoscopic cholecystectomy with choledochoduodenostomy in a patient with situs inversus totalis

A 50-year-old female presented to us with features of obstructive jaundice. Investigations revealed cholelithiasis with single large impacted calculus in the common bile duct (CBD) and significant dilatation of extrahepatic biliary tree. Incidentally, the patient was also detected to have situs inversus totalis (SIT). Attempt at extraction of the calculus in the CBD by endoscopic retrograde cholangiography failed, and a 7F stent was placed. The patient was subjected to laparoscopic cholecystectomy, CBD exploration with the extraction of the offending calculus and laparoscopic choledochoduodenostomy (LCDD). The patient had an uneventful recovery and is since discharged. PubMed search did not reveal LCDD in SIT as a procedure reported in literature to the best of our knowledge.

Technical Feasibility and Short-Term Outcome of Intracorporeal Hand-Sewn Esophagojejunostomy After Laparoscopic Total Gastrectomy: Our Experience

The purpose of this study was to demonstrate the safety and technical feasibility of intracorporeal hand-sewn esophagojejunostomy after laparoscopic total gastrectomy. Laparoscopic total gastrectomy (LTG) is a technically challenging procedure, especially for esophagojejunal anastomosis (EJA). Various techniques have been described to overcome these difficulties using staplers with variable results. We report successfully performed complete intracorporeal hand-sewn EJA after LTG. The perioperative clinical data and short-term outcomes for 30 patients who underwent LTG using hand-sewn EJA for gastric cancer between 2013 and 2015 have been retrospectively reviewed. The mean age was 49.9 years; 64 % of patients were male and 36 % were female. The mean body mass index (kg/m²) was 22.4, and the mean American Society of Anesthesiologists (ASA) score was 1.4. Eleven patients had co-morbidities, and six patients had previous abdominal operations. The mean operative time, time for EJA, and blood loss was 136.9 min, 13.25 min, and 166 ml, respectively. The conversion rate was nil. The mean time for the first oral feeding and mean hospital stay was 8.3 and 9.8 days respectively. The postoperative complications were found in 16 % of patients with one case of 30-day mortality because of lobar pneumonia. There were three cases of anastomotic stenosis; however, no leakage was identified both clinically and radiologically. Complete intracorporeal hand-sewn EJA is a safe and feasible technique in the hands of experienced surgeons that can be considered as an alternative cost-effective method when performing LTG.

Laparoscopic gastric cancer surgery: Current evidence and future perspectives

Laparoscopic gastrectomy has been widely accepted as a standard alternative for the treatment of early-stage gastric adenocarcinoma because of its favorable short-term outcomes. Although controversies exist, such as establishing clear indications, proper preoperative staging, and oncologic safety, experienced surgeons and institutions have applied this approach, along with various types of function-preserving surgery, for the treatment of advanced gastric cancer. With technical advancement and the advent of state-of-the-art instruments, indications for laparoscopic gastrectomy are expected to expand as far as locally advanced gastric cancer. Laparoscopic gastrectomy appears to be promising; however, scientific evidence necessary to generalize this approach to a standard treatment for all relevant patients and care providers remains to be gathered. Several multicenter, prospective randomized trials in high-incidence countries are ongoing, and results from these trials will highlight the short- and long-term outcomes of the approach. In this review, we describe up-to-date findings and critical issues regarding laparoscopic gastrectomy for gastric cancer.

Minimally invasive surgery for gastric cancer treatment: current status and future perspectives

Minimally invasive surgery, which has been extensively used to treat gastric adenocarcinoma, is now regarded as one of the standard treatments for early gastric cancer, and its suitability for advanced gastric cancer is being investigated. The use of cutting-edge techniques for minimally invasive surgery enables surgeons to deliver various treatment options to minimize a patient's distress and to maintain oncologic safety. Ongoing multicenter prospective studies aim to validate the efficacy of these surgical techniques and to expand the indications of minimally invasive surgery for the treatment of gastric cancer. In this review, we summarize the current status and issues regarding minimally invasive surgery for the treatment of gastric cancer.

Laparoscopic cholecystectomy in situs inversus totalis: Feasibility and review of literature

INTRODUCTION

Situs inversus totalis is a rare anomaly characterized by transposition of organs to the opposite site of the body. Laparoscopic cholecystectomy in those patients is technically more demanding and needs reorientation of visual-motor skills to left upper quadrant.

PRESENTATION OF CASE

Herein, we report a 10 year old boy presented with left hypochondrium and epigastric pain 2 months duration. The patient had not been diagnosed as situs inversus totalis before. The patient exhibit a left sided "Murphy's sign". Diagnosis of situs inversus totalis was confirmed with ultrasound, computerized tomography (CT) and magnetic resonant image (MRI) with presence of multiple gall bladder stones with no intra or extrabiliary duct dilatation. The patient underwent laparoscopic cholecystectomy for cholelithiasis.

DISCUSSION

Feasibility and technical difficulty in diagnosis and treatment of such case pose challenge problem due to the contra lateral disposition of the viscera. Difficulty is encountered in skelatonizing the structures in Calot's triangle, which consume extra time than normally located gall bladder. A summary of additional 50 similar cases reported up to date in the medical literature is also presented.

CONCLUSION

Laparoscopic cholecystectomy is feasible and should be done in situs inversus totalis by experienced laparoscopic surgeon, as changes in anatomical disposition of organ not only influence the localization of symptoms and signs arising from a diseased organ but also imposes special demands on the diagnosis and surgical skills of the surgeon.

200 consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder

INTRODUCTION

Because of the potential benefit of robotics in pancreatic surgery, we review our experience at two minimally invasive pancreatic surgery centers that utilize a robotically controlled laparoscope holder to see if smaller robots that enable the operating surgeon to maintain contact with the patient may have a role in the treatment of pancreatic disease.

METHODS

From March 1994 to June 2011, a total of 200 laparoscopic pancreatic procedures utilizing a robotically controlled laparoscope holder were performed.

RESULTS

A total of 72 duodenopancreatectomies, 67 distal pancreatectomies, 23 enucleations, 20 pancreatic cyst drainage procedures, 5 necrosectomies, 5 atypical pancreatic resections, 4 total pancreatectomies, and 4 central pancreatectomies were performed. Fourteen patients required conversion to an open approach and eight a hand-assisted one. A total of 24 patients suffered a major complication. Sixteen patients developed a pancreatic leak and 19 patients required reoperation. Major complications occurred in 14 patients and pancreatic leaks occurred in 13 patients. Ten patients required conversion to a lap-assisted or open approach and six patients required reoperation.

CONCLUSIONS

Currently, a robotically assisted approach using a camera holder seems the only way to incorporate some of the benefits of robotics in pancreatic surgery while maintaining haptics and contact with the patient.

Laparoscopic right hemicolectomy with D3 lymph node dissection for a patient with situs inversus totalis: report of a case

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by an inversion of the thoracic and abdominal viscera that creates a mirror image. The transposition of the organs imposes special demands on the diagnostic and technical skills of the surgeon, especially when performing laparoscopic surgery. We herein report the case of a 63-year-old man with colon cancer of the hepatic flexure who received a laparoscopic right hemicolectomy. Careful recognition by the surgeon of the mirror image anatomy and skillful use of his left hand resulted in a successful outcome. The surgery was not otherwise different from ordinary cases. Therefore, laparoscopic colectomy is considered to be a safe and feasible option for patients with colorectal cancer and SIT.

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro-con debate format.

A simple technique for performing laparoscopic purse-string suturing during circular stapling anastomosis

An esophagojejunostomy using a circular stapler requires the fixing of an anvil at the esophageal stump. When this placement procedure is laparoscopically performed, purse-string suturing is difficult, and there is a risk of loosening when a conventional needle driver is used. We herein present a simple but effective technique for performing laparoscopic purse-string suturing of the esophageal stump using a semiautomatic suturing device called the Endostitch. Gastrointestinal anvil placement was laparoscopically performed for 10 patients who underwent an esophagojejunostomy following a total gastrectomy. After the lumen of the esophagus was expanded using bowel forceps, the Endostitch was used to place approximately 12 encircling purse-string sutures. An anvil was positioned with support of the esophageal wall at three points with forceps. The Endostitch was used for the ligation with a sufficient degree of tension applied by extracorporeally pulling the sutures through the abdominal wall. The time for placement of the anvil averaged approximately 8 min. The ring formation following anastomosis was favorable in all patients. As a result, we consider our technique to be simple but very effective.

Laparoscopic exploration of common bile duct in difficult choledocholithiasis

BACKGROUND

This review investigated the role played by laparoscopic exploration of the common bile duct (LECBD) in the management of difficult choledocholithiasis.

METHODS

This retrospective study reviewed a prospective database of LECBD for difficult choledocholithiasis during the period 1995 to 2003.

RESULTS

Of the 97 LECBDs performed in the authors' center from 1995 to 2003, 25 were performed for difficult choledocholithiasis. Difficult choledocholithiasis was defined as failure of endoscopic stone retrieval for the following reasons: access and cannulation difficulty, the difficult nature of common bile duct (CBD) stones, and the presence of endoscopic retrograde cholangiopancreatography (ERCP)-related complications. There were seven unsuccessful cannulations because of previous gastrectomy (n = 5) and periampullary diverticulum (n = 2). Among the 18 patients with failed endoscopic extraction, there were 10 impacted stones, 2 incomplete stone clearances after multiple attempts, 2 type 2 Mirizzi syndromes, 1 proximal stent migration, 1 repeated post-ERCP pancreatitis, 1 situs inversus, and 1 stricture at the distal common bile duct. There were 14 male and 11 female patients with a mean age of 67.8 +/- 15 years. Initial presentations included cholangitis (n = 14, 56%), biliary colic (n = 3, 12%), jaundice/deranged liver function ( n = 5, 20%), cholecystitis (n = 2, 8%), and pancreatitis (n = 1, 4%). Regarding the approach for LECBD, there were 2 transcystic duct explorations and 23 choledochotomies. The mean operative time was 149.4 +/- 49.3 min, and there were three conversions (12%). The stone clearance rate was 100%, and no recurrence was detected during a mean follow-up period of 16.8 months. Five complications were encountered, which included bile leak (3 patients) and wound infection (2 patients). When the results were compared with the remaining 72 LECBDs for nondifficult stones during the same period, the complication rate, conversion rate, and rate of residual stones were similar despite a longer operation time (149.4 +/- 49.4 min vs 121.6 +/- 50.5 min).

CONCLUSION

When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones.