Surgery, Gastroenterology and Oncology

Background: Giant hiatal hernias (GHH) account for 5-10% of all hiatal hernias. Most patients are asymptomatic, while others have debilitating and persistent symptoms affecting quality of life (QoL). GHHs are usually associated with chronic digestive and gastroesophageal reflux symptoms and acute severe complications may occur. Surgical treatment is usually indicated in cases of failure of optimal medical treatment in smaller hernias, symptomatic patients with large hernias and asymptomatic patients with high risk for complications. Surgery is the treatment of choice in symptomatic GHH, a....[more] Read article

Introduction: Gastric lipomas are rare (<1% of all gastric tumors). Giant gastric lipomas (³4 cm) are even rare, with only 32 cases described since 1980, of which only 6 with ³10 cm. They are more common in the gastric antrum. The initial manifestation of these tumors may include obstruction, ulceration or gastrointestinal bleeding.

Case Report: We present a clinical case of a woman, 59 years old, with a history of papillary thyroid carcinoma with cervical metastases, asymptomatic. During the follow-up of the carcinoma, a large lipomatous formation was detected in the lesser curvature ....[more] Read article

Background: Choledocholithiasis occurs in 8–20% of patients with gallbladder stones. All patients with symptomatic gallbladder stone disease should be assessed for synchronous choledocholithiasis. When synchronous to symptomatic gallbladder stones disease, indication for treating both is clear. The most common treatment options are single-stage approach (SSA) with laparoscopic cholecystectomy and common bile duct (CBD) exploration or two-stage approach (TSA) combining pre- or post-operative ERCP (endoscopic retrograde cholangio-pancreatography) and laparoscopic cholecystectomy. SSA is gaining emphasis as surgeons’ experience ....[more] Read article

Introduction: Gastrointestinal stromal tumors frequently spread via hematogenous route to the liver or through peritoneal seeding in the abdominal cavity. Once metastization has occurred neither surgery alone nor systemic therapy can successfully accomplish persistent malignancy control. However, a grouping of both approaches may potentially achieve disease stabilization and significantly improve overall survival.

Case presentation: We describe the case of a 61-year-old male patient who had presented a large gastric GIST with tumor rupture seven years before. He was then submitted to atypical gastrectomy bearing microscopically positive ....[more] Read article

Cervical cancer is the fourth most common gynecological malignancy. It is a major health problem commonly affecting women in a young age. It is well known that the majority of cervical cancer cases are related to human papilloma virus. Therefore, in Europe the rate of cervical cancer is expected to decrease due to human papilloma virus vaccination (1-3). However, the discrepancy in cervical cancer cases is clearly seen between Eastern and Western European countries. Moreover, the estimated age-standardized incidence rate of cervical cancer is the highest in Bulgaria among all European countries (1-3). Surgery is the standard treatment therapy in early stages, whereas concurrent pelvic radiotherapy combi....[more] Read article

Traumatic diaphragmatic hernia (TDH) is an uncommon disease, with an incidence of about 0.5% and is usually associated with penetrating or blunt thoracoabdominal trauma (1). It is often associated with other thoracoabdominal, brain and musculoskeletal injuries, being a diagnostic and therapeutic challenge (2). These injuries worsen the prognosis, with a mortality of up to 31% (2, 3). Chest X-rays with bowel contrast studies and CT scans of the chest and the abdomen are a useful diagnostic tool for detecting TDH, being the latter more specific (4). The treatment involves repair of the diaphragmatic defect with or without a mesh, using a transthoracic and/or transabdominal approach (1). The recurrence of diaphragmatic hernia can ....[more] Read article

Introduction: Several interposition techniques have been described for reconstruction after total gastrectomy in FAP patients, in open (1) and laparoscopic assisted surgery (2,3,4). The Longmire technique has the advantage of allowing all the food to pass through the duodenum and better absorption of nutrients, such as iron (5). Here, we describe the use of a pedicled isoperistaltic jejunal flap interposition technique to reconstruct the digestive tract after total gastrectomy, fully performed by laparoscopic approach, in a patient with FAP that had previous total colectomy. Our patient was a 68-year-old woman, with “MUTYH-Associated Polyposis (MAP)”, a c.494A>G mutation at exon 7 and c.1145G>A mutation at exon 13. Sh....[more] Read article

Background: Parahiatal hernia is rare complication after esophagectomy. Is a rare form of diaphragmatic hernia, and its exact incidence is unknown. We report a case of para-hiatal hernia following laparoscopic esophagectomy, successfully managed laparoscopically. Case presentation: 63-year-old female, presenting a distal oesophageal adenocarcinoma, admitted in our Hospital in July 2018. The clinical TNM classification was T3, N2, M0 (stage IIIB). Initially treated by chemotherapy with partial response, after restaging a laparoscopic transhiatal esophagectomy with gastric tube reconstruction was performed. Two months after the surgery, the patient presented dyspnoea and left thoracic pain. Computed tomography confirmed presence of colon in the left hemithorax. The patient w....[more] Read article

Pancreatic adenocarcinoma has a poor prognosis, even after R0 resections. Metachronous disease usually arises as distant or regional metastasis, but local recurrence is infrequent. 66 year-old male patient with a subclinical pancreatic remnant lesion suspected to be malignant 10 years after duodenopancreatectomy for invasive mucinous cystoadenocarcinoma. After distant metastatic disease was ruled-out, laparoscopic distal pancreatectomy was performed. Pathology revealed a non-invasive intraductal papillary mucinous neoplasm (IPMN).
The decision to resect metachronous disease after pancreatic cancer surgery remains under debate, based on the type of recurrence. Pancreatic remnant lesions can be true recurrences or new primary tumors.
In this case, pathology suggests a slow growth recurrence or a ....[more] Read article

Introduction: Cirrhotic patients are difficult patients to operate on and are generally considered unsuitable for laparoscopy (1,2). We present the clinical case of a cirrhotic patient with comorbidities that was diagnosed with a hepatic nodule and cortisol secreting right adrenal tumor, for which a multidisciplinary team decided to submit him for laparoscopic intervention. Case report: N.D. is a 59 y.o. male, diagnosed in 2010 with alcoholic Child-Pugh B liver cirrhosis (score 9). In February 2019, a hepatic nodule in segment IV-A (2 cm) and cortisol secreting right adrenal tumor (6 4 4 cm) were found. He is also diagnosed with essential arterial hypertension grade II, mild diastolic dysfunction of the left ventricle, aortic sclerosis, chronic ischemic cardiomyopathy, type 2 diabetes mellitus and chronic gastritis. He ha....[more] Read article

Introduction: Abdominal hernias are more frequent in obese patients, associating more complications and worse therapeutic outcomes. These patients require a multidisciplinary treatment approach, including bariatric and hernia teams, and carried out in a specialized center.

Objective: To present the case of a 42yo obese patient with giant ventral hernia, and to discuss our therapeutic approach. This is a video presentation of a case report and literature review about the state of the art for hernia repair in obese patients.

Case report: 42 year-old female patient with previous history of surgical repair of esophageal atresia during childhood and long term feeding gastrostomy until adolescence. Laparotomic cholecystectomy in 2002 and laparotomic appendectomy in 2010.
Presenting the following comorbidities: ast....[more] Read article

The Glissonean pedicle approach in liver surgery provides new knowledge of the surgical anatomy of the liver and advances the technique of liver surgery. Extrafascial dissection of Glissonean pedicle without opening the liver substance, proposed by Takasaki, represents an effective and safe technique of anatomic liver resection.
Presented approach allows early and easy ischemic delineation of appropriate anatomic liver territory (hemiliver, section or segment) to be removed with selective inflow vascular control. It is not time consuming and it is very useful in re-resection, as well as oncological reasonable. According to the Sugioka's proposal, for technical standardization, it is important to recognize the four anatomical landmarks; the Arantius plate, the umbilical plate, the cystic plate and the Glissonean pedicle of the caudate process (G1c), and six Gates defined b....[more] Read article

Isolated caudate lobectomy (ICL) is technically demanding and its surgical techniques are not standardized. Herein, we describe our method of open and laparoscopic ICL by the extrahepatic Glissonean pedicle approach (GPA) and hepatic vein (HV) root-at first one-way parenchymal resection, which are both based on Laennec's capsule.
Firstly, all the Glissonean pedicles of the caudate lobe are isolated and divided extrahepatically without parenchymal dissection. We have devised two different techniques for the extrahepatic pedicle control. One is "the central hilar technique", where all the major hilar pedicles are utilized to isolate caudate pedicles, and the other is "the left-to-right tracking technique", where the caudate pedicles are serially divided along the hilar plate from the left to the right sides.
After controlling all pedicles of the caudate lobe, it is mobilized from the vena cav....[more] Read article

Anatomic resection of the segment VIII (SVIII) of the liver (segmentectomy VIII) is technically demanding either in open or laparoscopic procedure. Our approaches to anatomic liver resections are composed of the extrahepatic Glissonean pedicle approach (GPA) to isolate hilar pedicles and hepatic vein (HV) root-at first one-way resection of liver parenchyma in the cranio-caudal direction starting from the landmark HV root.
Both techniques are based on Laennec's capsule. Herein, we describe our standardized techniques for open and laparoscopic segmentectomy VIII. The standardized GPA to the Glissonean pedicle of SVIII (G-VIII) starts with cystic plate cholecystectomy and isolation of the anterior section pedicle by detaching the pedicle sheath from the Laennec's capsule.
Isolation of segment V pedicle facilitates that of G-VIII using the subtraction method. After confirmation of the demarcation line by clamping G-VII....[more] Read article

Laparoscopic central bisectionectomy (LCBS) is a highly advanced procedure for centrally located liver tumors. According to our approaches for anatomic liver resection composed of the Laennec's capsule-based extrahepatic Glissonean pedicle approach (GPA) and hepatic vein (HV) root-at first one-way parenchymal resection, we have standardized techniques for LCBS.
The extrahepatic GPA starts with cystic cholecystectomy facilitating extrahepatic isolation of the anterior section pedicle (G-ant), which is ligated. The segment IV pedicle (G-IV) is isolated extrahepatically.
Under occlusion of G-ant and G-IV, parenchymal dissection starts from exposing the root of middle hepatic vein (MHV) and continues in the cranio-caudal direction along the umbilical fissure vein, according to the left demarcation line. During parenchymal dissection, G-IV and MHV are divided.
Then, the right hepatic vein (RHV) is exposed at its root and tracked downward,....[more] Read article

Laparoscopic left hemihepatectomy (LLH) is one of the major hepatectomy procedures and its surgical techniques are not well standardized. According to our surgical strategies for anatomic liver resections, which are composed of the extrahepatic Glissonean pedicle approach (GPA) and hepatic vein (HV) root-at first one-way parenchymal dissection, we have standardized the surgical techniques for LLH.
Both approaches are based on the anatomical background of Laennec's capsule. The right and left sides of the root of the Glissonean pedicle including the umbilical portion of the portal vein (G-UP) are dissected with Laennec's capsule preserved on the liver parenchyma.
The G-UP is isolated extrahepatically and divided using a stapler. The common trunk of the left hepatic vein (LHV) and middle hepatic vein (MHV) is exposed from the left cranio-dorsal side and LHV is divided at its root.
Parenchymal dissection starts from exposing the root of MHV, which is tracked fro....[more] Read article

Laennec's capsule is a proper membrane of the liver, first described by Rene T. H. Laennec in 1802, covering not only the entire surface of the liver but also the intrahepatic parenchyma surrounding the Glissonean pedicles and the hepatic veins (HVs).
It is an essential structure for establishing liver resection, especially anatomic liver resection, which involves the isolation of the extrahepatic Glissonean pedicles and the exposure of the main HVs. Regarding the location of the capsule, Laennec and Couinaud described it as adjacent to the confluence of the main HVs.
Whereas, Hayashi revealed it to be around the peripheral branches. Recently, Kiguchi first reported that Laennec's capsule consists of two layers and proposed novel surgical procedures using this concept. Yet, its existence is still debated.
Herein, we show the precise anatomy and histology of Laennec's capsule around the HVs including its twolayered composition: one derived from the pericardium (the cardiac Laennec's ....[more] Read article

Background: Glissonean pedicle isolation is a very useful procedure during a laparoscopic anatomic hepatectomy (LAH); however, few studies have reported the precise layer structure around a Glissonean pedicle.
The aim of this study was to evaluate the layer structure around a Glissonean pedicle in cadaveric models and determine whether Glissonean pedicle isolation based on the layer structure can serve as a standard surgical procedure during a LAH.

Methods: From April 2017 to December 2019, LAHs were performed in 59 patients. Prior to the LAH, a cadaveric model was used to verify the layer structure around the Glissonean pedicle. The procedure was also performed in live patients during LAHs and pathologic verification was performed. In addition, we evaluated the short-term results of LAHs.

Results: Laennec's capsule covering the liver parenchyma was shown by histologic examination (Elastica van Gieson staining) in a cadaveric model and live patients. The gap between the Glissone....[more] Read article

We proposed a novel comprehensive surgical anatomy of the liver based on Laennec's capsule in 2017, which contributed to the standardization of extrahepatic Glissonean pedicle isolationâ?"the optimal method for Glissonean pedicle isolation without parenchymal destruction.
Thereafter, the scope of our concept included an extension to the hepatic vein and the plate system to establish the surgical technique of the anatomic liver resection that consisted of extrahepatic Glissonean pedicle isolation, exposure of the landmark hepatic vein, and parenchymal reresection to the optimum amount. The accumulated histological evidence supported our concept, employing elastic fiber staining as a means of visualization.
For the standardization of extrahepatic Glissonean pedicle isolation, it was necessary to accurately approach the six gates marked by four anatomical landmarks to enter a gap between the Glissonean pedicle and the Laennec's capsule that covers the liver parenchyma.
The cystic plate cholecystectomy and division of the anchors faci....[more] Read article

Background: Hepatectomy is the potentially curative treatment for liver tumors. The most critical postoperative complication of extensive liver resection is post-hepatectomy liver failure (PHLF) due to insufficient future liver remnant (FLR). The ALPPS (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy) effectively increases the resectability of inoperable liver tumors by achieving a rapid and an effective hypertrophy of the FLR, which lowers postoperative liver failure risk. However, this technique still carries on with high morbidity and mortality rate. Aim: To present the first case of total laparoscopic ALPPS for extended right hepatectomy which is shown in VDO resources. Our institute proposed this technique as a valid option aim to improve the outcomes of ALPPS procedure by careful patient selection.

Technique: Total laparoscopic ALPPS involves two stages. The first stage consisted in the ligation of the right portal branch and the partition of the liver. The second stage was performed on day 14 after the first stage whi....[more] Read article

Hepatic resection remains the only potentially curative treatment for patients with colorectal liver metastasis (CRLM) (1). Moreover, only15%-20% of patients with CRLM are suitable for surgical resection (2). Herein wepresent a video case-report of a radical laparoscopic central bisegmentectomy plus S3 subsegmentectomy for multiple liver metastasis after chemotherapy.
The patient was a 39-year-old man who was shown to have metachronous multiple liver metastases from sigmoid colon cancer. The size of the tumor in S3 was 7cm, and the size of the tumor in S4 S5 S8 was 13cm. At this point, it was judged that there was no indication for surgery, thuschemotherapy was started. ThemFOLFOX+panitumumabwas administered for 8 courses and FOLFILI+panitumumab was administered for 10 courses. The metastatic lesions showed a partial clinical response to the chemotherapy.
Because the tumors were limited in S3 and S4 5 8, a radical hepatectomy was thought to bepossible. A CT scan revealed that the tumor in S3was located near the root of G3, while the tumor in S4 S5 S8 was located near the anterior Glisso....[more] Read article

Anatomical central hepatectomy is technically demanding and is often excessive. It has an increased risk for insufficient remnant liver volume, especially in case of P8 dorsal pedicle for segment 7 and or P5 dorsal for segment 6, and or abnormal background liver. On the contrary, limited central hepatectomy (LCH) for centrally located tumors, based on preserving the P8 dorsal and some of P5 and P4 pedicles (depending on tumor placement) is conservative, and therefore has a low risk for insufficient remnant liver volume.
It is less technically demanding, when compared to anatomical central hepatectomy. The right side of the resection plane is driven along the P8 dorsal pedicle intersecting the P8 ventral pedicle and as few of the P5 pedicles as possible. The left side of the resection plane is established according to tumor placement anywhere in between the Cantlie's plane and the falciform ligament.

The video presents 5 cases that support the conclusion that LCH may be standardized, with good results, especially when using intraoperative ultrasound guidance. Read article

Living donor liver transplant predisposes both the donor and the recipient to high risk of small residual liver volume (in donor) and small-for-size graft syndrome (in recipient) (1).
Both of these risks can be overcomed by using two grafts from two different donors; this procedure is called "Living donor liver transplant using dual grafts" (2).

We present a video case-report of a "Living donor liver transplant using dual grafts" performed in a 51 yo female recipient for VHB+VHD cirrhosis, MELD score 22.
She received two liver grafts, a left hemiliver (Donor 2 in the video) and a left lateral section (Donor 1 in the video). The combined GRWR was 1.05 ( 0.71 + 0.34). For a better understanding of the technique, both donation and back-table procedures were combined in the same split-screen, being followed by the left lateral section (Donor 1) and left hemiliver (donor 2) implantations. Both donors had no postoperative complications. After 12 months of follow-up, both donors and the recipient are alive, with normal liver function.
Dual-graft Living donor liver transplant is a feasible option to achieve the required liver volume ....[more] Read article