Motion Picture
MP1: Laparoscopic cystojejunostomy for pancreatic pseudocyst
MY Chan and ACY Chan
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong SAR
Aim: Pancreatic pseudocyst is a common complication following pancreatitis. In cases where endoscopic drainage is not feasible, laparoscopic drainage should be considered. This video demonstrated the steps of laparoscopic cystojejunostomy, which was a relatively uncommon procedure.
Method: A 66-year-old gentleman presented with pancreatitis was found to have a large pancreatic pseudocyst on reassessment CT scan after the acute episode. The cyst remained persistent in size (around 15 cm) on serial CT and was causing epigastric discomfort to the patient. Since the pseudocyst was mainly in the infra-colic compartment, endoscopic drainage was deemed unsuitable. Laparoscopic cystojejunostomy was performed with Roux-en-Y loop. Necrotic material within the peudocyst was also debrided during the procedure.
Results: The operation time was 4 hours and 34 minutes. Blood loss was less than 50ml. Drain output was minimal and patient was discharged home 5 days after the operation. He remained asymptomatic after the operation.
Conclusion: Laparoscopic drainage is a feasible option for pancreatic pseudocysts which are not suitable for endoscopic drainage. In experienced hands, this approach remains safe and effective. Patient could benefit from less postoperative pain, shorter hospital stay and better cosmetic outcome than in open approach.
MP2: Neuro-endoscopy for recurrent obstructive hydrocephalus with aqueductal stenosis
DYC Chan, CXL Zhu and WS Poon
Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
Background and Aim: A 19-year-old girl with history of obstructive hydrocephalus and aqueductal stenosis was treated with endoscopic third ventriculostomy at 8-months old. Symptoms and signs were initially relieved and she had no focal neurological deficit. 18 years post operatively she had new onset of worsening headache with papilloedema from fundoscopy. Magnetic Resonance Imaging (MRI) showing newly increased hydrocephalus. MRI flow study showed decreased cerebral spinal fluid flow across the floor of the third ventricle. A second neuro-endoscopic operation was performed for this patient with recurrent hydrocephalus.
Method: Neuro-endoscopy was performed under General Anaesthesia. Patient was in supine position. Right frontal burr hole was performed. Neuro-endoscopy was inserted into the right frontal horn of the right lateral ventricule. Foremen of Monro and choroid plexus were identified. Neuro-endoscope was inserted into the third ventricle via the Foramen of Monro. An opening was identified at the floor of the third ventricule, in keeping with a previous third ventriculostomy. The Neuro-endoscope entered the pre-pontine cistern via this opening and identied the Basilar artery, Posterior cererbal artery and the Pons. The Liliquist membrane was identified at the floor of the pre-pontine cistern. It was thickened and stiff. An opening was created at the Liliquist membrane with Neuro-endoscopic forceps and Neuro-balloon.
Results: An opening was successfully created at the Liliquest membrane with Neuro-endoscopic focep and Neuro-balloon. There was no intraventricular haemorrhage or intracerebral haemorrhage. Post operatively intracranial pressure was normal. Symptoms was relieved with no headache. Post operatively computated tomography of the Brain shown improved hydrocephalus.
Conclusion: The anatomy of the deep brain structures were demostrated. The old third ventriculostomy opening remained patent, hence providing a rare opportunity for us to peek into the pre-pontine cistern. The Liliequist membrane was clearly identified in this operation. An opening of the Liliequist membrane had successfully relieved the hydrocephalus.
MP3: Robot-assisted laparoscopic resection of gallbladder remnant
WH Chan, DTM Chung, OCY Chan, ECH Lai and CN Tang
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong
A 61-year-old gentlemen underwent emergency laparoscopic subtotal cholecystectomy for acute cholecystitis, due to dense adhesion around Calot’s area. His recovery was complicated with controlled bile leakage from gallbladder remnant noted on post-operative day 4. Contrast-enhanced computerised tomography (CT) scan of abdomen showed a residual 2cm gallstone inside the gallbladder remnant. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with plastic biliary stent inserted. Bile leakage subsided afterwards. Robot-assisted laparoscopic resection of gallbladder remnant was performed 3 months after the subtotal cholecystectomy.
Operative time was 152 minutes. Intraoperative blood loss was 10ml. Post-operative course was uneventful and the patient was discharged on post-operativeday day 2. Follow up ERCP with biliary stent removal was performed 3 weeks after the operation.
With the use of robotic system, minimally invasive surgery is feasible in technically demanding surgery and patient recovery could be enhanced.
MP4: Pure laparoscopic right hepatectomy for hepatocellular carcinoma in cirrhotic patient
CY Cheung, ACY Chan, WC Dai and KSH Chok
Department of Surgery, Queen Mary Hospital, the University of Hong Kong
Aims: Pure laparoscopic right hepatectomy is a less invasive alternative to conventional open right hepatectomy. Some studies have shown reductions of postoperative ascites and liver failure in laparoscopic liver resection, without compromising long-term oncological outcomes. To describe the procedure and outcome with an operative video presentation.
Methods: A 44-year-old gentleman with Child’s A hepatitis B cirrhosis was found to have a 4cm lesion in the right lobe of liver, with the radiological diagnosis of hepatocellular carcinoma. A pure laparoscopic right hepatectomy was performed using the 3D laparoscopy.
Results: Laparoscopy showed the liver was cirrhotic. Intraoperative ICG retention test was 18.5%. There was a 4cm tumor in central part of the right liver. Postoperative recovery was uneventful. Histology confirmed the diagnosis of hepatocellular carcinoma with clear margins. 3-month postop CT scan showed no recurrence of hepatocellular carcinoma.
Conclusions: Pure laparoscopic right hepatectomy is a feasible and safe approach alternative to conventional open approach in experienced hand.
MP5: Robotic assisted laparoscopic excision of Mullerian remnant and bilateral orchidopexies in Persistent Mullerian Duct Syndrome
JWS Hung, KLY Chung, FSD Yam, YCL Leung, CSW Liu, PMY Tang, NSY Chao, MWY Leung and KKW Liu
Introduction: Persistent Mullerian Duct Syndrome (PMDS) is a rare disorder of sexual differentiation affecting 46 XY male. We reported the first robotic assisted excision of Mullerian remnant with bilateral orchidopexies in an Asian child.
Patient and Methods: A 12 months old boy presented with unilateral impalpable testis was diagnosed to have Persistent Mullerian Duct Syndrome with Anti-Mullerian Hormone receptor mutation after serial workups. Robotic assisted laparoscopic excision of Mullerian remnant with bilateral orchidopexies was performed with Da Vinci Xi system. Cystoscopy was performed with cannulation of Mullerian remnant and bilateral ureteric openings prior to robotic assisted procedure. Three 8mm robotic ports were used at supra-umbilical region, left and right flank and one accessory 5mm STEP port at right upper quadrant. Dissection of Mullerian remnant from both testes was performed safeguarding the vas deferens. Uterine vessels within broad ligament were cauterized and divided. The remnant was mobilized until insertion at prostatic urethra and divided. The short stump of insertion was closed with absorbable sutures. Bilateral transverse scrotal incision was done and both testes were brought down to base of scrotum and anchored.
Result: Operative time was 235 minutes and blood loss was minimal. Total length of hospital stay was 5 days. There was no intraoperative or post-operative complication. Both testes remained at base of scrotum on latest follow up.
Conclusion: Robotic assisted laparoscopic approach in Mullerian provides excellent anatomical visualization and enables a more complete excision of the Mullerian remnant.
MP6: Non-endoscopic minimally invasive thyroidectomy with minimally invasive anaesthesia
WWY Kwan, KPC Tsui and TL Chow
Division of Head and Neck Surgery, Department of Surgery, United Christian Hospital
Aim: Endoscopic thyroidectomy is mostly not minimally invasive surgery except the trans-cervical approach, because of the side effects of general anaesthesia and tissue dissection from the working ports. We illustrate the surgical techniques of thyroidectomy with a mini-incision under local anaesthesia.
Methods: A middle-aged lady with a 2cm right thyroid nodule underwent right hemithyroidectomy under local anaesthesia. Preoperative fine needle aspiration showed follicular lesion. Superficial cervical plexus block was performed with local anaesthesia using landmark methods. Light intravenous sedatives and analgesics were given. A 2cm cervical skin incision was used. Lateral approach allowed minimal tissue trauma. Layered local anaesthetics were infiltrated. Capsular dissection with meticulous hemostasis and individual vessel control facilitated bloodless operative field. Integrity of the recurrent laryngeal nerve can be tested by direct talking to the patient during the operation. Right hemithyroidectomy including resection of the pyramidal lobe and isthmus proceeded. Rapid recovery and discharge to home within the same day were illustrated.
Results: We have performed 50 thyroidectomies under local anaesthesia in the period 2013-2016 for thyroid nodules of sizes up to 4cm. The mean nodule size was 2.3cm. Mean operative time was 75 minutes. Median length of hospital stay was 1 day. 76% of the cases were done on a day surgery basis. None required conversion to general anaesthesia. None had complications of hematoma or required readmission.
Conclusions: Thyroidectomy with a mini-incision under local anaesthesia is a safe and feasible minimally invasive procedure. It evades the side effects of general anaesthesia including postoperative nausea, vomiting and sore throat. Rapid recovery of the patient facilitates ambulatory thyroidectomy.
MP7: Management of gastrointestinal stromal tumour in a challenging position of stomach
CK So, CT Lam, KW Leung, SH Lam and TL Chow
Aim: The surgical principle for gastrointestinal stromal tumour (GIST) is to excise the lesion with clear margin without rupture. However the intraluminal nature or specific position may hinder a simple laparoscopic wedge resection difficult. We described the surgical techniques for excision of GIST located at cardia and antrum.
Methods: The surgical techniques were examined and evaluated in two patients with intraluminal GIST located over cardia and antrum. Intraoperative and postoperative parameters were studied.
Results: A 65 year old lady had a 2cm GIST located at the cardia and the lesion was excised via a laparoscopic transgastric approach. Intraoperative blood loss was 10 ml. Total operative time was 156 minutes. Total length of hospital stay was 4 days. Upon three-month follow up, she did not experience any symptoms of bloating or dysphagia.
Another 68 year old lady had a 3cm GIST located at the posterior wall of antrum in which a laparoscopic Billroth I gastrectomy with delta anastomosis was performed. Intraoperative blood loss was 10 ml. Total operative time was 167 minutes. Total length of hospital stay was 5 days. Upon three-month follow up, she did not experience any reflux or dumping symptoms.
Conclusion: The surgical approaches applied for both patients were well tolerated without any surgical complication. We have to adopt an individualized approach in tackling gastric GIST in different locations particularly those not allowed a simple wedge resection.
MP8: Preservation of replaced left hepatic artery during laparoscopic gastrectomy for cancer – Importance of preoperative vascualr assessment
HC Yip, SM Chan, VW Wong, AY Teoh, SK Wong, PW Chiu and EK Ng
Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong Department of Surgery, 4/F Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, Shatin, NT.
Aim: Laparoscopic gastrectomy with D2 lymphadenectomy requires suprapancreatic dissection along major branches of the celiac artery. The procedure is difficult due to limitations of laparoscopy including reduced tactile feedback and two-dimensional view. Variations in the configuration of the celiac artery are common. A replaced left hepatic artery arising from the left gastric artery could be injured intraoperatively leading to hepatic ischemia. Preoperative vascular assessment with three-dimensional arteriography has been recommended. We report a case of laparoscopic gastrectomy and preservation of replaced left hepatic artery.
Methods: A 65 years old lady with carcinoma of stomach at distal body underwent elective surgical resection. Preoperative CT scan showed replaced bilateral hepatic arteries with left hepatic artery arising from left gastric artery. Laparoscopic distal gastrectomy with preservation of replaced left hepatic artery was performed.
Results: During suprapancreatic lymph node dissection, the common hepatic artery was traced to the celiac artery, where the proximal splenic artery was identified. The left gastric artery was preserved while adjacent lymphatic tissue was dissected. Gastric branches to the lesser curvature were ligated while the replaced left hepatic artery was preserved. The patient recovered uneventfully after operation. Post-operative CT scan showed that the replaced left hepatic artery remained patent.
Conclusion: Careful preoperative CT evaluation is crucial to identify variations of celiac vascular anatomy. Preservation of aberrant left hepatic artery, when large in size, have been found to significantly reduce liver function derangement. Laparoscopic D2 lymphadenectomy plus preservation of aberrant left hepatic artery is possible with careful surgical dissection.
