Motion Picture

Tung Wah Hospital, Hong Kong SAR

Aim: Spigelian hernia is a rare lateral ventral hernia traditionally repaired through open incision. Three laparoscopic techniques were reported in the literature: intraperitoneal onlay mesh (IPOM), transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP). TEP is a less practiced approach worldwide. We present TEP repair of a left Spigelian hernia in a 64-year-old lady.

Methods: After the induction of general anaesthesia, the urinary bladder was catheterized. The patient was placed in a supine position with both arms adducted. A three-port technique with open cut-down through an ipsilateral infra-umbilical incision and two midline working ports was adopted. The preperitoneal space was created by telescopic dissection at the midline. We used sharp dissection initially and identified the pubic bone and the inferior epigastric vessels. The Spigelian hernia sac was identified and reduced. After parietalization of the round ligament by 4 cm, a lightweight polyester mesh was inserted to cover both the Spigelian defect and the myopectineal orifice. The mesh was fixed with cyanoacrylate glue. Finally, the preperitoneal space was deflated under direct vision.

Results: The operative duration was 43 minutes. There was no conversion to open or intraoperative complication. The patient was discharged on postoperative day 1. There was no recurrence or chronic pain at follow-up after 9 months.

Conclusions: We find the TEP approach safe and effective for Spigelian hernia repair.

Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR

Aim: Robotic surgical system has been used in minimally invasive endocrine surgery, especially in laparoscopic adrenalectomy. It is believed that robotic adrenalectomy has advantages in patient with large adrenal nodules >6 cm, obese patient with BMI ≥ 30 kg/m2, with history of abdominal surgery, pheochromocytoma and cortico-sparing adrenalectomy. Herein, we present a case of robot-assisted laparoscopic right adrenalectomy in a patient with cortisol and catecholamine co-secreting adrenal adenoma.

Methods: A 39-year-old lady with history of hypertension and diabetes mellitus, presented with symptoms of headache, palpitation, weight loss and hand tremor. Physical examination found Cushingoid features with enlarged supra-clavicular fat pad. Endocrine work-up showed both unsuppressed low-dose dexamethasone suppression test and overnight dexamethasone suppression test. 24-hours urine catecholamine test was elevated. Overall hormonal assay was suggestive of a cortisol and catecholamine co-secreting adrenal adenoma. G1-68 DONATATE PET-CT shown a 3.6 cm markedly DONATATE-avid hypodense right adrenal mass, suspicious of pheochromocytoma. Robot-assisted right adrenalectomy was performed for right adrenal adenoma.

Results: Operative time was 47 minutes. Intra-operative blood loss was minimal. The operation was uneventful, the patient was discharged on second day after operation. The hormone profile was normalized after the operation. Pathology was adrenal cortical adenoma.

Conclusions: Robot-assisted laparoscopic right adrenalectomy is safe and technically feasible for management of adrenal adenoma and pheochromocytoma in experts' hands.

Kwong Wah Hospital, Hong Kong SAR

Aim: Inguinal hernia is one of the most common pediatric surgical conditions encountered with an incidence of 1%-5%, with most cases presenting at 3-4 years of age. This video presentation gives a brief review on the pathogenesis and epidemiology of paediatric inguinal hernias, explores its associations with congenial hydroceles and undescended testes, and moves on to discuss the benefits and risks of inguinal hernia repair using the laparoscopic approach.

Methods: A case of left inguinal hernia seen at Kwong Wah Hospital is then presented, with the clip of the procedure shown. Key elements and important steps of the operation, with emphasis on the usual practices employed by operating surgeons at Kwong Wah Hospital, were discussed.

Results: Data from Laparoscopic inguinal hernia repair from Kwong Wah Hospital performed between 2018 and 2020 were then presented. The median age of the patient group was 4 years old (25 males, 3 females). All were indirect inguinal hernias; 15 were right-sided; eight were left sided and five were bilateral. Eight were associated with a congenital hydrocele and two were associated with undescended testes, one of which was bilateral Mean operating time was 1 h and 24 minutes (range 41-177 minutes). None of the cases reported complications and three cases had recurrence requiring a second operation.

Conclusions: Inguinal hernia is one of the most common pediatric surgical conditions encountered with an association with hydroceles and undescended testes. The laparoscopic approach for inguinal hernia repair is a safe and feasible alternative to the traditional open inguinal approach.

Division of Breast Surgery, Department of Surgery, Queen Mary Hospital

Department of Surgery, The University of Hong Kong, Hong Kong SAR

Aim: With advancement and popularization of the technology, robotic-assisted nipple-sparing mastectomy with immediate implant reconstruction is now increasingly practiced for selected breast cancer patients.

Methods: A 42-year-old lady, with known BRCA2 mutation, had a history of left breast cancer treated with neoadjuvant systemic therapy followed by lumpectomy and sentinel lymph node biopsy (SLNB), and adjuvant radiotherapy in 2014. During surveillance, she decided to have risk-reducing bilateral nipple-sparing mastectomy with immediate implant reconstruction in August 2019. For the procedure, patient was in supine position with pre-operative marking. Oblique left axillary incision with length of 5 cm along the old SLNB scar was made and a single port was inserted (Glove Port, Nelis, Gyeonggi-do, Korea). Robot (da Vinci Xi, Intuitive Surgical) was docked and mastectomy was performed with three robotic arms (one for camera, right with monopolar scissors, left with ProGrasp). Anterior skin flap was dissected followed by posterior dissection to detach breast gland from pectoralis major muscle. Retro-aerolar tissue sent for frozen section was confirmed to be negative for malignancy. Subpectoral muscle pocket was created to facilitate implant insertion. Robot was undocked and the breast was removed via the axillary wound. Right side operation was performed in a similar manner. Immediate breast reconstruction with subpectoral implant insertion followed.

Results: The patient had good recovery without complications. Cosmetic outcome was satisfactory.

Conclusions: Robotic-assisted nipple-sparing mastectomy with immediate implant reconstruction is a safe and feasible technique with small and well-hidden scar. With maturation of skills it could be beneficial for patients with breast cancer.