monthly focus

surgical intervention video

Cholécystectomie subtotale antérograde laparoscopique pour prise en charge d'une cholécystite emphysémateuse chez une patiente atteinte de cancer

This video demonstrates the case of a 71-year-old woman with metastatic breast cancer who was admitted to hospital for acute pancreatitis, which had been managed pharmacologically. MRI showed an acute lithiasis cholecystitis and cholangitis. An endoscopic retrograde cholangiopancreatography (ERCP) did not show any stones in the biliary tract. Blood chemistry tests showed a reduced inflammation.

Surgery performed after 3 months revealed a chronic cholecystitis with a severe adhesion syndrome. Careful dissection revealed an emphysematous cholecystitis with parietal abscess. A partial cholecystectomy with V-Loc™ closure suture of the residual gallbladder was performed. The patient was discharged without complications on postoperative day 2.

Bibliography:

1\. Fatih Kulen, Deniz Tihan, Uğur Duman, Emrah Bayam, Gökhan Zaim. Laparoscopic partial cholecystectomy: A safe and effective alternative surgical technique in "difficult cholecystectomies". Ulus Cerrahi Derg 2016 Apr 6;32(3):185-90. doi: 10.5152/UCD.2015.3086. eCollection 2016. PMID: 27528821 PMCID: PMC4970776 DOI: 10.5152/UCD.2015.3086

2\. Daniel Henneman, David W da Costa, Bart C Vrouenraets, Bart A van Wagensveld, Sjoerd M Lagarde. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc 2013 Feb;27(2):351-8. doi: 10.1007/s00464-012-2458-2. Epub 2012 Jul 18. PMID: 22806521 DOI: 10.1007/s00464-012-2458-2

3\. Adriana Toro, Michele Teodoro, Mansoor Khan, Elena Schembari, Salomone Di Saverio, Fausto Catena, Isidoro Di Carlo. Subtotal cholecystectomy for difficult acute cholecystitis: how to finalize safely by laparoscopy-a systematic review. World J Emerg Surg 2021 Sep 8;16(1):45. doi: 10.1186/s13017-021-00392-x. PMID: 34496916 PMCID: PMC8424983 DOI: 10.1186/s13017-021-00392-x

4\. Mohamed Elshaer, Gianpiero Gravante, Katie Thomas, Roberto Sorge, Salem Al-Hamali, Hamdi Ebdewi. Subtotal cholecystectomy for "difficult gallbladders": systematic review and meta-analysis. JAMA Surg 2015 Feb;150(2):159-68. doi: 10.1001/jamasurg.2014.1219. PMID: 25548894 DOI: 10.1001/jamasurg.2014.1219

Laparoscopic subtotal antegrade cholecystectomy for the management of emphysematous cholecystitis in a cancer patient

Gastrectomie totale laparoscopique avec vert d'indocyanine pour cartographie des ganglions lymphatiques dans le cancer gastrique

Radical lymphadenectomy is a vital component of curative gastrectomy for cancer patients. The contemporary adoption of lymph node mapping (LNM) through indocyanine green (ICG) has gained prominence, enhancing the overall yield of resected nodes and contributing to prolonged oncological efficacy. This video presents the case of a 64-year-old woman, with no family history of gastric carcinoma or significant personal history, asymptomatic, who underwent FOBT (fecal occult blood test) with a positive result. Subsequent endoscopic scrutiny led to the identification of a neoplasm on the anterior surface of the gastric midbody, subsequently biopsied, revealing a poorly cohesive carcinoma characterized by signet ring cells. However, CT-scan of the chest, abdomen, and pelvis failed to visualize the neoplastic lesion, and neither suspicious regional lymph nodes nor metastases were observed. The patient underwent a laparoscopic radical total gastrectomy with a curative intent, incorporating lymph node mapping facilitated by indocyanine green. The postoperative period was uneventful. Histological analysis corroborated the biopsy findings, indicating a poorly cohesive carcinoma with signet ring cells, staged as pT1aN0M0. Of the 69 resected lymph nodes, none exhibited metastasis. The integration of indocyanine green as an adjunctive modality for enhancing lymphadenectomy in laparoscopic gastrectomy emerges as a noteworthy consideration.



Bibliography: 

1. Chen QY, Xie JW, Zhong Q, et al. Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer: A Randomized Clinical Trial. JAMA Surg. 2020;155(4):300-311. doi:10.1001/jamasurg.2019.6033

2. Watanabe A, Hamilton TD. Lymph node mapping in gastric cancer: a pilot study in Western patients. Can J Surg. 2022;65(5):E630-E634. Published 2022 Sep 21. doi:10.1503/cjs.019821

3. Degiuli M, De Manzoni G, Di Leo A, et al. Gastric cancer: Current status of lymph node dissection. World J Gastroenterol. 2016;22(10):2875-2893. doi:10.3748/wjg.v22.i10.2875

4. Symeonidis D, Diamantis A, Bompou E, Tepetes K. Current role of lymphadenectomy in gastric cancer surgery. J BUON. 2019;24(5):1761-1767.



Laparoscopic total gastrectomy using indocyanine green (ICG) for lymph node mapping (LNM) in gastric cancer

This video aims to demonstrate a systematic approach to a seemingly hazardous anastomosis in total gastrectomy by using a laparoscopic esophagojejunostomy with a linear-stapled overlap technique in a patient with gastric adenocarcinoma.

The linear-stapled overlap technique enhances visibility, supports high anastomosis or small-sized intestines, and reduces the risk of postoperative stenosis. The use of a nasogastric tube and preparation of a tension-free jejunal limb are essential for a secure anastomosis technique.

Bibliography:

1\. Hai Huang, Zhiyuan Guo, Wen Li, Mingkai Zhang, Yanbin Li. A comparative study of using linear anastomosis with circular anastomosis in digestive tract reconstruction after laparoscopic radical total gastrectomy: A retrospective study. Medicine (Baltimore) 2023 Sep 1;102(35):e34588. PMID: 37657064 PMCID: PMC10476817 DOI: 10.1097/MD.0000000000034588

2\. Noriyuki Hirahara, Takeshi Matsubara, Hikota Hayashi, Satoshi Takao, Ryoji Hyakudomi, Tetsu Yamamoto, Takahito Taniura, Yoshitsugu Tajima. Overlapping Esophagojejunostomy Using a Linear Stapler in Laparoscopic Total or Proximal Gastrectomy. J Laparoendosc Adv Surg Tech A 2023 Oct;33(10):988-993. doi: 10.1089/lap.2023.0027. Epub 2023 May 12. PMID: 37172302 DOI: 10.1089/lap.2023.0027.

Linear-stapled esophagojejunostomy in laparoscopic total gastrectomy for gastric cancer

Gastrectomie totale laparoscopique pour cancer gastrique : œsophagojéjunostomie par agrafage linéaire

Prise en charge laparoscopique d'une fistule appendiculo-cutanée - démonstration vidéo

This is the case of a 79-year-old man who was referred by his general practitioner (GP) to the surgical outpatient clinic with recurrent discharge from a sinus over his right iliac fossa, which he developed following percutaneous drainage of an appendicular abscess 18 months earlier.

Following the resolution of his symptoms and his discharge from hospital, he underwent a complete colonoscopy, which did not show any abnormalities. The patient kept experiencing episodes of weepy purulent discharge from the sinus, which was located at the previous abdominal drain site necessitating frequent visits to his GP, with a failed attempt of excision under local anesthesia. Following assessment in clinic, a sinogram was arranged with an injection of 10mL of Omnipaque 300™ through a fine-bore percutaneous catheter under fluoroscopic guidance. It was followed by a non-contrast CT-scan, which demonstrated a linear tract with contrast entering the caecum through a non-inflamed appendix, which was adherent to the anterior abdominal wall. After counselling the patient, he opted for a laparoscopic appendicectomy and excision of the confirmed fistula. The pneumoperitoneum was established through a 10mm port at the umbilicus. Two additional 5mm ports were inserted in the left iliac fossa and suprapubic regions respectively. Initial laparoscopy showed dense fibrous omental adhesions around the fistula tract, which was taken down with hook diathermy followed by the execution of an appendicectomy in a standard fashion. After closure of abdominal port sites, a probe was inserted through the abdominal wall with excision of the fistulous tract. The patient was discharged home on the following day with uneventful postoperative recovery.

Bibliography:

1\. Singh M P, Samaiya A, Sainia T K, Saxena A. Spontaneous appendico-cutaneous fistula: an unusual presentation of retroperitoneal appendicular perforation associated with psoas abscess, J Surg Case Rep. 2016 Jun 23;2016(6):rjw112. doi: 10.1093/jscr/rjw112. PMID: 27340228 PMCID: PMC4918459

2\. Faulkner G, Pettit S H. Post-traumatic appendicular–cutaneous fistula: a case report. Ann R Coll Surg Engl. 2010 Jan;92(1):W6-7. doi: 10.1308/147870810X476665. PMID: 20056046 PMCID: PMC5696821

Laparoscopic management of an appendiculocutaneous fistula - a video vignette

Median arcuate ligament syndrome (MALS) is a syndrome associated with chronic abdominal pain, which was primarily caused by compression of the celiac trunk by the median arcuate ligament (MAL). This disorder typically results in patients presenting with bloating, weight loss, nausea, vomiting, and abdominal pain. The diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria, and the imaging modalities usually reveal a stenosed celiac artery with post-stenotic dilation. In such cases, MAL decompression is indicated, and the laparoscopic approach is the treatment of choice. The surgery should be performed by surgeons with an extensive knowledge of supramesocolic anatomy and with extensive capacity for both laparoscopic and open vascular management. Most patients respond well to MAL decompression (85% or higher), especially if patients showed post-exertional pain prior to surgery.

Bibliography:

1\. Upshaw W, Richey J, Ravi G, Chen A, Spillers NJ, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Overview of Median Arcuate Ligament Syndrome: A Narrative Review. Cureus. 2023 Oct 8;15(10):e46675. doi: 10.7759/cureus.46675. PMID: 37942382; PMCID: PMC10629207.

2\. Sun Z, Zhang D, Xu G, Zhang N. Laparoscopic treatment of median arcuate ligament syndrome. Intractable Rare Dis Res. 2019 May;8(2):108-112. doi: 10.5582/irdr.2019.01031. PMID: 31218160; PMCID: PMC6557235.

3\. Goodall R, Langridge B, Onida S, Ellis M, Lane T, Davies AH. Median arcuate ligament syndrome. J Vasc Surg. 2020 Jun;71(6):2170-2176. doi: 10.1016/j.jvs.2019.11.012. Epub 2019 Dec 25. PMID: 31882314.

4\. Ho KKF, Walker P, Smithers BM, Foster W, Nathanson L, O'Rourke N, Shaw I, McGahan T. Outcome predictors in median arcuate ligament syndrome. J Vasc Surg. 2017 Jun;65(6):1745-1752. doi: 10.1016/j.jvs.2016.11.040. Epub 2017 Feb 8. PMID: 28189355.

Laparoscopic treatment of median arcuate ligament syndrome (MALS): a case report

Traitement laparoscopique du syndrome du ligament arqué médian : rapport de cas

Principes d'une approche laparoscopique sûre pour le « syndrome du ligament arqué médian »

Median arcuate ligament syndrome (MALS) is characterized by the constriction of the celiac trunk caused by fibrous connections originating from the median arcuate ligament (MAL) and diaphragmatic crura. It presents with symptoms often leading to misdiagnosis. In this study, we present three cases of MALS, with distinct manifestations. This case was diagnosed through comprehensive investigations and managed successfully using laparoscopic decompression. The diagnosis of MALS poses challenges due to its variable presentations and overlap with other conditions. Diagnostic imaging techniques such as Doppler ultrasound, CT-scans, and angiography play a role in confirming the diagnosis. Laparoscopic decompression has proven to be a treatment option, which relieves symptoms and restores blood flow. This series highlights the importance of considering MALS as a cause for abdominal pain cases. Early detection and the use of diagnostic techniques can result in favorable outcomes. 

Bibliography: 

1. Iqbal S, Chaudhary M. Median arcuate ligament syndrome (Dunbar syndrome). Cardiovasc Diagn Ther. 2021;11(5): 1172-1176. doi: 10.21037/cdt-20-846.

2. Almeida JI, Coelho MN, Armas I, et al. Median arcuate ligament syndrome: a case report of a rare disease. Int J Surg Case Rep. 2022;90:106686. doi: 10.1016/j.ijscr.2021.106686. 

3. Kim EN, Lamb K, Relles D, et al. Median arcuate ligament syndrome-review of this rare disease. JAMA Surg. 2016; 151(5):471-477. doi: 10.1001/jamasurg.2016.0002.

4. Duffy AJ, Panait L, Eisenberg D, et al. Management of median arcuate ligament syndrome: a new paradigm. Ann Vasc Surg. 2009;23(6):778-784.

Principles of safe laparoscopic approach for "median arcuate ligament syndrome" (MALS)

Cure de hernie hiatale par approche laparoscopique après œsophagectomie

Introduction:

Post-esophagectomy hiatal hernia is an underreported issue, and its incidence is becoming increasingly significant as the life expectancy of patients treated for esophageal cancer keeps rising.

Neoadjuvant therapy for esophageal cancer and minimally invasive esophagogastric surgery represent risk factors for transhiatal herniation. This complication may occur during both short-term and long-term follow-up.

Diaphragmatic hernia may lead to complications such as incarceration, perforation, or strangulation of the herniated organs, which may be life-threatening.

Objective:

This video aims to raise awareness about complicated diaphragmatic hernias in emergency surgery.

Methodology:

A 62-year-old man presented to the emergency department with epigastric pain radiating to the back for 6 hours, associated with nausea and vomiting. The patient had a history of Ivor Lewis hybrid radical subtotal esophagectomy for adenocarcinoma and was undergoing palliative chemotherapy due to disease progression. Imaging tests revealed an incarcerated type IV hiatal hernia of recent onset. The patient underwent emergency surgery, which confirmed massive diaphragmatic herniation of the entire small bowel and transverse colon into the thoracic cavity. The hernia content was reduced without signs of ischemia, and the diaphragmatic defect was repaired laparoscopically with a non-absorbable suture. The patient was discharged on postoperative day 3, and the postoperative period was uneventful.

Conclusion:

Diagnosing a diaphragmatic hernia may be challenging and often delayed due to its non-specific symptoms. It is essential to maintain a high index of suspicion and use appropriate diagnostic imaging techniques to accurately identify the hernia and assess its potential complications.

Surgery is the treatment of choice for complicated diaphragmatic hernias, and a minimally invasive approach is recommended for stable patients. However, there is a lack of recommendations or clinical guidelines regarding the surgical management of hiatal hernias following esophagectomy.

Bibliography:

1\. A H Hölscher, U K Fetzner. Paraconduit hiatal hernia after esophagectomy. Prevention—indication for surgery—surgical technique. Dis Esophagus 2021 Sep 9;34(9):doab025. doi: 10.1093/dote/doab025. PMID: 33912913 DOI: 10.1093/dote/doab025

2\. Mairead M Hennessy, Ivan Ivanovski, Eleftherios Spartalis, Dimosthenis Chrysikos, Antonios Athanasiou. Diaphragmatic hernia following esophagectomy for esophageal cancer: A systematic review. J BUON 2019 Sep-Oct;24(5):1793-1800. PMID: 31786839

3\. Mario Giuffrida, Gennaro Perrone, Fikri Abu-Zidan, Vanni Agnoletti, Luca Ansaloni, Gian Luca Baiocchi, Cino Bendinelli, Walter L Biffl, Luigi Bonavina, Francesca Bravi, Paolo Carcoforo, Marco Ceresoli, Alain Chichom-Mefire, Federico Coccolini, Raul Coimbra, Nicola de'Angelis, Marc de Moya, Belinda De Simone, Salomone Di Saverio, Gustavo Pereira Fraga, Joseph Galante, Rao Ivatury, Jeffry Kashuk, Michael Denis Kelly, Andrew W Kirkpatrick, Yoram Kluger, Kaoru Koike, Ari Leppaniemi, Ronald V Maier, Ernest Eugene Moore, Andrew Peitzmann, Boris Sakakushev, Massimo Sartelli, Michael Sugrue, Brian W C A Tian, Richard Ten Broek, Carlo Vallicelli, Imtaz Wani, Dieter G Weber, Giovanni Docimo, Fausto Catena. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg 2023 Jul 26;18(1):43. doi: 10.1186/s13017-023-00510-x. PMID: 37496073 PMCID: PMC10373334 DOI: 10.1186/s13017-023-00510-x

4\. P U Oppelt, I Askevold, R Hörbelt, F C Roller, W Padberg, A Hecker, M Reichert. Trans-hiatal herniation following esophagectomy or gastrectomy: retrospective single center experiences with a potential surgical emergency. Hernia 2022 Feb;26(1):259-278. doi: 10.1007/s10029-021-02380-1. Epub 2021 Mar 13. PMID: 33713205 PMCID: PMC8881432 DOI: 10.1007/s10029-021-02380-1

Post-esophagectomy hiatal hernia laparoscopic repair

The authors demonstrate a laparoscopic marginal resection of the inferior vena cava (IVC) with autologous vein patch reconstruction for an IVC leiomyosarcoma.

A 57-year-old woman with mild epigastric pain was admitted to hospital for evaluation of a retroperitoneal neoplasm attached to the IVC, as revealed by a CT-scan. Imaging showed a 6cm round-shaped tumor located anteriorly and medially to the right kidney, closely abutting the duodenum and in tight proximity to the IVC. However, the tumor’s exact origin remained unclear.

To further assess the tumor’s origin and determine the extent of the required intervention, endoscopic ultrasonography (EUS) was performed. Imaging revealed an extra-organ tumor at the level of the horizontal duodenum, measuring approximately 5.5 to 6cm, with a heterogeneous structure and a well-defined but irregular contour. The tumor was found to be firmly adjacent to the IVC, causing significant compression over a length of 2cm, although the IVC contour at the contact area remained smooth.

Based on such findings, the tumor was suspected to originate from the fourth (muscularis) echo-layer of the duodenum, leading to an initial diagnosis of a resectable gastrointestinal stromal tumor (GIST) of the duodenum, and the patient was referred for a laparoscopic duodenal resection. However, during the procedure, after the duodenum was mobilized and fully detached from the tumor, it became evident that the tumor originated from the infrarenal IVC, contradicting the preoperative EUS findings. This unexpected intraoperative discovery necessitated a marginal resection of the IVC. For reconstruction, the right gonadal vein was selected as an autologous patch to repair the IVC defect following marginal resection.

This video aims to demonstrate the feasibility of a laparoscopic approach for both IVC resection and reconstruction. Most importantly, it highlights the limitations of preoperative diagnostic imaging, including advanced modalities such as endoscopic ultrasonography, which may not always correlate with intraoperative findings. This case underscores the importance of surgical adaptability, as intraoperative surprises can significantly alter the surgical approach, requiring real-time decision-making and modifications to the planned procedure.

Bibliography:

Heather Wachtel, Meera Gupta, Edmund K Bartlett, Benjamin M Jackson, Rachel R Kelz, Giorgos C Karakousis, Douglas L Fraker, Robert E Roses. Outcomes after resection of leiomyosarcomas of the inferior vena cava: a pooled data analysis of 377 cases. Surg Oncol 2015 Mar;24(1):21-7. doi: 10.1016/j.suronc.2014.10.007. Epub 2014 Nov 8. PMID: 25433957 DOI: 10.1016/j.suronc.2014.10.007

Maggie Zhou, Christopher Javadi, Greg W Charville, Nam Q Bui, E John Harris, George A Poultsides, Jeffrey A Norton, Brendan Visser, Byrne Lee, Monica M Dua, Kristen N Ganjoo. Surgical resection of leiomyosarcoma of the inferior vena cava: A case series and literature review. Surg Oncol 2021 Dec:39:101670. doi: 10.1016/j.suronc.2021.101670. Epub 2021 Oct 22. PMID: 34710646 DOI: 10.1016/j.suronc.2021.101670

Hae Soo Joung, Michael J Nooromid, Mark K Eskandari, Jeffrey D Wayne. Surgical approach, management, and oncologic outcomes of primary leiomyosarcoma of the inferior vena cava: An institutional case series. J Surg Oncol 2020 Dec;122(7):1348-1355. doi: 10.1002/jso.26163. Epub 2020 Aug 8. PMID: 32772373 DOI: 10.1002/jso.26163

Seonjeong Jeong, Youngjin Han, Yong-Pil Cho, Tae-Won Kwon. Clinical Outcomes of Surgical Resection for Leiomyosarcoma of the Inferior Vena Cava. Ann Vasc Surg 2019 Nov:61:377-383. doi: 10.1016/j.avsg.2019.05.053. Epub 2019 Aug 5. PMID: 31394210 DOI: 10.1016/j.avsg.2019.05.053

Elodie Gaignard, Damien Bergeat, Fabien Robin, Lisa Corbière, Michel Rayar, Bernard Meunier. Inferior Vena Cava Leiomyosarcoma: What Method of Reconstruction for Which Type of Resection? World J Surg 2020 Oct;44(10):3537-3544. doi: 10.1007/s00268-020-05602-2. PMID: 32445073 DOI: 10.1007/s00268-020-05602-2

Eyas Alkhalili, Alissa Greenbaum, Mark Langsfeld, John Marek, Muhammed Ali Rana, Robert Glew, Itzhak Nir. Leiomyosarcoma of the Inferior Vena Cava: A Case Series and Review of the Literature. Ann Vasc Surg 2016 May:33:245-51. doi: 10.1016/j.avsg.2015.10.016. Epub 2016 Jan 21. PMID: 26802297 DOI: 10.1016/j.avsg.2015.10.016

Laparoscopic marginal resection of the inferior vena cava (IVC) with autologous vein patch reconstruction for IVC leiomyosarcoma

Résection marginale laparoscopique de la veine cave inférieure (VCI) avec reconstruction par patch de veine autologue pour léiomyosarcome de la VCI

Inguinal lymphadenectomy (IL) is the standard of care for locoregional control and staging of several malignancies which can metastasize to this area of the body, including genitourinary neoplasms, such as vulvar and penile cancers, and cutaneous malignancies, such as melanomas and Merkel cell carcinomas.

The purpose of IL is to remove the entire adipose areolar tissue containing the lymph nodes lying in the femoral triangle along the fascia plane of the sartorius and adductor longus muscles, cranially to the inguinal ligament, superficially to the external oblique aponeurosis.

Historically, IL was performed via an open incision, which was associated with a high morbidity, including wound infection, skin flap necrosis, wound dehiscence, lymphocele, lymphedema, and deep vein thrombosis (DVT). Reported complication rates range from 20 to 90% with a significant impact on quality of life and costs to the healthcare system, potentially limiting the application of recommended inguinal lymphadenectomy for oncologic purposes.

Video-endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive approach, which has the potential to achieve radical inguinal lymph node dissection with lower rates of postoperative complications in comparison to the classic, open technique. Such postoperative complications include the ones related to surgical wounds, which frequently require antibiotic therapy, prolonged wound care, and in some cases hospital readmission, which can eventually compromise the prompt administration of adjuvant systemic and regional treatments.

In this educational video, the authors present the case of a 46-year-old man with left inguinal lymph node metastasis from an occult Merkel cell carcinoma. An ipsilateral VEIL was performed.

Bibliography:

1\. Reza Nabavizadeh, Benjamin Petrinec, Behnam Nabavizadeh, Amitabh Singh, Sudhir Rawal, Viraj Master. Inguinal lymph node dissection in the era of minimally invasive surgical technology. Urol Oncol 2023 Jan;41(1):1-14. doi: 10.1016/j.urolonc.2020.07.026. Epub 2020 Aug 25. PMID: 32855056 DOI: 10.1016/j.urolonc.2020.07.026

2\. A Sommariva, S Pasquali, C R Rossi. Video endoscopic inguinal lymphadenectomy for lymph node metastasis from solid tumors. Eur J Surg Oncol 2015 Mar;41(3):274-81. doi: 10.1016/j.ejso.2014.10.064. Epub 2014 Dec 27. PMID: 25583458 DOI: 10.1016/j.ejso.2014.10.064

3\. M Tobias-Machado, Alessandro Tavares, Wilson R Molina Jr, Pedro H Forseto Jr, Roberto V Juliano, Eric R Wroclawski. Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes. Int Braz J Urol 2006 May-Jun;32(3):316-21. doi: 10.1590/s1677-55382006000300012. PMID: 16813678 DOI: 10.1590/s1677-55382006000300012

Video-endoscopic inguinal lymphadenectomy for Merkel cell carcinoma’s nodal metastasis

Lymphadénectomie inguinale par vidéo-endoscopie pour carcinome à cellules de Merkel métastatique

Syndrome de la pince aorto-mésentérique (syndrome de Wilkie) : duodéno-jéjunostomie laparoscopique

Background: Aorto-mesenteric compass syndrome, or Wilkie’s syndrome, is a rare clinical entity caused by the extrinsic compression of the third portion of the duodenum between the superior mesenteric artery (SMA) and the abdominal aorta. This condition leads to partial or complete duodenal obstruction and is often associated with rapid weight loss.

Case presentation: The authors present the case of a 30-year-old female patient with severe postprandial abdominal pain and an unintended weight loss of 30 Kg over a period of 6 months. Physical examination showed a soft depressible abdomen, painless on palpation, without abdominal defense or peritoneal reaction. Radiographic imaging with oral contrast revealed a significant narrowing in the third portion of the duodenum, leading to proximal dilation. Computed tomography confirmed features suggestive of SMA syndrome, including an aorto-mesenteric angle of 15 degrees (normal: 30 to 60 degrees) and a reduced aorto-mesenteric distance of 6mm (normal: 10 to 20mm). Given the patient’s poor tolerance of conservative nutritional therapy, a laparoscopic side-to-side duodenojejunostomy was decided upon.

Outcome: At the one-year follow-up, the patient remained asymptomatic, with complete oral intake and no endoscopic evidence of obstruction or food retention.

Conclusion: Laparoscopic duodenojejunostomy represents a safe and effective surgical option in patients with SMA syndrome unresponsive to conservative management, offering long-term symptom resolution and nutritional recovery.

Bibliography:

1\. Akihiko Oka, Muyiwa Awoniyi, Nobuaki Hasegawa, Yuri Yoshida, Hiroshi Tobita, Norihisa Ishimura, Shunji Ishihara. Superior mesenteric artery syndrome: Diagnosis and management. World J Clin Cases 2023 May 26;11(15):3369-3384. doi: 10.12998/wjcc.v11.i15.3369. PMID: 37383896 PMCID: PMC10294176 DOI: 10.12998/wjcc.v11.i15.3369

2\. J P Jonas, F Rössler, S Ghafoor, A Kobe, T Pfammatter, C Schlag, C A Gutschow, H Petrowsky, P C Müller, C E Oberkofler. Surgical therapy of celiac axis and superior mesenteric artery syndrome. Langenbecks Arch Surg 2023 Jan 24;408(1):59. doi: 10.1007/s00423-023-02803-w. PMID: 36690823 PMCID: PMC9870837 DOI: 10.1007/s00423-023-02803-w

3\. Ahmed Sabry, Ramy Shaalan, Carl Kahlin, Ahmed Elhoofy. Superior mesenteric artery syndrome managed with laparoscopic duodenojejunostomy. Minim Invasive Surg. 2022;2022:4607440. doi:10.1155/2022/4607440. PMID: 35965959 PMCID: PMC9365593 DOI: 10.1155/2022/4607440

4\. Nicole Van Horne, Jeremy P. Jackson. Superior Mesenteric Artery Syndrome. In: StatPearls \[Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. 2023 Jul 17. PMID: 29489172 Bookshelf ID: NBK482209

5\. Shao-Bei Lu, Yong-Qiang Guo, Ren-Yin Chen, Yu-Feng Zhang. Laparoscopic Surgery for Superior Mesenteric Artery Syndrome. J Invest Surg 2024 Dec;37(1):2387524. doi: 10.1080/08941939.2024.2387524. Epub 2024 Aug 27. PMID: 39191411 DOI: 10.1080/08941939.2024.2387524

6\. G C Kirby, E R Faulconer, S J Robinson, A Perry, R Downing. Superior mesenteric artery syndrome: a single centre experience of laparoscopic duodenojejunostomy as the operation of choice. Ann R Coll Surg Engl 2017 Jul;99(6):472-475. doi: 10.1308/rcsann.2017.0063. PMID: 28660836 PMCID: PMC5696976 DOI: 10.1308/rcsann.2017.0063

Focus on general surgery

Aorto-mesenteric compass syndrome (Wilkie's syndrome): laparoscopic duodenojejunostomy