Residents Can Do It! A Training Program in Laparoscopic Liver Surgery for General Surgery Residents.

INTRODUCTION: Laparoscopic liver resections (LLRs) constitute an area of surgery that has been kept away from residents in their hands-on training. The aim of our study is to assess the feasibility and the value of a didactic "step-by-step" program for LLR performed by residents using the swine training model. METHODS: From May 2018 to November 2019, three hands-on workshops were held. The protocol involved the performance of cholecystectomy, liver mobilization, minor and major hepatectomies. The participants' performance results in terms of operative time, blood loss, conversion, trainers' intervention, and intraoperative mortality, were recorded. The first workshop was comprised of 30 residents who previously participated in laparoscopic surgery workshops. In the second workshop, after six residents dropped out due to residency completion, the findings for the remaining 24 residents were compared to those for 24 junior-attending surgeons who did not follow the protocol and had not performed LLR previously, and to another 24 residents in a third workshop, who had not taken the training program before but followed the protocol. RESULTS: All residents fully completed the surgical procedures. Trained residents achieved better operative times and less blood loss compared to junior-attending surgeons (p < 0.017), however, the remaining parameters were comparable. When compared to non-trained residents, those who underwent training achieved significantly better results only in operative times (p < 0.001). CONCLUSION: A continuous LLR "step-by-step" training program on swine for residents is feasible and the "step-by-step" protocol is a valuable tool for a proper surgical education.

Duodenopancreatectomy for PDAC Associated with MALS: A Case Report.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive form of pancreatic malignancy which occurs in over 90% of such cases. Pancreaticoduodenectomy (PD) is used with a curative purpose for localized PDAC. Case presentation: A 68-year-old woman presented to our service through a transfer from another service, to be investigated and treated for a head of the pancreas tumor in a tertiary referral hospital. After a complete clinical and paraclinical evaluation, the patient was diagnosed with a PDAC and also with a median arcuate ligament syndrome (MALS). The surgical treatment was considered adequate, therefore, the patient underwent a PD with transmesocolic hepaticojejunostomy, pancreaticogastric anastomosis, precolic end-to-side gastrojejunostomy, Witzel jejunostomy and with the help of the cardiovascular surgery team from the Heart Institute, Cluj- Napoca, an aortohepatic bypass using saphenous vein graft was performed. Conclusion: Bypass was essential because the blood flow in the proper hepatic artery was not restored after sectioning the median arcuate ligament and clamping the gastroduodenal artery. The patient had a favorable outcome. The particularity of the present case consists of the complete occlusion of the celiac trunk by MALS and the total vascularization of the supramesocolic organs due to the superior mesenteric artery through the gastroduodenal artery.

How I do it: parastomal hernia repair and ventral post-incisional hernia repair using PCS/TAR A case report.

We present a medical case of a 61 year-old male patient who reported to the outpatient clinic with a parastomal hernia of 10 cm in diameter and a postincisional midline hernia of 15 cm in diameter. We emphasized that the patient had undergone surgery 4 years before for a rectal adenocarcinoma, in which we performed an abdominal perineal resection of the rectum with end colostomy. At the time of admission, there were no imagistic signs of local or distant relapse. The surgical technique used aimed to repair both of the abdominal defects by placing a large polypropylene mesh (30x30 cm) spanning into the retro-rectus space in a sublay position. On the colostomy side, the mesh is extended up to the median axillary line by performing TAR (transversus abdominis release), according to the technique described by Pauli, thus the colostomy side is not modified. The post-operatory evolution was favourable, with the return of intestinal transit for faeces and gas on the second post-operatory day. The patient was discharged on the 7th postoperatory day, after the suppression of the over-prosthetic drainage. KEY WORDS: Parastomal hernia, PCS/TAR.

Splenic abscesses.

Splenic abscesses are rare entities (autopsy incidence between 0.14-0.7%). The most frequent etiology is the septic emboli seeding from bacterial endocarditis (about 20% of cases) or other septic foci (typhoid fever, malaria, urinary tract infections, osteomielitis, otitis). The treatment of splenic abscesses was until recently splenectomy with antibiotherapy. The actual trends are more conservative (mini invasive or non-invasive) because the immunologic role of the spleen has been better understood over the last year