Robotic Central Hepatectomy for the Treatment of Gallbladder Carcinoma. Outcomes of Minimally Invasive Approach.

Gallbladder cancer (GBC) is an uncommon but very aggressive malignancy with poor prognosis. Concerns for oncological inferiority related to the technical difficulties in performing laparoscopic portal lymphadenectomy discourage many surgeons to undertake this operation minimally invasively. With wide application of robotic technology to solve limitations of conventional laparoscopy, we describe our initial outcomes of robotic central hepatectomy and portal lymphadenectomy for gallbladder carcinoma in 15 consecutive patients. Data were presented as median (mean ± SD). Patients were 70 (73 ± 10.9) years old with BMI of 26 (26 ± 3.6) kg/m2. Tumor size was 3(4 ± 1.9) cm. Operative duration was 222 (237 ± 85.7) minutes and estimated blood loss was 200 (222 ± 135.4) mL. There were no intraoperative complications and complete resection (R0) was obtained in nearly all patients. Postoperative complications were seen in two patients (bile leak (n = 1) and respiratory failure (n = 1)). Length of stay was 3 (4 ± 4.0) days without 30-day mortality. Robotic approach is safe and effective for the treatment of GBC.

Primary gallbladder paraganglioma: A case report and review of literature.

INTRODUCTION: Paragangliomas are tumors arising from paraganglia of the autonomic nervous system. They are rare tumors and occurrence inside the gallbladder is exceptionally rare. Biliary paragangliomas are thought to be associated with the parasymphathetic fibers and are therefore non-functioning and benign. There are less than 10 cases reported in literature and majority are found incidentally upon cholecystectomy. There is no specific treatment for these tumors and resection is considered sufficient. CASE PRESENTATION: 63 year old female presented with recurrent bliary colic exacerbated by fatty food. She underwent imaging work up that was consistent with biliary dyskinesia. She underwent uneventful elective laparoscopic cholecystectomy and was doing well post-operatively. Pathology report was significant for chronic cholecystitis, no calculi, and a small focus of paraganglioma. DISCUSSION: Little is known about primary gallbladder paragangliomas. Due to the non-functioning nature of these tumors there are felt to be benign. We know the paraganglia of the gallbladder consists of both parasymphathetic and sympathetic fibers. The sympathetic paragangliomas tend to act similar to pheochromocytomas and thus have malignant potential. CONCLUSION: We presented a case in which a primary gallbladder paraganglioma was identified incidentally in a patient who presented with symptomatic biliary dyskinesia. Due to the rarity of primary gallbladder paraganglioma and limited reported cases, optimal follow up remains unknown.

Sigmoid Diverticulitis and Perforation Secondary to Biliary Stent Migration.

INTRODUCTION: Biliary stent migration occurs in 5-10% of patients. Generally, this is a benign process and stents pass or are retrieved endoscopically. In rare instances, intestinal perforation has occurred. PRESENTATION OF CASE: A 79-year-old female presented with a one-day history of abdominal pain. She had undergone an ERCP four weeks previously for primary choledocholithiasis during which time a sphincterotomy and sphincteroplasty were performed, and stents were placed in the common bile duct. CT scan of the abdomen and pelvis demonstrated a biliary stent that had migrated into the sigmoid colon, appearing to perforate the colon with free air throughout the abdomen. Patient was taken for diagnostic laparoscopy and noted to have biliary stent perforating the sigmoid colon. Procedure was converted to open, and Hartmann's procedure was performed with end colostomy. CONCLUSION: Generally, biliary stent migration is a benign process, but in rare instances, intestinal perforation has occurred. Sites of perforation include the duodenum, distal small bowel, and colon. Perforation is more common with an additional pathology present such as hernias or diverticular disease. Migration and perforation also appear more common with straight biliary stents. In patients with known diverticular disease and straight biliary stents, considerations should be made for early stent removal.

Simultaneous Robot-assisted Laparoscopic Excision of Pre-pyloric Gastrointestinal Stromal Tumor and Cholecystectomy.

Operating on more than a single procedure in a same surgical intervention saves time, anesthesia duration and can increase the overall quality of life by lowering the duration of hospital stay and minimizing patient anxiety. But such interventions require expertise, high surgical performance, and precision in anatomical manipulation. We present a case of an outstanding performance of a unique minimally invasive simultaneous approach of removing a pre-pyloric gastrointestinal stromal tumor (GIST) along with a cholecystectomy by a robot-assisted laparascopic surgical system. So far, only 33 cases of GIST have been reported in literature that were managed by robot-assistance, and this case is the first of its kind. This is the case of a 60-year-old overweight female who presented for a follow-up for chest discomfort, shortness of breath, chronic gastric reflux and classical features of cholecystitis along with diarrheal and constipation episodes. A gastroduodenoscopy showed a mass in the pre-pyloric area that extended in the luminal cavity. A robot-assisted laparascopic approach was planned, and with precision and surgical expertise the mass was removed along with a cholecystectomy. The surgical specimen were confirmed on histopathology.

The diagnostic and surgical challenges of massive localized lymphedema.

BACKGROUND: Massive localized lymphedema (MLL) is a rare entity first described in 1998 in patients with morbid obesity; the incidence is rising with the increased prevalence of morbid obesity. This report defines the clinical presentation and surgical challenges in 6 patients with MLL. METHODS: The MLL in 6 patients with morbid obesity (weight range 270 to 585 lbs) involved the thigh in 3 patients, the calf in 1 patient, and the abdomen in 2 patients. The time from onset to presentation averaged 3 years (range 1 to 8 years). Two thigh lesions precluded ambulation because both legs could not be on the ground simultaneously; the 2 abdominal lesions were too heavy to permit ambulation. RESULTS: The surgical excision required the use of pulleys to elevate the MLL tissues, which, on excision, weighed between 24 and 78 lbs. A long oval horizontal incision and a long transverse incision were used for the 2 abdominal lesions. Long horizontal oval limb incisions with multiple perpendicular cross incisions had to be used to excise MLL in the 4 limb lesions. In 2 cases, the vessel-sealing device was employed successfully for dissecting subcutaneous edematous tissue. Loose wound closure permitted postoperative lymph leakage, which continued for 3 to 8 weeks. The histology demonstrated fibrotic lymphatic tissue with vascular and lymphatic proliferation and edema; all patients did well. CONCLUSIONS: MLL is rare and is best treated by surgical excision facilitated by pulleys and imaginative incisions to obtain primary closure. Long-term follow-up is necessary to assess for subsequent liposarcoma or angiosarcoma.