Category Archives: General Surgery

General Surgery, Print Release

PUBLISHED: Robotic Whipple Procedure for an Ampullary Intramucosal Carcinoma

Robotic Whipple Procedure for an Ampullary Intramucosal Carcinoma
Charles C. Vining, MD, FACS, FSSO; Rushin D. Brahmbhatt, MD, FACS; Lawrence M. Knab, MD, FACS, FSSO
Penn State Health Milton S. Hershey Medical Center

A 76-year-old man presented to the emergency department with fatigue and chest pain. Initial laboratory evaluation revealed significant anemia with a hemoglobin level of 7.4 g/dL. He was transfused one unit of packed red blood cells and discharged with plans for outpatient gastroenterology follow-up. Upper endoscopy performed shortly thereafter demonstrated a tubulovillous adenoma without high-grade dysplasia at the level of the ampulla. Subsequent cross-sectional imaging with CT of the abdomen and pelvis identified an area of mass-like thickening in the descending duodenum as well as two suspicious peripancreatic lymph nodes. Endoscopic ultrasound with biopsy confirmed the presence of a uT3N1 duodenal mass. Histopathologic analysis revealed at least intramucosal adenocarcinoma arising within an adenoma.

The case was reviewed at a multidisciplinary tumor board, where consensus recommendation was for surgical resection. The patient subsequently underwent diagnostic laparoscopy, laparoscopic liver biopsy, robotic pancreaticoduodenectomy (Whipple procedure), and falciform ligament flap. Pathologic examination of the resected specimen revealed an 8.2-cm, grade 2, moderately differentiated invasive adenocarcinoma of intestinal type, arising from a duodenal adenoma. The tumor demonstrated direct invasion into the pancreas, peripancreatic soft tissues, and periduodenal tissue. All surgical resection margins were negative for carcinoma. A total of 22 lymph nodes were examined, of which 6 were positive for metastatic adenocarcinoma, consistent with a final pathologic stage of pT3b pN2 duodenal adenocarcinoma.

This case highlights the diagnostic and therapeutic challenges associated with duodenal adenocarcinoma, a rare and often late-presenting malignancy. It further demonstrates the role of a multidisciplinary approach in guiding management, as well as the feasibility of a minimally invasive robotic pancreaticoduodenectomy in selected patients.

General Surgery, Print Release

PUBLISHED: Parathyroidectomy and Four-Gland Exploration for Hyperparathyroidism

Parathyroidectomy and Four-Gland Exploration for Hyperparathyroidism
Allison S. Letica-Kriegel, MD, MSc; Antonia E. Stephen, MD
Massachusetts General Hospital

Primary hyperparathyroidism is a common endocrinopathy. Surgery is the mainstay of treatment. Preoperative imaging is useful in localization of diseased glands and can allow for focal rather than four-gland exploration. Intraoperative adjuncts such as intraoperative parathyroid hormone (ioPTH) monitoring can be useful in select cases in determining the extent of parathyroid resection.

General Surgery, Print Release

PUBLISHED: Robotic Cholecystectomy for Chronic Cholecystitis for a Patient with Recurrent Gallstone Pancreatitis and a Percutaneous Cholecystostomy Tube

Robotic Cholecystectomy for Chronic Cholecystitis for a Patient with Recurrent Gallstone Pancreatitis and a Percutaneous Cholecystostomy Tube
Charles C. Vining, MD, FACS, FSSO; Mark Knab, MD, FACS, FSSO; Rushin D. Brahmbhatt, MD
Penn State Health Milton S. Hershey Medical Center

A 66-year-old man with chronic pancreatitis and prior exploratory laparotomy and appendectomy for perforated appendicitis presented with persistent right upper quadrant pain, nausea, and weight loss after placement of a percutaneous cholecystostomy (PC) tube for gallstone pancreatitis and chronic cholecystitis. Imaging confirmed gallbladder distension with equivocal wall thickening. He underwent robotic cholecystectomy with removal of the PC tube. The procedure was notable for extensive intra-abdominal adhesions requiring prolonged adhesiolysis. A critical view of safety was achieved, and the gallbladder was removed without complication. This case illustrates the technical considerations and challenges of delayed cholecystectomy following PC tube drainage.

General Surgery, Ob/Gyn, Pediatrics, Print Release

PUBLISHED: Pediatric Exploratory Laparotomy and Left Ovarian Cystectomy

Pediatric Exploratory Laparotomy and Left Ovarian Cystectomy
Swetha Jayavelu, MD; Marc Mankarious, MD; Bryanna M. Emr, MD
Penn State Milton S. Hershey Medical Center

Ovarian cysts are a common gynecologic finding in adolescent females and are typically benign, often resolving without requiring intervention. However, larger cysts can cause significant symptoms and pose a risk for complications such as torsion. These cysts were traditionally removed with a full midline laparotomy. Surgery as a field has moved towards minimally invasive approaches to promote healing and aesthetics. With large benign cysts, this is achieved with controlled intentional decompression, allowing for extraction with a smaller incision. In this case, we present a 14-year-old female who presented with abdominal discomfort and was found to have a 24x20x9-cm left ovarian cyst. She underwent controlled cyst decompression into a specimen bag, minimizing peritoneal contamination prior to removal of the cyst. This was achieved in a 5-cm Pfannenstiel incision. The patient was discharged the same day without complications and demonstrated full recovery with no cyst recurrence at the 12-week follow up. This case highlights the safe, effective management of large benign ovarian cysts using controlled decompression and innovative containment strategies to enable minimally invasive surgical access.

General Surgery, Print Release

PUBLISHED: Hepatic Artery Infusion (HAI) Pump Placement For Unresectable Intrahepatic Cholangiocarcinoma With Vessel Abutment and Intrahepatic Metastasis

Hepatic Artery Infusion (HAI) Pump Placement For Unresectable Intrahepatic Cholangiocarcinoma with Vessel Abutment and Intrahepatic Metastasis
Rushin D. Brahmbhatt, MD
Penn State Health Milton S. Hershey Medical Center

The management of unresectable intrahepatic cholangiocarcinoma (ICC) faces major difficulties due to limited therapeutic options for liver-confined disease. A 72-year-old woman with a centrally-located ICC that involved both portal vein branches received robotic HAI pump placement. The procedure started with diagnostic laparoscopy before moving to robotic arterial dissection for catheter placement in the gastroduodenal artery (GDA) and ending with comprehensive perfusion testing using indocyanine green and methylene blue.

Preoperative imaging results showed less disease presence than the intraoperative ultrasound results that displayed multiple hepatic metastases, which led to a change in treatment approach from neoadjuvant to definitive palliative care. The surgeons confirmed proper hepatic perfusion and no abnormal extrahepatic blood flow after they placed the catheter successfully. The robotic HAI pump placement system provides a minimally invasive solution for delivering regional chemotherapy in cases of unresectable ICC through improved visualization and precision compared to open surgical approaches.

General Surgery, Print Release

PUBLISHED: Robotic Cholecystectomy for Porcelain Gallbladder and a 6.8-cm Stone

Robotic Cholecystectomy for Porcelain Gallbladder and a 6.8-cm Stone
Rushin D. Brahmbhatt, MD
Penn State Health Milton S. Hershey Medical Center

The incidence of porcelain gallbladder is low but carries a potential risk of malignancy. Large gallstones pose technical obstacles for minimally invasive surgical procedures. In this case, a 72-year-old woman undergoes a robotic cholecystectomy because of her porcelain gallbladder and a 6.8-cm gallstone. The surgical procedure involved appropriately addressing two major concerns: obtaining sufficient gallbladder retraction because of the large size of the stone, and the presence of hepatic steatosis. Key modifications included strategic port placement, utilizing stone position for retraction, and early cystic artery division. The procedure finished without any issues. The frozen section analysis results showed benign pathology. The patient recovered from surgery without any complications. Key takeaways are that robotic cholecystectomy can be safely performed for a porcelain gallbladder with large gallstones using appropriate technical modifications, and that flexibility in the operating room is crucial in cases where standard methods become impractical.

General Surgery, Print Release, Vascular Surgery

PUBLISHED: Conversion of Failed Right Leg Below-Knee Amputation to Above-Knee Amputation for Severe Peripheral Arterial Disease

Conversion of Failed Right Leg Below-Knee Amputation to Above-Knee Amputation for Severe Peripheral Arterial Disease
Faizaan Aziz1; Andrew Shevitz, DO2; Faisal Aziz, MD, MBA, FACS, DFSVS2
1University of Michigan
2Penn State Health Milton S. Hershey Medical Center

Patients with severe peripheral arterial disease and critical limb-threatening ischemia are at high risk for limb loss. This video presents a 76-year-old male with extensive comorbidities who underwent above-knee amputation after failed healing of a below-knee amputation. Despite patent inflow vessels, poor distal perfusion led to non-healing wounds. The patient tolerated the above-knee amputation well, with an uneventful recovery and discharge to rehabilitation on postoperative day five. This case illustrates the role of above-knee amputation in patients with severe peripheral arterial disease and non-healing below-knee amputation, emphasizing technical steps and perioperative management.

General Surgery, Print Release

Laparoscopic-Assisted Takedown of a Gastrocutaneous Fistula

Laparoscopic-Assisted Takedown of a Gastrocutaneous Fistula
Victoria J. Grille, MD1; Eric M. Pauli, MD, FACS, FASGE2
1Jersey Shore University Medical Center
2Penn State Milton S. Hershey Medical Center

A gastrocutaneous fistula is an abnormal connection between the stomach and skin, most commonly occurring after removal of a gastrostomy feeding tube. This video demonstrates the surgical technique of laparoscopic takedown of a gastrocutaneous fistula, performed in conjunction with upper endoscopy. The patient is a pediatric patient with a history of gastrostomy tube placement and Nissen fundoplication for reflux during infancy. Despite removal of the tube, the fistula persisted. Prior endoscopic interventions, including over-the-scope clip placement, were unsuccessful. Due to ongoing drainage and patient preference for definitive closure, surgical intervention was pursued.

General Surgery, Ob/Gyn, Plastic Surgery, Print Release

PUBLISHED: Extralevator Abdominoperineal Resection (APR) for Recurrent Anal Cancer With an En Bloc Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy and Total Vaginectomy With Permanent Colostomy Formation and Pelvic Floor Reconstruction Using a Right Rectus Abdominis Flap

Extralevator Abdominoperineal Resection (APR) for Recurrent Anal Cancer With an En Bloc Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy and Total Vaginectomy With Permanent Colostomy Formation and Pelvic Floor Reconstruction Using a Right Rectus Abdominis Flap
Zoe Garoufalia, MD; Steven D. Wexner, MD, FACS
Cleveland Clinic Florida

This video provides a step-by-step, detailed demonstration of this extensive surgical procedure performed on a 53-year-old female patient with recurrent anal cancer after initial chemoradiotherapy. The surgical technique is thoroughly illustrated, emphasizing the importance of proper anatomical planes, multidisciplinary coordination, and reconstructive considerations.

General Surgery, Print Release

PUBLISHED: Diagnostic Laparoscopy and Small Bowel Resection for a Large Meckel’s Diverticulum in Adult with Persistent GI Bleed

Diagnostic Laparoscopy and Small Bowel Resection for a Large Meckel’s Diverticulum in Adult with Persistent GI Bleed
Julie Thomann, MD; Nicole B. Cherng, MD, FACS, FASMBS
UMass Memorial Medical Center

Symptomatic Meckel’s diverticulum is a diagnosis most commonly associated with male children under two years old. It typically presents with painless hematochezia and is diagnosed with a Meckel’s scan, which uses Technetium-99 to detect ectopic gastric tissue. In an adult with gastrointestinal bleeding, the differential is far broader, including an extensive and at times, inconclusive, work-up. Here, we describe a diagnostic laparoscopy for suspicion of Meckel’s diverticulum in a young adult male whose work-up showed evidence of small bowel bleeding without a definitive source. A large 6.2-cm, broad-based Meckel’s diverticulum was identified about 90 cm proximal to the ileocecal valve and resected via small bowel resection.