Category Archives: General Surgery

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration

Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration
Marc Mankarious, MD1; Benjamin S. C. Fung, MD, FRCSC2; Joshua S. Winder, MD1
1Penn State Health Milton S. Hershey Medical Center
2North York General Hospital, University of Toronto

Choledocholithiasis complicates cholecystectomy in 10–15% of patients. In individuals with prior Roux-en-Y gastric bypass (RYGB), altered foregut anatomy renders traditional endoscopic retrograde cholangiopancreatography (ERCP) technically challenging or unsuccessful. This report details the use of robotic-assisted transcystic endoscopic common bile duct exploration (TCBDE) in a patient with RYGB and choledocholithiasis. For patients with surgically altered anatomy and urgent need for stone clearance, robotic TCBDE represents a safe, cost-effective, single-stage alternative to two-stage approaches, effectively bypassing the anatomical limitations imposed by RYGB.

General Surgery, Pediatrics, Print Release

PUBLISHED: Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male

Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male
Yuki Noguchi, MD, PhD; Kohga Masuda, MD, PhD; Shohei Hiwatashi, MD, PhD; Satoshi Umeda, MD, PhD; Masahiro Zenitani, MD, PhD; Keigo Nara, MD, PhD
Osaka Women’s and Children’s Hospital

This report describes the surgical management of a one-year eight-month-old boy with concurrent right inguinal and umbilical hernias, highlighting both clinical rationale and operative technique. Pediatric inguinal hernias are typically indirect and rarely resolve spontaneously, carrying a persistent risk of incarceration that necessitates surgical repair once diagnosed.

Ultrasonography confirmed a right indirect inguinal hernia with reducible protrusion of the small intestine through a patent processus vaginalis. Although the umbilical hernia showed partial improvement with external compression, the inguinal hernia was unlikely to resolve spontaneously. Therefore, laparoscopic percutaneous extraperitoneal closure (LPEC) was planned, with simultaneous umbilical hernia repair.

LPEC enables high ligation of the hernia sac with minimal dissection and excellent visualization. In male patients, careful technique is required to avoid injury to the spermatic vessels and vas deferens. Tip rotation should be avoided; instead, the needle tip is advanced perpendicularly across these structures at the shortest possible distance to minimize dissection. Gentle manipulation facilitates safe passage, and confirmation that critical structures are not entrapped within the suture loop is essential before ligation. Caudal traction of the testis may further reduce the risk of iatrogenic cryptorchidism.

General Surgery, Print Release

PUBLISHED: Endoscopic Evaluation of a Twisted Gastric Sleeve Causing Severe Reflux and Epigastric Pain

Endoscopic Evaluation of a Twisted Gastric Sleeve Causing Severe Reflux and Epigastric Pain
Saamia Shaikh, DO, JD; Eric M. Pauli, MD, FACS, FASGE, FEBSAWS (Hon.)
Penn State Health Milton S. Hershey Medical Center

Upper endoscopy is an essential diagnostic and therapeutic tool in the evaluation of patients with gastrointestinal symptoms. Particularly in bariatric surgery patients, endoscopy is a valuable tool in the preoperative, intraoperative, and postoperative period. It is an increasingly important skill for surgeons managing surgical complications. This article presents a 48-year-old female who presented one year after undergoing a robotic-assisted sleeve gastrectomy and cholecystectomy with persistent epigastric pain and severe reflux symptoms. She had multiple emergency department visits following surgery, and prior computed tomography imaging was initially interpreted as normal without evidence of leak or obstruction, but on further review demonstrated a twisted configuration of the gastric sleeve.

Upper endoscopy was performed using an Olympus GIF-HQ190 gastroscope, with the scope advanced under direct visualization through the esophagus, stomach, and into the second portion of the duodenum. Endoscopy revealed a widened hiatus consistent with a small hiatal hernia, as well as moderate luminal stenosis near the incisura with a spiral configuration of the staple line, consistent with a gastric sleeve twist. Proximal gastric dilation and bile reflux were also appreciated. This case highlights the importance of surgeon review of imaging studies and surgeon performed endoscopy in evaluating complex postoperative anatomy and underscores its role as a critical skill for surgeons involved in the long-term care of surgical patients.

General Surgery, Print Release

PUBLISHED: Single-Port Hybrid Open and Laparoscopic Approach for Pediatric Appendectomy for Acute Appendicitis

Single-Port Hybrid Open and Laparoscopic Approach for Pediatric Appendectomy for Acute Appendicitis
Yuki Noguchi, MD, PhD; Shogo Saito, MD; Shohei Hiwatashi, MD, PhD; Satoshi Umeda, MD, PhD; Masahiro Zenitani, MD, PhD; Keigo Nara, MD, PhD
Osaka Women’s and Children’s Hospital

Acute appendicitis is one of the most common surgical conditions in pediatric patients, and laparoscopic appendectomy is widely accepted as the standard treatment. However, conventional multi-port laparoscopic techniques and intracorporeal single-port approaches can be technically demanding in children due to the limited intra-abdominal working space and instrument interference.

This case involved a 4-year 9-month-old girl presenting with acute abdominal pain and vomiting. Ultrasonography demonstrated appendiceal enlargement with suspected appendicolith, supporting the diagnosis of acute appendicitis and indicating a potential risk of progression and recurrence.

To address both anatomical and technical considerations, a hybrid laparoscopic–open appendectomy using a single umbilical incision was adopted. A small longitudinal incision was made at the umbilicus, and a wound protector with a multiport cap was applied. Adequate exposure was confirmed when the surgeon could insert an index finger into the abdominal cavity. The laparoscopic component was limited to identifying and grasping the appendix, which was then retracted and exteriorized through the umbilical incision. Appendectomy was performed extracorporeally under direct visualization, thereby avoiding technically demanding intracorporeal maneuvers. In this case, the degree of inflammation was mild, allowing smooth mobilization and uncomplicated extracorporeal removal.

This hybrid approach simplifies the procedure while preserving the advantages of minimally invasive surgery, including reduced operative complexity and improved cosmetic outcomes, and represents a practical option for pediatric appendicitis.

General Surgery, Print Release

PUBLISHED: Left Lateral Neck Dissection for Metastatic Papillary Thyroid Carcinoma

Left Lateral Neck Dissection for Metastatic Papillary Thyroid Carcinoma
Sarah A. Brownlee, MD; Allison S. Letica-Kriegel, MD, MSc; Antonia E. Stephen, MD
Massachusetts General Hospital

Papillary thyroid carcinoma frequently metastasizes to lateral neck lymph nodes, necessitating compartment-based lymph node dissection following initial thyroidectomy. Surgical education videos provide valuable resources for training surgeons in complex neck dissection techniques. A detailed surgical procedure was documented in a patient with biopsy-proven metastatic papillary thyroid carcinoma in level IV lymph nodes following prior total thyroidectomy and central neck dissection. A compartment-based dissection of levels IIb, III, and IV was performed with preservation of vital neurovascular structures. The procedure was successfully completed with removal of metastatic lymph nodes while preserving the critically important physiological structures throughout the dissection.

General Surgery, Print Release

PUBLISHED: Robotic Hepatectomy for a Segment V/VI Suspected HCC Lesion with Cholecystectomy and Evaluation by Ultrasound and Excisional Biopsy of a Segment IVb Lesion

Robotic Hepatectomy for a Segment V/VI Suspected HCC Lesion with Cholecystectomy and Evaluation by Ultrasound and Excisional Biopsy of a Segment IVb Lesion
Ji Ho Park, MD; Corbin S. Morris, MD; Kelsey L. Fletcher, MD; Charles C. Vining, MD, FACS, FSSO; Lawrence M. Knab, MD, FACS, FSSO; Rushin D. Brahmbhatt, MD, FACS
Penn State Health Milton S. Hershey Medical Center

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is associated with high morbidity and mortality. In this case, the patient was incidentally found to have a segment V/VI lesion consistent with HCC and a IVb lesion indeterminate probability of malignancy. He underwent a robotic-assisted hepatectomy for a segment V/VI lesion with cholecystectomy and evaluation by ultrasound and excisional biopsy of a segment IVb lesion. His postoperative course was unremarkable, and he was discharged on postoperative day four. The pathology demonstrated well-differentiated HCC with resection margins negative for carcinoma. This video demonstrates an experienced surgeon’s technique for performing a robotic hepatectomy for a segment V/VI lesion with cholecystectomy and evaluation by ultrasound and excisional biopsy of a segment IVb lesion. It also highlights effective management of bleeding during hepatic parenchymal transection.

General Surgery, Print Release

PUBLISHED: Robotic Preperitoneal eTEP Repair for Umbilical Hernia and Diastasis

Robotic Preperitoneal eTEP Repair for Umbilical Hernia and Diastasis
Hector A. Valenzuela Alpuche, MD; Juan P. Saucedo Gonzalez, MD; Roland K. Cethorth Fonseca, MD
Hospital Angeles del Carmen, Guadalajara, Mexico

Robotic extraperitoneal approaches have expanded the possibilities of minimally invasive abdominal wall reconstruction. The suprapubic preperitoneal eTEP (PeTEP) technique offers an alternative for selected patients with small-to-medium midline hernias, with or without rectus diastasis, in whom preservation of the retrorectus plane is desirable. This article describes the application of PeTEP in a 58-year-old male with a 3-cm primary umbilical hernia and a 5-cm rectus diastasis, using a suprapubic robotic extraperitoneal approach to achieve functional midline reconstruction while maintaining the integrity of the retrorectus space. The procedure includes pretransversalis access, development of the preperitoneal and pretransversalis planes, midline restoration, and placement of a preperitoneal polypropylene mesh. This technique avoids posterior sheath division, neurovascular bundle manipulation, and retromuscular dissection, thereby reducing potential morbidity in selected patients. This case illustrates the feasibility of PeTEP in a carefully selected patient. The authors do not propose this approach as a replacement for open or transabdominal techniques, but rather as an additional option within a broader reconstructive spectrum.

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Repair for Ventral Hernias

Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Repair for Ventral Hernias
Daphne Y. Lu, MD, MPH, MBA; Olivia Ziegler, MD; Saamia Shaikh, DO, JD; Jerome R. Lyn-Sue, MD, FACS
Penn State Health Milton S. Hershey Medical Center

This case describes a 58-year-old man who developed a symptomatic incisional ventral hernia following a trauma laparotomy and left nephrectomy after a motor vehicle collision. The patient presented with multiple midline hernia defects associated with bulging and discomfort. This video demonstrates a robotic transabdominal preperitoneal (rTAPP) repair with mesh. The case highlights practical strategies for managing intra-abdominal adhesions and a prior gastrostomy site, while outlining alternative operative approaches for cases in which preperitoneal flap development is technically challenging.

General Surgery, Print Release

PUBLISHED: Robotic Retromuscular eTEP Repair of Ventral Incisional Hernias and Diastasis

Robotic Retromuscular eTEP Repair of Ventral Incisional Hernias and Diastasis
Benjamin S. C. Fung, MD, FRCSC1; Eric M. Pauli, MD, FACS, FASGE2
1North York General Hospital, University of Toronto
2Penn State Health Milton S. Hershey Medical Center

A 55-year-old female has a history of multiple abdominal surgeries including laparoscopic cholecystectomy, appendectomy, laparoscopic hysterectomy, tubal ligations, and multiple cesarean sections through a low transverse (Pfannensteil) incision. Cross-sectional imaging demonstrated multiple midline hernias ranging from 1–3 cm, a rectus diastasis measuring 4 cm wide, and intraparietal cesarean section (C-section) hernia (Zanellato Type II). She underwent a robotic retromuscular extended totally extraperitoneal (eTEP) repair wherein her ventral midline hernias, rectus diastasis, and intraparietal hernia were all repaired and reinforced with wide mesh overlap. This case highlights the strengths of an eTEP approach, the decision making behind considering all of a patient’s abdominal wall pathology, and the considerations with intraparietal hernias post C-section.

General Surgery, Print Release

PUBLISHED: Excision of Suspected Chronic Infected Suture Sinus

Excision of Suspected Chronic Infected Suture Sinus
Benjamin S. C. Fung, MD, FRCSC1; Eric M. Pauli, MD, FACS, FASGE2
1North York General Hospital, University of Toronto
2Penn State Health Milton S. Hershey Medical Center

A 65-year-old female with a history of a left deep inferior epigastric perforator (DIEP) flap for breast reconstruction presented with an incisional hernia and a draining sinus tract overlying the site for her DIEP flap harvest confirmed on physical exam and cross-section imaging. She underwent a wound exploration where the entire suture sinus was excised, and it was confirmed that there was no residual foreign material left in the area. This case highlights the importance of staged abdominal wall reconstruction and addressing chronic infection before proceeding with surgery.