For long-term enteral nutrition, percutaneous endoscopic gastrostomy (PEG) is considered the standard of care; however, it often leads to a number of complications: tube migration, blockage, inadvertent tube slipping and removal, and less often, perforation. PEG involves insertion of a feeding tube through the skin and into the stomach, with the assistance of endoscopic intraluminal visualization of the stomach. PEG is a blind procedure, making it difficult to detect organs interposed between the stomach and the abdominal wall (e.g., colon, small intestine, greater omentum). To avoid these complications, laparoscopic-assisted PEG (LAPEG) was introduced.
LAPEG tube placement stands out as a minimally invasive surgical intervention that combines the techniques of laparoscopy and endoscopy to establish enteral access for nutritional support. The laparoscopic approach provides visualization for the feeding tube insertion and for approximation of the gastric and abdominal walls. This method proves particularly beneficial for individuals who require long-term enteral feeding while having obstacles with conventional approaches to stomach access due to diverse medical conditions.
Over the past decade, laparoscopic donor nephrectomy has gradually replaced the conventional open approach and has become the standard of care in living donor kidney transplantations. Compared to open nephrectomy, laparoscopic nephrectomy reduces postoperative pain, shortens the length of hospital stay, and improves the cosmetic outcome. This article illustrates the author’s technique of pure laparoscopic donor nephrectomy.
Airway injury remains a leading cause of early mortality in patients with trauma. Despite its rarity, direct traumatic airway injury and tracheobronchial injury (TBI) pose significant challenges for emergency clinicians, with an estimated incidence of 0.5–2% among trauma patients. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway blockage. Trauma can cause airway obstruction by itself or by blood clots, tissue edema, or gastric contents clogging the airway lumen. The added complexity of associated spinal injuries further underscores the need for precise and timely airway assessment.
In the context of trauma patients, a fundamental aspect of care involves prompt airway assessment. The Advanced Trauma Life Support (ATLS) algorithm, a cornerstone in trauma care, outlines a systematic approach focusing on a sequential assessment and management of Airway, Breathing, Circulation, Disability, and Exposure (ABCDE), as part of the initial evaluation of the injured individual. While adapted for battle and disaster environments, the ATLS algorithm consistently emphasizes the timely assessment and treatment of life-threatening airway and breathing issues before shifting focus to circulation problems. The CAB sequence has become more widely embraced in the last ten years, surpassing the airway-breathing-circulation (ABC) model for individuals with serious bleeding injuries. When bleeding is severe or life-threatening, prioritizing control of the bleeding takes precedence over interventions related to airway and breathing․
Barbed suture is an increasingly popular type of suture used by surgeons across the world. It is an efficient suture that provides several benefits, including better distributed tensile strength, reduced surrounding inflammatory reaction and local tissue hypoxia, and less foreign body exposure. However, there have been a handful of cases of complications with barbed sutures over the past few decades.
This is the case of a patient who initially underwent an uncomplicated robotic transabdominal preperitoneal ventral hernia repair (rTAPP) and re-presented postoperative day two with a small bowel obstruction. This video shows the operative findings from the return to the operating room with the identification of a barbed suture that had become caught in the mesentery, causing kinking of the bowel.
Acute cholecystitis occurs when gallstones become impacted in the neck of the gallbladder or cystic duct in approximately 90–95% of cases. Symptoms may include acute right upper quadrant pain, fever, nausea, and emesis often associated with eating. Acute cholecystitis generally has imaging findings of gallbladder wall thickening, edema, gallbladder distension, pericholecystic fluid, and positive sonographic Murphy sign. However, acute cholecystitis is largely a clinical diagnosis of persistent right upper quadrant (RUQ) pain and associated tenderness on palpation of the RUQ in the setting of gallstones.
The standard treatment is a cholecystectomy to prevent recurrent cholecystitis or sequelae of gallstones. Timing of the cholecystectomy is dependent on length of symptoms, which reflect the degree of inflammation. This is the case of a 74-year-old male who presented with six days of acute cholecystitis symptoms who was initially managed with antibiotics. After improvement of his pain and no systemic symptoms of infection, he underwent an interval robotic cholecystectomy. This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.
Laparoscopic Sleeve Gastrectomy Ozanan R. Meireles, MD1; Julia Saraidaridis, MD1; Amir Guindi2 1Massachusetts General Hospital 2Ross University School of Medicine
The goal of obesity treatment is to reach and maintain a healthy weight. The primary treatment consists of diet and physical exercise; however, maintaining weight loss is difficult and requires discipline. Medications such as orlistat, lorcaserin, and liraglutide may be considered as adjuncts to lifestyle modification.
One of the most effective treatments for obesity is bariatric surgery. There are several bariatric surgery procedures, including laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. Sleeve gastrectomy is the most commonly performed bariatric surgery worldwide. It is performed by removing 75% of the stomach, leaving a tube-shaped stomach with limited capacity to accommodate food. This is the case of an obese patient who undergoes laparoscopic sleeve gastrectomy.
An umbilical hernia occurs due to weakened umbilical fascia or at the site where the involuted umbilical vessels exited. Depending on the hernia contents—preperitoneal fat, omentum, or small intestine—symptoms may include a new bulge at the umbilical site, abdominal pain, tenderness to palpation, color changes to the surrounding skin, as well as obstructive symptoms such as nausea, emesis, and constipation. Given that umbilical hernias tend to have narrow necks compared to size of the sac, incarceration and strangulation are relatively common. Elective repair of symptomatic umbilical hernias is done to minimize these risks.
Here we present the case of an 81-year-old male with a recurrent umbilical hernia who first presented secondary to obstructive symptoms caused by an incarcerated umbilical hernia. After reduction was successful, he underwent an elective robotic transabdominal (rTAPP) umbilical hernia repair with intra-abdominal preperitoneal underlay mesh (IPUM). This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.
The spleen is highly vascular, is the largest secondary lymphoid organ, and is the most commonly injured organ in the setting of blunt abdominal trauma. Patients may present asymptomatically or with abdominal pain, nausea and vomiting, or signs of hemodynamic instability. Although many splenic injuries caused by blunt abdominal trauma may be managed conservatively, free intra-abdominal fluid with hemodynamic instability warrant surgical management in the form of exploratory laparotomy and splenectomy.
This video report demonstrates the management of a patient who was assaulted, sustaining blunt abdominal trauma and a hemodynamically significant grade IV splenic laceration. An exploratory laparotomy and splenectomy were performed.
Maintenance of intact skin throughout the body is essential to prevent dehydration, to act as a barrier to infection, to allow unrestricted movement, and to provide a normal appearance. A flap is a piece of body tissue, usually skin and fat, that always has its own blood supply. Therefore, a flap can be moved anywhere it can reach without worrying about the circulation present at the place that needs it, which is called the recipient site. When compared with all other possible choices, a flap best meets all the requirements for any area needing skin replacement.
The keystone type flap as one such option is so named because its design has the shape of the keystone of a Roman arch. If taken from loose tissues adjacent to a defect, it can be simply cut and advanced for any necessary skin coverage. Direct closure of the donor site where this flap comes from is possible so that usually a quite good overall cosmetic result is also obtained. These virtues are shown as an overview in this video where a keystone flap is transferred after removal of a common basal cell skin cancer from the lower lip.
Open Cholecystectomy for Gallbladder Disease Jacob C. Mesiti1; Yoko Young Sang, MD2; Peter F. Rovito, MD2; 1Lake Erie College of Osteopathic Medicine 2World Surgical Foundation
Gallbladder diseases are a subset of a spectrum of pathologies of the biliary system and are a particularly common etiology of abdominal pain encountered in modern medicine. These pathologies most often share a similar underlying mechanism of disease: obstruction of a portion of the biliary tree by cholelithiasis, or gallstones.
Gallstones, for the most part, form initially in the gallbladder with the exception of primary common bile duct (CBD) stones that form primarily in the CBD. Risk factors include a wide variety of conditions both pathologic and physiologic, including hyperlipidemia, hemolysis, and pregnancy. The resulting obstruction creates a state of biliary stasis, eventually leading to inflammation, pain, and an increased risk of infection. The anatomical location of the obstruction contributes greatly to both the clinical presentation and the ultimate treatment of the disease.
A hallmark of the treatment of gallbladder disease, ranging from simple biliary colic to life-threatening emphysematous cholecystitis, is the cholecystectomy. In modernized countries, this procedure is almost invariably performed laparoscopically. However, in certain clinical scenarios, such as when a patient cannot tolerate the pneumoperitoneum associated with laparoscopic surgery or when the procedure takes place in a developing country with limited access to laparoscopic capabilities, an open approach is preferred.
