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General Surgery
Laparoscopic Staging and Approaches to Cancer
Built from Maingot's Abdominal Operations
What’s inside
9 sections · 183 slides
Rationale for laparoscopic staging
What the procedure is, and the gap in imaging it fills
- Definition of laparoscopic staging
- Cancers assessed by laparoscopic staging
- Aims of a staging procedure
- Limits of noninvasive imaging
- What laparoscopy adds to imaging
- Laparoscopic staging alongside other modalities
- Effect of a positive laparoscopy on care
Technique of laparoscopic staging
Access, the systematic survey, washings and ultrasound
- Timing and setting of the procedure
- Anaesthesia and patient positioning
- Equipment for laparoscopic staging
- Access to the peritoneal cavity
- Access after previous abdominal surgery
- Establishing pneumoperitoneum
- Port placement for staging laparoscopy
- Sequence of the peritoneal survey
- Examination of the liver
- Indirect palpation of the liver surface
- Biopsy of a suspicious liver lesion
- Electrosurgical coupling injuries
- Examination of the porta hepatis
- Assessment of the duodenum and bile duct
- Inspection of the transverse mesocolon
- Tumour infiltration of the colonic mesocolon
- Entering the lesser sac
- Incision of the omentum to enter the lesser sac
- The gastric pillar and coeliac axis
- Hepatic artery and gastric pillar in the lesser sac
- Peritoneal lavage cytology
- Working with the cytologist
- Rationale for laparoscopic ultrasound
- Laparoscopic ultrasound probes
- Scanning the liver with ultrasound
- Superficial liver metastasis on ultrasound
- Ultrasound of the biliary tree and pancreas
- Retropancreatic structures on laparoscopic ultrasound
Oesophageal carcinoma
Where imaging stops and laparoscopy starts
- Burden and outlook in oesophageal cancer
- Diagnostic modalities for staging oesophagogastric cancers
- Comparative roles of EUS, CT and FDG-PET
- Endoscopy and endoscopic palliation
- Multislice CT for oesophageal staging
- Endoscopic ultrasonography for TNM staging
- Accuracy and cost of EUS with fine-needle aspiration
- Uptake of EUS-FNA in practice
- FDG-PET and the primary tumour
- Uptake value and depth of tumour invasion
- FDG-PET after chemoradiotherapy
- FDG-PET for metastases and restaging
- FDG-PET/CT for radiotherapy planning
- Occult disease remaining after imaging
- Value of laparoscopy in oesophageal cancer
- Laparoscopy compared with endoscopic ultrasound
- The largest staging laparoscopy series
- Tumour site and yield of laparoscopy
- Explanation for the site effect
- Adding laparoscopic ultrasound in oesophagogastric cancer
- Combined endoscopic and laparoscopic ultrasound
- Yield by histology and the authors' recommendation
Gastric cancer
Occult peritoneal disease, and what the washings say
- Changing epidemiology of gastric cancer
- Outcome and the reasons for it
- Staging tools in gastric cancer
- Treatment algorithm for gastric cancer
- Yield of laparoscopy in gastric cancer
- Accuracy of nodal and T staging
- Peritoneal metastasis in gastric cancer
- Diagnostic performance of staging laparoscopy
- Upstaging and change of treatment plan
- Limits of modern CT for peritoneal disease
- Positive peritoneal cytology as a prognostic marker
- Cytology conversion after chemotherapy
- Cytology as an independent predictor of death
- Combining peritoneal deposits with cytology
- Newcastle disease virus for free cancer cells
- Sensitivity of the virus method by stage
- Laparoscopy in early gastric cancer
Liver and gallbladder cancer
Selecting who benefits, with a clinical risk score
- What makes liver disease unresectable
- Rationale for laparoscopy before liver resection
- Memorial Sloan-Kettering experience
- Comparison with straight-to-laparotomy patients
- Larger follow-up analysis
- Clinical risk score for resectability in hepatic colorectal disease
- Using the clinical risk score
- Validation of the clinical risk score
- Staging after previous colectomy
- Adding intraoperative and laparoscopic ultrasound
- Isolated liver metastasis on laparoscopic ultrasound
- Ultrasound-guided biopsy of liver lesions
- Clinical impact of ultrasound-guided biopsy
- Ultrasound compared with MRI for resectability
- Hepatocellular carcinoma
- Laparoscopy as a treatment platform in liver cancer
- Ultrasound and ablation in cirrhosis
- Noncolorectal, nonneuroendocrine liver metastases
- Gallbladder and biliary cancer
Pancreas cancer
The largest evidence base, and the sharpest disagreement
- Outlook in pancreatic adenocarcinoma
- Rationale for laparoscopic staging in pancreatic cancer
- Gains from avoiding an unnecessary laparotomy
- Origins of laparoscopic staging
- “
- Quality of the preoperative CT scan
- Effect on resectability rates
- Criteria for unresectability at laparoscopy
- Hepatic metastases from pancreatic cancer
- Venous involvement and resectability
- Outcome of the Memorial Sloan-Kettering series
- Contemporary yield of staging laparoscopy
- Doran periampullary series
- Detection of intraabdominal metastases at laparoscopy
- Carbohydrate antigen 19-9 as a selection tool
- Optimal CA 19-9 cut-off
- Treatment algorithm for pancreas cancer
- Population-based evidence for selective use
- Adding laparoscopic ultrasound in pancreatic cancer
- Where ultrasound changes the plan
- Resection rates with and without ultrasound
- Coeliac axis and splenic artery infiltration on ultrasound
- Grading vascular involvement on CT
- Meta-analysis of laparoscopy and ultrasound
- Peritoneal cytology in pancreatic cancer
- Predictive value of positive peritoneal cytology
- Molecular detection in peritoneal washings
- Arguments against routine laparoscopy
- Selective strategies in current practice
- Laparoscopy in locally advanced disease
- Further series in locally advanced disease
- Nonductal and periampullary tumours
Complications and port-site recurrence
How safe the procedure is, and what a port-site implant means
- Safety of staging laparoscopy
- Early concern about port-site implants
- Reported port-site recurrence rates
- Comparison with open wound recurrence
- What a port-site recurrence signifies
- Proposed mechanisms of port-site implantation
Laparoscopic biliary and gastric bypass
Palliating jaundice and gastric outlet obstruction
- Need for palliation in pancreatic cancer
- Choice of biliary bypass
- Laparoscopic cholecystojejunostomy
- Selecting patients for cholecystojejunostomy
- When cholecystojejunostomy is not possible
- Early laparoscopic palliation series
- Laparoscopic compared with open palliation
- Comparative data on gastrojejunostomy
- Single-incision gastrojejunostomy
- Incidence of gastric outlet obstruction
- Delayed gastric emptying without obstruction
- Need for later bypass after staging laparoscopy
- Positioning and ports for bypass
- Bringing the jejunal loop to the gallbladder
- Jejunal loop brought up to the gallbladder
- Approximating bowel to gallbladder
- Making the enterotomies
- Creating the enterotomies for the anastomosis
- Firing the linear stapler
- Stapled cholecystojejunal anastomosis
- Checking and closing the anastomosis
- Intracorporeal closure of the enterotomy
- Hand-sewn and assisted alternatives
- Result of the assisted technique
- Technique for gastrojejunostomy
- Creating and closing the gastrojejunal anastomosis
- Completed laparoscopic gastrojejunostomy
- Goals of a palliative procedure
Summary and references
Where laparoscopic staging stands today
- Summary of the role of laparoscopy
- Points to carry away
- References
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- Maingot's Abdominal Operations, 12th Edition