Introduction

Pancreatic surgery has historically been associated with significant morbidity and mortality. However, advancements in robotic surgical technology have revolutionized the approach to complex pancreatic procedures. This case study highlights the successful implementation of a totally robotic spleen-sparing distal pancreatectomy for a patient with multiple pancreatic neuroendocrine tumors, demonstrating the precision and advantages of robotic-assisted surgery in preserving critical organs while effectively treating pathology.

Patient Presentation and History

A 58-year-old male with multiple comorbidities including type 2 diabetes, hypertension, and hyperlipidemia initially presented with back pain in 2019. Despite not exhibiting classic symptoms typically associated with pancreatic tumors (such as jaundice, weight loss, or digestive difficulties), diagnostic imaging revealed concerning findings that warranted further investigation.

The patient’s initial workup included:

• MRI and MRCP (Magnetic Resonance Cholangiopancreatography) scans that detected a non-functioning pancreatic tumor
• Identification of a large cystic lesion in the liver
• Institution of regular imaging surveillance due to the asymptomatic nature of the findings

Comprehensive Diagnostic Evaluation

In March 2024, following a period of watchful waiting with regular imaging follow-ups, the patient underwent a comprehensive diagnostic evaluation to better characterize the lesions and determine appropriate management.

Advanced Imaging and Tissue Sampling

1. Endoscopic Ultrasound (EUS)
   • Revealed a 3.4 cm cystic lesion in the pancreatic body and tail region
   • Identified a concurrent liver lesion in the right lobe
   • Facilitated fine needle aspiration (FNA) biopsies of both lesions
2. Histopathological Analysis
   • Pancreatic lesion: Confirmed a well-differentiated Grade 1 neuroendocrine tumor
   • Liver lesion: Showed evidence of steatohepatitis without malignancy
3. CT Scan of Abdomen and Pelvis
   • Documented progression with multiple pancreatic lesions:
     • 3.3 × 3.3 cm lesion in the mid-body
     • 10 mm lesion in the tail
     • 9 mm lesion in the proximal body
   • Revealed a 4 × 3 cm lobulated cystic lesion in segment 6 of the liver
4. DOTA PET Scan
   • Demonstrated somatostatin receptor-expressing lesions in the pancreas
   • Identified additional satellite lesions
   • Provided functional characterization of the tumors

Multidisciplinary Approach to Treatment Planning

Despite negative tumor markers and normal serum Chromogranin-A levels (a biomarker typically elevated in neuroendocrine tumors), a multidisciplinary team (MDT) recommended surgical intervention based on the imaging findings and histological confirmation. The patient was specifically referred to the Department of Gastrointestinal Surgery for consideration of robotic surgery—an approach that would allow for precise tumor removal while potentially preserving the spleen.

Surgical Approach and Technical Considerations

Following thorough preoperative counseling and evaluation, the surgical team proceeded with a totally robotic spleen-sparing distal pancreatectomy. This approach offered several key advantages:

1. Enhanced Visualization: The robotic system provided magnified, high-definition 3D visualization of the surgical field, essential for identifying and preserving the splenic vessels.
2. Intraoperative Ultrasonography: Used to precisely locate the tumors and guide the extent of resection, ensuring complete removal of all lesions while preserving maximum healthy pancreatic tissue.
3. Precision Dissection: The robotic instruments allowed for meticulous dissection around critical vascular structures, particularly important in separating the pancreas from the splenic vessels.
4. Minimal Blood Loss: The procedure was completed with less than 100 mL of blood loss, significantly lower than traditional open approaches.
5. Efficient Operative Time: Despite the complexity of the procedure, the operation was completed in 5 hours.

Surgical Technique: Preserving the Spleen While Removing Diseased Pancreas

The spleen-sparing technique employed in this case deserves special attention. In traditional distal pancreatectomy, the spleen is often removed along with the distal pancreas because of their shared blood supply. However, preserving the spleen offers significant immunological benefits, particularly important for long-term health and prevention of post-splenectomy infections.

The robotic approach facilitated:

1. Warshaw Technique Modification: Preservation of the splenic vessels while completely mobilizing the pancreas from surrounding structures.
2. Selective Vascular Control: Precise ligation of small pancreatic vessels without compromising the main splenic vasculature.
3. Real-time Assessment: Continuous evaluation of splenic perfusion throughout the procedure.

Postoperative Course and Outcomes

The patient experienced an exceptionally smooth recovery:

• Minimal postoperative pain, effectively managed with standard analgesics
• Resumed oral intake on the first postoperative day
• Normalized bowel function by the second postoperative day
• Discharged home on the third postoperative day
• No evidence of pancreatic fistula or other complications
• Maintained excellent follow-up status with preserved glycemic control

Technical Challenges and Considerations

The case presented several technical challenges that highlight why robotic approaches offer advantages in complex pancreatic surgery:

1. Patient Factors: The patient’s obesity represented a technical challenge that was mitigated by the enhanced dexterity and visualization of the robotic system.
2. Multiple Pancreatic Neoplasms: The presence of several tumors throughout the distal pancreas required precise localization and comprehensive resection.
3. Splenic Preservation: Maintaining adequate blood supply to the spleen while completely removing the distal pancreas was technically demanding, particularly due to the intricate vascular anatomy behind the pancreas.

Discussion: Advantages of Robotic Approach in Pancreatic Surgery

This case exemplifies the unique advantages of robotic-assisted surgery for complex pancreatic procedures:

Enhanced Technical Capabilities

The da Vinci Robotic Surgical System offers:

• Superior Visualization: High-definition 3D imaging allows for better appreciation of fine tissue planes.
• Increased Dexterity: The robotic “wrists” enable 540-degree rotation and movement in tight spaces, critical when working around major vessels.
• Tremor Filtration: Elimination of natural hand tremor enhances precision during delicate dissection.
• Improved Ergonomics: The surgeon’s improved positioning reduces fatigue during lengthy procedures.

Clinical Benefits

Patients undergoing robotic pancreatic surgery often experience:

• Reduced blood loss compared to open procedures
• Lower conversion rates to open surgery compared to conventional laparoscopy
• Shorter hospital stays
• Faster return to normal activities
• Improved cosmetic outcomes due to smaller incisions

Organ Preservation Benefits

The spleen plays critical roles in:

• Immune function, particularly against encapsulated bacteria
• Blood filtration and recycling of red blood cells
• Serving as a blood reservoir

Preserving this organ provides long-term benefits to the patient, including reduced risk of overwhelming post-splenectomy infection (OPSI) and maintained hematological function.

Conclusion

This case demonstrates the successful application of robotic technology in performing a complex spleen-sparing distal pancreatectomy. The robotic approach facilitated precise tumor removal while preserving the immunologically important spleen, despite the technical challenges posed by the patient’s body habitus and the presence of multiple neoplasms.

The excellent postoperative outcome, characterized by minimal blood loss, short hospital stay, and rapid recovery, underscores the potential benefits of robotic surgery in selected patients with pancreatic pathology. As this technology continues to evolve and surgical teams gain more experience, robotic approaches may become increasingly important in the management of complex pancreatic diseases.

This case, managed by Dr. Ali Iyoob Valiyaveettil, Consultant & Head of Gastrointestinal Surgery, serves as an excellent example of how cutting-edge robotic technology can be leveraged to achieve optimal surgical outcomes while prioritizing organ preservation and minimizing surgical trauma.

Experts

Introduction

Intussusception, a condition where one segment of the intestine telescopes into an adjacent segment, is predominantly seen in children but rarely occurs in adults. When it does appear in adults, it presents unique diagnostic and treatment challenges that require careful consideration. This case study examines an unusual presentation of ileocolic intussusception in a middle-aged patient and highlights the importance of prompt surgical intervention.

Patient Presentation

A previously healthy 56-year-old woman presented to the emergency department with a two-day history of concerning gastrointestinal symptoms. Her chief complaints included:

• Lower abdominal pain that had progressively worsened
• Multiple episodes of vomiting
• Constipation with no bowel movements for two days

These symptoms had developed suddenly with no apparent trigger, leading to her seeking medical attention after conservative measures at home failed to provide relief.

Diagnostic Journey

Initial Assessment

Upon presentation, the patient appeared uncomfortable but had stable vital signs. Physical examination revealed tenderness in the lower right quadrant of the abdomen with mild distension. The initial clinical impression suggested a possible bowel obstruction, necessitating further investigation.

Laboratory Findings

Blood work demonstrated a mild elevation of inflammatory markers:

• Slightly elevated white blood cell count
• Moderately increased C-reactive protein levels
• Other laboratory parameters remained within normal ranges

Imaging Studies

A computed tomography (CT) scan of the abdomen and pelvis proved crucial for diagnosis, revealing:

• Classic “target sign” indicating ileocecal intussusception
• Proximally dilated small bowel loops suggestive of partial obstruction
• No evidence of perforation or ischemia

Based on these findings, a diagnosis of ileocolic intussusception was established, and the patient was prepared for urgent surgical intervention.

Surgical Management

Given the patient’s age and the rarity of intussusception in adults, the surgical team approached the case with careful consideration that the condition likely had a pathological lead point.

Operative Approach

The patient underwent laparotomy, which confirmed the preoperative diagnosis of ileocolic intussusception. The surgical procedure involved:

• Careful manual reduction of the intussusception
• Identification of a large, smooth-surfaced, rubbery ileal polyp as the lead point
• Ileocecal resection with primary ileocolic anastomosis

The decision for bowel resection rather than simple reduction was based on the understanding that adult intussusception typically has a pathological lead point that requires removal.

Histopathological Findings

Examination of the resected specimen confirmed:

• A benign ileal polyp measuring approximately 3.5 cm in diameter
• No evidence of dysplasia or malignancy
• Normal surrounding mucosa

These findings validated the surgical approach and provided reassurance regarding the patient’s prognosis.

Post-Operative Course

The patient’s recovery proceeded smoothly with:

• Gradual return of bowel function on the second postoperative day
• Successful transition from intravenous to oral nutrition
• Adequate pain control with standard analgesics
• No postoperative complications

She was discharged home on the fourth postoperative day with appropriate follow-up arrangements and dietary guidance.

Discussion

Uniqueness of Adult Intussusception

This case highlights several important aspects of adult intussusception:

1. Epidemiological rarity: While common in children, intussusception accounts for only 1-5% of all cases of intestinal obstruction in adults.
2. Etiology differences: Unlike pediatric cases that are usually idiopathic, adult intussusception nearly always has a pathological lead point, which in this case was a benign ileal polyp.
3. Surgical management: The standard approach in adults is resection rather than reduction alone due to the high likelihood of pathological lead points and potential for malignancy.

Diagnostic Challenges

Diagnosing adult intussusception can be challenging due to:

• Non-specific symptoms that can mimic other abdominal conditions
• Chronic, intermittent presentations in some cases
• Varying clinical presentations depending on location and duration

In this case, the acute presentation and comprehensive imaging studies facilitated timely diagnosis and intervention.

Surgical Considerations

The surgical management of this case illustrates important decision-making factors:

• Assessment of the lead point’s nature during surgery
• Determining appropriate extent of resection
• Balancing oncological principles with preservation of bowel length

The confirmation of a benign pathology justified the limited resection performed.

Conclusion

This case demonstrates the successful management of adult ileocolic intussusception caused by a benign ileal polyp. Despite being uncommon in adults, intussusception should remain in the differential diagnosis for patients presenting with bowel obstruction symptoms. The case underscores the importance of prompt surgical intervention and careful pathological assessment in adult intussusception cases.

The patient’s smooth recovery and uncomplicated postoperative course highlight the effectiveness of timely surgical management. This case, managed by Dr. Talat Shaban Abdullah Al-Shaban, Consultant General Surgeon, represents a textbook example of the proper approach to adult intussusception.

Key Learning Points

• Adult intussusception is rare but should be considered in the differential diagnosis for bowel obstruction.
• CT scanning is the imaging modality of choice for diagnosis.
• Unlike in children, adult intussusception typically requires surgical resection rather than simple reduction.
• Identifying the nature of the lead point is crucial for determining the extent of surgical resection.
• Most adult intussusceptions have an identifiable lead point, which can range from benign polyps to malignant lesions.

Experts

A novel technique combining laparoscopic surgery with on-table flexible ureteroscopy has been successfully implemented at Lifecare Hospital, a Burjeel Holdings facility, offering new hope for patients with complex ureteric strictures.

Complex Case Presentation

A 41-year-old male presented with persistent left flank pain and recurrent urinary tract infections over a one-year period. His medical history revealed a previous ureteroscopic intervention for a left mid-ureteric stricture that had developed secondary to an impacted ureteric stone. The initial management included balloon dilation and stenting, but despite these standard interventions, the patient experienced symptom recurrence indicative of stricture reformation.

Diagnostic ultrasound demonstrated left-sided hydronephrosis, while previous intraoperative retrograde ureterogram had confirmed a mid-ureteric stricture approximately 2 cm in length with proximal ureteral dilation. Laboratory tests showed normal renal function with no active infection at the time of presentation.

Innovative Surgical Approach

The urology team at Lifecare Hospital, led by Dr. Althaf Hussain and Dr. Anand Srivastava, implemented a novel combined approach that integrated both laparoscopic and endourological techniques in the same procedure.

Traditional management of recurrent ureteric strictures typically involves either:

1. Endoscopic management (balloon dilation, endoureterotomy)
2. Open surgical reconstruction (ureteroureterostomy, ureteral reimplantation)
3. Standard laparoscopic repair

The innovative aspect of this case was the simultaneous use of flexible ureteroscopy during the laparoscopic procedure, providing enhanced visualization and precision that neither technique alone could achieve.

Technical Advantages

This combined approach offers several significant benefits over conventional methods:

Enhanced Visualization: The flexible ureteroscope provides real-time endoluminal imaging during laparoscopic dissection, allowing for precise identification of the stricture’s proximal and distal extent. This dual visualization prevents inadvertent injury to healthy segments of the ureter.

Minimally Invasive: The laparoscopic approach minimizes surgical trauma compared to open surgery, while the addition of flexible ureteroscopy reduces the need for extensive ureteral mobilization and dissection.

Improved Technical Precision: The combined technique enables more accurate placement of sutures during reconstruction and immediate confirmation of ureteral patency following repair.

Reduced Morbidity: By minimizing dissection and handling of the ureter, this approach potentially reduces the risk of devascularization, which can lead to recurrent stricture formation.

Advancing Urological Care

“Recurrent ureteric strictures, particularly in the mid-ureter, present significant therapeutic challenges,” notes Dr. Hussain. “This novel approach represents a promising advancement in the management of complex strictures that have failed conventional treatment.”

The technique demonstrated at Lifecare Hospital merits further investigation and could potentially become a standard approach for managing similar cases, offering patients the benefits of minimally invasive surgery with enhanced precision and potentially improved long-term outcomes.

This case exemplifies the commitment to surgical innovation within the Burjeel Holdings network, where specialists continuously explore new approaches to address challenging clinical scenarios and improve patient outcomes.

Patients suffering from complex regional pain syndrome (CRPS) often experience debilitating symptoms that significantly impact their quality of life. At Burjeel Day Surgery Center, specialists are employing advanced interventional pain management techniques to provide relief for these challenging cases.

Understanding Complex Regional Pain Syndrome

CRPS is a disabling condition that typically affects limbs following an injury or surgery. The condition manifests through severe pain, swelling, limited range of motion, temperature changes, and skin discoloration. While the definitive pathology remains incompletely understood, current evidence suggests CRPS involves immune system disruption affecting the nervous system.

Dr. Shailendra Chauhan, Consultant Anesthesia and Pain Management at Burjeel Day Surgery Center, explains: “CRPS is categorized into two types: Type 1 (Reflex Sympathetic Dystrophy) when there is no obvious nerve injury, and Type 2 (Causalgia) when there is a clear nerve injury. Both types present with overlapping symptoms but differ in their underlying mechanisms.”

Diagnosis relies on clinical criteria such as the Budapest Criteria, which evaluates sensory, vasomotor, sudomotor/edema, and motor/trophic changes to establish the presence of CRPS.

Targeted Intervention

A lumbar sympathetic block is a minimally invasive pain procedure designed to disrupt nerve signals from the sympathetic chain to the lower extremities. This intervention is particularly valuable for various painful conditions, including CRPS, phantom limb pain, hyperhidrosis, vascular insufficiencies, and herpes zoster.

“The densest portion of the lumbar sympathetic ganglia is located at the L2 and L3 vertebral levels,” notes Dr. Chauhan. “For optimal results, we typically perform the initial diagnostic block at the L3 level using only local anesthetic. If significant relief is achieved, we proceed with radiofrequency ablation at L2, L3, and L4 levels for longer-lasting benefit.”

Case Study: Post-Surgical CRPS

A young male patient was referred from the orthopedic department after developing CRPS following right knee surgery three months prior. His presentation included:

• Elevated skin temperature around the knee
• Moderate to severe pain (VAS 7/10)
• Mild swelling
• Hypoesthesia (decreased sensation) along the lateral aspect of the limb
• Allodynia (pain from normally non-painful stimuli) along the anterior aspect

Conservative management had failed to provide adequate relief, prompting consideration of interventional techniques.

After thorough counseling and informed consent, the patient underwent a lumbar sympathetic diagnostic block at the right L3 level. The procedure was performed under fluoroscopic guidance to ensure precise needle placement.

Remarkable Results

Following the diagnostic block, the patient experienced immediate pain relief and demonstrated improved range of motion in the affected knee. This dramatic response confirmed the sympathetic nervous system’s involvement in his pain condition and established him as an excellent candidate for radiofrequency ablation.

The patient was subsequently scheduled for radiofrequency ablation, which involves creating controlled lesions to interrupt pain signals for a longer duration than temporary nerve blocks allow. This comprehensive treatment plan will continue at Burjeel Day Surgery Center, Al Reem.

“While CRPS typically doesn’t have a definitive cure, timely interventions like lumbar sympathetic blocks can significantly slow disease progression and provide crucial pain relief, helping patients maintain daily function and quality of life,” Dr. Chauhan emphasizes.

This case highlights the importance of a multidisciplinary approach to chronic pain conditions and the value of specialized interventional techniques in managing complex pain syndromes refractory to conventional medical management.

Experts

In a remarkable surgical achievement, specialists at Burjeel Hospital have successfully treated a rare vascular condition that affects only a tiny fraction of the population worldwide. The patient presented with debilitating symptoms that were successfully resolved through an innovative surgical approach.

Extremely Rare Diagnosis

A young male patient arrived at Burjeel Hospital with short-distance claudication – severe pain that occurred after walking only brief distances. This symptom significantly limited his mobility and quality of life, prompting a thorough diagnostic investigation.

CT angiogram and MRI examinations of the right knee revealed an unusual finding: cystic adventitial disease affecting the popliteal artery. This exceedingly rare vascular disorder involves cystic degeneration in the wall of an artery, most commonly occurring in the popliteal artery behind the knee.

“Since its first description in 1947, only about 300 cases have been reported worldwide,” explains Dr. Moatasiem Bukhari, Consultant Vascular Surgeon at Burjeel Hospital. “This makes it one of the rarest vascular conditions we encounter in clinical practice.”

Tissue biopsy confirmed the diagnosis, and the case was thoroughly reviewed in Burjeel’s Vascular Multidisciplinary Team meeting, where specialists concurred on the optimal approach to treatment.

Surgical Management Challenges

The consensus was to perform an open surgical procedure using a posterior approach to access the affected area. This challenging operation was further complicated by several factors:

1. The rarity of the condition, with minimal precedent cases for reference
2. Severe inflammatory changes affecting both the artery itself and surrounding tissues
3. The compact anatomical space of the popliteal fossa where the affected artery was located
4. This was the first such case to be treated within the Burjeel Holdings hospital network

The surgical team successfully performed an interposition graft procedure, using the patient’s own long saphenous vein from the same leg to create a bypass around the affected arterial segment. This approach preserves blood flow while eliminating the diseased portion of the vessel.

Excellent Patient Outcome

Following surgery, the patient remained in the hospital for five days for observation and recovery before being discharged in good health. The procedure restored normal blood flow to the lower extremity, alleviating the painful claudication symptoms and allowing the patient to resume normal daily activities.

This case exemplifies the specialized expertise available at Burjeel Hospital for treating even the most uncommon vascular conditions. The successful outcome resulted from meticulous diagnosis, careful surgical planning, and the precise execution of a complex vascular procedure.

The case underscores the importance of considering rare vascular disorders in the differential diagnosis of patients with atypical claudication symptoms, particularly in younger individuals without traditional risk factors for peripheral arterial disease.

Experts

A remarkable case of a forgotten double J stent retained for six years presented unique challenges for urologists at LLH Hospital, who successfully removed the heavily encrusted stent through a combination of innovative techniques.

Case Background

A 35-year-old female patient presented to LLH Hospital with right flank pain and burning during urination. Her medical history revealed that she had undergone ureteroscopy with double J stent placement six years prior while working outside the UAE. Due to various circumstances, the stent—which is typically removed after 4-6 weeks—had never been extracted.

“Double J stents are essential tools in urological practice, providing effective drainage from kidney to bladder in various conditions,” explains Dr. Jai Pal Paryani, Specialist Urologist at LLH Hospital. “However, when forgotten or neglected, these temporary devices can create serious complications including stone formation, infection, and renal impairment.”

Diagnostic Findings

Initial ultrasound and X-ray KUB (kidney, ureter, bladder) examinations revealed a heavily encrusted double J stent with a large bladder stone measuring approximately 6 cm. CT scan confirmed the findings, showing calculus deposits along the entire length of the stent, with particular concentration around the upper coil in the kidney.

Laboratory tests revealed slightly elevated creatinine levels and a urinary tract infection with Staphylococcus aureus. This case represented one of the longest-retained stents with the highest stone burden documented in the UAE.

Treatment Approach

The management strategy developed by Dr. Paryani and Dr. Jana Kalyan Vijaya Kumar involved a multi-step approach:

1. Initial Antibiotic Treatment: The patient received appropriate antibiotics to address the urinary infection before surgical intervention.
2. Extracorporeal Shock Wave Lithotripsy: An initial attempt to break up the stones around the upper coil of the stent using ESWL proved unsuccessful in releasing it from the renal pelvis mucosa.
3. Combined Endourological Procedure:
   • Introduction of a 20 Fr nephroscope sheath to remove the large bladder stone using pneumatic lithotripsy
   • Deployment of a 6 Fr ureteroscope alongside the encrusted stent within the ureter
   • Careful internal lithotripsy to fragment stone formations throughout the ureter
   • Delicate freeing of the upper coil from renal pelvis mucosa where it had become embedded
   • Successful removal of the entire stent with all fragmented stones

Technical Excellence

The case presented extraordinary technical challenges. The stent had become an integrated part of the urinary tract after six years, with significant encrustations throughout its length. The bladder stone alone was substantial, while the embedded nature of the upper coil required exceptional care to avoid renal injury.

“Managing forgotten stents requires a careful, individualized approach,” notes Dr. Vijaya Kumar. “In this case, we utilized multiple techniques across several specialties, including endourology, lithotripsy, and minimally invasive approaches to achieve complete removal with minimal trauma.”

Preventive Strategies

This case underscores the importance of proper stent management systems in urological practice. Key preventive measures include:

• Comprehensive patient education about temporary nature of stents
• Clear follow-up protocols with reminder systems
• Maintenance of stent registries in hospitals
• Patient tracking mechanisms for those relocating between healthcare systems

The successful management of this complex case highlights the sophisticated urological capabilities available at LLH Hospital and serves as an important reminder about the potential complications of medical device oversight.

A two-year-old boy’s life was saved through the swift and coordinated efforts of a multidisciplinary medical team at Burjeel Specialty Hospital in Sharjah, after he had swallowed 17 small magnetic pieces that posed a significant risk to his digestive system.

Critical Presentation

The toddler was brought to the hospital after experiencing nausea and refusing food for approximately 72 hours. His parents, unaware of what might be causing these symptoms, sought medical attention when the refusal to eat persisted. An abdominal X-ray revealed the alarming presence of 17 magnetic pieces that had been ingested at least 72-96 hours prior, according to parental estimates.

By the time of presentation, the child had not passed stool for 48 hours and was showing signs of discomfort, irritability, and anxiety. Clinical examination revealed sluggish bowel sounds, suggesting developing intestinal obstruction—a potentially life-threatening complication.

Immediate Intervention

“Foreign body ingestion in children is a relatively common occurrence, but multiple magnetic pieces represent a particularly dangerous scenario,” explains Dr. Mohamed El Sayed Eraki Ibrahium, Medical Director and Consultant of General & Laparoscopic Surgery at Burjeel Specialty Hospital Sharjah. “When multiple magnets are swallowed, they can attract each other through intestinal walls, leading to pressure necrosis, perforation, and peritonitis.”

The medical team devised a two-phase approach:

Phase 1: Endoscopic Retrieval Under general anesthesia, Dr. Mehreen Zamanr, Specialist Gastroenterologist, performed an emergency gastroscopy. The procedure revealed multiple magnet pieces in the stomach body and antrum, with some impacted at the pylorus—the stomach’s exit point.

Using specialized endoscopic tools including rat-tooth forceps and snares, the team successfully retrieved 13 magnetic pieces over a two-hour period. The remarkable challenge during this phase was the powerful magnetic force between the pieces, which caused them to resist separation and required exceptional technical skill to overcome.

Phase 2: Surgical Intervention Fluoroscopic imaging during gastroscopy revealed that four remaining magnetic pieces had already passed into the distal intestine, likely stuck at the ileocecal junction. An immediate colonoscopy attempt proved unsuccessful due to stool impaction.

After consultation with general surgeons Dr. Eraki and Dr. Saima Asrar, the decision was made to proceed with a laparotomy to retrieve the remaining magnets. During surgery, all four magnets were located in the ileum and successfully removed through a small enterotomy. Significantly, the team observed early ulceration of the intestinal wall where the magnets had lodged—confirming the urgency of intervention before perforation could occur.

Technical Challenges

“This case presented unique challenges due to the magnetic properties of the foreign bodies,” notes Dr. Saima Asrar. “When attempting to remove one piece endoscopically, if it slipped from the forceps, it would immediately be drawn back to the remaining stack by magnetic forces. Additionally, the duration of impaction had begun to cause superficial necrosis of the stomach lining where some pieces had been stationed.”

The successful outcome was achieved through seamless coordination between gastroenterology and surgical teams, along with rapid decision-making when initial approaches required modification.

Public Health Importance

This case highlights the critical importance of keeping small magnetic objects away from young children. Parents and caregivers should be vigilant about magnetic toys, decorative items, and household objects that could pose ingestion risks.

Dr. Eraki emphasizes: “Immediate medical attention is crucial if magnetic ingestion is suspected or witnessed. The window for non-surgical intervention narrows significantly after 48-72 hours, and delays can lead to serious complications including intestinal perforation, peritonitis, and sepsis.”

Thanks to the coordinated efforts of the medical team at Burjeel Specialty Hospital Sharjah, this young patient made a full recovery from a potentially life-threatening situation.

Experts

In a remarkable feat of surgical expertise, a multidisciplinary team at Burjeel Hospital successfully removed a massive retroperitoneal liposarcoma weighing over 16 kilograms, dramatically improving a patient’s quality of life after years of increasingly debilitating symptoms.

Patient Journey

A 63-year-old man presented to the Outpatient Department at Burjeel Hospital with progressive abdominal distension that had begun approximately eight years prior. While the growth had been relatively slow initially, it had accelerated dramatically over the previous six months, causing severe discomfort and significantly impacting his daily activities.

The patient, who described himself as having avoided medical attention due to fear of hospitals and surgical procedures, was experiencing severe challenges with mobility, difficulty sleeping, lower extremity swelling, and chronic back pain. Basic activities like bending had become impossible.

Comprehensive Assessment

Upon examination, the medical team discovered an extraordinarily large abdominal mass measuring approximately 50 x 50 x 40 centimeters, occupying all quadrants of the patient’s abdomen. The mass had caused significant physical changes including umbilical stretching, abdominal wall edema, and bilateral lower extremity swelling extending to the thighs.

Dr. Mohammed Basheeruddin Inamdar, Consultant Surgical Oncologist, explains: “Cases of this magnitude are exceedingly rare in modern healthcare settings. Most patients seek intervention long before a tumor reaches such proportions.”

Diagnostic imaging was vital to surgical planning:

• CT scans revealed a heterogeneous mass with fatty, solid, and calcified components occupying most of the abdomen and pelvis
• The mass had displaced bowel loops superiorly and compressed vital structures including the urinary bladder, aorta, and inferior vena cava
• PET-CT confirmed the absence of metastatic disease
• All tumor markers (AFP, Beta HCG, LDH, CEA, CA 19-9) were within normal limits

Multidisciplinary Approach

The case was comprehensively reviewed by Burjeel Hospital’s Oncology Multidisciplinary Team, including medical oncologists, surgical oncologists, radiation oncologists, radiologists, and nuclear medicine specialists. After thorough evaluation, the team recommended surgical intervention as the primary treatment.

The surgical plan included:

1. Bilateral ureteric catheterization to protect the ureters during dissection
2. Laparotomy with careful dissection around major blood vessels
3. Complete resection of the retroperitoneal tumor

Surgical Challenges

The 5-hour procedure presented several significant technical challenges:

• The tumor’s massive size and weight (16.2 kg) required careful handling to prevent vascular injury
• Severely dilated blood vessels throughout the tumor bed increased bleeding risk
• Compression of major vessels (IVC, aorta, iliac vessels) had distorted normal anatomy
• The extensive adhesions and large surgical field required meticulous dissection

Despite these challenges, Dr. Inamdar and the surgical team successfully completed the procedure with minimal blood loss. Postoperative recovery was smooth, and the patient was discharged on the sixth postoperative day.

Life-Changing Outcome

“Retroperitoneal sarcomas of this magnitude severely compromise quality of life,” notes Dr. Inamdar. “Before surgery, this patient was barely able to walk and had bilateral pitting pedal edema to the knee joint. These slow-growing tumors can reach massive proportions if neglected.”

The patient expressed profound gratitude for the life-changing results following recovery. With the massive tumor burden removed, he could return to normal activities and experience significant relief from his symptoms.

This case highlights the importance of seeking timely medical attention for unusual symptoms and showcases the exceptional surgical capabilities available at Burjeel Hospital, where complex oncological procedures are performed with excellent outcomes.

The multidisciplinary team involved in this case included Prof. Dr. Humaid Obaid bin Harmal Al Shamsi (Consultant Oncologist), Dr. Mehdi Afrit (Specialist Oncologist), Dr. Mohammed Eid Ali (Consultant Anesthesiologist), and Dr. Omar Hnaidi (Consultant Urologist).

Experts

Burjeel Medical City has successfully implemented an innovative, minimally invasive approach to treating cerebral cavernous malformations, offering new hope for patients with this challenging neurological condition.

Understanding the Patient’s Journey

A 23-year-old male patient presented with a history of cerebral cavernous malformation diagnosed approximately one year prior. His condition was initially discovered following a seizure episode with loss of consciousness that required ICU admission. Initial MRI revealed a left frontal hematoma, which was managed conservatively with anti-epileptic medications.

Two weeks prior to his presentation at Burjeel Medical City, the patient experienced a recurrence of symptoms following an episode of hypertension. Upon examination, he was fully conscious with no neurological deficits, but required a comprehensive evaluation to prevent further episodes.

Sophisticated Diagnostic Approach

High-resolution MRI performed at Burjeel Medical City revealed:

• Focal cortical-based altered signal intensity areas in the left temporal and left frontal lobes with enhancement measuring approximately 2.1 and 1.8 cm respectively, classified as type II Zabramski
• Multiple small centimeter to subcentimeter foci throughout the supratentorial brain parenchyma
• Additional tiny dot-like foci in the pons and left cerebellar hemisphere, classified as type IV Zabramski

These findings confirmed the diagnosis of multiple cavernous vascular malformations, with the larger lesions posing a significant risk for future bleeding events.

Multidisciplinary Treatment Approach

The neurosurgical team at Burjeel Medical City, led by Dr. Mohamed A. Elzoghby and Dr. Essam Elgamal, carefully assessed the patient’s condition in collaboration with radiology, oncology, and radiation oncology specialists through the CNS tumor board.

After thorough evaluation, the team recommended surgical intervention for the two larger lesions in the left frontal and temporal lobes. The surgical plan incorporated several advanced techniques:

1. Minimally invasive craniotomies (3 cm each) precisely targeted to each malformation
2. Neuronavigation guidance for pinpoint accuracy
3. Continuous electrophysiological monitoring to protect critical brain functions
4. Intraoperative MRI for real-time confirmation of complete resection

Surgical Challenges and Innovations

The procedure presented several unique challenges:

Critical Location: The lesions were located near the motor area in the dominant hemisphere, requiring exceptional precision to avoid permanent neurological deficits. One particularly delicate aspect involved a cortical artery running directly over one of the malformations, which required careful dissection and preservation.

Pathology Considerations: Cavernous malformations contain abnormally thin-walled blood vessels prone to bleeding. The surgeons utilized microsurgical techniques to meticulously remove the lesions while minimizing the risk of intraoperative hemorrhage.

During the procedure, frozen section analysis confirmed the diagnosis, and intraoperative MRI verified complete resection of both lesions without residual malformation or vascular complications.

Advancing Neurosurgical Excellence

This case exemplifies the significant advantages of combining minimally invasive surgical approaches with advanced intraoperative imaging and monitoring technologies. For patients with cavernous malformations in critical brain regions, this approach offers:

• Reduced surgical trauma
• Lower risk of neurological deficits
• Confirmation of complete resection before closure
• Improved recovery and outcomes

The multidisciplinary team also included Dr. King Jee Dhar (Anesthesiologist), Dr. Rawia Mubarak Mohamed (Anatomic Pathology), and Dr. Mohsin Saleem Basade (Radiology), highlighting Burjeel Medical City’s comprehensive approach to complex neurological conditions.

Experts

In a landmark surgical achievement, a team at Burjeel Medical City (BMC) successfully performed a totally robotic Whipple pancreatoduodenectomy, showcasing the hospital’s cutting-edge technical capabilities and specialized expertise in complex surgical interventions.

Patient Journey

The patient, an Emirati woman with previous breast cancer history, presented with abnormal liver function tests during routine follow-up. Comprehensive diagnostic imaging—including abdominal ultrasound, CT scan, MRI, and endoscopy—revealed a blocked biliary system causing jaundice. The blockage was located at the lower end of her bilio-pancreatic ductal system, specifically at the ampulla region.

Endoscopic evaluation identified a small tumor in the periampullary region, with biopsy confirming periampullary cancer blocking both bile and pancreatic ducts. Further workup confirmed the absence of metastatic spread, making her an ideal candidate for surgical intervention.

Advanced Surgical Approach

“The Whipple procedure is the most complex surgery of the gastrointestinal system,” explains Dr. Ali Iyoob, Consultant & HOD of Gastro-intestinal Surgery at Burjeel Medical City. “Using the technically most demanding robot for this type of surgery is the real challenge.”

Following evaluation at BMC’s multidisciplinary tumor board, the surgical team recommended a minimally invasive approach using the da Vinci Xi Robotic System—a significant advancement over traditional open surgery techniques.

The procedure involves removing:

• Bile duct
• Gallbladder
• Portion of the pancreas
• Duodenum
• Part of the stomach
• Part of the small intestine
• Regional lymph nodes

Following removal, the surgical team meticulously reconstructs the digestive pathway to restore normal function.

Technical Innovations

What distinguishes this procedure is that it was performed entirely using the da Vinci Xi Robot, making it a truly unique surgical achievement. Very few medical centers worldwide have the capability to perform a totally robotic Whipple procedure.

The robotic approach offers significant advantages over both traditional open surgery and laparoscopic techniques:

• Enhanced 3D magnification for surgeons
• Superior dexterity and precision
• Finer tissue manipulation
• Better cancer clearance
• Enhanced lymph node harvesting
• Reduced complications

Successful Outcome

The surgical procedure lasted approximately 500 minutes and proceeded without complications. Postoperative recovery was remarkably smooth, with the patient being able to begin oral nutrition after just 24 hours. She was discharged after 9 days with excellent wound healing and has since returned to a normal diet.

“The reconstruction and joining of pancreas and bile duct to the digestive pathway is the most challenging aspect of this surgery,” notes Dr. Iyoob. “Using the da Vinci Robot, this can be accomplished with minimal risk of leakage complications.”

The surgical team included Dr. Bipin Thomas Prasad, Specialist in General Surgery, and Dr. Murali Shankar, Consultant Anesthesiologist, highlighting the multidisciplinary approach essential for such complex procedures.

This case demonstrates Burjeel Medical City’s position at the forefront of adopting advanced robotic surgical techniques, offering patients in the UAE and Gulf region access to world-class minimally invasive surgical options for even the most complex conditions.

Expert