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444 Management of Anatomic Hilar Variations During Laparoscopic Right Hepatectomy
to lateral” and “lateral to medial dissection”. Immediate follow-up demonstrated similar outcomes in terms or blood loss, hospital stay and pain, with slight increases in operative time. Follow up of patients up to two years has resulted in comparable results to multiport laparoscopy. To date, one hernia has been identified in a patients SPA incision which was used for colon extraction. With initial procedures performed in April 2007, we are now able to report 18 month follow-up of a novel laparoscopic approach utilizing standard instrumentation. We demonstrate that Single Port Access (SPA) surgery is a comparable alternative to multiport procedures with the benefit being decreased number of incisions and improved cosmesis for the patient. Long term and large series will be necessary to assess pain, recovery and hernia formation. 315 The Hindgut Improves Glucose Homeostasis After Metabolic Surgery Independent of Weight Loss and Insulin Secretion in the Goto-Kakizaki Rat Tammy L. Kindel, Stephanie M. Yoder, David D'Alessio, Patrick Tso
442 Totally Laparoscopic Anatomic Segment 6 Liver Resection Carlos U. Corvera
Introduction. Roux-en-y gastric bypass results in the rapid resolution of type 2 diabetes in 80-90% of morbidly obese patients. RYGB involves gastric restriction, duodenal exclusion and early hindgut stimulation by nutrients. Separating metabolic and hormonal changes due to the surgery from those due to weight loss has been difficult. We hypothesized that in diabetic Goto-Kakizaki (GK) rats early stimulation of hormone release from the hindgut accounts for improved glucose homeostasis, independent of weight loss. We compared 2 metabolic surgeries that cause early hindgut stimulation, ileal transposition (IT) and duodenal-jejunal exclusion (DJE), in GK rats. Methodology. DJE bypasses the duodenum and first 10 cm of the jejunum with a 15 cm jejunal limb. IT involves transposing a 10 cm segment of ileum into the jejunum, 10 cm distal to the ligament of Treitz. We performed a DJE, IT, DJE Sham, and IT Sham on male, 14 week old GK rats (n=9 per group), and monitored the responses for 5 wk. An oral glucose tolerance test (OGTT) was performed at 0, 2, and 4 weeks post-operatively. At 5 weeks a jugular catheter was inserted and incretin hormones were measured after a mixed meal gavage. Results. There was no difference in body weight or food intake among any of the GK groups at the end of the 30 day study period. A statistically significant improvement in the OGTT was noted at 4 weeks in DJE and IT rats (mean glucose at 120 min ± SE: DJE 198.4 ± 10.6 vs DJE Sham 241.2 ± 15.0, p=0.03; IT 191.7 ± 17.4 vs IT Sham 242.4 ± 8.2, p=0.02). Insulin concentrations during the OGTT did not differ in the DJE/IT and Sham rats, nor did the response to an insulin tolerance test. Plasma GLP-1 levels 30 min after a mixed meal were elevated in both DJE and IT rats (DJE: 4.51 ± 0.36 vs DJE Sham 2.75 ± 0.22, p=0.001; IT 4.38 ± 0.52 vs IT Sham 3.06 ± 0.25, p=0.005). Conclusions. In GK rats, DJE and IT improve glucose tolerance, suggesting that hindgut stimulation is the responsible factor. This is supported by the comparable increase in the incretin GLP-1 after both surgical procedures. Neither surgery resulted in a statistically significant increase in insulin secretion or improvement in insulin sensitivity, leading us to postulate that the primary mechanism in this model is in an extrapancreatic action of GLP-1.
After positioning, the operation begins with a standard cholecystectomy. The liver is mobilized and short caudate venous branches to the inferior vena cava are secured with clips and divided. Hilar dissection is focused on the posterior sectoral pedicle. The arterial branch to the posterior sector is isolated and divided. A partial caudate hepatomy is done to expose the bifurcation of the portal venous branches to segment 6 & 7. The portal vein branch to segment 6 is divided with a vascular stapler resulting in a zone of perfusion demarcation. The parenchyma is transected using a bipolar cautery device and vascular stapler. The specimen is removed through a limited umbilical incision. 443 Robotic Liver Tumor Resection Awad M. Jarrar, John J. Fung, Eren Berber The experience with Robotic-assisted laparoscopic liver resection is still very limited and indications for such surgery have not been extensively reported. Some of the advantages of such technique are the 3-dimensional view along with a 360-degree range of motion. We, hereby, report our experience with of a well-differentiated HCC located in segment 5 in an 83-year old patient. This video illustrates a unique technique for laparoscopic robotic liver tumor resection using radiofrequency ablation to pre-coagulate the resection line. Intraoperative laparoscopic liver ultrasound is also included. The tumor was completely resected with macroscopically negative free margins 444 Management of Anatomic Hilar Variations During Laparoscopic Right Hepatectomy Aziz M. Merchant, Edward Lin, Juan M. Sarmiento
SSAT Abstracts
316 Margin Positive Pancreaticoduodenectomy Is Superior to Palliative Bypass in Advanced Stage Pancreatic Adenocarcinoma Harish Lavu, Andres A. Mascaro, Dane Grenda, Patricia K. Sauter, Ernest L. Rosato, Eugene P. Kennedy, Charles J. Yeo
We present 3 scenarios of hilar dissection: 1-Portal vein (PV) trifurcation and lowering of the hilar plate. The hilar plate is lowered on the right and left side to take the right hepatic artery and then the right naterior and posterior PV separately. 2-High bifurcation of the PV and lateral transection of the cystic plate. The anterior and posterior branches of the right hepatic artery are taken separately. By transecting the gallbladder plate, there is access to the PV bifurcation. 3-Continuation of the hilum into the Incissura Dextrus of Gans. The Incissura is visible in the hilum in the right lobe without liver parenchyma interposition and is easily identified and dissected.
BACKGROUND: Pancreatic adenocarcinoma is an aggressive disease. Surgical therapy with negative margins of resection (R0) offers the only opportunity for cure. Patients who have advanced disease that precludes R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvent chemoradiation. OBJECTIVE: To determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for the treatment of advanced stage pancreatic adenocarcinoma. METHODS: We reviewed our pancreatic surgery database (11/28/2005-12/1/2007) to identify patients undergoing R0 and MP PD, PB, and PX for the treatment of pancreatic adenocarcinoma. RESULTS: We identified 127 patients who underwent PD, PB, or PX. 57 patients underwent RO PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and 9 patients underwent PX. In the PB group 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients 25% underwent the procedure for locally advanced disease and 75% for metastatic disease. All 9 patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP group the distribution of positive margins on permanent section was 57% uncinate/ posterior, 11% pancreatic neck, 8% bile duct, 5% circumferential, and 19% with more than one positive margin. The median follow-up for the entire cohort was 25.7 months. Estimated blood loss, complications, median length of postoperative stay, readmission rates, median survival, and one year survival rates for the R0/MP/PB/PX groups are shown in the accompanying table. The 30 day perioperative mortality for the entire cohort was 1.6%. Both deaths were in the RO group (3.5%). CONCLUSIONS: Palliative surgery for advanced stage pancreatic adenocarcinoma in highly selected patients can be performed safely with low perioperative morbidity and mortality. Further work to determine the role of adjuvant treatment and longer term follow-up are required to assess the durability of survival outcomes for patients undergoing MP resection. Table 1.
SSAT Abstracts
445 Key Images and Technical Considerations for Minimally Invasive Robotics in Pancreaticobiliary Surgery Shawn MacKenzie, Kambiz Kosari, Timothy D. Sielaff Advances in robotic surgery have allowed the frontiers of minimally invasive surgery to expand to Pancreaticobiliary surgery A discussion of minimally invasive robotic operative techniques, with video illustrations for the Whipple procedure, distal pancreatectomy, and a choledochal cyst excision, will be presented. Focus will be on key technical maneuvers in pancreaticobiliary surgery; including robotic visualization & magnification, portal vein dissection, sewing the pancreatic duct anastomosis, dissecting in the porta hepatis, and transection of the uncinate process during a pancreaticoduodenectomy 446 Completion of Pancreatectomy for IPMN Recurrence After Pylorus-Preserving Pancreatoduodenectomy with a New Pancreaticogastrostomy Technique Laureano Fernández-Cruz, Raquel Garcia Sanchez, Mario A. Acosta Pimentel, Jaume Comas, Miguel Angel López-Boado Woman 82 years old underwent 2 years ago a pylorus-preserving pancreatoduodenectomy with gastric partition and pancreaticogastrostomy anastomosis for invasive IPMN main-duct variant. Pancreatic resection margins showed low-grade dysplasia. She developed recurrence in the pancreatic remnant. This video emphasizes the technical steps taken to maximize the opportunity to achieve free of disease following resection. With our technique distal pancreatic resection is performed en-block with the segment of the stomach involved in the pancreaticogastrostomy anastomosis. She made excellent postoperative progress and was discharged on the 8th postoperative day.
A-870
442 Totally Laparoscopic Anatomic Segment 6 Liver Resection Carlos U. Corvera
Introduction. Roux-en-y gastric bypass results in the rapid resolution of type 2 diabetes in 80-90% of morbidly obese patients. RYGB involves gastric restriction, duodenal exclusion and early hindgut stimulation by nutrients. Separating metabolic and hormonal changes due to the surgery from those due to weight loss has been difficult. We hypothesized that in diabetic Goto-Kakizaki (GK) rats early stimulation of hormone release from the hindgut accounts for improved glucose homeostasis, independent of weight loss. We compared 2 metabolic surgeries that cause early hindgut stimulation, ileal transposition (IT) and duodenal-jejunal exclusion (DJE), in GK rats. Methodology. DJE bypasses the duodenum and first 10 cm of the jejunum with a 15 cm jejunal limb. IT involves transposing a 10 cm segment of ileum into the jejunum, 10 cm distal to the ligament of Treitz. We performed a DJE, IT, DJE Sham, and IT Sham on male, 14 week old GK rats (n=9 per group), and monitored the responses for 5 wk. An oral glucose tolerance test (OGTT) was performed at 0, 2, and 4 weeks post-operatively. At 5 weeks a jugular catheter was inserted and incretin hormones were measured after a mixed meal gavage. Results. There was no difference in body weight or food intake among any of the GK groups at the end of the 30 day study period. A statistically significant improvement in the OGTT was noted at 4 weeks in DJE and IT rats (mean glucose at 120 min ± SE: DJE 198.4 ± 10.6 vs DJE Sham 241.2 ± 15.0, p=0.03; IT 191.7 ± 17.4 vs IT Sham 242.4 ± 8.2, p=0.02). Insulin concentrations during the OGTT did not differ in the DJE/IT and Sham rats, nor did the response to an insulin tolerance test. Plasma GLP-1 levels 30 min after a mixed meal were elevated in both DJE and IT rats (DJE: 4.51 ± 0.36 vs DJE Sham 2.75 ± 0.22, p=0.001; IT 4.38 ± 0.52 vs IT Sham 3.06 ± 0.25, p=0.005). Conclusions. In GK rats, DJE and IT improve glucose tolerance, suggesting that hindgut stimulation is the responsible factor. This is supported by the comparable increase in the incretin GLP-1 after both surgical procedures. Neither surgery resulted in a statistically significant increase in insulin secretion or improvement in insulin sensitivity, leading us to postulate that the primary mechanism in this model is in an extrapancreatic action of GLP-1.
After positioning, the operation begins with a standard cholecystectomy. The liver is mobilized and short caudate venous branches to the inferior vena cava are secured with clips and divided. Hilar dissection is focused on the posterior sectoral pedicle. The arterial branch to the posterior sector is isolated and divided. A partial caudate hepatomy is done to expose the bifurcation of the portal venous branches to segment 6 & 7. The portal vein branch to segment 6 is divided with a vascular stapler resulting in a zone of perfusion demarcation. The parenchyma is transected using a bipolar cautery device and vascular stapler. The specimen is removed through a limited umbilical incision. 443 Robotic Liver Tumor Resection Awad M. Jarrar, John J. Fung, Eren Berber The experience with Robotic-assisted laparoscopic liver resection is still very limited and indications for such surgery have not been extensively reported. Some of the advantages of such technique are the 3-dimensional view along with a 360-degree range of motion. We, hereby, report our experience with of a well-differentiated HCC located in segment 5 in an 83-year old patient. This video illustrates a unique technique for laparoscopic robotic liver tumor resection using radiofrequency ablation to pre-coagulate the resection line. Intraoperative laparoscopic liver ultrasound is also included. The tumor was completely resected with macroscopically negative free margins 444 Management of Anatomic Hilar Variations During Laparoscopic Right Hepatectomy Aziz M. Merchant, Edward Lin, Juan M. Sarmiento
SSAT Abstracts
316 Margin Positive Pancreaticoduodenectomy Is Superior to Palliative Bypass in Advanced Stage Pancreatic Adenocarcinoma Harish Lavu, Andres A. Mascaro, Dane Grenda, Patricia K. Sauter, Ernest L. Rosato, Eugene P. Kennedy, Charles J. Yeo
We present 3 scenarios of hilar dissection: 1-Portal vein (PV) trifurcation and lowering of the hilar plate. The hilar plate is lowered on the right and left side to take the right hepatic artery and then the right naterior and posterior PV separately. 2-High bifurcation of the PV and lateral transection of the cystic plate. The anterior and posterior branches of the right hepatic artery are taken separately. By transecting the gallbladder plate, there is access to the PV bifurcation. 3-Continuation of the hilum into the Incissura Dextrus of Gans. The Incissura is visible in the hilum in the right lobe without liver parenchyma interposition and is easily identified and dissected.
BACKGROUND: Pancreatic adenocarcinoma is an aggressive disease. Surgical therapy with negative margins of resection (R0) offers the only opportunity for cure. Patients who have advanced disease that precludes R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvent chemoradiation. OBJECTIVE: To determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for the treatment of advanced stage pancreatic adenocarcinoma. METHODS: We reviewed our pancreatic surgery database (11/28/2005-12/1/2007) to identify patients undergoing R0 and MP PD, PB, and PX for the treatment of pancreatic adenocarcinoma. RESULTS: We identified 127 patients who underwent PD, PB, or PX. 57 patients underwent RO PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and 9 patients underwent PX. In the PB group 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients 25% underwent the procedure for locally advanced disease and 75% for metastatic disease. All 9 patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP group the distribution of positive margins on permanent section was 57% uncinate/ posterior, 11% pancreatic neck, 8% bile duct, 5% circumferential, and 19% with more than one positive margin. The median follow-up for the entire cohort was 25.7 months. Estimated blood loss, complications, median length of postoperative stay, readmission rates, median survival, and one year survival rates for the R0/MP/PB/PX groups are shown in the accompanying table. The 30 day perioperative mortality for the entire cohort was 1.6%. Both deaths were in the RO group (3.5%). CONCLUSIONS: Palliative surgery for advanced stage pancreatic adenocarcinoma in highly selected patients can be performed safely with low perioperative morbidity and mortality. Further work to determine the role of adjuvant treatment and longer term follow-up are required to assess the durability of survival outcomes for patients undergoing MP resection. Table 1.
SSAT Abstracts
445 Key Images and Technical Considerations for Minimally Invasive Robotics in Pancreaticobiliary Surgery Shawn MacKenzie, Kambiz Kosari, Timothy D. Sielaff Advances in robotic surgery have allowed the frontiers of minimally invasive surgery to expand to Pancreaticobiliary surgery A discussion of minimally invasive robotic operative techniques, with video illustrations for the Whipple procedure, distal pancreatectomy, and a choledochal cyst excision, will be presented. Focus will be on key technical maneuvers in pancreaticobiliary surgery; including robotic visualization & magnification, portal vein dissection, sewing the pancreatic duct anastomosis, dissecting in the porta hepatis, and transection of the uncinate process during a pancreaticoduodenectomy 446 Completion of Pancreatectomy for IPMN Recurrence After Pylorus-Preserving Pancreatoduodenectomy with a New Pancreaticogastrostomy Technique Laureano Fernández-Cruz, Raquel Garcia Sanchez, Mario A. Acosta Pimentel, Jaume Comas, Miguel Angel López-Boado Woman 82 years old underwent 2 years ago a pylorus-preserving pancreatoduodenectomy with gastric partition and pancreaticogastrostomy anastomosis for invasive IPMN main-duct variant. Pancreatic resection margins showed low-grade dysplasia. She developed recurrence in the pancreatic remnant. This video emphasizes the technical steps taken to maximize the opportunity to achieve free of disease following resection. With our technique distal pancreatic resection is performed en-block with the segment of the stomach involved in the pancreaticogastrostomy anastomosis. She made excellent postoperative progress and was discharged on the 8th postoperative day.
A-870