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Extraperitoneal pancreatic transplant
Electronic Poster Abstracts records were interrogated for clinical outcome of such cases in terms of operative management and histological reports. Results: Clinical and radiological data of total 398 patients who had HIDA scans for recurrent biliary symptoms were collected. Out of 398 patients, 77 underwent cholecystectomy. All of them had histologically proven chronic cholecystitis. Those cases were reviewed in the retrospective order to see the results of their preoperative HIDA and USG scans. Forty-six chronic cholecystitis cases (59%) had negative preoperative USG and HIDA scans. Six-week clinical follow up showed improved symptoms after surgery. Thus after combining the true and falsely detected cases in the diagnostic tests, positive (21%) and negative predictive values (84%) of HIDA scan were calculated. Conclusion: In immunocompetent patients with recurrent biliary symptoms, image negative chronic cholecystitis should be considered as a separate disease entity and cholecystectomy is a justified treatment modality.
EPTT-008 WOUND CATHETERS FOR POSTOPERATIVE PAIN PREVENTION AFTER HEPATO-PANCREATO-BILIARY SURGERY T. H. Mungroop and M. G. Besselink Academic Medical Center Amsterdam, The Netherlands Introduction: Post-operative pain prevention is essential for the recovery of patients after surgery. In many centers worldwide, the standard method of pain prevention after (hepato-pancreato-biliary) laparotomies consists of epidural analgesia. A much less known variant is postoperative pain prevention by means of wound catheters. This is an alternative to epidural analgesia, probably without many of the disadvantages of epidurals. Benefits of wound catheters:
- More patient friendly e because of placement under narcosis. - Safer e there is no chance on serious side effects like the epidural hematoma and abscess (chance of 1 in 5,700e 12,000 in thoracic epidurals), possibly resulting in persistent neurologic complications. - Comparable pain relief e Ventham, 2013 (1) e WongLun-Hing, 2014 (2) - Broader scope of application e in patients refusing epidural analgesia, with coagulation disorders, after conversion from laparoscopy, in emergency surgery and in preoperative failure of placement of the epidural catheter. - Less chance on perioperative hypotension, requiring IV fluid boluses and vasopressor usage possibly extending hospital stay.
HPB 2016, 18 (S1), e385ee601
e587
- Fast removal of indwelling urinary catheter. Methods: We use the standard epidural catheters, not an expensive commercial one, resulting in only 50 euro extra costs per patient.
[wound catheter subcost] Results/conclusions: The introduction of this technique led to much enthusiasm in our hospital, even the most in patients. Results of the POP-UP trial (NTR4948) will draw conclusions about the definitive role of wound catheters in the field of Hepato-Pancreato-Biliary surgery. 1. Br J Surg. 2013; 100: 1280e9. 2. HPB (Oxford). 2014; 16: 601e9.
EPTT-009 EXTRAPERITONEAL PANCREATIC TRANSPLANT M. Molinari, S. Guler and S. Cimen Surgery, Dalhousie University, Canada We describe a technique where pancreas transplants are positioned in the pre-peritoneal space with violation of only a few centimeters of the peritoneum necessary for the creation of the duodeno-enteric anastomosis. Retrieval and back-table of the pancreatic graft are performed in the standard fashion. After a Gibson incision is performed, the common and external iliac vessels are isolated and the head of the pancreas is laid in caudal position in the iliac fossa. The graft portal vein is anastomosed end-to-side to the recipient’s common or external iliac vein. The arterial inflow is obtained anatomosing the “Y” iliac artery graft to the recipient’s common or external iliac artery. After reperfusion, a 3e4 cm peritoneal incision in the medial aspect of the surgical field is performed and a loop of the recipient’s small intestine is brought into the retroperitoneal space and anastomosed with a side to side or end to side to the free surface of the donor’s duodenum without a Roux-en-Y intestinal loop. After completion of the duodeno-enteric
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Electronic Poster Abstracts
anastomosis, the loop of intestine is repositioned in the peritoneal cavity and the suture line is approximated to the level of the recipient’s peritoneal window. The advantages of this technique are several. Among them, the extra-peritoneal location of the pancreatic graft prevents formation of intestinal adhesions, facilitates percutaneous pancreatic graft biopsies and decreases the risk of diffuse peritonitis in patients who develop enteric leaks or peripancreatic infections.
EPTT-012 THE FALCIFORM LIGAMENT WINDOW IN LAPAROSCOPIC LEFT LATERAL SEGMENTECTOMY e A WINDOW OF OPPORTUNITY N. Shivathirthan Department of Surgical Gastroenterology, Apollo BGS Hospital, India Introduction: Laparoscopic Left Lateral Segmentectomy is fast becoming a gold standard in liver resections. We describe a technique of Falciform Ligament Window creation which we have successfully used with resulting advantages. Method: The Falciform Ligament is an anatomical landmark for the start of the dissection in Laparoscopic Left Lateral Segmentectomy. The classical technique involves taking down the falciform ligament. We describe a technique for Laparoscopic left Lateral Segmentectomy where in the falciform ligament is not divided, but a window is created in it to allow the left hand working instrument to aid in parenchymal dissection. Results: The creation of a Falciform Ligament Window is a simple technique which allowed us to proceed in parenchymal dissection unhindered by the ligament as the left hand working instrument was able to adequately work through the falciform window. Conclusion: The creation of a Falciform Ligament Window during Laparoscopic Left Lateral Segmentectomy is a simple technique and it helps by providing a natural suspension for the Liver during parenchymal dissection thereby avoiding the need for an additional port. The sling like nature of the Falciform ligament may help in reduction of blood loss during parenchymal dissection by acting like a natural tourniquet. The creation of the window makes the process of refixing of the Falciform ligament obsolete.
Introduction: Anterior approach is a safe technique for liver resection for large renal or adrenal tumours involving right lobe of liver and inferior vena cava (IVC) as they pose difficulty in dissection and mobilisation of the right lobe in a standard manner. Methods: We report use of an anterior approach without hanging manoeuvre for transection of liver parenchyma and subsequent ligation and division of right sectorial vessels and ducts in management of a giant adrenal tumour involving right kidney, IVC and right lobe of the liver. (Figure 1) Results: A 26 year old female with a history of neurofibromatosis presented with abdominal pain. Imaging showed a giant right adrenal tumour involving upper pole of right kidney, IVC, right lobe of liver and diaphragm. She was planned for en-bloc excision of her giant tumour. On exploration an anterior approach was used for transection of hepatic parenchyma. As the tumour was also densely adhered to IVC, it was not possible to create a plane between the IVC and the liver for a hanging manoeuvre. Suprahepatic and infrarenal IVC control was taken, hepatoduodenal ligament was accessed for intermittent Pringle manoeuvre and hepatic transection performed using CUSA. Tumour was removed en-bloc with a sleeve of IVC and a lateral repair of the IVC performed. The patient had an uneventful postoperative course. Conclusion: The anterior approach for liver transection without hanging manoeuvre is a safe option for en-bloc excision of giant adrenal tumours involving liver and IVC.
EPTT-013 ANTERIOR APPROACH WITHOUT HANGING MANOEUVRE FOR LIVER TRANSECTION FOR GIANT ADRENAL TUMORS INVOLVING INFERIOR VENA CAVA AND RIGHT LOBE OF LIVER e A SAFE TECHNIQUE R. Sayyed, M. T. Pirzada, K. Mir, A. A. Syed and F. Hanif Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan
[Figure 1]
HPB 2016, 18 (S1), e385ee601
EPTT-008 WOUND CATHETERS FOR POSTOPERATIVE PAIN PREVENTION AFTER HEPATO-PANCREATO-BILIARY SURGERY T. H. Mungroop and M. G. Besselink Academic Medical Center Amsterdam, The Netherlands Introduction: Post-operative pain prevention is essential for the recovery of patients after surgery. In many centers worldwide, the standard method of pain prevention after (hepato-pancreato-biliary) laparotomies consists of epidural analgesia. A much less known variant is postoperative pain prevention by means of wound catheters. This is an alternative to epidural analgesia, probably without many of the disadvantages of epidurals. Benefits of wound catheters:
- More patient friendly e because of placement under narcosis. - Safer e there is no chance on serious side effects like the epidural hematoma and abscess (chance of 1 in 5,700e 12,000 in thoracic epidurals), possibly resulting in persistent neurologic complications. - Comparable pain relief e Ventham, 2013 (1) e WongLun-Hing, 2014 (2) - Broader scope of application e in patients refusing epidural analgesia, with coagulation disorders, after conversion from laparoscopy, in emergency surgery and in preoperative failure of placement of the epidural catheter. - Less chance on perioperative hypotension, requiring IV fluid boluses and vasopressor usage possibly extending hospital stay.
HPB 2016, 18 (S1), e385ee601
e587
- Fast removal of indwelling urinary catheter. Methods: We use the standard epidural catheters, not an expensive commercial one, resulting in only 50 euro extra costs per patient.
[wound catheter subcost] Results/conclusions: The introduction of this technique led to much enthusiasm in our hospital, even the most in patients. Results of the POP-UP trial (NTR4948) will draw conclusions about the definitive role of wound catheters in the field of Hepato-Pancreato-Biliary surgery. 1. Br J Surg. 2013; 100: 1280e9. 2. HPB (Oxford). 2014; 16: 601e9.
EPTT-009 EXTRAPERITONEAL PANCREATIC TRANSPLANT M. Molinari, S. Guler and S. Cimen Surgery, Dalhousie University, Canada We describe a technique where pancreas transplants are positioned in the pre-peritoneal space with violation of only a few centimeters of the peritoneum necessary for the creation of the duodeno-enteric anastomosis. Retrieval and back-table of the pancreatic graft are performed in the standard fashion. After a Gibson incision is performed, the common and external iliac vessels are isolated and the head of the pancreas is laid in caudal position in the iliac fossa. The graft portal vein is anastomosed end-to-side to the recipient’s common or external iliac vein. The arterial inflow is obtained anatomosing the “Y” iliac artery graft to the recipient’s common or external iliac artery. After reperfusion, a 3e4 cm peritoneal incision in the medial aspect of the surgical field is performed and a loop of the recipient’s small intestine is brought into the retroperitoneal space and anastomosed with a side to side or end to side to the free surface of the donor’s duodenum without a Roux-en-Y intestinal loop. After completion of the duodeno-enteric
e588
Electronic Poster Abstracts
anastomosis, the loop of intestine is repositioned in the peritoneal cavity and the suture line is approximated to the level of the recipient’s peritoneal window. The advantages of this technique are several. Among them, the extra-peritoneal location of the pancreatic graft prevents formation of intestinal adhesions, facilitates percutaneous pancreatic graft biopsies and decreases the risk of diffuse peritonitis in patients who develop enteric leaks or peripancreatic infections.
EPTT-012 THE FALCIFORM LIGAMENT WINDOW IN LAPAROSCOPIC LEFT LATERAL SEGMENTECTOMY e A WINDOW OF OPPORTUNITY N. Shivathirthan Department of Surgical Gastroenterology, Apollo BGS Hospital, India Introduction: Laparoscopic Left Lateral Segmentectomy is fast becoming a gold standard in liver resections. We describe a technique of Falciform Ligament Window creation which we have successfully used with resulting advantages. Method: The Falciform Ligament is an anatomical landmark for the start of the dissection in Laparoscopic Left Lateral Segmentectomy. The classical technique involves taking down the falciform ligament. We describe a technique for Laparoscopic left Lateral Segmentectomy where in the falciform ligament is not divided, but a window is created in it to allow the left hand working instrument to aid in parenchymal dissection. Results: The creation of a Falciform Ligament Window is a simple technique which allowed us to proceed in parenchymal dissection unhindered by the ligament as the left hand working instrument was able to adequately work through the falciform window. Conclusion: The creation of a Falciform Ligament Window during Laparoscopic Left Lateral Segmentectomy is a simple technique and it helps by providing a natural suspension for the Liver during parenchymal dissection thereby avoiding the need for an additional port. The sling like nature of the Falciform ligament may help in reduction of blood loss during parenchymal dissection by acting like a natural tourniquet. The creation of the window makes the process of refixing of the Falciform ligament obsolete.
Introduction: Anterior approach is a safe technique for liver resection for large renal or adrenal tumours involving right lobe of liver and inferior vena cava (IVC) as they pose difficulty in dissection and mobilisation of the right lobe in a standard manner. Methods: We report use of an anterior approach without hanging manoeuvre for transection of liver parenchyma and subsequent ligation and division of right sectorial vessels and ducts in management of a giant adrenal tumour involving right kidney, IVC and right lobe of the liver. (Figure 1) Results: A 26 year old female with a history of neurofibromatosis presented with abdominal pain. Imaging showed a giant right adrenal tumour involving upper pole of right kidney, IVC, right lobe of liver and diaphragm. She was planned for en-bloc excision of her giant tumour. On exploration an anterior approach was used for transection of hepatic parenchyma. As the tumour was also densely adhered to IVC, it was not possible to create a plane between the IVC and the liver for a hanging manoeuvre. Suprahepatic and infrarenal IVC control was taken, hepatoduodenal ligament was accessed for intermittent Pringle manoeuvre and hepatic transection performed using CUSA. Tumour was removed en-bloc with a sleeve of IVC and a lateral repair of the IVC performed. The patient had an uneventful postoperative course. Conclusion: The anterior approach for liver transection without hanging manoeuvre is a safe option for en-bloc excision of giant adrenal tumours involving liver and IVC.
EPTT-013 ANTERIOR APPROACH WITHOUT HANGING MANOEUVRE FOR LIVER TRANSECTION FOR GIANT ADRENAL TUMORS INVOLVING INFERIOR VENA CAVA AND RIGHT LOBE OF LIVER e A SAFE TECHNIQUE R. Sayyed, M. T. Pirzada, K. Mir, A. A. Syed and F. Hanif Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan
[Figure 1]
HPB 2016, 18 (S1), e385ee601