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Laparoscopic parenchymal-sparing resection of segment eight
E-AHPBA: VIDEO ABSTRACTS e SPILL OVER SESSION FREE VIDEOS (FRIDAY 24TH APRIL 2015)
MISCELLANEOUS 0426 LAPAROSCOPIC MIDDLE PANCREATECTOMY S. Dokmak, B. Aussilhou, A. Sauvanet and F. S. Ftériche Beaujon Hospital, HBP Department and Liver Transplantation, France Aims: Although laparoscopic surgery is now extensively used, laparoscopic middle pancreatectomy (LMP) has rarely been described. Methods: A 45-year-old female was diagnosed with branch duct intraductal papillary mucinous neoplasia (IPMN) at the pancreatic neck, which was discovered after numerous attacks of acute pancreatitis. LMP was decided for treatment. Results: The patient underwent pure LMP with right to left dissection and one layer pancreatogastric anastomosis. Surgery lasted 160 minutes with 20 ml of blood loss. A frozen section showed negative margins on both sides. The postoperative course was uneventful with 15 days in the hospital. Histology confirmed the diagnosis of branch duct IPMN with moderate dysplasia and negative margins. The patient is symptom free 9 months after surgery. Conclusions: Our results and the data in the literature suggest that the laparoscopic approach is indicated for MP because there are no technical or oncological contraindications and the outcome is similar to that with the open approach.
PANCREAS CANCER 0437 HANGING MANEUVER OF THE SUPERIOR MESENTERIC ARTERY FOR PANCREATICODUODENECTOMY D. Bergeat and L. Sulpice CHU Rennes HÃ’pital de Pontchaillou, France Aims: Dissection of the retroportal lamina is the critical step during pancreaticoduodenectomy and determines directly the oncological results. An interesting technique was firstly describe by Pessaux et al., the hanging maneuver of the superior mesenteric artery. This technique is may be useful to standardize the resection of the retroportal lamina and consequently improving R0 resection rate. Methods: We performed the technique of the hanging maneuver of the superior mesenteric artery during an open surgery pancreaticoduodenectomy. In this case, a vascular resection and reconstruction was necessary. Conclusions: For us, the hanging maneuver is very interesting to facilitate and standardize the complete resection of the retroportal lamina. This technique could improve R0 resection rate and more generally oncological outcomes.
HPB 2016, 18 (S2), e807ee809
PANCREAS CANCER 0501 THE PARIETAL PERITONEUM FOR THE RECONSTRUCTION OF THE MESENTERICOPORTAL VEIN DURING PANCREATICODUODENECTOMY S. Dokmak Beaujon Hospital, HBP department and liver transplantation, France Aims: The reconstruction of the mesenterciportal vein (MPV) during HBP surgery by the parietal peritoneum was described for the first time recently by our group. Methods: 75 year old male patient was admitted for the management of pancreatic head adenocarcinoma developed on IPMN. The same disease was treated 5 years ago by distal pancreatectomy (T3N0R0) with adjuvant chemotherapy. On imaging studies the lesion was classified as borderline related to lateral invasion (<180 C) of the right border of the MPV. There was no jaundice. We decided totalisation by pancreaticoduodenectomy. After resection, the MPV was reconstructed by a large lateral patch harvested from the parietal peritoneum of the prerenal area. Results: The postoperative course was uneventful with standard preventive anticoagulation therapy and 10 days of hospital stay. Histology confirmed the presence of well differentiated adenocarcinoma (T3N0R0) with focal invasion of the portal vein. Adjuvant chemotherapy was started. CT scan done 2 months postoperatively showed complete patency of the reconstructed MPV. Conclusions: The parietal peritoneum is safe, rapid to harvest, of unlimited size and efficient autogenous substiture for venous reconstruction in HBP surgery.
LIVER 0538 LAPAROSCOPIC PARENCHYMALSPARING RESECTION OF SEGMENT EIGHT F. Cipriani, M. Rawashdeh, E. Francone, B. Jaber and M. A. Hilal University Hospital Southampton NHS Foundation Trust, United Kingdom Aims: Surgical management of liver lesions has moved toward «parenchymal-sparing» strategies, when possible. Whilst open parenchymal-sparing liver resections are supported by encouraging results, laparoscopic limited resections have been extensively reported for peripheral lesions, but their applicability for non-peripheral tumours is still questionable. In this video we demonstrate our technique developed through the years to accomplish safe and radical laparoscopic parenchymal-sparing liver resections for non-peripheral tumours. Methods: A 60 year-old woman was diagnosed with a solitary 25 mm colorectal metastasis in Segment 8. A
e808
E-AHPBA: Video Abstracts
laparoscopic parenchymal-sparing resection was performed. A 5-port configuration was fitted with an «L-shape» around the medial and inferior side of the tumour, a «square-shaped» transection area was outlined at 2 cm nearly from the tumour. Cross sectional imaging and intraoperative ultrasound allowed continuous assessment of the transection planes in relation to the edges of the lesion and key vascular/biliary structures. Fine CUSA dissection permitted millimetric early adjustments of the transection plane to avoid bearing toward the edges of the tumour. Intermittent inflow control was adopted to minimize blood losses. Results: Operative time and blood losses resulted 180 mins and 250 mL respectively. The patient was discharged in 5 postoperative day and postoperative course was uneventful. R0 resection was confirmed on histological exam (15 mm tumour free margin). Conclusions: With appropriate adjustments of surgical technique and in experienced hands, laparoscopic parenchymal-sparing resections for non-peripheral liver lesions can be safe and feasible. Few tips and tricks are essential to be adopted in order to achieve a safe oncological resection.
BILIARY 0577 TOTALLY LAPAROSCOPIC RESECTION OF A CHOLEDOCHAL CYST AND RECONSTRUCTION WITH RETROCOLIC RETROGASTRIC ROUXEN-Y HEPATICOJEJUNOSTOMY S. López-Ben, M. T. A. Quer, F. Verdaguer, C. Gutierrez, C. Barreras, G. Garcia, J. F. Felip and M. C. Robert Hospital Universitari Dr Josep Trueta, Spain Aims: Show full laparoscopic resection and recontruction of a Todani Ib choledochal cyst. Methods: Initial four port technique was performed. Cholecystectomy was the first step, follow by craneal ling of the bile duct. Crano caudal dissection of the cyst until the intrapancreatic portion was accomplished. A Roux-en-Y limb was ascended by the retrocolic retrogastric route in two steps. Finally end-to-side hepaticojejunostomy was performed in the running fashion. Results: A intra abdominal bleeding was the only complication that could be successfully fixed by interventional radiology. Hospital stay was 10 days. Pathological report show changes in bile duct consistent with choledochal cyst, without atypia. Conclusions: Laparoscopy is a good indication for benign biliary disease as all the surgical steps can be done as in open surgery.
TRANSPLANT 0646 ROBOTIC-ASSISTED SPLENIC ARTERY NEURISM RESECTION AND REESTABLISHMENT OF THE FLOW WITH A PROSTHETIC CONDUIT AN A LIVER TRANSPLANT RECIPIENT V. Scuderi1, A. Patriti2 and R. Troisi1 1 Department of General and Hepato-Biliary Surgery Liver Transplantation Service; 2Hospital San Matteo degli Infermi, Italy
Aims: The Splenic Artery Aneurysms (SAA) in the liver transplant population remains a significant source of morbidity and mortality due to the risk for rupture. The best treatment for asymptomatic aneurysms remain undefined but considering that the survival following transplantation continues to improve, appropriate diagnosis and management of the SAA is mandatory. To reduce the postoperative morbidity of the surgical management of SAA the minimally invasive approach has been proposed. The robotic approach is considered superior to the laparoscopic one due to the 360 movements of the instruments and the easier reconstructive phase. In this video the robotic-assisted surgical SAA repair is showed. Methods: A female 50 yo patient with NASH cirrhosis and morbid obesity (BMI 49.5) underwent a standard liver transplant procedure. Eighteen months later, a laparoscopic sleeve gastrectomy was successfully performed. During this operation, a large saccular aneurysm of the splenic artery was diagnosed. The angio MRI detected a double aneurism (15 16 23 mm, 11 6 mm) with a common ostium. The aneurysm was thereafter resected with reestablishment of the flow using a prosthetic conduit (GoreTex) between the proximal and the distal artery with the da Vinci System. Results: The operative time lasted 270 min. The patient was discharged on the 2nd POD. The follow-up with CT scan @ 7 m showed a good vascularization of the splenic parenchyma. Conclusions: Vascular dissection and reconstruction phases with the Da Vinci System are a very advanced technique successfully assisting the minimally invasive HPB procedures.
BENIGN HPB 0680 RESECTION OF A TODANI IVB BILE DUCT CYST AND RECONSTRUCTION WITH A HEPATICOJEJUNOSTOMY M. H. Fard-Aghaie, K. Schuetze, A. Papalampros, G. A. Stavrou, K. J. Niehaus and J. K. Oldhafer Asklepios Hospital Barmbek, Germany Aims: Bile duct cysts are rare anomalies of the biliary tree and associated with a 10 to 30-fold increased rate of malignancy compared to the general population. Although 60% are diagnosed in children, advances in imaging lead to an increasing number of adults with this disease. Methods: This video shows a resection of a type IVb bile duct cyst and reconstruction with a hepaticojejunostomy. The female patient, 36 years old, was referred to us with recurrent abdominal pain and choledocholithiasis. A laparoscopic cholecystectomy was performed at the referring hospital 8 years ago. The diagnostic work-up with ultrasound and MRCP showed the bile duct anomaly. Results: The postoperative course of the patient was uneventful. Postoperative cholestasis serum parameters were only slightly elevated and back to normal on the 3rd postoperative day (pod). The patient was discharged at the 15th pod in a very good condition. The histology showed no malignancy. Conclusions: Bile duct cysts are very rare (0,1% incidence) and their presentation range from subtle abdominal discomfort to cholangitis or calculi formation, leading to a delayed diagnosis. Todani IV bile duct cysts are evident in
HPB 2016, 18 (S2), e807ee809
MISCELLANEOUS 0426 LAPAROSCOPIC MIDDLE PANCREATECTOMY S. Dokmak, B. Aussilhou, A. Sauvanet and F. S. Ftériche Beaujon Hospital, HBP Department and Liver Transplantation, France Aims: Although laparoscopic surgery is now extensively used, laparoscopic middle pancreatectomy (LMP) has rarely been described. Methods: A 45-year-old female was diagnosed with branch duct intraductal papillary mucinous neoplasia (IPMN) at the pancreatic neck, which was discovered after numerous attacks of acute pancreatitis. LMP was decided for treatment. Results: The patient underwent pure LMP with right to left dissection and one layer pancreatogastric anastomosis. Surgery lasted 160 minutes with 20 ml of blood loss. A frozen section showed negative margins on both sides. The postoperative course was uneventful with 15 days in the hospital. Histology confirmed the diagnosis of branch duct IPMN with moderate dysplasia and negative margins. The patient is symptom free 9 months after surgery. Conclusions: Our results and the data in the literature suggest that the laparoscopic approach is indicated for MP because there are no technical or oncological contraindications and the outcome is similar to that with the open approach.
PANCREAS CANCER 0437 HANGING MANEUVER OF THE SUPERIOR MESENTERIC ARTERY FOR PANCREATICODUODENECTOMY D. Bergeat and L. Sulpice CHU Rennes HÃ’pital de Pontchaillou, France Aims: Dissection of the retroportal lamina is the critical step during pancreaticoduodenectomy and determines directly the oncological results. An interesting technique was firstly describe by Pessaux et al., the hanging maneuver of the superior mesenteric artery. This technique is may be useful to standardize the resection of the retroportal lamina and consequently improving R0 resection rate. Methods: We performed the technique of the hanging maneuver of the superior mesenteric artery during an open surgery pancreaticoduodenectomy. In this case, a vascular resection and reconstruction was necessary. Conclusions: For us, the hanging maneuver is very interesting to facilitate and standardize the complete resection of the retroportal lamina. This technique could improve R0 resection rate and more generally oncological outcomes.
HPB 2016, 18 (S2), e807ee809
PANCREAS CANCER 0501 THE PARIETAL PERITONEUM FOR THE RECONSTRUCTION OF THE MESENTERICOPORTAL VEIN DURING PANCREATICODUODENECTOMY S. Dokmak Beaujon Hospital, HBP department and liver transplantation, France Aims: The reconstruction of the mesenterciportal vein (MPV) during HBP surgery by the parietal peritoneum was described for the first time recently by our group. Methods: 75 year old male patient was admitted for the management of pancreatic head adenocarcinoma developed on IPMN. The same disease was treated 5 years ago by distal pancreatectomy (T3N0R0) with adjuvant chemotherapy. On imaging studies the lesion was classified as borderline related to lateral invasion (<180 C) of the right border of the MPV. There was no jaundice. We decided totalisation by pancreaticoduodenectomy. After resection, the MPV was reconstructed by a large lateral patch harvested from the parietal peritoneum of the prerenal area. Results: The postoperative course was uneventful with standard preventive anticoagulation therapy and 10 days of hospital stay. Histology confirmed the presence of well differentiated adenocarcinoma (T3N0R0) with focal invasion of the portal vein. Adjuvant chemotherapy was started. CT scan done 2 months postoperatively showed complete patency of the reconstructed MPV. Conclusions: The parietal peritoneum is safe, rapid to harvest, of unlimited size and efficient autogenous substiture for venous reconstruction in HBP surgery.
LIVER 0538 LAPAROSCOPIC PARENCHYMALSPARING RESECTION OF SEGMENT EIGHT F. Cipriani, M. Rawashdeh, E. Francone, B. Jaber and M. A. Hilal University Hospital Southampton NHS Foundation Trust, United Kingdom Aims: Surgical management of liver lesions has moved toward «parenchymal-sparing» strategies, when possible. Whilst open parenchymal-sparing liver resections are supported by encouraging results, laparoscopic limited resections have been extensively reported for peripheral lesions, but their applicability for non-peripheral tumours is still questionable. In this video we demonstrate our technique developed through the years to accomplish safe and radical laparoscopic parenchymal-sparing liver resections for non-peripheral tumours. Methods: A 60 year-old woman was diagnosed with a solitary 25 mm colorectal metastasis in Segment 8. A
e808
E-AHPBA: Video Abstracts
laparoscopic parenchymal-sparing resection was performed. A 5-port configuration was fitted with an «L-shape» around the medial and inferior side of the tumour, a «square-shaped» transection area was outlined at 2 cm nearly from the tumour. Cross sectional imaging and intraoperative ultrasound allowed continuous assessment of the transection planes in relation to the edges of the lesion and key vascular/biliary structures. Fine CUSA dissection permitted millimetric early adjustments of the transection plane to avoid bearing toward the edges of the tumour. Intermittent inflow control was adopted to minimize blood losses. Results: Operative time and blood losses resulted 180 mins and 250 mL respectively. The patient was discharged in 5 postoperative day and postoperative course was uneventful. R0 resection was confirmed on histological exam (15 mm tumour free margin). Conclusions: With appropriate adjustments of surgical technique and in experienced hands, laparoscopic parenchymal-sparing resections for non-peripheral liver lesions can be safe and feasible. Few tips and tricks are essential to be adopted in order to achieve a safe oncological resection.
BILIARY 0577 TOTALLY LAPAROSCOPIC RESECTION OF A CHOLEDOCHAL CYST AND RECONSTRUCTION WITH RETROCOLIC RETROGASTRIC ROUXEN-Y HEPATICOJEJUNOSTOMY S. López-Ben, M. T. A. Quer, F. Verdaguer, C. Gutierrez, C. Barreras, G. Garcia, J. F. Felip and M. C. Robert Hospital Universitari Dr Josep Trueta, Spain Aims: Show full laparoscopic resection and recontruction of a Todani Ib choledochal cyst. Methods: Initial four port technique was performed. Cholecystectomy was the first step, follow by craneal ling of the bile duct. Crano caudal dissection of the cyst until the intrapancreatic portion was accomplished. A Roux-en-Y limb was ascended by the retrocolic retrogastric route in two steps. Finally end-to-side hepaticojejunostomy was performed in the running fashion. Results: A intra abdominal bleeding was the only complication that could be successfully fixed by interventional radiology. Hospital stay was 10 days. Pathological report show changes in bile duct consistent with choledochal cyst, without atypia. Conclusions: Laparoscopy is a good indication for benign biliary disease as all the surgical steps can be done as in open surgery.
TRANSPLANT 0646 ROBOTIC-ASSISTED SPLENIC ARTERY NEURISM RESECTION AND REESTABLISHMENT OF THE FLOW WITH A PROSTHETIC CONDUIT AN A LIVER TRANSPLANT RECIPIENT V. Scuderi1, A. Patriti2 and R. Troisi1 1 Department of General and Hepato-Biliary Surgery Liver Transplantation Service; 2Hospital San Matteo degli Infermi, Italy
Aims: The Splenic Artery Aneurysms (SAA) in the liver transplant population remains a significant source of morbidity and mortality due to the risk for rupture. The best treatment for asymptomatic aneurysms remain undefined but considering that the survival following transplantation continues to improve, appropriate diagnosis and management of the SAA is mandatory. To reduce the postoperative morbidity of the surgical management of SAA the minimally invasive approach has been proposed. The robotic approach is considered superior to the laparoscopic one due to the 360 movements of the instruments and the easier reconstructive phase. In this video the robotic-assisted surgical SAA repair is showed. Methods: A female 50 yo patient with NASH cirrhosis and morbid obesity (BMI 49.5) underwent a standard liver transplant procedure. Eighteen months later, a laparoscopic sleeve gastrectomy was successfully performed. During this operation, a large saccular aneurysm of the splenic artery was diagnosed. The angio MRI detected a double aneurism (15 16 23 mm, 11 6 mm) with a common ostium. The aneurysm was thereafter resected with reestablishment of the flow using a prosthetic conduit (GoreTex) between the proximal and the distal artery with the da Vinci System. Results: The operative time lasted 270 min. The patient was discharged on the 2nd POD. The follow-up with CT scan @ 7 m showed a good vascularization of the splenic parenchyma. Conclusions: Vascular dissection and reconstruction phases with the Da Vinci System are a very advanced technique successfully assisting the minimally invasive HPB procedures.
BENIGN HPB 0680 RESECTION OF A TODANI IVB BILE DUCT CYST AND RECONSTRUCTION WITH A HEPATICOJEJUNOSTOMY M. H. Fard-Aghaie, K. Schuetze, A. Papalampros, G. A. Stavrou, K. J. Niehaus and J. K. Oldhafer Asklepios Hospital Barmbek, Germany Aims: Bile duct cysts are rare anomalies of the biliary tree and associated with a 10 to 30-fold increased rate of malignancy compared to the general population. Although 60% are diagnosed in children, advances in imaging lead to an increasing number of adults with this disease. Methods: This video shows a resection of a type IVb bile duct cyst and reconstruction with a hepaticojejunostomy. The female patient, 36 years old, was referred to us with recurrent abdominal pain and choledocholithiasis. A laparoscopic cholecystectomy was performed at the referring hospital 8 years ago. The diagnostic work-up with ultrasound and MRCP showed the bile duct anomaly. Results: The postoperative course of the patient was uneventful. Postoperative cholestasis serum parameters were only slightly elevated and back to normal on the 3rd postoperative day (pod). The patient was discharged at the 15th pod in a very good condition. The histology showed no malignancy. Conclusions: Bile duct cysts are very rare (0,1% incidence) and their presentation range from subtle abdominal discomfort to cholangitis or calculi formation, leading to a delayed diagnosis. Todani IV bile duct cysts are evident in
HPB 2016, 18 (S2), e807ee809