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Totally laparoscopic resection of a choledochal cyst and reconstruction with retrocolic retrogastric Roux-En-Y hepaticojejunostomy
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
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