Oral (pre-recorded)
General HPB 
 
Friday 27 November 21:00 – 21:30   Oral Library
OTT01 Tricks of the Trade: Oral (pre-recorded) 
Selection of Presentations from Abstract Submissions


OTT-02  Flip the Liver for Segment 7 Resection
Christoph Kummerli, United Kingdom


C. Kummerli1,2, C. Tschuor1,3, M. Abu Hilal1,2
1University Hospital Southampton, United Kingdom, 2Istituto Fondazione Poliambulanza, Italy, 3University Hospital Zurich, Switzerland

The hepatic segment 7 is considered the most difficult segment to treat due to its anatomical location close to the diaphragm and adjacent to the ribs making it difficult to expose and access during laparoscopic liver surgery (Figure 1). Some authors proposed a transthoracic and transdiaphragmatic approach or intercostal port placement.
For a transabdominal approach to Segment 7, we herein describe the “Flip the Liver” maneuver. Four steps are mandatory for success of this trick:
i) Thorough mobilization of the right hemiliver including division of the round ligament and dissection of the retroperitoneal reflection
ii) followed by pulling the liver caudally towards the patients left leg grasping the falciform ligament or the gallbladder.
iii) Ensure anticlockwise rotation and caudalisation of segment 7 and
iv) finally check that the Pringle tape exits the abdominal wall through a port at a location permitting to pull the liver in the same caudal direction on the left side.
The resulting localisation of segment 7 towards former segment 6 facilitates any liver resection in this segment. “Topographically” segment 7 becomes segment 6, “a posterior segment becomes an anterior segment “(Figure 1). Moreover, the posterior part of segment 7 becomes more accessible for the subxyphoidal port and a resection, preferably using the diamond technique, can be applied safely.

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OTT-03  Tips and Tricks During the Performance of Total Laparoscopic Perichystectomy for Hydatid Cyst of All Liver Locations
Csar Muoz, Chile


C. Muoz1,2, D. Palominos1,2, G. Sepulveda1,2, S. Sotelo1,2, F. Gonzalez1,2, C. Varela2
1Digestive and HPB Surgery Unit, Universidad Catolica del Maule, Chile, 2Digestive and HPB Surgery Unit, Hospital Regional de Talca, Chile

Total laparoscopic perichystectomy (TLP) for hydatid cyst has been debated and poorly developed due to the risk of parasite dissemination during surgery. In the last 5 years, we have systematically performed TLP for cysts < 15 cm located in all segments of the liver. During the development and perfection of the technique we have implemented some perioperative protocols and learned some tricks that facilitate surgery by reducing the risks of dissemination. Our goal is to present the clinical study protocol, the technique used and some tricks developed during the performance of TLP in liver hydatidosis of any location. It is presented through videos: the preoperative study, the positioning of the patient to address the different lesions located in all the segments, the treatment of the parasite in the intraoperative in the open and closed TLP, as well as the treatment of some complications occurred during the surgery. In more than 30 patients who underwent surgery using these principles, we have not had Clavien morbidity> III in the postoperative period. During the systematic and standardized postoperative follow-up, we have not had cases of recurrence nor the complications derived from the residual cavity that exists in other less radical techniques. TLP is an implementable and reproducible technique with low recurrence risks, without the morbidity of the residual cavity that exists in conservative techniques and with the benefits of minimally invasive surgery.

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OTT-04  Ultrasound-Guided Inguinal Intranodal Lymphangiography (INLA) to Treat Postoperative Refractory Ascites after Major HPB Surgery as a Less Invasive Modality
Hiroshi Nakano, Japan


H. Nakano1, S. Kobayashi2, T. Matsushita1, T. Otsubo2
1Surgery, NHO Shizuoka Medical Center, Japan, 2Gastroenterological Surgery, St. Marianna University School of Medicine, Japan

Refractory ascites occasionally occurs after major HPB surgery as a result of damage to the intraabdominal lymphatic vessels. Treatment of low-fat diet, octreotide, or surgical ligation of the site of lymphatic leak may not be effective. Reliable less invasive treatment should be needed to control refractory ascites. Our group preliminary reported the utility of minimal invasive therapy using inguinal intranodal lymphangiography (INLA) in order to treat uncontrollable ascites (Hirata M, et al. Cardiovasc Intervent Radiol 40:1281;2017). We here report three cases with refractory ascites after major HPB surgery who were dramatically treated with ultrasound-guided inguinal INLA. The first patient underwent left hepatectomy with caudate lobe resection plus pancreaticoduodenectomy due to widespread cholangiocarcinoma. The second patient underwent right hepatectomy, caudate lobectomy, and extrahepatic bile duct resection due to gall bladder carcinoma. The third patient underwent right hepatectomy due to huge hepatocellular carcinoma. Abdominal drains were not able to remove because of uncontrollable ascites more than one month after surgery in these three patients. Ultrasound-guided inguinal INLA using Lipiodol was performed in these patients. In the second patient, two series of bilateral inguinal INLA was needed, but the other two patients were treated by only once right inguinal INLA. Refractory ascites was dramatically treated in these patients, and they immediately discharged. The INLA using Lipiodol can act as an embolic agent within the leaking lymphatic vessel and induce a local inflammatory reaction to seal the leak. The ultrasound-guided inguinal INLA is less invasive treatment for postoperative refractory ascites after major HPB surgery.

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OTT-05  Cholangioscopic Holmium Laser Lithotripsy (CHOLI): Novel Surgical Technique for Complete Clearance of Intrahepatic Stones in Hepatolithiasis
Nitin Vashistha, India


N. Vashistha1, A. Kumar2, D. Singhal1
1Department of Surgical Gastroenterology, Max Super Speciality Hospital, India, 2Department of Urology & Kidney Transplant, Max Super Speciality Hospital, India

Background: In Hepatolithiasis without liver atrophy, abscess or cholangiocarcinoma (hepatectomy not indicated) complete stone clearance is essential for recurrence free long term outcome.
For this purpose we used CHOLI using flexible ureterorenoscope (versatile, easy availability) instead of choledochoscope (limited utility).
CHOLI: Key Steps
1. Right Kocher's incision
2. Cholecystectomy
3. Choledochotomy and choledocholithotomy
4. Flexible ureterorenoscope (Karl Storz Flex 2, external diameter 7 F) introduced through choledochotomy.
5. Systematic biliary endoscopy and CHOLI for left and right hepatic ducts and segmental ducts and beyond. For this 200 micron holmium laser fiber was introduced through ureterorenoscope and stones pulverized. (Video)
6. Larger stone fragments removed with basket (Ngage nitinol stone extractor, size 1.7 F, length 115 cm; Cook Medical), while smaller stones were flushed out.
7. Choledochoscopy (ureterorenoscope) for residual stones in distal CBD.
8. Choledochocojejunostomy (Roux loop 60 cm)
Outcomes:
Setting: Tertiary care hospital in non endemic area
Patients: 4 (2 males, 2 female; age 51-59 years)
Extent: Left lobe + CBD (1), Bilobar + CBD (3)
Operating time: 360-420 minutes
Complete stone clearance: All patients
Complications (Clavien-Dindo ≥ 3 ): None
Follow up: 7-84 months
Recurrence: None
Advantages:
- Complete clearance of biliary system with single intervention (cf. endoscopic/percutaneous techniques)
Flexible ureterorenoscope can access most peripheral ducts
Holmium laser results in complete pulverization of stones
- Technically simple, parenchyma preserving (cf. hepatectomy)
- Lesions suspicious of concomitant cholangiocarcinoma can be biopsied
Conclusions:
CHOLI achieves complete stone clearance in hepatolithiasis.
[CHOLI: Technique and outcome]

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OTT-06  Temporary Mesenteric-Portal Shunt Using Prosthetic Graft Together with Intermittent Superior Mesenteric Artery Clamping (Pringle-Like) during Complex Venous Resction/Reconstruction in Pancreaticoduodenctomy for Locally Advanced Pancreatic Tumours
Mohammed Ghallab, United Kingdom


M. Ghallab1, C. Maulat2, M. Tedeschi2, A. Sa Cunha2, D. Cherqui2
1Queen Elizabeth Hospital Birmingham, United Kingdom, 2HPB, Paul Brousse Hospital - Paris South University, France

Introduction: Portal and superior mesenteric vein resection and reconstruction during pancreatic surgery for locally advanced tumors poses a challenging surgical scenario. Potential problems are; major bleeding, prolonged clamping with hepatic ischemia, venous congestion of the gut, and using the more difficult artery first approach. This potentially may increase morbidity and mortality of the procedure. To obviate these potential problems, we propose a pre-emptive temporary SMV-portal venous shunt with intermittent SMA clamping (pringle-like). This would allow for extensive dissection of the pancreatic head mass without interruption of portal venous flow.
Method: Exposure of infrapancretic SMV and supra-pancreatic portal vein is achieved preserving splenic and inferior mesenteric vein. A 10mm ringed Gore-Tex graft is anastomosed end to end to the SMV and end to side to the portal vein allowing extensive pancreatic resection and separation of the tumour from SMA. This was done in combination with intermittent clamping of the SMA to farther decrease venous congestion of the midgut and provide good haemostasis. After the tumour is resected, the Gore-Tex graft was then replaced with a cryo-preserved cadaveric vein graft used for reconstruction end-to-end anastomosis for both ends, and closing the side portal veinotomy.
Results and conclusion: The combined use of intermittent SMV/PV shunt and intermittent arterial clamping of SMA facilitates a complex pancreaticoduedenal resection. This was done avoiding serious potential complications and no time pressure. Also the SMA was appropriately and carefully assessed giving the opportunity to do an arterial resection re-construction if needed. The patient had an uneventful postoperative stay.

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OTT-07  Mesocaval Shunt to Decompress Cavernous Transformation in Pancreatic Surgery
Rebecca Kim, United States


R. Kim1, S. Tsai1, R. Buddithi2, D. Evans1, K. Christians1
1Surgery, Medical College of Wisconsin, Milwaukee, United States, 2Anesthesia, Medical College of Wisconsin, Milwaukee, United States

Cavernous transformation of the portal vein (PV) due to obstruction or severe narrowing of the spleno-porto-mesenteric confluence in pancreatic diseases often renders surgical removal of the pancreatic head impossible. A mesocaval shunt (MCS) allows for decompression of the porta hepatis and peripancreatic varices necessary for safe dissection in patients who would otherwise be considered inoperable.
We utilize the left internal jugular (IJ) vein as the vascular conduit as it offers the best size match. An IJ vein-to-inferior vena cava(IVC) end-to-side anastomosis is created caudal to the left renal vein junction with a running 6-0 polypropylene suture. The superior mesenteric vein (SMV) is then divided just cephalad to its bifurcation into the jejunal and ileal branches. An end-to-end SMV-to-IJ vein anastomosis is created with 6-0 polypropylene interrupted suture. When combined with a splenorenal bypass, all mesenteric venous return is temporarily diverted to the systemic circulation. After removal of the pancreatic head, the IVC anastomosis is disconnected and hepatopetal flow in the portal vein is restored with an end-to-end anastomosis of the IJ graft to the PV. Occasionally, we have left a MCS bypass intact as a permanent shunt when the splenoportal confluence can be preserved.
A MCS allows for resection of the pancreatic head in the setting of profound porta hepatis varices in patients with cavernous transformation of the PV.
[Preoperative imaging and intraoperative photo]

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OTT-08  Anterior Sector Outflow Reconstruction Using Polytetrafluoroethylene (PTFE) Graft in Right Lobe Living Donor Liver Transplantation: A Step towards Donor Safety and Optimising Recipient Outcomes
Ashish Singhal, India


A. Singhal, V. Chorasiya, K. Makki, A. Srivastava, A. Khan, M. Qaleem, V. Vij
Liver Transplantation & HPB Surgery, Fortis Hospitals, India

Outflow reconstruction in right lobe living donor liver transplantation (RL-LDLT) is critical; especially in liver allografts without middle hepatic vein (MHV). Preserving the MHV with the donors add to donor safety but leads to multiple segmental veins in the graft, which have impact on segmental regeneration of allograft and can cause graft dysfunction. As an institutional policy, we routinely preserve the MHV with donor and reconstruct the anterior sector venous tributaries in recipient. We have been using expanded polytetrafluroethylene (ePTFE) vascular graft to reconstruct the anterior sector tributaries in RL-LDLT. On bench, we created a “Neo-MHV” using ePTFE graft and anastomosing to segment 5/8 veins in an end-to-end/end-to-side fashion. In past, graft right hepatic vein (RHV) and Neo-MHV were anastomosed at separate sites on inferior venacava (IVC) (Separate Drainage). Since February 2016, the end of Neo-MHV was anastomosed with end of graft RHV in side-to-side fashion to create a common ostium. A single Neo-MHV-RHV (common ostium) to caval RHV orifice anastomosis was performed (Single Composite Drainage). At six months, 15.6% patients had occluded interposition conduits. Considering that graft regeneration occurs mainly during the first month, long-term patency of the interposition grafts for V5/8 drainage is not a major concern. All these patients remained asymptomatic and had normal liver functions. None of these patients underwent any intervention. In centers with limited access to deceased donor vascular grafts, use of ePTFE graft is a viable option with excellent patency and patient outcomes.
[Outflow Reconstruction in LDLT (Right Lobe without MHV)]

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OTT-09  Tips and Tricks for the Uncinate Dissection during Laparoscopic Pancreaticoduodenectomy
Dominic Sanford, United States


D. Sanford1, C. Hammill1, W. Hawkins1, H. Asbun2
1Washington University in Saint Louis, United States, 2Miami Cancer Institute, United States

Background: Laparoscopic pancreaticoduodenectomy (LPD) is a complex operation, and the uncinate dissection is perhaps the most difficult step in the resection phase of this procedure. The purpose of this presentation is to demonstrate our technique (using videos) for uncinate dissection during LPD along with a few commonly encountered scenarios.
Technique: The setup is extremely important to the success of this challenging step. Specifically, camera port location (Cam) as well as surgeon and assistant instrument choice and port site usage can greatly affect the difficulty of this phase of the operation (see Figure). We routinely use a port to the right of midline for the camera. The surgeon stands to the right of the patient with his/her right hand (S-RH) in the midline port with a vessel sealing device, while a large grasper in the left hand (S-LH) serves to retract the entire specimen to the patient's right. The assistant stands on the patient's left side using a suction in the right hand (A-RH) to keep the operative field dry and a laparoscopic kitner in the left hand (A-LH) to retract the superior mesenteric (SMV)/portal vein (PV) to the patient's left thereby exposing the superior mesenteric artery (SMA). The dissection proceeds from caudad to cephalad taking care to ligate the inferior pancreaticoduodenal artery as well as large venous branches from the SMV/PV.
Conclusion: This technique is a safe and reproducible method for removing the pancreatic head from the SMV/PV and SMA.
[Laparoscopic Uncinate Dissection Setup. Surgeon left hand (S-LH) and right hand (S-RH), Assistant left hand (A-LH) and right hand (A-RH), Camera (Cam)]

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OTT-10  Laparoscopic Partial Splenectomy with Distal Pancreatectomy Preserves Splenic Function
Nicholas O'Rourke, Australia


N. O'Rourke, D. Kilburn
Royal Brisbane Hospital, University of Qld, Australia

Introduction: Distal Pancreatectomy often requires splenectomy, for oncologic reasons, or because splenic vessels are involved. The immune function of the spleen is increasingly recognized, and many national guidelines suggest long term antibiotics following splenectomy.
Method: In many patients planned for distal pancreatectomy and splenectomy, it may be possible to preserve the upper pole of the spleen, with blood supply from the short gastric vessels.
Results: This technique is demonstrated laparoscopically in a 58 yo female with an enlarging cystic lesion in the tail of the pancreas. The spleen is divided using an energy device with topical haemostatic agents.
Follow up imaging demonstrates hypertrophy of this splenic remnant, and blood analysis suggests competent splenic function.
Conclusions: In selected patients undergoing (laparoscopic) distal pancreatectomy, preservation of a portion of the spleen, may avoid sacrificing immunocompetence.

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