PL04 Liver: Technical Surgery (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PL04-01 Lateral Approach toward Hepatoduodenal Ligament during Laparoscopic Radical Cholecystectomy for GB Cancer
Kwangyeol Paik, Korea, Republic of

K. Paik, J.S. Oh
The Catholic University of Korea College of Medicine, Korea, Republic of

Introduction: Lymph node dissection (LND) during laparoscopic radical cholecystectomy (LRC) is usually approached through an anterior approach, mimicking and with similar view than in open surgery. However, safe and complete isolation of the post-pancreatic node or retro-portal node are sometimes more difficult in laparoscopic surgery because the dorsal structures of hepatoduodenal ligament are embedded and might be difficult to expose.
Methods: During last 20 years, we performed 120 surgery for GBC including 12 cases LRC in our institution. Most of all diagnosed prior to operation two cases of incidental cancer underwent 2nd operation of LND and liver resection. Half of cases were dissected lymph nodes only and six liver resection were done.
Results: Majority of them revealed T2 and T1b finally. LRC is performed successful using lateral laparoscopic approach. None of patients undergoing LRC required conversion to another view during hilar dissection. The retro-portal vein and pancreas head LND could be reached expeditiously and safely prior to parenchymal transection. Retrieved nodes were 1 to 17 and median was 7. There was one complication of small bowel perforation during adhesiolysis.
Conclusion: Lateral approach during LRC appears to facilitate the visualization, exposure and dissection of the dorsal part of hepatoduodenal ligament and very useful for LND #12,13.
PL04-02 Origin Regression in Right Anatomical Hepatectomy for 70 Years
Atsushi Nanashima, Japan

A. Nanashima1, S. Ariizumi2, M. Yamamoto2
1Department of Surgery, University of Miyazaki, Japan, 2Department of Surgery, Tokyo Womens Medical University, Japan

Right anatomical hepatectomy (RH) is a standard procedure for liver malignancies and its history is quite fascinating.To understand origin and concept such as pioneers, development of procedures and future aspects of RH, we attempted to review the “hidden” history worldwide since 1945 by searching not only English but also non-English published documents, and international experts' comments. In RAH, anatomical concept and identification, vascular control technique, approaches, preoperative managements are considered to be important issues. Basis of the modern liver anatomy has been clarified in French article by Tung (Vietnam) and Meyer-May in 1939, who applied to liver anatomical resection thereafter. Who was a pioneer? Honjo in 1949 and Jacob in 1951 succeeded RH in 1941 and 1951 in each, which were published in Japanese and French, respectively. This is a begging of RH and RH has began to spread as the surgical treatment of liver malignancies worldwide since then. Vascular in-flow control is divided as intrafascial, extrafascial or transfissual access. The anatomical border along the main hepatic veins was clarified for transection according to establishment of liver anatomy. Anterior approach were proposed as an alternative option in the hazardous situations of right liver rotation. Hanging maneuver for anterior approach has been developed for various anatomical hepatectomies. Laparoscopic or robotic new technology provides patient's benefit even in RH. Thus,understanding origin sources regarding RH established for 70 years is quite necessary for liver surgeons. Future aspects of RH will include changes of concepts, new technology to ensure patient safety and disease curability.
PL04-03 Role of Robotic Surgery in the Management of Benign Hepatobiliary Diseases
Eli Kakiashvili, Israel

E. Kakiashvili1, E. Brauner2
1General Surgery, Galilee Medical Center, Israel, 2General Surgery, Rambam Medical Center, Israel

Background: Recently robotic surgery has emerged as one of the most promising surgical advances. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (HBP) surgery remains relatively unexplored.
Our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies.
Methods: A retrospective analysis of a prospectively maintained database on clinical outcomes was performed for 26 consecutive patients that underwent robotic assisted surgery for benign HBP disease at Rambam Medical Center during 2013-2015.
Results: There were 26 robotic assisted surgical procedures performed for benign HBP pathologies during the study period. There were 3 anatomical robotic liver resections for symptomatic hemangiomas , 9 cases of giant liver cyst, 5 robotic assisted surgery for type I choledochal cyst, 2 case of benign (iatrogenic) common bile duct (CBD) stricture, 3 cases of robotic (CBD) exploration due to large intra choledochal stones and 6 cases of cholecystectomy for cholelithiasis. The median postoperative hospital stays for all procedures were 3.5 days
(range 1-6 days). General morbidity (minor) was 2%. There was no mortality in our series.
Conclusions: Robotic surgery is feasible and can be safely performed in patients with different benign HBP pathologies. Further evaluation with clinical trials is required to validate it's real benefits.
PL04-04 Laennec's Approach for Laparoscopic Anatomic Hepatectomy Based on Laennec Capsule
Decai Yu, China

Y. Hu1, J. Shi2, S. Wang3, W. Zhang3, Q. Liu3, B. Sun3, D. Yu3
1Biobank and Department of Pathology, The Affiliated Drum Tower Hospital, School of Medicine, Nanjing University, China, 2Pathology, The Affiliated Drum Tower Hospital, School of Medicine, Nanjing University, China, 3Hepatobiliary and Pancreatic Center & Liver Transplantation Center, The Affiliated Drum Tower Hospital, School of Medicine, Nanjing University, China

Background: Although Glissonean pedicle isolation and hepatic vein isolation should be the critical procedure for anatomical liver resection (ALR), there is no standardized approach for the hepatic vein and Glissonean pedicles. We proposed the novel Laennec's approach for laparoscopic anatomic hepatectomy (LAH) based on Laennec's capsule, which serves as the key anatomic landmark for Glissonean pedicle and hepatic vein isolation, liver mobilization, and Hanging maneuver.
Methods: 156 cases were enrolled in this trial. They underwent LAH for the liver diseases, such as benign or malignant neoplasms, or hepatolithiasis. We conducted the novel Laennec's approach for LAH based on Laennec's capsule. The liver tissues close to Glissonean pedicle, hepatic veins, naked area, and inferior vena cava (IVC) were collected for H&E and resorcinol-fuchsin staining, and immunohistochemistry for smooth muscle actin. The operative index were also collected.
Results: All staining showed that there was the capsule packaging the whole liver independent to the adjacent tissues and intrahepatic vessels. There was the natural gap between Laennec's capsule and the adjacent tissues at different sites. Laennec's capsule serves as the landmark for Glissonean pedicle and hepatic vein isolation, liver mobilization, and Hanging maneuver. 156 cases underwent LAH with this strategy. Operation time was 258.34 minutes, and four cases has been transferred to open hepatectomy for bleeding. Hospital day was 9.4 days. Four cases had bile leakage.
Conclusion: Laennec's approach based on Laennec's capsule would contribute to standardize the surgical techniques for LAH, and would bring innovative changes for spreading safe and curable liver resection under laparoscopy.
PL04-06 Haemostatic Efficacy of Topical Agents during Hepatectomy: A Network Meta-Analysis
Cameron Wells, New Zealand

C. Wells1, C. Ratnayake1, K. Mentor2, G. Sen2, J. French2, C. Wilson2, D. Manas2, S. White2, S. Pandanaboyana2
1Department of Surgery, The University of Auckland, New Zealand, 2HPB and Transplant Unit, Freeman Hospital, United Kingdom

Background: Hepatic resection carries a high risk of parenchymal bleeding both intra- and post-operatively. Topical haemostatic agents are frequently used to control bleeding during hepatectomy, with multiple products currently available. However, it remains unknown which of these is most effective for achieving haemostasis and improving peri-operative outcomes.
Methods: A systematic review and random-effects Bayesian network meta-analysis of randomised trials investigating topical haemostatic agents in hepatic resection was performed. Interventions were analysed by grouping into similar products; fibrin patch, fibrin glue, collagen products, energy devices, and control. Primary outcomes were the rate of haemostasis at 4 and 10 minutes.
Results: Twenty-three randomized controlled trials were included in the network meta-analysis, including a total of 3,552 patients and 8 different interventions. Fibrin patch was the most effective intervention for achieving haemostasis at both 4 minutes and 10 minutes, followed by fibrin glue. There were no significant differences between haemostatic agents with respect to blood loss, transfusion requirements, bile leak, post-operative complications, reoperation, or mortality.
Conclusions: Amongst the haemostatic agents currently available, fibrin patch is the most effective method for reducing time to haemostasis during liver resection.
PL04-07 Anatomic versus Limited Non-Anatomic Resection for Solitary Hepatocellular Carcinoma: A Retrospective Study of 1515 Cases
Binhao Zhang, China

B. Zhang, C. Wang, B. Zhang, X. Chen
Surgery, Tongji Hospital of Huazhong University of Science and Technology, China

Introduction: Surgical resection remains the only curative treatment for HCC. The optimal resection choice in patients with solitary HCC is controversial with regards to underlying diseases, remnant functional hepatic parenchyma and substantial heterogeneity of HCC. The aim of this retrospective investigation was to determine whether anatomical resection (AR) is superior to limited non-anatomical resection (NAR) for single HCC tumor.
Methods: From January 2013 to December 2015, 1515 consecutive patients received solitary HCC resection were selected from a database of 3835 cases. Among them, 859 patients underwent anatomical resection (AR Group) and the other 656 cases had non-anatomical resection (NAR Group). Basic characteristics, tumor factors, intra- and post-operation characteristics, mortality, recurrence and metastasis patterns were compared between groups.
Results: There was no significant difference in basic characteristics, tumor locations, post-operative complication or mortality between AR and NAR Group. AR Group presented with longer surgery time (p< 0.001), while blood loss and transfusion showed no difference. AR Group obtained optimal prognosis with total recurrence rate lower than that in NAR Group (p< 0.001). NAR Group presented higher rates of intrahepatic, resection margin and adjacent segment recurrences. However, AR Group showed higher distal segment recurrence, which might due to the death caused by intrahepatic recurrence in NAR Group before distal recurrence happened. No statistical difference was observed in lung or abdominal metastasis.
Conclusion: Patients can clinically benefit from anatomical resection and major resection provided that they have well-preserved liver function. Further prospective randomized controlled trials were requested to determine this conclusion.
PL04-08 Massage of the Hepatoduodenal Ligament Recovers Portal Vein Flow Immediately after the Pringle Maneuver in Hepatectomy
Junji Ueda, Japan

J. Ueda1, Y. Mamada2, N. Taniai3, M. Yoshioka2, A. Hirakata4, Y. Kawano1, T. Shimizu2, H. Takata4, H. Yoshida2
1Nippon Medical School Chiba Hokusou Hospital, Japan, 2Surgery, Nippon Medical School, Japan, 3Nippon Medical School Musashi Kosugi Hospital, Japan, 4Nippon Medical School Tamanagayama Hospital, Japan

Introduction: The Pringle maneuver is often used in liver surgery to minimize bleeding during liver transection. Many authors have demonstrated that intermittent use of the Pringle maneuver is safe and effective when performed appropriately. However, some studies have reported that the Pringle maneuver is a significant risk factor for portal vein thrombosis. In this study, we evaluated the effectiveness of portal vein flow after the Pringle maneuver and the impact that massaging the hepatoduodenal ligament after the Pringle maneuver has on portal vein flow.
Materials and methods: Patients treated with the Pringle maneuver for hepatectomies performed to treat hepatic disease at our hospital between August 2014 and March 2019 were included in the study (N=101). We divided these patients into two groups, a massage group and nonmassage group. We measured portal vein blood flow with ultrasonography before and after clamping of the hepatoduodenal ligament. We also evaluated laboratory data after the hepatectomy.
Results: Portal vein flow was significantly lower after the Pringle maneuver than before clamping of the hepatoduodenal ligament. The portal vein flow after the Pringle maneuver was improved following massage of the hepatoduodenal ligament. After hepatectomy, serum prothrombin time was significantly higher and serum C-reactive protein was significantly lower in the massage group than in the nonmassage group.
Conclusion: Massage of the hepatoduodenal ligament is recommended after the Pringle maneuver to immediately recover portal vein flow during hepatectomy allowing us to shorten the declamping time, which may contribute to a reduction in the operation time.
PL04-09 Image-Guidance for Non-Anatomical Liver Resections: An ex-vivo Study
Iwan Paolucci, Switzerland

I. Paolucci1, R.-M. Sandu1, L.A. Sahli1, G.A. Prevost2, F. Storni2, D. Candinas2, S. Weber1, A. Lachenmayer2
1ARTORG Center for Biomedical Engineering Research, University of Bern, Switzerland, 2Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Switzerland

Introduction: Non-anatomical resections of liver tumors are becoming more popular because they spare a larger portion of healthy liver parenchyma. However, the lack of anatomical landmarks to follow during the resection process makes them technically more challenging than anatomical resections. Image-guidance systems have been introduced to provide additional guidance, but are rarely used due to their inaccuracy, time-effort and complexity in usage and setup. Therefore, we have designed a new navigation approach that renders a surgical plan intra-operatively in real time using only navigated ultrasound.
Method: The ultrasound based navigation approach comprises the following steps:
i) scanning the surface using the navigated ultrasound,
ii) marking the tumor location and size on a midsection ultrasound image,
iii) specifying a resection shape and a safety margin to create an optimal surgical plan.
In this study, we evaluated this method in an ex-vivo porcine model by three experienced hepatobiliary surgeons with respect to R0 resection status.
Results: In 22 out of 23 resections an R0 resection (margin > 1mm) was achieved (95.7%) with a median resection margin of 5.9 mm (IQR 3.5 - 7.7 mm). There was a difference between the surgeons in terms of resection margin with operators 1,2 and 3 having 7.8 mm, 4.15 mm and 5.1 mm median resection margin respectively (p = 0.054).
Conclusions: This navigation approach could represent a useful tool for intra-operative guidance in non-anatomical resection alongside conventional ultrasound guidance. A clinical pilot trial with 10 patients is currently in planning and will start beginning of 2020.
PL04-10 Tailored Segmentectomy for HCC Located in Segment 8 According to Intrahepatic Anatomical Variation of Glisson Pedicles
Hee-Jung Wang, Korea, Republic of

H.-J. Wang, T.-K. Kim, M. Kim, S.-Y. Hong, B.-W. Kim
Surgery, Ajou University School of Medicine, Korea, Republic of

There are three techniques in systematic segmentectomy 8 for HCC located in Couinaud segment 8. The first approach is the US-guided dye injection technique, proposed by Professor Makuuchi. The second technique is Takasaki's cone unit resections through the dorsocranial opening of the main portal fissure. And the third approach is a technique through the anterior opening of main portal fissure. As the anterior liver is thin, the hepatotomy requires a little efforts. It is followed by confirmation, ligation and division of the G8 pedicle(s), and the surface of the S8 is discolored. Thereafter, we remove the stained liver.
Since 2016, we have used preoperative 3D image (Synapse 3D, Fuji film), and have confirmed the patterns of intrahepatic anatomical variations of portal veinous branches. And we could select the tailored technique in systematic segmentectomy 8 getting the high success rate of anatomical resection. We got the 3D images using Synapse 3D (Fuji film) in 96 LDLT donor liver. There were four types in anatomical variation of right anterior portal branches: Type A (Cranio-caudal type:
49 cases, 46.2%), Type B(Ventral-dorsal type: 14 cases, 13.2%), Type C (Radial type: 37 cases, 34.9%) and Type D (Slidden branch type between RAS and RPS: 6cases, 5.7%). We can do anatomical segmentectomy 8 in only Type A (46%) using conventional technique. Today, I would like to show experiences of tailored surgical approaches (to apply complementally one of the three approaches) according to their patterns for HCC located in segment 8.
PL04-11 High Complexity Major Liver Resection by Thunderbeat as a Sole Device under the Pringle Maneuver and Infra-Hepatic Inferior Vena Cava Clamping (With Video)
Teruo Komokata, Japan

T. Komokata, B. Aryal, N. Tada, K. Yoshikawa, M. Kaieda, K. Nuruki
Department of Surgery, National Hospital Organization Kagoshima Medical Center, Japan

Introduction: In addition to conventional major or minor classification in liver resection (LR), recently, a complexity classification with 3 categories (low, medium, or high) according to its technical difficulty was proposed and validated. We describe the outcomes of high complexity major LR by Thunderbeat (TB) as a sole device under the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping.
Methods: Of 85 patients undergoing LR between July 2013 and November 2019, we reviewed seven patients who underwent this procedure. To evaluate the safety and rapidity, we compared the parenchymal transection time (PTT), estimated blood loss (EBL), and postoperative major complications (PMC) with nine patients who underwent medium or high complexity open major LR by the basic procedure, i.e. the clamp-crushing or the CUSA with supplemental use of energy devices.
Results: Seven patients underwent extended right hepatectomy with hepaticojejunostomy (n=3), anatomical middle hepatectomy (n=2), and right trisectionectomy (n=1) or extended left hepatectomy (n=1) with IVC resection and reconstruction. Two patients experienced PMC (Clavien-Dindo classification IIIa: n=1, IIIb: n=1). There was no in-hospital mortality. Six patients are currently alive without recurrence with a median follow-up of 24 months. PTT [median (range)] in the TB group was significantly shorter: 19 (13-45) compared to 52 (18-174) min in the basic group (p=0.012). There was no significant difference in terms of EBL (p=0.918) and PMC (p=0.771).
Conclusions: TB with the Pringle maneuver and infra-hepatic IVC clamping is feasible and may offer rapidity during high complexity major LR.
PL04-13 Laparoscopic Extrahepatic Glissonean Pedicle Approach (Takasaki Approach) for Anatomical Liver Resection by Indocyanine Green (ICG) Fluorescence Counterstaining
Xiao Liang, China

X. Liang, J. Zheng, J. Cai, L. Tao, Y. Xie, M. Kirih
Department of General Surgery, Zhejiang University, School of Medicine, Sir Run Run Shaw Hospital, China

Introduction: Although the extrahepatic Glissonean pedicle (Takasaki) approach has been widely used in open anatomic liver resection (ALR), it is still the most challenging procedure in laparoscopy. This study aimed to introduce our strategy of the laparoscopic Takasaki approach using a fluorescence counterstaining (ICG) technique and report perioperative outcomes.
Methods: From April 2017 to December 2019, a total of 43 consecutive patients underwent ALR by laparoscopic Takasaki approach in our institution. The innovatively key steps of the procedure are as follows:
1) preoperative 3D construction of portal territory;
2) prearrangement of Pringle maneuver rubber band tourniquet;
3) descending the hilar plate using laparoscopic Peng's multifunctional operative dissector and ultrasonic energy devices (Two-handed technique);
4) test-clamping the target Glissonean pedicle;
5) visualization of territory by ICG counterstaining technique;
6) transection liver parenchymal according to ICG boundary.
All patients were postoperatively managed under the concept of ERAS.
Results: The extent of resections included segmentectomy (n=10), left lateral sectionectomy (n=3), bisegmentectomy (n=12), left hemihepatectomy (n=4), right hemihepatectomy (n=12) and central hepatectomy (n=2). There was no case converting to open and no postoperative mortality. The median operation time was 200 min (range 110-445), and the median estimated blood loss was 200 ml (range 50-800). The overall complication rate was 32.5 % (grade I, 8; grade II, 4; grade III, 2). The median length of postoperative hospital stay was 6 days (range 3-17).
Conclusions: Laparoscopy can achieve safe and feasible anatomical liver resection via an extrahepatic Glissonean pedicle approach with the technique of ICG counterstaining.
 Operation time, min (IQR)Estimated blood loss, ml (IQR)Postoperative hospital stay, day (IQR)Complication, n (%) (IQR)
Segmentectomy, n=10195 (175-213)125 (87.5-125)4.5 (4-5)2 (20%)
Left lateral sectionectomy, n=3130 (130-445)50 (50-400)5 (3-9)1 (33.3%)
Bisegmentectomy, n=12222.5 (191.3-260)200 (125-300)7 (4.25-7.8)1 (8.3%)
Left hemihepatectomy, n=4177.5 (126.3-206.3)100 (62.5-175)7 (3.75-3.3)2 (50%)
Right hemihepatectomy, n=12200 (182.5-287.5)200 (100-275)6.5 (6-7)7 (58.3%)
Central hepatectomy, n=2222.5 (210-235)275 (20-500)11.5 (6-17)1 (50%)
[Postoperative outcomes of the patients who undergoing laparoscopic ALR]
PL04-16 "Zoom Resection": A Two-Step Wedge Liver Resection Technique to Resect Deep Tumors and Spare Parenchyma
Guillermo Pfaffen, Argentina

G. Pfaffen, J. Sotelo, N. Ortiz, R. Moran Azzi, V. Serafini
HPB Surgical Unit, Sanatorio Guemes, Argentina

In certain cases, huge liver resections are required to deal with deep tumors located near vascular pedicles. However, this implies a higher risk of postoperative liver failure and mortality. Liver parenchyma sparing techniques play an essential role in decreasing these risks. In November 2018, our surgical team reported a new two-step wedge liver resection technique to resect deep tumors in an easy way. Although it was a case report, more patients have already been successfully operated with this approach since then. Regarding the technique itself, intraoperative ultrasound is a very important tool employed to plan and guide both steps of the procedure. Initially, we put stitches and resect a cylindrical piece of normal liver parenchyma above the deep tumor. This way, we can "superficialize" the tumor. After that, we place stitches on the future specimen and resect it in the same way it is done with superficial metastases. The main advantage of this procedure is the clear sight and vascular control that can be achieved in those cases in which the tumor is close to vascular pedicles. As a result, the bigger the chance of preserving vascular pedicles, the bigger the chance of sparing parenchyma as well. We have named this procedure “zoom resection” because its dynamics is similar to that of the photograph camera telescopic system.
PL04-18 The Safety and Feasibility of Two-surgeon Technique During Anatomical Laparoscopic Liver Resection
Takahisa Fujikawa, Japan

T. Fujikawa, S. Naito, N. Takemoto, N. Nakamura, T. Furuya
Surgery, Kokura Memorial Hospital, Japan

Introduction: Although laparoscopic liver resection(LLR) has the potential advantages such as minimal degree of body wall damage, decreased surgical blood loss, and fewer postoperative complications, it has been associated with a much slower adoption than other laparoscopic procedures. The aim of the study is to assess the impact of "two-surgeon technique" during anatomical LLR on the surgical outcome.
Methods: Consecutive 162 patients receiving anatomical liver resection at our institution
between 2010 and 2019 were retrospectively reviewed. We introduced and maintained “two-surgeon technique” during LLR in order to perform safe liver parenchymal transection without critical intraoperative bleeding (Fujikawa, World J Gastrointest Endosc 2017;9:396-404). In this technique, the primary surgeon dissects the hepatic parenchyma, while the secondary surgeon is focused on hemostasis using a saline-linked electrocautery. The included patients were classified into three groups: patients undergoing open liver resection(OLR group, n=97), those undergoing hybrid LLR(HLR group, n=26) and those receiving pure LLR(LLR group, n=39), and outcome variables were compared between the groups.
Results: 66 bi-/tri-sectionectomy and 96 sub-/mono-sectionectomy were included in the cohort. The duration of operations were similar between the groups(344 vs 304 vs 352min, p=0.11), although significantly less surgical blood loss (590 vs 190 vs 70mL, p< 0.001) and shorter length of postoperative day (16 vs 12 vs 8days, p< 0.001) were observed in the LLR group. Severe complications(Clavien-Dindo class>=3) occurred more often in the OLR group than HLR or LLR groups(16% vs 0% vs 5%, p=0.033).
Conclusion: The two-surgeon technique is feasible and safely performed even during anatomical LLR.
PL04-19 Short Term Result of Parenchymal Sparing Anatomical Liver Resection Based on Portal Ramification of the Right Anterior Section: A Single Center Experience
Giang Nguyen, Viet Nam

G. Nguyen, A. Pham, T. Nguyen, H. Nguyen, H. Nghiem, D. Pham
Hepatobiliary and Pancreatic Surgery, Vietnam National Cancer Hospital, Viet Nam

Introduction and Objectives: Anatomical liver resection is the treatment of choice for primary liver cancer. However, the remnant liver volume is equally important in patient selection for operation. Recent appreciation of the liver segmentation could divide the right anterior section (RAS) into ventral-dorsal segment or segment 5-segment 8. Thus, we aim to evaluate the short term results of parenchymal sparing liver resection based on portal ramification of the right anterior section.
Material and Methods: From July 1,2018 to December 30, 2019, 19 patients with primary liver cancer underwent ventral or dorsal segment sparing hepatectomy. The portal ramification of RAS were analyzed using the Multidetector Computed Tomography scan. The procedures were performed by 4 liver surgeons.
Results: Among 19 patients with ventro-dorsal type of the RAS, there were 17 men with HCC and 2 women with ICC. The mean age was 59.8 ± 11.5 years. The ventral-segment preserving right hepatectomy was performed in 16 patients, the dorsal-segment mesohepatectomy in 2 patients and the dorsal-segment trisectionectomy in 1 patient. The mean operative time was 244.7 ± 44.1 minutes with a mean estimated blood loss of 277.4 ± 275.6 ml. Post-operative morbidity was reported in 4 cases (21.1%). The mean length of hospital stay was 13.3 ± 9.1 days. There was one operative death due to acute portal vein thrombosis.
Conclusions: The pre-operative evaluation of RAS's anatomy is very important to decide the method of parenchymal sparing liver resection. This procedure is technically safe and feasible.
PL04-20 Short Term Result of Anterior Approach with Liver Hanging Maneuver for Anatomical Resection: A Single Center Experience
Giang Nguyen, Viet Nam

G. Nguyen, A. Pham, T. Nguyen, H. Nguyen, H. Nghiem, D. Pham
Hepatobiliary and Pancreatic Surgery, Vietnam National Cancer Hospital, Viet Nam

Introduction and Objectives: Anatomical liver resection is the treatment of choice for hepatocellular carcinoma (HCC). Anterior approach with liver hanging technique is useful to prevent the dissemmination of tumor cells to systemic circulation. Thus, we aim to evaluate the short term results of anterior approach with liver hanging maneuver for anatomical resection.
Material and Methods: A retrospective review of all patients with HCC who underwent anatomical resection from July 1 to December 20, 2019. The procedures were performed by 4 liver surgeons.
Results: Among 9 patients, there were 5 men and 4 women. The mean age was 53.3 ±11.5 years. The right hepatectomy was performed in 5 patients, the right anterior sectionectomy in 2 patients, and ventral segment preserving right hepatectomy in 2 patients with small left lobe. Anterior approach with liver hanging maneuver was performed in all patients. The mean tumor size is 8.9 cm. Two patients had macrovascular invasion (right hepatic vein and right posterior portal vein). The mean operative time was 231.1 ± 37.2 minutes with a mean estimated blood loss of 303.3 ± 450.6 ml. Complications included 1 bilake (Clavien-Dindo grade II) and 1 acute portal vein thrombosis (grade IVa) were reported. The mean length of hospital staybil was 12.2 ± 8.4 days. There was no reported 30 days mortality.
Conclusions: The anterior approach with liver hanging technique can be apply for various kind of anatomical resection. This procedure is technically safe and feasible.
PL04-25 Laparoscopic Anatomic Resection Guided by Indocyanine Green Fluorescence Imaging - A Single Institution Experience -
Kan Toriguchi, Japan

K. Toriguchi, M. Tada, Y. Kawabata, S. Tamagawa, H. Iwama, K. Iida, H. Sueoka, I. Nakamura, E. Hatano
Surgery, Hyogo College of Medicine, Japan

In laparoscopic anatomic resection, especially in the sub-segmentectomy of segment 8 or 7, it can be difficult to detect and dissect the targeted branch of Glisson sheath from the hepatic hilum. When that is the case, we inject dye into the targeted portal vein to stain the resection area by using an ultrasound-guided vascular access system for laparoscopic surgery.
We use the Bk5000/9066 (BK medical) ultrasound machine with a built-in probe for ultrasound-guided vascular access. This system has an advanced laparoscopic ultrasound transducer that has a small hole for the needle on the tip of the probe which can draw a guideline for the needle. We also use the laparoscope Indocyanine Green (ICG) fluorescence imaging camera system (Storz). The dye is a mixture of ICG and Indigo carmine. Under guidance of ultrasonography, we detect the targeted portal vein and percutaneously insert the PTCD needle into the portal vein. Then, we slowly inject the dye observing the dyeing process with the ICG imaging camera. By using ICG together with Indigo carmine we can detect the color contrast between the area to be resected and the rest of the liver more precisely, especially when we cannot get a clear border line with Indigo carmine for whatever reason.
The US-guided injecting ICG together with Indigo carmine into the targeted portal vein can draw a demarcation line more efficiently and clearly than was previously possible. This system should be useful, especially in the laparoscopic anatomic resection of the sub-segment or a smaller area.
PL04-26 The Dorsal Approach to Laparoscopic Major Hepatectomy
Richard Bryant, Australia

R. Bryant, D. Cavallucci, N. O'Rourke
Royal Brisbane and Women's Hospital, Australia

Introduction: This new technique, a modification of the caudal approach of Soubrane, involves a posterior to anterior transection of the liver for laparoscopic major hepatectomies. It was conceived to enable a standardised technique, and to broaden the indications for laparoscopic resection particularly for larger tumours and with anatomical variations of the porta.
Methods: As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral, enabling safe stapling. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, maintaining good surgical orientation especially for tumours close to the midline or cava. Similar concepts apply for a left hemihepatectomy, with dissection beginning in the in the Arantius groove.
Results: 31 major resections (23 right +/- extended, 8 left +/- extended) have utilised this technique. 2 required conversion, and 1 required transfusion. R0 resection was achieved in 29 cases. Median hospital stay was 6 days. With this technique conversion rate has decreased from 29% to 6% (P = 0.032) and selection of a laparoscopic approach for major resections increased from 24% to 60% (P < 0.001).
Conclusion: The dorsal approach to laparoscopic major hepatectomy is a novel technical variation that enables a safe, standardised technique and an expanded set of indications for a laparoscopic approach.
PL04-27 Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (Alpps) for Large Hepatocellular Carcinomas
Naga Sudha Ashok Reddipalli, India

N.S.A. Reddipalli
Surgical Gastroenterology, Yashodha Super Speciality Hospital, Hyderabad, India

Background: ALPPS was developed to induce accelerated future liver remnant (FLR) hypertrophy in order to increase hepatic tumour resectability and reduce the risk of post hepatectomy liver failure(PHLF).The only means of achieving long-term survival in hepatocellular carcinoma is complete tumor resection or liver transplantation. Patients with large hepatocellular carcinomas are currently not considered for liver transplantation.So, ALLPS is indicated in selected patients to induce rapid hepatic hypertrophy.
Methods: Three patients initially presented with tumor measuring around 20-15 cm × 10-15cm in the right lobe of the liver. The liver was cirrhotic but liver function was normal in all 3 cases. CTvolumetry done and future liver remnant volume(FLRV) is < 40%. So we did ALLPS procedure to induce rapid and maximum hypertrophy in FLRV. During the first part of the procedure the right portal vein was ligated with complete liver parenchymal transection 1cm right of falciform ligament.. The second procedure performed after 10-14 days with the division of right hepatic artery, right bile duct, right hepatic vein and liver segments 4-8 with tumor were removed.
Results: >80% hypertrophy in FLRV was achieved in 10-14 days.Tumour was resected without developing PHLF . After 1 year follow up, patients are doing well with no signs of liver failure and recurrence
Conclusion: ALPPS leads to sufficient hepatic hypertrophy within 2 weeks, avoiding PHLF in most patients. ALPPS should be considered in selected patients with large hepatocellular carcinomas.
PL04-28 Feasibility of Hyaluronate Carboxymethylcellulose-based Bioresorbable Membrane in Two-staged Pancreatojejunostomy
Shintaro Yamazaki, Japan

S. Yamazaki, Y. Mitsuka, N. Yoshida, T. Takayama
Nihon University School of Medicine, Japan

Background: Two-staged pancreatoduodenectomy with exteriorization of pancreatic juice is a safe procedure for high-risk patients. However, two-staged pancreatoduodenectomy requires complex re-laparotomy and adhesion removal. We analyzed whether using hyaluronate carboxymethylcellulose-based bioresorbable membrane (HCM) reduced the time required for the second operation and facilitated good fistula formation in two-staged pancreatoduodenectomy.
Methods: Between April 2011 and December 2018, data were collected from 206 consecutive patients who underwent two-staged pancreatoduodenectomy. HCM has been used for all patients since 2015. Patients for whom HCM was used (HCM group; n=61) were compared to historical controls (before 2015) without HCM (Control group; n=145) in terms of feasibility of the second operation (operation time, adhesion grade, and complications) and optimal granulation around the external tube at second laparotomy.
Results: The HCM group showed significantly shorter median operation time [105 min (30-228 min) vs. 151 min (30-331 min); p< 0.001] and smaller median blood loss [36 mL (8-118 mL) vs. 58 mL (12-355 mL); p< 0.001] for the second operation. Neither overall postoperative complication rate (p=0.811) nor severe-grade complication rate (p=0.857) differed significantly. Both groups showed good fistula formation, with no significant difference in rate of optimal fistula formation (HCM group, 95.1% vs. control, 95.9%; p=0.867).
Conclusion: HCM placement significantly improved safety and duration for the second operation, while preserving good fistula formation.
PL04-30 Transradial Vascular Access as an Optimal Way for Chemoembolization of Liver Arteries
Dmitry Panchenkov, Russian Federation

D. Lebedev1, D. Astakhov2, E. Zvezdkina1, Y. Ivanov1, V. Kosiy1, D. Panchenkov3
1Federal Research Clinical Center for Specialized Types of Health Care and Medical Technologies of Federal Medical and Biology Agency, Russian Federation, 2Evdokimov Moscow State University of Medicine and Dentistry, Russian Federation, 3State Scientific Center for Laser Medicine of Federal Medical and Biology Agency, Russian Federation

Introduction: The goal is to compare the effectiveness of vascular accesses in patients with unresectable liver metastases during the chemoembolization of liver arteries.
Methods: In 42 patients with unresectable liver metastases transradial and transfemoral accesses were used to provide chemoembolization of the liver arteries. Microcatheter technique was used to introduct the drug-saturated microspheres.
Results: According to our data we can conclude that the left radial access in the normal type of the liver blood supply demonstrated significantly shorter duration of chemoembolization of the hepatic arteries and fluoroscopy, which amounted to 35 ± 3.1 min and 10.9 ± 1.8 min, respectively (p < 0.05). Use of the right femoral access for embolization of the right hepatic artery the above assessment criteria were the highest - 72 ± 9 min and 21.1 ± 4.2 min, respectively. The number of postoperative hospital days in case of femoral access was significantly higher in comparison with right radial access, It was 5 ± 0.5 days, and 2 ± 0.7 days respectively. Postembolization syndrome lasted 1.43 ± 0.5 which was similar for radial access 1.18 ± 0.4 days.
Conclusion: The use of microcatheter technique for hqTACE expanded the possibilities of transradial access. Significantly better tolerance and safety of transradial access was proven in 86.2% of the studied patients.
PL04-32 Retroperitoneoscopic Resection of a Posterior Tumor of the Liver
Kazue Morishima, Japan

K. Morishima1, H. Miyato1, A. Yoshida1, K. Endo1, H. Sasanuma1, Y. Sakuma1, A.K. Lefor1, Y. Yasuda2, N. Sata1
1Department of Surgery, Jichi Medical University, Japan, 2Department of Surgery, Haga Red Cross Hospital, Japan

Laparoscopic surgery of the posterior segment of the liver is challenging.
We present a retroperitoneoscopic approach to resect a posterior tumor of the liver.
A 75-year-old man with hepatic cirrhosis had a hepatic tumor mimicking an adrenal tumor. Abdominal contrast CT scan revealed a 20mm mass in the right adrenal gland. On MRI scan, fat within the lesion was seen and the tumor was suspected to be an adrenal adenoma. One year later, the tumor increased to 32mm, and resection was undertaken. The patient was placed in the left decubitus position and the operation performed with four trocars using a retroperitoneal approach. First, the right adrenal gland was resected, but no tumor was found. The tumor showed extrahepatic development. We performed a partial resection of segment7 of the liver. Liver dissection was performed with an ultrasonic energy device. The operative time was 167 min, and the estimated blood loss was minimal. The patient was discharged on postoperative day 11 following an uneventful postoperative course. Pathology of the specimen confirmed hepatocellular carcinoma with free surgical margins.
A retroperitoneal approach to the posterior segment of the liver does not require full mobilization of the right lobe. Although bleeding control may be difficult, this approach may be suggested as an additional therapeutic option, especially in patients needing partial resection of the posterior segments.
PL04-33 Application of Indocyanine Green Fluorescence Imaging in Laparoscopic Liver Surgery
Yufeng Yuan, China

Y. Yuan, Z. Zhang
Zhongnan Hospital Wuhan University, China

To study the clinical use of indocyanine green(ICG)fluorescence imaging in laparoscopic liver surgery, the clinical and pathological data of 68 patients who underwent laparoscopic hepatectomy using the ICG fluorescence imaging technique during the study period from September 2016 to October 2018 in Zhongnan Hospital of Wuhan University were retrospectively analyzed. Analysis was carried out on the surgical methods, fluorescence navigation methods, ICG injection time and dose, tumor characteristics, and pathological studies of the resected specimens. Of 68 patients, only 3 patients were converted to open surgery. 32 patients underwent ICG fluorescent guided laparoscopic anatomical resection of lower hepatic segment/hepatic hemilivers(positive staining in 17 patients, negative staining in 15 patients), with 19 patients successfully staining with ICG(59.4%). Postoperative histopathology showed primary hepatic solid tumors(n=31), secondary liver tumors(n=12), hepatic cysts(n=4), hepatic hemangiomas(n=5), hepatolithiasis(n=12)and hepatic focal nodular hyperplasia(n=1). These lesions were combined with hepatitis B liver fibrosis in 29 patients. ICG fluorescence imaging positively impacted on laparoscopic liver surgery. Proper preoperative ICG injection was helpful for the identification, localization and intraoperative surgical guidance of tumors, especially for patients with deep-seated and central tumors. As a consequence, oncological and surgical safety of laparoscopic liver surgery was improved. Targeted visualization of liver segments and surgical navigation using intraoperative ICG injections facilitated accurate and precise resection of anatomical liver segments or hemi-hepatectomies. The use of intraoperative ICG fluorescence technology for hepatic hemangioma, hepatic cyst, intrahepatic bile duct stones and other benign liver lesions, helped to improve safety of surgery.
PL04-35 The Comparison of Postoperative Pain Between Umbilical and Suprapubic Incision in Laparoscopic Liver Resection
Shunsuke Murakami, Japan

S. Murakami, M. Hidaka, T. Hamada, T. Kugiyama, T. Hara, K. Natsuda, A. Soyama, T. Adachi, S. Eguchi
Department of Surgery, Nagasaki University, Japan

Introduction: In laparoscopic hepatectomy, wounds for specimen removal are indispensable. The umbilical incision is commonly used in laparoscopic colectomy and is familiar to gastroenterologists. On the other hand, it has been pointed out that the suprapubic incision method, which is often performed in the gynecological surgery, is superior in terms of postoperative pain, but there is no report comparing the two.
Method: From November 2007 to May 2019, 19 patients who underwent laparoscopic lateral segmental resection at our hospital under complete arthroscopy were included. In 11 patients with umbilical incision and 8 patients with suprapubic incision, the operation time, bleeding volume, wound length, duration of continuous intravenous fentanyl infusion immediately after surgery and the number of flushes, and period of regular oral administration of NSAIDs were evaluated.
Results: There was no significant difference between the two groups in terms of patient background, age, operation time, and bleeding volume. However, suprapubic incision was significantly longer in wound length than in umbilical incision. Subsequently, for postoperative pain, the duration of continuous intravenous fentanyl administration was 1 day (1-2 days) for umbilical incisions and 1.5 days (1-2 days) for suprapubic incisions, with no significant difference. About the number of fentanyl, the result was comparable. In the period of regular NSAIDs administration, there was also no significant difference with POD14 (POD5-35) in umbilical incisions and POD8 (POD7-32) in suprapubic incisions.
Conclusions: In laparoscopic hepatectomy, extirpation of the specimen by umbilical incision is acceptable.
PL04-36 ALPPS and Simultaneous Sleeve Gastrectomy: A Valuable Association for Obese Patients with Liver Tumor
Roberto Brusadin, Spain

R. Brusadin, V. López-López, D. Ruiz de Angulo, A. López-Conesa, Á. Navarro-Barrios, A. Caballero-Planes, P. Parrilla-Paricio, R. Robles-Campos
Virgen de la Arrixaca University Hospital (IMIB-Virgen de la Arrixaca), Spain

Introduction: There are two ways to increase FLR / BW ratio: increase the FLR or decrease the body weight. In the present study, we present the first case combining both mechanisms by performing a simultaneous Tourniquet-ALPPS (T-ALPPS) and sleeve gastrectomy to further increase the FLR/BW ratio.
Method: 54-year-old woman with colorectal liver metastases, diabetes mellitus and morbid obesity (weight 150 kg, height 1.6 m, BMI 58.59). The FLR was 480 cc, representing 30.3% of the total liver volume, and the FLR/BW ratio was 0.31. We decided to perform an ALPPS-Tourniquet combined with a simultaneous sleeve gastrectomy during the first stage with interstage chemotherapy.
Results: Six months after the first stage, the FLR increased to 810 cc (figure 1a), with a weight loss of 51 kg (figure 1b) and 59.3% excess weight loss. The increase of the FLR was 68.8% and the FLR / BW ratio was 0.82 (Figure 1c). The second stage of T-ALPPS was finally performed completing the right trisectionectomy.
Discussion: To our knowledge, this is the first case in which a sleeve gastrectomy is performed during the first stage of ALPPS in order to reduce the body weight with the purpose of increase the FLR/BW ratio. The role of bariatric surgery in the oncological setting is not well established, and only a few clinical cases have been published. Considering the limitations of a clinical case report, we believe that perform a sleeve gastrectomy in the first stage of ALPPS could be feasible and beneficial in selected obese patients.
PL04-37 Significance of ICG Fluorescent Real-time Navigation and Visualization for Intersegmental Plane in Laparoscopic Liver Resection
Kenichiro Araki, Japan

K. Araki, N. Harimoto, N. Kubo, A. Watanabe, T. Igarashi, M. Tsukagoshi, N. Ishii, T. Yamanaka, K. Shirabe
Division of Hepatobiliary and Pancreatic Surgery, Gunma University, Japan

Introduction: Advancements in laparoscopic liver resection (LLR) has revolutionized the field of liver surgery. Currently, indocyanine green (ICG) fluorescent image technology is developed as intraoperative navigation tool to detect tumors and demarcation line in LLR. We assessed significance and surgical outcomes of ICG fluorescent surgery in LLR for navigation of demarcation line and intersegmental plane.
Methods: We assessed 118 cases who had been performed LLR in our hospital. ICG fluorescent imaging was used with VECELA ELITE II® (Olympus) or PINPOINT® (Stryker). Preoperative 3D simulation was performed and evaluated glissonian pedicle feeding the tumor. After clamping glissonian pedicle, we injected 2.5 mg of ICG intravenously. Then, demarcation line was assessed to decide transection line. During parenchymal transection, visualization of intersegmental plane was also assessed. In eight cases (S6: 3patients, S5: 1patient, S3: 4patients), we performed this technique and assessed intraoperative navigation of transection line and surgical outcomes.
Results: In all cases, demarcation line could be detected by ICG navigation. New system of ICG fluorescent navigation could be detected intersegmental plane during parenchymal transection. In this series, surgical outcome was acceptable compared with other cases, and had no major complication and no mortality. However, it was difficult to recognize bleeding points from hepatic veins in ICG fluorescent mode of camera. To assure bleeding points, it is still needed to use normal-light mode of laparoscopy system.
Conclusion: The new system of ICG fluorescent navigation makes it possible to visualize not only superficial demarcation line but intersegmental plane during parenchymal transection in LLR.
PL04-38 Application of Indocyanine Green Fluorescence Imaging in Laparoscopic Hepatic Middle Lobe Resection
Yufeng Yuan, China

Y. Yuan
Zhongnan Hospital Wuhan University, Wuhan, China

To investigate the clinical value of indocyanine green (ICG) fluorescence imaging technique in laparoscopic mesohepatectomy. A retrospective analysis was performed on the clinical and pathological data of patients undering mesohepatectomy from September 2016 to November 2018, including surgical methods, ICG fluorescence navigation, pathological results, postoperative liver function, complications and length of hospital stay. Of the 24 patients with mesohepatectomy. 11 patients underwent open mesohepatectomy and 13 patients were given ICG fluorescence imaging guided 1aparoscopic mesohepatectomy. There were no perioperative deaths. Clavien Dindo grade Ⅲ complication occurred in 3 cases. The operation time was significantly longer (261±80min VS 201±40 min, P< 0.05), but the liver function recovered significantly faster and the averagehospital stay was significantly shorter in laparoscopic group (8.5±3.3 VS 1 1.7±4.0 days, P< 0.05) than those in open group. Mesohepateetomy is a safe and feasible treatment for central liver tumor. ICG fluorescence imaging technique can further improve the safety and effectiveness during laparoscopic hepatectomy.
PL04-39 ALPPS for Hepatocarcinoma under Cirrhosis: A Feasible Alternative to Portal Vein Embolization
Victor Lopez Lopez, Spain

V. Lopez Lopez, R. Robles-Campos, R. Brusadin, A. Lopez Conesa, J. De la Peña, A. Caballero, A. Navarro, P. Gomez, P. Parrilla
Clinica and University Virgen de la Arrixaca Hospital, Spain

Introduction: Hepatocellular carcinoma (HCC) is one of the most common and malignant tumors. Preoperative portal vein embolization (PVE) is currently the most accepted treatment before major hepatic resection for HCC in patients with liver fibrosis or cirrhosis and associated insufficient future liver remnant (FLR). In the last decade, ALPPS technique has been described to obtain an increase of volume regarding PVE and a decrease of drop out.
Methods: We provide a review about HCC in cirrhotic patients treated ALPPS or PVE utilizing EMBASE, Medline/PubMed, Cochrane and Scopus databases.
Results: In PVE postoperative hepatic liver failure was inferior than ALPPS (0-9% vs 0-50%, respectively). Mayor complications (11.7-62.5% vs 0-30%) and mortality (12.5-50% vs 0-7.1%) was higher in ALPPS. Volume of the FLR was higher in ALLPS (38.1-71.1% vs 31.1-41%). Drop out ranged 0-20% in ALPPS versus 8-14.2%. While all de PVE groups present drop out in ALPPS in 4 of the 7 studies all the patients achieved the second stage.
Conclusion: The initial excessive morbidity and mortality of this technique have decreased drastically due to a better selection of patients, the learning curve and the use of less aggressive variations of the original technique in the first stage. For both techniques a complete preoperative assessment of the FLR is the most important issue and only patients with and adequate FLR should be resected. ALPPS could be a feasible technique in very selected patients with HCC and cirrhosis.
PL04-41 Laparoscopic Left Hemihepatectomy Using “Arantius-first Approach”
Yusuke Ome, Japan

Y. Ome, G. Honda, Y. Kawamoto, N. Yoshida
Gastroenterological Surgery, New Tokyo Hospital, Japan

Introduction: Laparoscopic major hepatectomy is performed increasingly these days.
Methods: We have devised and standardized “Arantius-first approach” for laparoscopic left hemihepatectomy (LLH). We report our current procedures and short-term outcomes of 20 cases of LLH.
Results: Operative procedure; After the mobilization of the left lateral section, the Arantius plate is dissected from the liver parenchyma, holding the left lateral section to the ventral side. The parenchymal transection is initiated just above the Arantius duct. Then, the left and dorsal aspect of the root of the left Glissonean pedicle (Glt) is exposed. The dorsal side of the middle hepatic vein (MHV) can be also identified behind the LHV in the same view. After the dissection of the right side of the root of Glt from segment 4, Glt can be easily encircled and divided because a sufficient space has been already obtained behind Glt. The MHV is exposed continuously from the root side to the periphery in a dorsal view with the left lobe held up to the ventral side. Short-term outcomes; Three cases underwent extended LLH, and 7 did simultaneous resection of other lesions. The median operative time was 341 min (117-430 min), the blood loss was 110 mL (minimal-430 mL), and the postoperative hospital stay was 9 days (6-25 days). There were no cases of intraoperative transfusion, conversion to open surgery, severe mortality, or mortality. R0 resection was achieved in the all patients.
Conclusion: “Arantius-first approach” is useful procedure utilizing a laparoscopic magnified caudo-dorsal view.
PL04-42 Hepatectomy with Concomitant Ablation: Comparison of Radiofrequency and Microwave Techniques
Elizabeth Gleeson, United States

E. Gleeson1, C. Barnett2, H. Pitt3
1Surgical Oncology, Icahn School of Medicine at Mount Sinai, United States, 2Surgical Oncology, University of Colorado School of Medicine, United States, 3Surgery, Temple University Health System, United States

Introduction: Hepatectomy with concomitant ablation expands the pool of patients who otherwise would be relegated to systemic chemotherapy alone. While radiofrequency ablation (RFA) has been utilized most often, microwave ablation (MA) has gained popularity. The aims of this study were to compare utilization over time and outcomes of RFA and MA in North American patients undergoing hepatectomy.
Methods: Patients undergoing hepatectomy with concomitant ablation were identified in the 2014-17 ACS-NSQIP procedure targeted database. Patients having concomitant biliary-enteric anastomoses or colectomy were excluded. Patients having RFA or MA were compared over time by control charts. RFA and MA patients were propensity score matched based on their age, race, disseminated cancer, operative approach, hepatectomy extent and perioperative transfusions. Outcomes were compared by standard statistical tests.
Results: Of 1,589 patients undergoing concomitant hepatectomy and ablation, 964 (60%) had RFA and 635 (40%) received MA. Control chart analysis over 16 quarters demonstrated no change in the frequency of RFA (mean 60 procedures/quarter). In comparison, the quarterly frequency of MA increased from 21 to 79 (p< 0.05). After matching, RFA and MA patients had similar mortality, serious morbidity, bile leaks, post hepatectomy liver failure, organ space infections, reoperations and length of stay. However, MA was associated with lower rates of deep vein thrombosis (DVT) and sepsis (each p< 0.05).
OutcomeRFA (n=549)MA (n=549)p-value
Mortality (%)
Serious Morbidity (%)
Bile Leak (%)
Post-Hepatectomy Liver Failure B/C (%)
Organ Space Infection (%)
Deep Venous Thrombosis (%)
Sepsis (%)
Reoperation (%)
Length of Stay (days)550.39
[Table. Comparison of Outcomes in Hepatectopmy Patients Undergoing Concomitant RFA and MA]

Conclusions: In recent years, MA is being utilized more frequently in patients undergoing hepatectomy while concomitant RFA rates have not changed. MA is associated with fewer postoperative DVTs and lower rates of procedure related sepsis.
PL04-43 The Significance of Microwave Ablation in the Treatment of Primary and Metastatic Liver Cancer
Mikhail Trandofilov, Russian Federation

M. Trandofilov, E. Prazdnikov, A. Sizova, V. Svetashov, O. Romanenko
A. Evdokimov Moscow State Medical and Dentistry University, Russian Federation

Extensive liver resection is the main method of treating patients with primary and metastatic liver cancer, which allows to achieve a significant prolongation of life. In patients with a reduced functional reserve of the liver or an insufficient volume of the remaining liver parenchyma, the applying of these interventions becomes impossible due to the increased risk of post-resection acute liver failure.
One of the most modern and promising ways to overcome this obstacle is the use of minimally invasive methods of tumor destruction. We present clinical observations of the use of the microwave ablator: liver resection and percutaneous microwave ablation of colorectal cancer metastases to the liver.
The presented experience demonstrates the justification for the use of microwave destruction of metastatic malignant tumors of the liver and demonstrates the possibilities of microwave thermal ablation therapy in patients who cannot be performed radical surgical treatment.
PL04-44 Laparoscopic Left Lateral Sectionectomy Using the Glisson-first Approach
Kazuki Hashida, Japan

K. Hashida, J. Muto, M. Okabe, H. Kitagawa, K. Kawamoto
Surgery, Kurashiki Central Hospital, Japan

Introduction: Laparoscopic left lateral sectionectomy (Lap-LLS) is generally performed by transecting the liver parenchyma followed by Glisson dissection. However, in this method, it is difficult to perform liver parenchymal transection at the correct line toward the Glissonean pedicle. Particularly for tumors close to the Glissonean pedicle, very careful transection of the liver is needed. We report our standardized procedure of Lap-LLS using the Glisson- first approach, in which we can perform anatomically precise transection of the liver.
Methods: Between July 2019 and January 2020, 7 patients underwent Lap-LLS using our approach in our hospital. The mean patient age was 76 years (range 69-86 years), and they consisted of 3 male patients and 4 female patients. Four patients had metastatic liver tumor, 2 patients had hepatocellular carcinoma, and 1 patient had combined hepatocellular cholangiocarcinoma. All the patients' liver functions were Child-Pugh class A and liver damage A. Of the 7 patients, 3 patients underwent partial hepatectomy for the other lesions, 2 patients underwent cholecystectomy, and 1 patient underwent colostomy closure simultaneously.
Results: The mean operative time was 253 min (range 187-337 min), and the mean estimated blood loss was 4 g (range a little-11 g). No operation was converted to open surgery. Postoperative bleeding, bile leakage, hepatic failure, and mortality did not occur. The median postoperative hospital stay was 8 days.
Conclusion: Our standardized procedure of Lap-LLS using Glisson-first approach is feasible and provide an advantage for accurate anatomical hepatectomy.
PL04-45 Single Institute Early Experience of 22 Consecutive Robotic Liver Resection: The Feasibility and Safety of Short Term Surgical Outcomes
Jin Ho Lee, Korea, Republic of

J.U. Jeong, J.H. Lee, H.S. Lee, K.H. Kwon
Surgery, National Health Insurance Service Ilsan Hospital, Korea, Republic of

Background: Minimal invasive liver resection is a challenging procedure. However, the robotic surgery system enable to minimal invasive liver resection even for beginners.
Methods: From August 2016 to November 2019, 22 consecutive patients underwent robotic hepatectomy in our hospital. Among them, right hepatectomy was the most common with 8 cases, followed by left hepatectomy was 7 cases using robotic surgical system (the da Vinci Xi® Surgical System (Intuitive Surgical®, Sunnyvale, CA)).
Results: 12 patients were female and the rest were male. The mean patient age was 57.65±10.153 (34-75). And 10 patients were diagnosed hepatocellular carcinoma (HCC), three were intrahepatic duct (IHD) stone, two were liver metastasis and MCN-liver. And biliary cystadenoma, cavernous hemangioma, IPNB-with high grade intraepithelial neoplasm were diagnosed in one case each. And the mean operation time was 457.6 ± 131.596 (238-694) minutes and the mean estimated blood loss was 455.5 ± 564.041 (30-2600) ml and there was only one transfusion case. And mean length of hospital stay was 7.3 ± 1.525 (5-10) days. There was no major complication other than six grade I-II complications such as pleural effusion or abdominal fluid collection.
Conclusion: Robotic liver resection seems to be feasible and can be safely performed by beginners at both laparoscopic and robotic liver resection. Robotic liver resection is a fast-adjustable surgical technique, even for beginners. However, if you learn the surgical skill through a well-prepared training program, anyone will be able to jump over the learning curve in a short time.
PL04-49 Pneumatic Packing Method for High-grade Liver Injuries
Mauricio Pasten, Bolivia

M. Pasten
Surgery Department, Bolivian Japanese Institute of Gastroenterology, La Paz, Bolivia

The liver is the largest solid abdominal organ and is one of the most commonly injured organs in abdominal trauma. Patients with high-grade liver injuries have high rate mortality, between 40 to 80 %. There are many techniques to treat these injuries, like packing, liver resection, hepatectomy and liver transplantation. The usual method describe is the gauze packing, but have complications like re operations and bleeding when is removed.
We develop a novel technique using a pneumatic balloon, as a packing compressive method, for patient with hemodynamic instability. The patients selected for this technique were unstable patients that need blood transfusion and Intensive Care Unit manage. A midline incision made with abdominal exploration and liver mobilization was perform. Identification of the blunt trauma, we consider the use of the technique in liver injuries grade III to V. A Pringle maneuver, and liver mobilization is important, to have the lacerated area exposed. We use hem collagen as a film between the liver and the balloon, the balloon is insufflated until no bleeding is seen, and Pringle maneuver is removed.
The patients are observed in the intensive care unit, the pneumatic balloon was controlled in a daily basis, and air from the balloon is removed after 72 hrs. The balloon stays in situ for at least one week. Then, if no blood from drainages appear and hemodynamic stability is achieved, the balloon is removed, without need of another surgery for this reason. We consider this technique safe and suitable for instable patients.
PL04-50 Right Extended Hepatectomy and Cyst Fenestration in a Rare Severe Polycystic Liver Disease: How I Do it Safely
Soumen Roy, India

S. Roy1, S. Anupurva2, D. Das3, M. Bhoi4, S. Mohanty5
1GI-HPB Surgery, AMRI Hospital, India, 2Department of Anesthesia, Bluewheel, India, 3Department of Interventional Radiology, Bluewheel Hospital, India, 4Pathology, Bluewheel Hospital, India, 5GI surgery, Amri hospital, India

Introduction: Polycystic liver disease (PLD) is characterised by the presence of multiple fluid-filled liver cysts, >10 cysts. According to Gigot, type 3 (severe) is multiple cysts occupying >75% of TLV. Treatment options are limited, including surgical like aspiration-sclerotherapy, fenestration, hepatectomy, liver transplantation, and medical options such as somatostatin analogs. However, the efficacy of these treatments remains uncertain except liver transplantation which is curative especially in severe variety.
Case: 32 year old female with a BMI of 26 presented with history of abdominal pain and swelling since 5 years with post prandial fullness. Preoperative evaluation with CT scan showed Gigot Type 3 PLD. She opted for all treatments except transplant. Right-extended hepatectomy and fenestration of cyst in seg 2,3(remnant volume 21%) was done in this patient. Intra-operatively the liver was so large that mobilisation was difficult leading to compression of the heart leading to hypotension every time liver was pushed. Routine outflow control was not feasible. 10 mins Intermittent dissection and 10 mins intermittent stoppage gave time to anesthesist for proper resuscitation. Careful parenchymal transection along the cantles line using the Belghiti technique prevented blood loss since the portal tracts are completely distorted. Some cyst were decompressed along with wall cauterisation to prevent post-operative ascites and in some tetracycline was injected as a sclerosant to prevent recurrence.
Conclusion: Severe PLD is very rare. Extended hepatectomy and fenestrations are good palliative options for relieving patients symptoms. Few technical improvisations during hepatectomy along with energy devices can help HPB surgeons achieve these feats.
PL04-51 Surgical Approach for the Resection of Tumour-involved Common Hepatic Artery during Pancreaticoduodenectomy
SamirJohn Sahay, United Kingdom

S. Sahay, F. Giovinazzo, J.A. Attard, J. Isaac, N.A. Chatzizacharias
HPB & Transplant, University Hospital Birmingham, United Kingdom

Introduction: In locally advanced pancreatic cancer resection of the common hepatic artery (CHA) for tumour involvement has been advocated after neoadjuvant therapy (chemotherapy +/- chemoradiation) for selected cases, more so for cases where aberrant anatomy is responsible for the locally advanced stage of the disease. Peri-operative morbidity has been reported 17-100% and post-operative mortality 0-45%. We describe our approach to resection of replaced CHA (rCHA) when involved by tumour.
Method: The procedure follows the steps of a standard pancreaticoduodenectomy. During the hilar dissection, the rCHA is identified and dissected towards the pancreas until tumour involvement is identified. The uncinate process of the pancreas is dissected from the SMA. The origin of the rCHA is identified and dissected until tumour involvement is identified. When an arterial resection is deemed necessary the operation continues to a total pancreatectomy and splenectomy with preservation of the splenic artery. At the end of the resection, which includes the arterial resection, a decision is made on the appropriate reconstruction. If length is adequate for a tension-free repair, an end-to-end primary reconstruction is performed. Otherwise, transposition of the splenic artery is used.
Conclusion: In the context of periampullary tumours when resection of the common hepatic artery is required, our preference is reconstruction with the above described technique. A total pancreatectomy is always performed to avoid the risk for arterial-related complications from a potential pancreatic leak in the presence of an arterial reconstruction.
[Replaced Common Hepatic Anastomosed to Splenic Artery After Total Pancreatectomy Splenectomy]
PL04-53 The Least Aggressive ALPPS Variant: Partial-Tourniquet-ALPPS
Victor Lopez Lopez, Spain

V. López López, R. Robles, R. Brusadin, A. Lopez Conesa, A. Navarro, P. Gomez, V. Cayuela, P. Parrilla
Clinica and University Virgen de la Arrixaca Hospital, Spain

Introduction: The first variant reported was Tourniquet-ALPPS (T-ALPPS), which occludes the intrahepatic circulation by means of a tourniquet around the liver.
Methods: We present a modification of our surgical technique, T-ALPPS, named “partial Tourniquet-ALPPS” (pT-ALPPS) which avoids the pass of the tourniquet by hanging maneuver and the right extraglissionan approach. The first Stage of this variant is easier, quicker and less risky compared to ALPPS, p-ALPPS or T- ALPPS.
Results: In our HBP unit 65 T-ALPPS have been performed. Since February 2017 we underwent a prospective study comparing T-ALPPS with pT-ALPPS, including 6 patients with colorectal liver metastases (CRLM) in each group. The first case of pT-ALPPS, was performed in a patient with bilobar metastases and one of them was located in segment, in front of the inferior vena cava thus the tourniquet could not be passed by hanging maneuver. After clearing the future liver remnant (FLR) of CRLM, we ligate the right portal vein. Considering that the ventral portion of the liver to the right portal pedicle is a non-vascularized area, and with the aid of intraoperative ultrasonography, an Adson clamp was passed through the liver parenchyma. This clamp emerged between the right and middle hepatic vein. A tourniquet was then passed and knotted under ultrasound control. In Stage 2, we used the tourniquet as hanging maneuver for right hepatectomy or right trisectionectomy depending on its location.
Conclusion: In selected patients P-T-ALPPS is an accessible technique easier than T-ALPPS as the clamp passes through an avascular area.
PL04-54 Hepatectomy Procedures with Awareness of Repeated Resection
Hiroyuki Ishida, Japan

H. Ishida, Y. Seyama, M. Matsumura, S. Nemoto, K. Tani
Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Japan

Introduction: Repeat hepatectomy is often performed for intrahepatic recurrence of primary and metastatic liver cancers. However, repeat hepatectomy requires complicated procedures due to adhesion and deviation of anatomical position. We present surgical techniques for repeat hepatectomy and its results.
Method: From January 2016 to November 2019, 317 cases of hepatectomy were performed at our hospital, and among them 50 cases of repeat hepatectomy were performed. At the initial hepatectomy, laparoscopic approach was preferably selected. The gallbladder was preserved if possible, and the round ligament and the falciform ligament of the liver were reconstructed. Adhesion barriers were placed around the hepatoduodenal ligament, the diaphragmatic surface of the liver, and at the left hepatectomy, the minor curvature of the stomach to prevent gastric rotation. At repeat hepatectomy, laparoscopic approach was attempted because pneumoperitoneum could be useful for the division of adhesion. To secure the hepatoduodenal ligament, we approached the hepatic hilum through the round ligament, and performed Kocherization if needed. Thoracotomy was used if adhesion was severe.
Results: All the 50 cases included metastatic liver tumor (n=30), hepatocellular carcinoma (n=8), intrahepatic cholangiocarcinoma (n=2), and peritoneal dissemination (n=1). Laparoscopic surgery was performed in 27 cases (54%). Extent of liver resection included partial resection (n=30), segmentectomy (n=6), sectionectomy (n=8), and hemihepatectomy (n=6). Median operation time was 241 minutes (39-519) and the median blood loss was 100 ml (0-1400). Postoperative bile leakage (Clavien-Dindo classification Grade IIIa or higher) occurred in 2 cases(4.0%).
Conclusions: Repeat hepatectomy can be performed safely by devising surgical techniques.
PL04-55 Benefits of Hepatic Resection in Recurrent Pyogenic Cholangitis among Bangladeshi Residents
Hashim Rabbi, Bangladesh

H. Rabbi1, M.M. Rashid1, A.H.M.T. Ahmed1, H.A.N. Hakim2, A.Q. Chowdhury3, M. Mohammad Sarder4, M. Ali1
1HBP Surgery, BIRDEM General Hospital, Bangladesh, 2HBP Surgery, Dhaka Medical College Hospital, Bangladesh, 3HBP Surgery, Dhaka Medical College, Bangladesh, 4HBP Surgery, BRB Hospitals Limited, Bangladesh

Introduction: Surgery is the corner stone treatment strategy for Recurrent pyogenic cholangitis (RPC) with stones and stricture. Sepsis is often a grave complication. Identification of source of sepsis to delineate the extent of disease and resection of unhealthy segment is the key to successful management.
Method: This prospective study includes 523 cases of RPC surgically treated in a cohort of Bangladeshi patients, during January 2007 to January 2020. The study intended to analyze outcome of hepatic resection in RPC. Distortion of hepatic parenchymal architecture, stones, strictures and crowding of ducts were indications of hepatic resections with hepatolithotomy followed by T-tube or bilioenteric drainage with or without an access loop were treatment strategies.
Result: Patients presented were between 20-77 yrs, 301 male (57.55%) and 222 were female (42.44%). 374 patients (71.51%) from south eastern part of Bangladesh. 29.06 % patients presented with Recurrent abdominal pain, Jaundice and fever. Isolated left duct stone found in 329 patients (62.09%), right duct stone in 33 patients (6.03%,) bilateral stones in 87 patients (14.91%) and both Intra-extrahepatic litihiasis in 74 patients (14.14%). Left Lateral Segmentectomy was the most common procedure in 387 cases. 184 patients required T-tube drainage, hepaticojejunostomy in 339 patients, Access loop in 34 patients (8.22%). Post-operative complications occured in 15% cases.
Conclusion: Treatment strategy of RPC is tailored, depends on extent of disease and future remnant liver. Left ductal approach following left lateral segmentectomy ensure better approach to right ductal system for better ductal clearance to prevents recurrence.
PL04-56 Delineation of the Demarcation Line for Left Hepatic Trisectionectomy Using ICG Fluorescence-based Imaging
Masaharu Tada, Japan

M. Tada, Y. Kawabata, S. Tamagawa, H. Iwama, H. Sueoka, K. Toriguchi, K. Iida, I. Nakamura, E. Hatano
Department of Hepato- Biliary- Pancreatic Surgery, Hyogo College of Medicine, Japan

Introduction: Left hepatic trisectionectomy is a high-risk procedure. Conventionally, anatomical hepatic resection has been performed using the hepatic vein as a guidepost. However, the right hepatic vein (RHV) did not precisely define the border of the anterior and posterior sections. In order to more accurately recognize the transection line during surgery, we used an indocyanine green (ICG) fluorescent camera.
Patients: According to the preoperative CT simulation of 121 cases in our hospital, transected surface of the posterior section is
1) Plain (almost coincides with RHV: 64 cases (53%)),
2) Convex (anterior Glissonian head-side branch crossed RHV: 18 (15%)),
3) Concave (posterior Glissonian caudal branch crossed RHV: 14 (11%)),
4) Other: 25.
The boundary between the anterior and posterior segments is not always a plain along RHV. It was presumed that intraoperative color change and RHV could not accurately indicate the boundaries of left hepatic trisectionectomy.
Methods: After the treatment of hilar portal vein, 0.25 mg ICG was intravenously administered prior to the parenchymal resection. It was possible to confirm the liver parenchyma where blood flow remained by the ICG camera. Even when the condition of the liver surface was poor such as after PTCD or PVE, the planned incision line was described accurately.
Conclusion: By using the ICG fluorescence method, it was easy to recognize the posterior section that remaining blood flow, and the left hepatic trisectionectomy was completed more safely.