General HPB 
PTT01 Tricks of the Trade (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PTT-02 Medical Capacity Building in War-Torn Nations: Kurdistan, Iraq as a Model
Quyen Chu, United States

Q. Chu1, G. Zibari2, L. Smith3, R. Zibari4, T. Lagraff5, A. Annamalai6, B. Guthikonda7, H. Shokouh-Amiri2, S. Jha8
1Surgery, LSU Health - Shreveport, United States, 2John C McDonald Regional Transplant Center, Willis Knighton Health System, United States, 3Surgery, University of Tennessee Medical Center, United States, 4LSU Health - Shreveport, United States, 5Union College, United States, 6Cedars of Sinai Medical Center, United States, 7Neurosurgery, LSU Health - Shreveport, United States, 8Anesthesiology, Keck School of Medicine USC, United States

Medical capacity building is an arduous endeavor, particularly in war-torn, politically unstable regions. Regardless, medical capacity can be built through perseverance and careful deliberation. We present our 28-year experience of capacity building in Kurdistan, Iraq.
Methods: We annotated our experience with surgical capacity building in Kurdistan, Iraq since 1992. Annually, 1-2 trips were undertaken. Prior to each trip, colleagues with desired surgical expertise were invited. A symposium was also organized at the end of each trip.
Results: Over 80% of cholecystectomies are now done laparoscopically, compared to none prior to our arrival. Other advanced laparoscopic operations include adrenalectomy, splenectomy, nephrectomy, Nissen fundoplication, and gynecologic procedures. More than 3,000 renal transplantations have been performed since 2004. Complex neurosurgical procedures such as craniotomy, spinal decompression/stabilization, and complex HPB and surgical oncology operations such as Whipple, liver resections, gastrectomies, and pelvic exenterations are now routinely performed. Care of trauma patients includes prehospital patient care, mass casualty triage, and management of patients exposed to chemical weapons. Other accomplishments include helping local surgeons to gain membership to the American College of Surgeons, supporting the establishment of a medical journal, and assisting with the creation of a new medical school.
Conclusion: With good intentions and perseverance, it is possible to empower war-torn nations to build advanced surgical programs. What we have achieved in Kurdistan over two decades is testament to effective and meaningful collaboration with major stakeholders.
PTT-03 Is Right or Left Hepatic Resection Better for Perihilar Cholangiocarcinoma? A Cadaveric Study on the Length of the Right and Left Hepatic Ducts
Atsushi Shimizu, Japan

A. Shimizu1, Y. Noda2, A. Lefor1, Y. Sakuma1, H. Horie1, Y. Hosoya1, J. Kitayama1, N. Sata1
1Surgery, Jichi Medical University, Japan, 2Anatomy, Jichi Medical University, Japan

Introduction: The optimal surgical procedure for perihilar cholangiocarcinoma is based on tumor location and the longitudinal and horizontal extensions. Right-sided hepatectomy is often used because it appears to be oncologically advantageous assuming that, in addition to possible arterial involvement, the left hepatic duct is longer than the right and a negative ductal margin is expected. However, few studies addressed the length of the duct in normal livers. The aim of this study is to examine the lengths of the right and left hepatic ducts to guide surgical strategy for perihilar cholangiocarcinoma.
Methods: Twenty-seven adult cadavers were used in this study, preserved in 10% formaldehyde. After entering the abdominal cavity, the entire liver, with the retro-hepatic vena cava, hepatic artery, portal vein and bile duct, was removed, in a manner similar to harvesting a liver for transplantation. The bile duct was opened longitudinally and the intraluminal lengths of the right and left ducts measured.
Results: The right and left hepatic ducts measured 13.7±7.5 and 11.9±6.6 mm, respectively (p=0.11). In each specimen, the right duct was longer in 13 (48%), the left in 11 (41%) and the same length in 3 (11%) with no statistically significant difference (p=0.30).
Conclusions: The left hepatic duct is not significantly longer than the right in a majority of specimens examined. Judicious selection of the surgical procedure is necessary for Bismuth type IV perihilar cholangiocarcinoma with similar ductal extension.
PTT-05 A Tiny Choledochotomy Keeps T-Tube Troubles Away. Insertion and Removal Tricks to Minimize T-Tube Related Complications in Liver Transplantation
Gabriele Spoletini, Italy

G. Spoletini, G. Bianco, A. Franco, S. Agnes
General Surgery and Liver Transplantation, Fondazione Policlinico Universitario A. Gemelli IRCCS, Italy

Introduction: The use of T-tubes in duct-to-duct biliary anastomoses in liver transplantation (LT) has been debated for decades. Beside skepticism around real benefits, many centers use T-tubes as little as possible due to the fear of complications related to accidental removal, leak around the insertion site and post-removal biliary peritonitis.
We have continued to use T-tubes per routine; refined our insertion technique and adopted a removal protocol to minimize T-tube-related complications.
Methods: Insertion procedure. With a n.11 blade we create a < 2 mm-long choledochotomy. Using a silk tie, a mountable stitch and our smallest right-angle, we position a 5 Ch rubber T-tube (Figure 1). Our original technique allows not to grab the T-tube directly and keep the choledochotomy just the size of the tube.
Removal procedure. We remove T-tubes three months later as an in-patient procedure, position a temporary Nelaton drain to capture possible bile leaks and avoid biliary peritonitis. The drain is removed as bile discharge stops.
Results: Since we started to use the 5 Ch T-tube, we have completed our T-tube insertion/removal protocol in 66 LTs. There have been no perioperative bile leaks. After elective T-tube removal, there have been no episodes of biliary peritonitis requiring surgery and 16 patients had a controlled biliary fistula out of which 4 required endoscopic stent.
Conclusions: The use of T-tube is safe and the risk of complications related to its use can be mitigated by adopting insertion and removal precautionary measures.
[t-tube insertion in LT]
PTT-07 Decreasing Morbidity of Pancreatic Fistula after Pancreaticoduodenectomy by Pair Watch Suturing Technique Duct to Mucosa Pancreaticojejunostomy (PWS-PJ)
Warakorn Jaseanchiun, Thailand

W. Jaseanchiun
Surgery, Bhumibol Adulyadej Hospital, Royal Thai Air Force, Saimai, Thailand

Methods: Pair watch suturing technique duct to mucosa pancreaticojejunostomy (PWS-PJ) perform by absorbable-monofilament totally 12 stitches, start at 9 o'clock of pancreatic duct to 3 o'clock of jejunal side, 7 stitches at posterior side and 5 stitches at anterior side. Post operative pancreatic fistula was diagnosis using amylase activity on post operative day 3 and day 7.
Objectives: Investigated pancreatic fistula rate and related complication of conventional duct to mucosa pancreaticojejunostomy (C-PJ) and PWS-PJ.
Results: 86 Pancreaticoduodenectomy during Jan 2009 to Dec 2019 were retrospective cohort analysis. 48 C-PJ performed from Jan 2009 to Dec 2016 whereas 38 PWS-PJ started since Jan 2017 to Dec 2019. There is no significant different of PF on POD3 (C-PJ 26.9% (95%CI 9.9-43.9) while PWS-PJ 31.6% (95%CI 29.2-34)(P=0.689)) and on POD7 (C-PJ 23.1% (95%CI 7-39.2) while PWS-PJ is 15.8% (95%CI 4.3-27.3) (P=0.525)), Odd ratio 1.6 (95%CI 0.45-5.65). Base on international study group of pancreatic surgery, PWS-PJ lower rate of grade B/C 15.8% while C-PJ 27.1% (p=0.21),Odd ratio 1.98 (95%CI 0.67-5.83). We reviewed that the C-PJ was perform by multi-surgeons but PWS-PJ has been done by single surgeon and more aggressive surgery on pancreatic cancer, the most common location of cancer on C-PJ was ampulla 50%, Head of pancreas 16.7% whereas PWS-PJ ampulla 23.7%, Head of pancreas 55.3% (p=0.020), however, blood loss, hospital stay, complication related and death related shown no significant different on both anastomotic technique.
Conclusions: Pancreatic fistula and relate complication reduced by Pair watch suturing technique even more aggressive radical surgery on pancreatic cancer.
PTT-08 Modified Meso-Rex Bypass for Portal Vein Cavernous Transformation
Rui Tang, China

R. Tang, Q. Lu
Beijing Tsinghua Changgung Hospital, China

Objective: The aim of this study was to evaluate the utility of modified meso-rex bypass(MRB) for portal vein cavernous transformation(PVCT).
Methods: From July 2013 to June 2019, 20 patients underwent MRB surgery. The MRB surgery anastomosis way including left portal vein or umbilical vein-bypass end- to-side anastomosis, Bypass-superior mesenteric vein, -splenic vein or -coronary vein end- to-end or end-to-side anastomosis. The follow-up endpoint was set at January 2019.
Results: All patients underwent surgery successfully and were able to obtain decompression effect after bypass surgery. Intraoperative SMV pressure dropped from 36.13±4.37cmH2O to 23.45±5.18cmH2O (p< 0.01).The opening time of bypass were 0-72 months (median 18.5months). By the end of follow-up, 12 MRB kept opening. 6 patients underwent surgery or interventional treatment of the thrombus or stenosis of bypass vessels. Bypass diameter were 2-7,5mm (median 5mm), MRB thrombosis occurred in all patients with the diameter less than 4mm. 11 patients used allograft vein and the others unsed internal jugular vein. Patients who used allograft vein were susceptible to bypass thrombosis (p< 0.05). Different surgical methods had no significant effect on the effect of bapass.
Conclusion: MRB is an effective method to treat PVCT, which can reduce portal venous pressure through different surgical methods.
PTT-09 How to Rescue a Extreme Vasculobiliary Injury from Liver Failure
Nicolas Jarufe, Chile

N. Jarufe1, E. Briceño2
1Hepatobiliary and Transplant Surgery, Clinica las Condes, Chile, 2Digestive Surgery, P. Universidad Catolica de Chile, Chile

To describe a case treated with "tricks of the trade", in order to avoid liver transplantation in a patient with extreme vasculobiliary injury (VBI).
A 22 years old woman underwent a open cholecystectomy with bile duct exploration. An important inflammatory process was found and massive bleeding from the hepato-duodoenal pedicle, requiring several stiches of hemostasis, ending the surgery without proper identification of the pedicle structures.
Patient developed jaundice and commitment of conscience.
Three days after, she was transferred due to increased deterioration of clinical condition. A CT scan was performed revealing a right liver lobe infarct, absence of the right and left hepatic artery, normal flow of an accessory artery from left gastric artery, portal vein thrombosis.
Patient was taken to the OR. Surgical findings where: bile peritonitis, right hepatic lobe necrosis and ischemia of left lobe, complete resection of the common bile duct at the level of the confluence of right and left ducts, thick stiches on main portal vein and complete section of the hepatic artery. The accessory artery of the left gastric was not damaged. With those findings, a right hepatectomy was performed with revascularization of the left hepatic lobe using a jump-graft from superior mesenteric vein to left portal branch at the level of REX process, with a cadaveric iliac vein and Roux-en-Y hepaticojejunostomy to the left hepatic duct. After four months, patient has adequate biliary drainage and normal portal and arterial flows with good regeneration of the left hepatic lobe.
PTT-10 Liver Transection First Approach for Living-Donor Hepatectomy with Complex Biliary and Vascular Anatomy
Satoshi Ogiso, Japan

S. Ogiso, S. Yagi, T. Ito, T. Ishii, N. Kamo, S. Seo, K. Hata, K. Taura, S. Uemoto
Surgery, Kyoto University, Japan

Introduction: Aberrant donor anatomy is a challenge in living-donor liver transplantation (LDLT), potentially associated with recipient complications. The concept of minimal hilar dissection has been reported to avoid biliary ischemia and intimal damage to hepatic artery, which result in recipients' biliary complications and hepatic arterial thrombosis, respectively. However, complex donor anatomy forces extensive dissection and retraction when isolating vessels in the limited field at the liver hilum. Herein, we present the liver transection first approach (LTFA) for living-donor hepatectomy, which is beneficial especially in donors with complex anatomy to facilitate hilar dissection and prevent vascular/biliary damage.
Methods: The graft-side Glissonean pedicle is first isolated en bloc at liver hilum, without dissecting each vessel, and cholangiography is performed to decide the division line of biliary ducts and liver parenchyma. Following graft liver mobilization, the graft-side hepatic vein is isolated and a hanging tape is placed onto the retrohepatic vena cava and above the Glissonean pedicle so that liver parenchyma is transected towards the tape. In the wide surgical field after completing parenchymal transection, graft-side hepatic arteries and portal veins are isolated with minimal dissection and the remining tissue within the Glissonean pedicle is divided concomitantly with graft-side bile ducts.
Results: LTFA was used in 23 of 41 donor hepatectomy for adult-to-adult LDLT between 2017 and 2018. Biliary complication was observed in 9.8%, without any differences between donors with a single versus multiple bile ducts, and hepatic artery complications was zero.
Conclusions: LTFA is helpful to decrease morbidity after LDLT.
PTT-11 Where Is the Optimal Site for Division of Donor and Recipient Bile Duct for Duct-to-duct Anastomosis During Liver Transplantation?
Yasuhito Iwao, United Kingdom

Y. Iwao, N.D. Heaton
Institute of Liver Studies, King's College Hospital, United Kingdom

Background: The blood supply of the bile duct (BD) is a key to minimizing biliary complications (BC) after liver transplantation (LT).
Method: A literature review was performed.
Results: The retroportal artery (RPA) and 3 and 9 o'clock arteries were first reported by Northover and Terblanche in 1979. They found the RPA in all 21 human resin casts and classified it into two variants; type I RPA arising from the superior mesenteric artery or the Coeliac trunk, and crossing the back of the portal vein to join the posterior superior pancreaticoduodenal artery: and type II RPA which crosses the posterior surface of the supraduodenal BD, and ascends to join the right hepatic artery. They recommended making the donor BD as short as possible.
Rath et al described 6 types of marginal arteries of the BD. They suggested dividing both donor and recipient BD just below the confluence of the cystic duct.
According to anatomical descriptions of the RPA, which should be included in any description of connective tissue related to the pancreatic head, and contains the BD innervation from the coeliac and superior mesenteric nerve plexuses. Higher division is preferable in order to avoid injury to the recipient RPA and accompanying nerves, which may cause ampullary dysfunction on the recipient.
Conclusion: The focus has always been on the donor, but we identify preservation of arterial inflow and innervation of the recipient BD as being important. Deeper consideration and modification of techniques for these small structures may reduce BC after LT.
PTT-12 Safe and Reliable Technical Strategies of Pancreaticojejunostomy in the Soft Pancreas in Pancreaticoduodenectomy in a Non-high Volume Center
Hiroaki Terajima, Japan

H. Terajima, T. Kawai, K. Iguchi, R. Kamimura
Dept. of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Japan

The standardization and step-by-step renovations of technical skills is indispensable for the improvement of surgical outcome even in non-high volume centers. We demonstrate our technical strategies of pancreaticojejunostomy in the soft pancreas for the last decade.
Technical tricks: (1) Pancreatic parenchyma is transected by ultrasonic scalpel. (2) Saline-irrigating bipolar electrocautery is used for sealing and hemostasis of the pancreatic stump to prevent minor pancreatic leakage from minute peripheral ducts and the laceration of soft pancreatic parenchyma by suturing hemostasis. (3) To tightly approximate the pancreatic stump to the jejunal wall, the modified Blumgart anastomotic technique (Fujii, et al. J Gastrointest Surg 18:1108) is applied. One to three transpancreatic/jejunal seromuscular sutures are made to completely cover the stump by the jejunal wall using double-armed long-needle 3-0 Prolene sutures. One suture always crosses the pancreatic duct. (4) Duct-to-mucosa anastomosis is performed using 6-0 strongly-curved absorbable PDS sutures by watch dial method, which enables at least 6 sutures even in a very small duct without lacerating the duct wall. The 6-0 PDS suture is appropriate for tight ligation. (5) A 4-0 polyvinyl tube shortly cut for internal drainage is placed in the pancreatic duct in patients with a non-dilated duct (less than 5mm after extension).
Results: The incidence of pancreatic fistula (PF) Grade B (ISGPS 2016 definition) in the soft pancreas is 6.6% (5/76) since January 2014, and no PFs have developed in consecutive 26 cases since January 2018.
PTT-13 The Complexities of HCC in Mongolia from A-Z
Jigjidsuren Chinburen, Mongolia

J. Chinburen
Hepato-Pancreato Biliary Surgery, National Cancer Center of Mongolia, Ulaanbaatar, Mongolia

HCC accounts for 43% of all male cancers and 35% of female cancers. It's the leading cause of cancer death for both sex in Mongolia. In 2018, a total of 2,241 incident cases of HCC were diagnosed and 1,773 HCC deaths were recorded in Mongolia (population 3 million). Among HCC patients, about 46% had HCV, 34% had HBV, and 14% had co-infection. The government initiated a Healthy Liver Program nationwide. Through this program, more 1.7 million people have been screened for HCV and HBV.
January 2020, additional changes have been made on health law to screen 7 types of common cancers in Mongolia for targeted population.
HPB surgical department was founded at 2008 with help of Swiss surgical team and Japanese HPB society. We used to perform 60 HPB cancer surgeries at beginning stage, increased to 700 in 2019. The Post-operative mortality rate is 1.8%. LDLT program was started in 2018, until now within 2 years we have performed 16 LDLT and 4 DDLT cases.
We are now paying more attention on molecular biology studies. We propose to apply high-throughput genomic profiling to identify key biomarkers and drivers relevant to HBV-HDV coinfection in Mongolian HCC patients. These studies may provide a genomic landscape of HDV-HCC in Mongolian patients. Another study aims to perform the first molecular HCC characterization in a large Mongolian cohort, with high HBV-HDV prevalence.
We are sharing our ingenuous experience to IHPBA community, how Mongolian HPB society together with politicians are fighting against HCC burden in Mongolia.
PTT-15 Telescopic Invagination Transpancreatic End-to-end Pancreatojejunostomy
Miroslav Levy, Czech Republic

M. Levy
Surgical Department, Thomayer Hospital, Charles University Prague, Praha, Czech Republic

Background: Postoperative pancreatic fistula is the main cause of operative morbidity andmortality in patients who undergo pancreatoduodenectomy. Various pancreatoenteric anastomosis techniques have been reported to minimize the postoperative fistula rate. No consensus exists regarding the most effective form of pancreaticojejunostomy. In this presentation the telescopic invagination transpancreatic end-to-end pancreatojejunostomy is described.
Method: Especially in soft pancreas we are using the telescopic invagination method. We are using two double-armed PDS mattress sutures going through two layers of jejunum making an intestinal cuff, after that through the pancreas, another two layers of jejunum and the same on the way back. After suturing the invagination is created. Another two PDS sutures on the edges of anastomosis are usually sufficient.
Results: There were 81 pancreatoduodectomies in 3 years provided in our surgery, 10 of these were operated with described telescopic method (one surgeon). In this group the rate of pancreatic fistula is 10%, in other group (different methods and surgeons) the pancreatic fistula rate is 21%.
Conclusion: Telescopic invagination transpancreatic end-to-end pancreatojejunostomy seems to be good technique. Further studies with more patients are needed.
PTT-18 The Use of Barbed Sutures in Robotic Surgery Decreases the Risk of Fistulas
Enrique Jimenz-Chavarria, Mexico

E. Jiménez-Chavarría1, H.F. Noyola Villalobos1, S. Pimentel-Meléndez2
1Surgery, Hospital Central Militar, Mexico, 2HPB, Hospital Central Militar, Mexico

Among the most frequent complications in pancreatic surgery are leaks or fistulas, pancreatic fistula being the most common, however leaks can occur in any of the three anastomoses that are performed in the reconstruction of pancreatoduodenectomy with pyloric preservation (PPDP), resulting in a headache for the patient and the surgeon, remembering that the PPDP has a first phase of resection and a second phase of reconstruction, in robot-assisted surgery, in the second phase we perform the anastomosis with continuous surging with Barbed sutures, first the hepatojejuno anastomosis is performed using barbed sutures of absorbable material with continuous surging with V-loc 3-0 suture, then we perform the pancreato jejunum anastomosis with 2-0 non-absorbable beard suture with double needle starting at the distal vertex of the stump pancreatic with continuous surge in two planes, performing the mucosal duct anastomosis with PDS 4-0, in this anastomosis, the posterior plane is first made, covering the posterior aspect of the pancreas to the jejunum serosa with a barbed suture with continuous surget and at the end of the surjete the suture is left as a reference, the serous is opened and the the mucosal duct anastomosis with separate points by placing a silastic endoprotesis, taking advantage of the excellent exposure and magnification that is obtained with the use of the robot, continuous surget is performed on the anterior face of the pancreas with the same suture closing both vertices, until now. They have performed 10 cases without fistulaor leakage.
PTT-19 The Use of Autologous Falciform Ligament as a Vascular Graft
Grace Wu, New Zealand

G. Wu1, A. Boue1, P. Fagan1, P. Johnston1, W. Meyer-Rochow2, A. Bartlett1
1Auckland City Hospital, New Zealand, 2Waikato Hospital, New Zealand

As a consequence of taking on more complex hepatic resections, vascular reconstruction is frequently required. We report an innovative technique in which autologous falciform ligament was used to reconstruct the inferior vena cava (IVC). A 57-year-old male presented with recurrence of a retro-peritoneal low-grade spindle cell carcinoma 7 years following radical resection of a right supra-renal retroperitoneal tumour in 2012. The recurrence was situated posterior to the liver, involving the dorsal aspect of the right liver and retro-hepatic IVC, up to but not including the confluence of the hepatic veins (HV). The liver was transected on the middle HV, leaving the tumour attached to the right liver and IVC. The segment of involved IVC was isolated with complete caval occlusion. Single catheter veno-venous bypass via the left femoral vein to the left internal jugular was established. The segment of IVC that was resected en bloc with the right liver was reconstructed using autologous falciform ligament. At six months post-operatively the patient has a patent IVC with no evidence of tumour recurrence. Falciform ligament is an autologous graft that is readily accessible, and as it is a double membrane structure, is sufficiently strong to be used for venous reconstruction.
Figure 1. Left. Pre-operative CT showing a previous right adrenalectomy, right nephrectomy, and partial hepatectomy. Right. Post-operative CT showing extensive liver resection and IVC reconstruction.
[Figure 1]
PTT-20 At Centres with Limited Access to Ultrasonic Dissector, Bipolar Electrosurgical Energy Can Accomplish Laparoscopic Cholecystectomy (LC) in Patients with Cardiac Implantable Electronic Device (CIED)
Siddharth Singhal, India

S. Singhal, K. Murty, S. Mishra, S. Pandey, M.K. Maheshwari
Surgery, Chattrapati Shivaji Subharti Hospital, India

Background: Patients with symptomatic cholelithiasis and CIED (e.g. pacemakers) present challenging clinical scenario for smooth LC for surgeons practicing in low - middle income countries (LMIC).
Monopolar electrosurgical energy (MEE) is not recommended for use in such patients while use of ultrasonic dissector (UD) may be restricted by lack of equipment or cost constraints.
For more than 2 decades, bipolar electrosurgical energy (BEE) is recognized to be safe and its use recommended for laparoscopy especially in anatomically crowded areas.
BEE has several attributes that make it particularly suitable for LC in patients with CIED.
Key Steps: Standard 4 port LC with BEE as sole energy source (video)
- Calot's triangle dissection
- Gallbladder dissection from liver bed
- Patients: 6 patients with symptomatic cholelithiasis with CIED
- Setting: Tertiary care hospital
- Period: August 2017 - December 2019
- Operation time (mean): 48 minutes
- No adverse cardiac event
- Number of times the camera lens cleaned (mean): 1.5
- Gallbladder perforation: 1/6
- No major bilio-vascular injury or conversion
Advantages - Safety profile
  • Current flow limited only to tissue between the arms of forceps electrodes; no adverse effect on CIED
  • prevents damage to adjacent structures
  • less chances of accidental burns to the patient
- Ease of use - less smoke
- Easy availability of equipment with no recurring costs
Conclusion: LC can be safely performed using BEE as sole energy source.
BEE: Particularly useful in CIED patients in LMIC hospitals with limited access to UD
PTT-21 Small Bowel Skewer Technique for Pancreatic Stenting in Robotic Whipple
Laurence Webber, Australia

D. Cavallucci1, L. Webber2
1Royal Brisbane and Women's Hospital, Australia, 2Fiona Stanley Hospital, Australia

Use of an external pancreatic stent is a proven fistula mitigation strategy for high risk anastomoses during PD.
We propose a novel technique for passing and securing an internal - external pancreatic stent from skin via small bowel limb and into pancreas during PJ to facilitate totally robotic reconstruction phase in high fistula risk situations.
This will be several slides and a 3 minute video outing the process and technique to be presented in 'Tricks of the Trade'.
PTT-22 Emergency Surgery for Severe Liver Injury Through the Inferior Vena Cava
Nobuyuki Takemura, Japan

N. Takemura, K. Ito, R. Hirooka, F. Mihara, N. Kokudo
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Japan

Background: Hepato-biliary-pancreatic surgeons are also required to have knowledge of trauma to the hepatobiliary-pancreatic region. Hepatic venous trauma is an area in which hemostasis is difficult with IVR and requires the knowledge and skills of surgeons.
Results: A 20-year-old man is transported in emergency by shock due to abdominal stab wound. The FAST examination was positive and the blood pressure did not respond to the infusion, the patient underwent an emergency laparotomy in the emergency room.
Emergent left hemihepatectomy was done under the Pringle maneuver and with the bleeding point compression, however, the bleeding did not subside at all. The stab wound was deeper than the cross section of the hepatectomy and was switched to damage control surgery. A second-look surgery was then performed on the 3rd operative day. Intraoperative ultrasonography confirmed a free fluid anterior to the IVC, suggesting an IVC injury. Total vascular exclusion (TVE) was planned to stop the persistent bleeding. The anterior wall of IVC was sutured together with the liver parenchyma. TVE time was 27 minutes in total.
Conclusion: Emergent surgery for the hepatic injury to the inferior vena cava was done successfully, which enabled to save the life. It was a rare case and we would like to display videos and share policies and procedures.
PTT-23 Technique of Safe Pancreatico-jejunostomy for Small Pancreatic Duct during Pancreaticoduodenectomy
Gunjan Desai, India

G. Desai, P. Pande, N. Chavan, P. Wagle
Surgical Gastroenterology, Lilavati Hospital and Research Centre, India

Pancreaticojejunostomy is the Achilles heel of pancreaticoduodenectomy. Despite technical advances, better understanding of patient selection criteria and perioperative care, pancreatic fistula rates still remain high at 7-13%. A lot of techniques have been described for pancreatico-enteric anastomosis. We perform modified Blumgart technique for pancreaticojejunostomy under magnification using loupes. In presence of a small duct < 3 mm, we have used a specific sequence of steps to ensure a safer anastomosis which is described here (Figure 1).
The first step is to mobilize the pancreas 1 cm beyond the resection margin so as to allow the full thickness 'U' stitch of modified Blumgart technique. The pancreatic transaction after taking the corner hemostatic stitches should be done with the knife at 75o angle to the horizontal so that the pancreatic cut surface faces towards the jejunal loop. After this, for a duct of around 1 mm ( < 3 mm), the trick is to use an infant feeding tube of 4/5 French size cut obliquely. This end of the infant feeding tube is then used to feed the pancreatic duct for upto 5 cm depth after cutting. It is kept there for 10 minutes. When you remove the feeding tube, you will see that the duct has dilated to more than twice its pre-procedure size thus, enabling the anastomosis using the standard modified Blumgart technique with 6-0 PDS for inner layer and 3-0 PDS for 'U' stitch.
[Figure 1: Steps for facilitating a safe anastomosis using an infant feeding tube]
PTT-26 Pancreatic Fistula Treatment Using Continuous Wall Suction as an Easy, Effective, and Safe Procedure
Adeodatus Yuda Handaya, Indonesia

A. Yuda Handaya1, V.A.P. Werdana2
1Surgery, Gadjah Mada University/Sardjito Hospital, Indonesia, 2Gadjah Mada University/Sardjito Hospital, Indonesia

Introduction: Postoperative pancreatic fistula (POPF) is still becomes a nightmare for digestive surgeons. The prevalence of POPF is estimated at 13% - 41%. The mortality rate of patients with major pancreatic fistula is up to 28%. It requires complex treatment with a large cost burden.
Presentation of case: Here we report a patient with pancreatic injury repair of pancreatic laceration with unidentified intraoperative pancreatic duct injurie. In the hospital ward, the patient developed wound dehiscence and a clear viscous pancreatic juice came out from the wound with high output. The patient is then placed abdominal wall suction with continuous pressure according to the number of products per day, where the pressure is -150mmHg for products more than 500cc, -100mmHg for products 250-500cc, -50mmHg if less than 250cc, and if less than 50cc patients can be treated on the road. After 4 weeks, the patient showed good outcomes, the pancreatic juice output decreased and diminished, the wound also narrowed and closed.
Discussion: Continuous wall suction with NPWT principle can reduce pooling of fluid, reducing shear stress and tissue hypoxia at the wound edges, and stimulating the release of vascular endothelial growth factor in pancreatic fistula wound milieu. It is possible to accelerates wound healing and closure of the pancreatic fistula.
PTT-27 Recipient Hepatic Arterial Dissection During Living Donor Liver Transplantation - A Trick for the Tricky Situation
Gunjan Desai, India

G. Desai1, N. Chavan1, A. Bharadwaj1, A. Kirange1, T. Shaikh2, N. Mehta2
1Surgical Gastroenterology, Lilavati Hospital and Research Centre, India, 2Liver Transplantation, Lilavati Hospital and Research Centre, India

Dissection of Recipient hepatic artery although rare, can lead to difficult and tricky situation during living donor liver transplantation. We would like to share our experience of this rarely reported event and its subsequent management.
Ideally in living donor liver transplantation, a high hilar dissection followed by preservation of long length of recipient arteries is desirable. In some cases, proximal 'dissection' of the hepatic artery is observed. If right and left hepatic artery is deemed un-usable due to proximal 'dissection', some surgeons prefer using gastroduodenal artery. However, it may be difficult to safely isolate it due to severe portal hypertension. Also, length of GDA may be insufficient to reach the right lobe artery. In such case, another alternative is to use the right gastroepiploic artery. It is separated from the greater curvature of stomach upto its origin from the gastroduodenal artery, thereby proving a good length which is then brought upto the right liver graft by mobilizing through retro-gastric space and allowing a tension-free anastomoses. Adequate arterial flow is confirmed on intra-operative doppler study.
We continued to record doppler flows of the liver graft for 7 days post operatively. The patient had an uneventful recovery and was discharged at 2 weeks from the date of surgery. Step-wise management of this situation is described here (Figure 1). Hence, Right Gastro-epiploic artery may be used in this tricky situation where no other local artery is available for hepatic arterial anastomoses.
[Figure 1: Steps for rotating the right gastro-epiploic artery for anastomosis]
PTT-29 Pancreatic Anastomosis for Soft Pancreas and Small Pancreatic Duct Without Pancreatic Fistula
Thun Ingkakul, Thailand

T. Ingkakul1,2
1Surgery, Bangkok Hospital, Bangkok, Thailand, 2Surgery, Phramongkutklao Hospital, Bangkok, Thailand

Postoperative pancreatic fistula (POPF) is one the most concerned postoperative complication of pancreaticoduodenectomy (PD), its incidence was up to 45%. The predictors of the occurrence of POPF included soft texture of pancreas and small main pancreatic duct (MPD). Currently several techniques of pancreatic anastomosis were proposed to reduce the POPF especially for the soft pancreas and small pancreatic duct. The modified Blumgart technique with internal stent was planned for the pancreatic anastomosis. After preparing the jejunal limb and mobilization of the posterior side of the pancreatic remnant, the internal pancreatic duct stent was placed, the double-arm Prolene 3-0 was used for trans-pancreatic sutures and placed through the full thickness of the pancreas, from the anterior side of pancreas, then sutured the seromuscular layer of jejunum and from the posterior side through pancreas, usually 2-3 stitches depending on pancreatic width. At this step we carefully sutured and avoided the MPD injury. Duct-to-mucosa anastomosis sutures were performed at 3, 6, 8, and 12 o'clock positions with Prolene 5-0, pancreatic duct stent was fixed with suture of 12 o'clock. The needles of Prolene 3-0 was sutured through seromuscular layer of jejunum then tied. This technique created an invagination of the jejunum and cover the pancreatic cutting surface. It also prevented pancreatic parenchymal tearing and decreased tension of duct-to-mucosa anastomosis. This technique is suitable for small MPD and soft pancreas with lower rate of pancreatic leak and no clinical-relevant POPF.
PTT-31 Hybrid Mini ALPSS as a Solution for a Complex Big Size Tumor
César Muñoz, Chile

C. Muñoz, D. Palominos, M. Naranjo, J. Morales, C. Varela, G. Sepúlveda, F. González, S. Sótelo, J. Rojas Lizana
Hospital Regional de Talca, Chile

Introduction: ALPPS procedure is probably the last significative progress in the liver surgery. ALPPS didn't more morbidity than classic approach 2-stage for colorectal liver metastases but its utility in another tumor is controverial. To reduce aggressiveness in the first surgical stage, Hybrid mini-ALPPS (intraoperative embolization portal, parenchymal transection and minimize liver mobilization) was developed with minimal cases reported. Our aim is to present the approach using Hybrid mini-ALPPS in a complex big size tumor.
Methods: A 43 years old patient with a complex big liver tumor that involves the right hepatic lobe, medial sectory and Inferior cavus vein (IVC). The preoperative evaluation is concordant with resectable intrahepatic cholangiocarcinoma (ICC) with a future liver remnant (FLR) of 433cc (lower< 20%).
Our video shows how first surgery time was performed thorugh a laparoscopic approach partial parenchymal transection (90%), with bipolar using Pringle technique and intraoperative embolization of the right hepatic vein though canulation of the inferior mesenteric vein (VMI).
The second surgery time was performed after 2 weeks with a new manometry that shows an increase in FKR to 883cc (an increase in 204% of the FLR). Right trisectionectomy and resection of IVC tumor and diaphragm was performed. The 5th postoperative day is discherged in good condition with a slight increase in trasaminases levels.
Conclusion: The Hybrid mini-ALLPS is a feasible technique and could be considered in complex big tumour not colorectal liver metastases when a short time solution of surgical problem is necessary for a mutidisciplinary team approach.
PTT-32 Development and Evolution of Laparoscopic Radical Cholecystectomy for Incidental and Non-incidental Gallbladder Cancer
César Muñoz, Chile

C. Muñoz1,2, J. Rojas1, D. Palominos3, G. Sepúlveda4
1Digestive and HPB Surgery Unit, Universidad Catolica del Maule, Chile, 2Digestive and HPB Surgery Unit, Hospital Regional de Talca, Chile, 3Hospital Regional de Talca, Universidad Católica de Maule, Chile, 4Hospital Regional de Talca, Universidad Católica del Maule, Chile

Laparoscopic radical cholecystectomy for the treatment of incidental and non-incidental gallbladder cancer is a less developed surgical technique around the world compared to other HPB surgeries. Chile is a country with a high incidence of gallbladder cancer and our unit adopted 5 years ago laparoscopy as an initial approach for all patients with incidental gallbladder cancer and preoperative suspicion. In the last 5 years we have evaluated more than 250 patients with gallbladder cancer (incidental and preoperative suspicion). In 30 patients the surgery has been completely completed by laparoscopy. Our objective is to present through videos the evolution of the technique that we have developed, the tips to facilitate intercavoaortic sampling and laparoscopic lymphadectomy as well as hepatic transection of segments IVB and V. The use of the systematic approach for laparoscopy of gallbladder cancer It has allowed us to reduce non-therapeutic laparotomy as well as develop a learning curve for laparoscopic radical resection with minimal complications and excellent long-term results that are absolutely comparable with patients operated by open surgery.
PTT-34 Temporary Porto-Caval Shunt- 3-9 O Clock Technique in Liver Transplant- Tricks of Trade
Sachin Daga, India

S. Daga
HPB & Liver Transplant, Medicover Hospital, Hyderabad, India

Introduction: Temporary porto-caval shunts is done during liver transplant to decrease blood transfusion, improve renal perfusion and reduce hepatic injury in liver transplantation
Methods: During liver transplant performing temporary pcs is challenging when caudate lobe is enlarged, hilum is shortened or patient is more antero-posterior depth. In such situation or as a part of routine if temporary pcs can be performed using single suture, starting from 3 o clock and moving towards 9o clock on either sides, a technically simple and easy anastomosis can be performed.
Results: When a temporary pcs is performed using this technique it can be under vision as compared to a technique of performing from 6o clock to 12 o clock first posteriorly and then anteriorly. Appropriate angle sutures can be taken under vision.
Conclusion: Temporary PCS performing from 3-9 o clock is technically simple, under vision with less time required than as compared to 6-12 o clock anastomosis.
PTT-35 Liver Mobilisation during Recipient Hepatectomy Using Argon Plasma Coagulation - Tricks of Trade
Sachin Daga, India

S. Daga
HPB & Liver Transplant, Medicover Hospital, Hyderabad, India

Introduction: Recipient hepatectomy is one of the difficult and challenging procedure during liver transplant. Blood loss during recipient hepatectomy is one of the main determinants of outcome during liver transplant. In a patient with recurrent spontaneous bacterial peritonitis there are dense adhesion between liver and peritoneum which are highly vascularized. It is difficult to find plains for blood less dissection. In order to over come this problem we have developed our own technique of mobilization of liver.
Methods: There are many energy devices available for blood less dissection during mobilization of liver. Right from electrocautery, bipolar, harmonic scalpel, ligasure, argon plasma coagulation and many more. We have developed our own technique for mobilization of liver when dense adhesions are present between liver and peritoneal area. We use APC for releasing right and left triangular ligament. Using gentle traction on liver and spraying APC between liver and adherent area.
Results: With use of APC a blood less dissection is feasible perticulary in the areas where there is no clear plain for dissection. Moreover, it helps in prevention of rents of diaphragm. If dissection is done either with other devices there is need to dissect plain which leads to bleeding from newly formed collaterals and if they are used without dissection can lead to rents in diaphragm.
Conclusion: A blood less dissection is feasible in recurrent SBP patient using APC.
PTT-36 Peri-adventitial SMA Dissection during Pancreaticoduodenectomy for Resectable Pancreatic Cancer
Francesco Giovinazzo, United Kingdom

F. Giovinazzo, S. Sahay, K.J. Roberts, N.A. Chatzizacharias
Queen Elizabeth Hospital Birmingham, United Kingdom

Background: The incidence of R1 resection after Pancreaticoduodenectomy is variable and is directly correlated with worse long-term survival. Retrospective data suggest that periadventiatial SMA dissection may decrease the R1 rate and improve the survival outcome. However, the utilisation of this surgical technique varies amongst surgeons.
SMA could be approached in different ways based on the surgeon's preference (artery first, posterior, anterior, combination). In our institution, peri-adventitial dissection describes the clearance of the right side of the SMA from lymphoneural tissue for at least 180 degrees and from the “angle” of the artery to the level of inferior border of the uncinate process. The retroperitoneal soft-tissue of the uncinate process is dissected. The small vascular structure in this area are carefully tied and the right lateral margin of the SMA is skeletonized, removing all pancreatic tissue and draining lymphatics from the peri-vascular plan. In the presence of an accessory or replaced right hepatic artery the peri-adventitial dissection should also be carried out around this vessel as well.
Results: Routine practice of peri-adventitial dissection during pancreaticoduodenectomy for resectable tumours has been performed in a subset of patients. The results suggest a R1 rate of 20%, with SMA margin positivity 5%, compared to a rate of 44% margin positivity within the same unit. There have been no incidences of vascular related injury or complication related to the technique; or persistent chyle leak (one episode of chyle leak grade A recorded that was managed conservatively).
[Periadventitial dissection]
PTT-37 Amniotic Membrane over Pancreatic Anastomosis after High Risk Pancreaticoduodenectomy: Preliminary Experience of a Prospective Study
Isabella Frigerio, Italy

I. Frigerio1, E. Bannone2, D. Trojan3, P. Regi1, R. Girelli1, A. Giardino1, V. Allegrini1, B. Giovanni1
1Pancreatic Surgical Unit, Pederzoli Hospital, Italy, 2Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy, 3Treviso Tissue Bank Foundation, Italy

Introduction: Relevant pancreatic fistula(CR-POPF) after pancreatic resection is a life-threatening complication. None of the existing strategies is effective in reducing its incidence. Many studies suggest that amniotic membrane (AM) is effective in tissue regeneration and prevention of fluid leakage at many surgical sites.We reported the first case of AM implantation after pancreaticoduodenectomy(PD).
Aim: We present the results of the prospective study ongoing in our Institution to determine whether AM implantation can reduce CR-POPF.
Patients and methods: Patients undergone PD were intra-operatively enrolled in the study if Fistula Risk Score(FRS) was between 5-10. AM was provided by Fondazione Banca Tessuti Treviso Onlus and displaced as in Figures. Pre and post-operative data were recorded and compared with same risk population without AM.
Statistics: Continous variables were analysed using Student's t-test or Mann-Whitney U test. Categorical variables were compared using Chi-Square test or Fisher's exact test when appropriate. A p-value< 0 .05 was considered as statistically significant.
Results: Thirteen patients in each group were included in the analysis: the two groups were comparable regarding preoperative and intraoperative data. No significative differences were found in postoperative course regarding abdominal complications pancreatitits, DGE, fluid collection, need for reoperation and lenght of stay. POPF occurred in 53,8% and 92,3% in AM and noAM patients respectively(p=0.073) and may reflect a trend in AM efficacy to reduce POPF.
Conclusion: AM seems to improve POPF after PD in high risk patients but this trend needs to be validated in a bigger population.
[AM displacement after pancretic anastomosis]
PTT-38 Three Ports Laparoscopic Distal Pancreatectomy (Anterior RAMPS, Posterior RAMPS and Splenic Preserve): Systematic Antegrade Dissection Is the Key Point to Success
Supreecha Asavakarn, Thailand

S. Asavakarn
Bangkok Hospital, Bangkok, Thailand

Many literature had described standardize technique for laparoscopic distal pancreatectomy (LDP) using 5 ports. In our experience, only three ports suffice for LDP whether it is anterior RAMPS, posterior RAMPS or splenic preservation. Another 2 ports for stomach and colon retraction were not necessary. Systematic antegrade dissection and vascular approach from infero-posterior border of pancreas is the key to success. Our step begin with opening the gastrocolic ligament from medial toward splenic flexure of colon. Then we divide splenocolic ligament and dissected Colon from inferior border of pancreas by dissecting back from left to right until reaching portal vein. Lifting pancreas toward abdominal which will also lift the stomach upward. By dissecting the pancreas from inferior border and lifting the neck of pancreas, spleno-portal vein junction can easily identified from posterior surface of pancreas. From this caudal view, we can see common hepatic artery and superior border of pancreas (Figure 1). Now we can encircled neck of pancreas and divided. After pancreas was divided, we can encircled splenic vein and divided. By lifting pancreas to the left, we can continue dissecting upper border of pancreas form retroperitoneum and hepatic artery until reaching splenic artery take-off. In this step, we can now divided the splenic artery at its origin. After that, continue dissection the pancreas from retroperitoneum along the plane of anterior or posterior RAMPS. If the spleen is to be preserved, it can be done with this approach. With this technique, we can reduce ports insertion thus reduce pain.
[Figure 1]
PTT-40 Technique of Biliary Anastomosis: Targeting the “Achilles´ Heel” of Adult Living Donor Liver Transplant
Ashish Singhal, India

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

Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. In most series, overall biliary complications (biliary leaks and strictures) were reported between 10%-30%.
At our center, we have made few innovations/modifications in surgical technique of biliary reconstruction, which have significantly reduced incidence of biliary complications (< 5%).
1. The standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. In addition, modified technique: corner-sparing sutures and mucosal eversion of the recipient duct was done. The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT.
2. Bile leak may occur from anastomotic site, cystic duct stump, cut surface pedicles or from divided caudate ducts. The first three sites are amenable to post-operative endoscopic stenting as they are in continuation with biliary ductal system. However, leaks from divided isolated caudate ducts can be stubborn. We have defined and classified the biliary drainage/anatomy of the caudate lobe in liver donors based on intraoperative cholangiograms (IOCs) with special attention to crossover caudate ducts. Proper intraoperative identification and closure of divided isolated caudate ducts can prevent bile leak in recipients as well as donors.
[Technique of Biliary Anastomosis: Corner sparing & Mucosal eversion/Biliary Anatomy of Caudate Lobe]
PTT-41 Hydatid Surgery Resurgence in Australia: How to Perform Safe Effective Liver Surgery for Hydatid Disease
Izhar-Ul Haque, Australia

I.-U. Haque1, B. Zogovic2, A. Das1
1Hepato Pancreatico Biliary Surgery, Liverpool Hospital, Australia, 2Hepato Pancreatico Biliary Surgery, Liverpool Hospital, Australia

Introduction: Hydatid disease has had a recent resurgence in Australia probably due to immigration from endemic countries. Echinococcosis can lead to formation of Hydatid Cysts in the Liver, which sometimes need surgical intervention.
OPERATIVE TECHNIQUE - TRICKS OF THE TRADE: Spillage can cause anaphylaxis and care should be taken during Hydatid surgery. After rooftop incision and liver mobilisation, stay sutures with 3-0 PDS are applied to the thick cyst wall. Chlorhexidine soaked sponges are placed around the large cyst. 5 mm Laparoscopic port is inserted into the cyst around stay sutures and sucker attached to drain the turbid light grey fluid. The port is then converted to 12 mm port to allow cyst wall/germinal layer to come up the sucker and sent as specimen. Scolocidal agent Chlorhexidine with Cetrimide is then poured into the cyst wall and aspirated multiple times. Minor spillage onto a soaked sponge should be suctioned out. Harmonic scalpel is used to open cyst wall and Echelon flex 60 white staplers are used to take cyst wall of the liver edge. No scraping of the cyst base is done to avoid bile leak. Daughter cysts are removed. Whole abdomen is washed with Chlorhexidine with Cetrimide solution. Then whole abdomen is washed with Normal Saline to prevent fibrosis from Chlorhexidine. Haemostasis is achieved using diathermy, floseal and Tisseel. Omentum is mobilised and sutured to cyst side wall with 2-0 Chromic. Blake drain is placed, pain catheters in the wound and closed in layers.
PTT-42 “French Position” for Open Pancreaticoduodenectomy: Coming Back from Laparoscopy to Open Surgery
Helena Facundo, Colombia

H. Facundo1, B. Escobar2, O.A. Guevara3
1Gastroenterology, Instituto Nacional de Cancerologia, Colombia, 2Anestesiology, Universidad Nacional de Colombia / Instituto Nacional de Cancerologia, Colombia, 3Surgery, Universidad Nacional de Colombia / Instituto Nacional de Cancerologia, Colombia

Introduction: Minimally invasive surgery has arrived slowly in pancreaticoduodenectomy (PD). Even that, most of PDs remains performed Open. Some advantages of laparoscopy can be reintroduced to Open surgery. We propose the “French position” to Open PD, to facilitate the access of the second assistant (usually a Fellow or Resident).
Methods: After a pair of conversions of laparoscopic PD to open, we realized that French position (supine with open legs) allows a better performance for the surgical team, specially the second assistant participation. After that, one of the authors (HF) proposed to start open PDs using the advantages of French position.
Results: In last 20 Open PDs we start with the patient in French position. Surgeon remains on the right side of the patient, first assistant of the left side and second assistant between de patient legs. We feel that this position allows a better participation of the second assistant and the surgeon have more room to work. In some cases, the surgeon changed the position between the patient's legs, during uncinate process dissection, taking advantage for dissection parallel to mesenteric vessel instead of perpendicular fashion. Another advantage is to get open the patient's arms if is required for the anesthetist. Some limitations: it requires special attention to avoid pressure areas.
Conclusion: French position to perform Open PDs can facilitate the disposition of the surgical team and in some cases the surgeon can operate in front of the uncinate process changing the direction in parallel instead of perpendicular.
PTT-44 Flurbiprofen Axetil Injection Test Reduce Bile Leaks for Laparscopic Hepatectomy
Wanguang Zhang, China

W. Zhang, Z. Zhang, X. Chen
Hepatic Surgical Center, Tongji Hospital of Huazhong University of Science and Technology, China

Aim: Among the postoperative complications, bile leaks represents a primary one and frequently requires for treatment of invasive diagnostic and therapeutic interventions undergoing laparoscopic liver resection. Here we report Flurbiprofen Axetil injection test can reduce the bile leaks for laparoscopic liver resection.
Methods: Flurbiprofen Axetil injection test was injected through cystic duct or common bile duct after finishing liver parenchymal transection. From January 2017 to December 2019, patients with liver tumor who underwent minimally invasive liver resection were enrolled in this study. Perioperative bile leakage were recorded. Variables associated with bile leaks were identifified using multiple logistic regression analysis.
Results: During the study period, 237 patients perform laparoscopic liver resection. 16 patients (6.8%) in the series were presented with post-resection bile duct leaks. Tumor size, type of liver cancer, operation time, blood loss and blood transfusion were independent risk factors for BL.Propensity score-adjusted multivariable regression identifified Flurbiprofen Axetil injection test can reduce the incidence of bile leaks.
Conclusion: Our data suggest the incidence of bile leaks can be reduce with Flurbiprofen Axetil injection test throught cystic duct or common bile duct injection.
PTT-45 Is There an Answer to Post-operative Cholangitis and Delayed Gastric Emptying after Pancreaticoduodenectomy?
Nagesh Nayakarahalli Swamy, India

N. Nayakarahalli Swamy1,2, R. Pendlimari2
1Institute of Gastroenterology and Organ Transplant, India, 2Bangalore Medical College and Research Institute, India

Background: Pancreaticoduodenectomy (PD) is associated with high morbidity. Delayed gastric emptying DGE(>15%) is the most common complication and Cholangitis (>5%) is the most dreadful infectious complication in the post-operative period. A change in our technique and alteration in post-operative care has minimized the both.
1. Unlike resection in conventional PD, after transection of distal stomach, we ligate the GDA and then uncinate is dissected from SMA before pancreas is resected. The advantages are that there is less bleeding during the pancreas transection and there is minimal handling of the portal vein.
2. The bile duct is never clamped during the dissection procedure allowing free flow of bile into the
enteric system. Hilum is dissected and bile duct is transected at the end.
3. The patients received levosulpiride (75mg/day) starting immediately after the surgery.
Data: The above mentioned technical alterations were brought into practice in Sep 2018. A total of 25 patients underwent PD. All of them had pre-operative biliary stenting. Grade A pancreatic leak occured in 5 (20%), Grade B in 1 patient (4%). Post-operative cholangitis was noted in none of the patients. Delayed gastric emptying was noted in 2 patients (8%).
Conclusions: We believe that minimal handling of portal vein during dissection, delaying the clamping/transecting the bile duct is associated with fewer cholangitis / infectious -complications in the post-operative period. We also noticed there is less delayed gastric emptying in these patients and whether it is due to Levosulpiride/ the technique needs to be discussed.
PTT-46 Hepaticojejunostomy- THREE Critical Sutures to Exterminate the Dreaded Complication Bile Leak
Nagesh Nayakarahalli Swamy, India

N. Nayakarahalli Swamy1,2, R. Pendlimari2
1Institute of Gastroenterology and Organ Transplant, Bangalore, India, 2Bangalore Medical College and Research Institute, Bangalore, India

Background: The dreaded complications after Hepaticojejunostomy were bile leak and stricture. Bile leak is reported as high as 6% and long-term stricture rate as high as 13%. Most commonly utilized technique for Hepaticojejunostomy (HJ) described by
Blumgart, is retrocolic roux-en-Y Hepaticojejunostomy with multiple interrupted absorbable sutures.
Technique: A retro-colic Roux-loop of jejunum is anastomosed to the bile duct with end to side fashion. PDS 4-0 suture is used for the anastomosis. Three critical stitches taken on either side:
1. Corner but posterior
2. Corner
3. Corner but anterior.
After the three critical stitches were taken, firstly the corner but posterior suture is tied on either side. Then the posterior layer is anastomosed with intermittent sutures with knots inside lumen. Then corner suture is tied. Then anterior layer is anastomosed with intermittent sutures with knots outside. Then the corner but anterior suture is tied. Fewer sutures are required than the standard Blumgart technique to complete the anastomosis. Two anchoring sutures with silk were taken from jejunal loop to the hilar plate/adjacent fibrous tissue to relieve the tension on anastomosis.
Results: Over the last 5 years, 320 patients underwent hepaticojejunostomy for various reasons (benign and malignancy). Bile leak was noticed in 6 patients (1.9%).
Conclusions: The three critical sutures described are vital for the hepaticojejunostomy anastomosis. These three sutures should be taken and tied diligently to prevent bile leak.
PTT-47 Early Splitting of the Liver for Retroperitoneal Adrenal Mass
Chaya Shwaartz, Canada

C. Shwaartz1, I.D. McGilvary2
1University Health Network, Canada, 2HPB and Transplantation, University Health Network, Canada

Adrenocortical carcinoma often invades surrounding anatomical structures and surgical resection can be extremely challenging even in experienced hands.
Some of the surgical challenges are exposing the entire circumference of these giant tumors, the inferior vena cava, the renal vasculature, and the aorta while maintaining oncological principles and a proper vascular control. Injudicious mobilization of the tumor may lead to excessive bleeding caused by avulsion of the renal/adrenal veins, iatrogenic tumor rupture, and spillage of cancer cells into the systemic circulation. To avoid the aforementioned disadvantages, our approach is to split the liver early. The technique involves initial vascular inflow control, parenchymal transection of the liver, and complete venous outflow control, prior to the tumor mobilization. In this manner the difficult aspects of the resection, such as mobilization of the tumor from the cava and diaphragm, retroperitoneal mobilization in the retrohepatic space, and possible caval replacement, are more straightforward and better visualized.
PTT-48 Ex-Vivo Resection with Small-Bowel Auto-Transplantation for Tumors at the Root of the Mesentery
Chaya Shwaartz, Canada

C. Shwaartz1, I.D. McGilvary2
1HPB Surgery, University Health Network, Toronto General Hospital, Canada, 2University Health Network, Toronto General Hospital, Canada

Tumors involving the root of the mesentery can be extremely challenging and even defined non-resectable when considering conservative surgical techniques alone. Surgical resection of these tumors can result in resection of large portions of the intestine. As a consequence, patients may develop short bowel syndrome and remain dependent on either total parenteral nutrition or need for intestinal transplantation for survival.
In these cases of complex involvement of the superior mesenteric artery, Ex-vivo resection and auto-transplantation may prevent excessive bleeding and ischemic related damage to the small intestine and other abdominal viscera. Additionally, this technique provides better exposure that may assist in obtaining better oncological resections.
In this manner the difficult aspects of the resection such as resections with negative margins, proper exposure, are more straightforward and better visualized, with less ischemic damage to the bowel.
PTT-49 Different Approaches to Management of Common Duct Stone (CBDS) in Patients who Had Roux-En-Y Gastric Bypass (RYGB)
Gazi Zibari, United States

A. Marsala1, R. Zibari2, S. Ahmadzadeh2, H. Shokouh-Amiri3, Q. Chu2, D. Dies4, G. Zibari3
1Willis Knighton Health System, United States, 2LSU Health - Shreveport, United States, 3John C. McDonald Regional Transplant Center/Willis Knighton Health System, United States, 4Gastrointestinal Specialist-Shreveport/ Willis Knighton Health Sytem, United States

Introduction: Symptomatic CBDS are commonly diagnosed in obese patients after Roux-en-Y gastric bypass RYGB. Management can be challenging due to the altered gastrointestinal anatomy. Various techniques are available, we present a cohort of patients who were safely managed with three different approaches to remove CBD stones.
Method: A retrospective chart review of patients who had symptomatic CBDS after RYGB underwent: Percutaneous trans-hepatic CBDS removal, Laparoscopic assisted trans-gastric/ ERCP, Robotic CBD exploration & choleducho-duodenostomy/choleducho-jejunostomy.
Results: From April,2011 to June,2019 a total of 25 patients (93.3% Caucasian; 70% female; age ranges from 38-90 years) were successfully managed with PTC, balloon sphincteroplasty and stone forced down to the duodenum (#18). Laparoscopic trans gastric ERCP (#4) and Robotic CBD exploration & CBD bypass & cholecystectomy (#3). There were four complications, two hemobilia, one bile leak and one enterotomy and no mortality.
Conclusion: We have presented three different safe approaches to manage CBD stones in patients with gastric bypass with low morbidity and no mortality.
PTT-50 Parenchymal Transection and Dissection with Ultrasonic Scalpel as a Single Disposable Instrument in Laparoscopic Liver Surgery
Jaime Arthur Pirola Kruger, Brazil

J.A.P. Kruger, G.M. Fonseca, V.B. Jeismann, F.F. Coelho, P. Herman
Liver Surgery Unit, University of Sao Paulo - Hospital das Clinicas, Brazil

Parenchymal transection techniques are an ever-going discussion between liver surgeons and remain largely a matter of equipment availability and personal preference. This video shows how transection can be performed with the use of a single disposable device, the ultrasonic scalpel. Dissection can be performed opening the jaw, exposing the active blade and moving the tip sideways, without pressure on vessels and without blind insertion inside the parenchyma. Vessel sealing is applied with the common use of the equipment, closing the tip around the dissected vessel (after hemostatic clips when needed). Three short videos are shown:
1) left hepatectomy in healthy liver parenchyma bearing an biliary cystic neoplasia closely related to the middle hepatic vein;
2) segment 5 resection in a post-chemotherapy parenchyma for metastatic colorectal carcinoma and
3) another segment 5 resection for HCC on a cirrhotic patient. Our institution has performed 424 minimally invasive liver operations, 267 of those were totally laparoscopic approaches. The ultrasonic scalpel was applied in 202 cases.
[Figure 1. Correct use of the ultrasonic scalpel's active blade]
PTT-51 Pure Laparoscopic Donor Right Hepatectomy (PLDRH) - Maneuvers to Achieve Adequate Exposure with Technical Tips and Tricks
S Srivatsan Gurumurthy, India

S. Srivatsan Gurumurthy, M. Srinivasan, P. Senthilnathan, N. Anand Vijai, S. Swaminathan, C. Palanivelu
Dept. of HPB, Minimally Invasive Surgery & Liver Transplant, Gem Hospital, India

Pure Laparoscopic Donor Right Hepatectomy is a technically challenging surgery requiring long hours of focussed team effort.
Access and mobilisation:
  • Placement of camera ports as high as possible in the line of hilum, right subcostal region
  • Goldfinger/Snake Liver Retractor 5mm via epigastric port for adequate right lobe liver retraction
  • Use of endoloop for traction of Gall bladder and divided end of falciform ligament.
Hilar dissection:
  • Gold finger passed anterior to the cava and brought out in the space created between the right hepatic vein and middle hepatic vein in the suprahepatic space.
  • Umbilical tape passed in the space created by the gold finger which helps achieve hanging, useful for parenchymal transection .
  • ICG guided Liver parenchymal surface marking for accurate parenchymal transection
Parenchymal transection:
  • Use of rubber band traction for sustained and firm liver traction.
  • Use of CUSA excel (CUSA with monopolar cautery in the same device) for adequate hemostasis while parenchymal transection
  • Gold finger is used to encircle the entire right portal pedicle, and umbilical tape is brought in this space which helps in completing the remaining parenchymal transection by hanging manoeuvre.
Organ procurement via pfannensteil incision:
  • Right hepatic duct is encircled with hilar sheath using ICG guidance and divided with scissors sharply after placing a clip to the right hepatic duct orifice.
  • Right hepatic artery clipped, right portal vein stapled and divided while the right hepatic vein and IVC ligament is divided using a stapler.
PTT-52 Intra-operative Indocyanine Green (ICG) Cholangiography: An Improved Sensitive Method to Identify Bile Leakage after Hepatic Resection
Mafalda Couto, France

M. Couto1, P. Leon1, F. Quenet2, F. Navarro1, F. Panaro1
1Division of HBP Surgery and Transplantation, Department of Surgery, St. Eloi Hospital, CHRU Montpellier, France, 2Institut de Cancérologie de Montpellier, France

Bile leakage remains the most important complication after a liver resection, affecting 3 to 33% of patients. In order to prevent bile leak, the meticulous control of the cut surface of the liver has been advocated. The intraoperative identification and ligation of any leaking bile duct is mandatory to limit postoperative complications' occurrence. The intra-operative trans-cystic injection of ICG solution is our preferred method to identify bile leak.
Fluorescent cholangiography with ICG shows a high detection rate for small bile leaks compared to white-lap or blue tests.
The ICG dye is injected through a trans-cystic catheter in the biliary tree, the common bile duct is then clamped distally to the catheter and near-infra-red fluorescent imaging is performed. Any side-effects were observed.
The fluorescent cholangiography shows a powerful enhancement of tissue contrast and allows the fine detection of small leaking ducts. The major contribution of this technique is to shows all the bile-ducts on the cutting surface (deep 8-10 mm) and not only those are leaks. In contrast to the others techniques, with the ICG test we focused major attention on these fluorescents sites. In our experience, fluorescent ICG cholangiography may represents a most sensitive method for intra-operative detection of bile leak.
PTT-53 A Technique of Hepatic Artery Anastomosis in Living Donor Liver Transplantation: Back-wall First Technique
Muthukumarassamy Rajakannu, India

M. Rajakannu, J.S. Rajasekar, M.S. Reddy, M. Rela
Liver Transplantation and HPB Surgery, Dr. Rela Institute and Medical Center, India

Microvascular technique of placing three stay sutures at 120° intervals around the circumference of the arteries to be anastomosed is limited in its usefulness in LDLT as hepatic artery (HA) is shorter, smaller, and thin-walled hindering the surgeon's ability to rotate it with the vascular clamps in situ whilst completing the anastomosis. Our technique of HA reconstruction overcomes this problem by placing two adjacent sutures at 6 O'clock in the posterior wall after preparing and positioning donor's and recipient's HAs (A). These two posterior wall sutures are knotted and they help in holding the arteries in position for anastomosis. Then interrupted sutures are placed on either side of these two knots under vision on the posterior wall and knotted till the corners are reached (B). The posterior wall of anastomosis is kept short and straight than the anterior wall to prevent posterior wall being caught by the anterior sutures. Two stay sutures are placed on the corners and interrupted sutures are placed on the anterior wall of the anastomosis without the need to rotate the arteries (C). Anterior wall sutures are knotted after flushing with heparinized saline and removing the distal vascular clamp (D). Bleeding from the interrupted suture lines is not a problem and can be managed with additional sutures. Another advantage is that size mismatch between the donor and recipient HAs can be easily adjusted.
During 90-day post-operative period, eleven patients (1.2%) developed anastomotic complications [thrombosis in eight; pseudoaneurysm in three] in 923 consecutive adult and pediatric LDLTs.