Video Pancreas |
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VP02 Video Pancreas: Minimal Invasive Pancreas Surgery |
Selection of Video Presentations from Abstract Submissions |
VP02-01 | Laparoscopic Frey's Procedure for Chronic Calcific Pancreatitis S Srivatsan Gurumurthy, India
S. Srivatsan Gurumurthy, M. Srinivasan, P. Senthilnathan, C. Palanivelu Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India
28
yr old female a k/c/o chronic calcific pancreatitis for over 10 years presented
with intractable pain. CECT abdomen showed multiple chunky intraductal calculi
in head, body and tail of pancreas with MPD dilated to about 8 mm. She was
planned for a laparoscopic Frey's procedure. The patient was positioned supine
with legs split under GA, abdomen painted and draped. Pneumo created using
verres needle and ports placed. Gastrocolic omentum incised and Lesser sac
opened. Pancreas firm and atrophied. Gastrocolic trunk of henle divided to
expose head of pancreas. Hepatic flexure is taken down and duodenum kocherised.
MPD opened after aspiration and extended upto tail of pancreas about 2 cm from
splenic hilum. Duct opened into head upto medial border of duodenum and till uncinate
process . Intraductal stones extracted. Head coring done. Roux loop of jejunum
about 25 cm from DJ flexure brought through mesocolon and side to side
pancreaticojejunostomy done using single layer 2-0 PDS continuous sutures.
Jejunojejunostomy done with Endo GIA stapler . Haemostasis achieved. Abdominal
drain placed near PJ site. Port sites closed. The patient had an uneventful
recovery and significant pain relief from the procedure on followup. |
VP02-02 | Indocyanine Green Enhanced Fluorescence in Laparoscopic Duodenum-Preserving Pancreatic Head Resection Pan Gao, China
P. Gao, Y. Cai, B. Peng West China Hospital, Sichuan University, China
Introduction: In 1972, Beger first described the duodenum-preserving pancreatic head resection (DPPHR) for patients with severe chronic pancreatitis and then DPPHR was proved that it also can provide comparable long-term oncological outcomes in setting of benign or low-grade malignant tumors. As an organ-preserving procedure, DPPHR preserves the integrity of the digestive tract and improves the patient's quality of life comparing with pancreaticoduodenectomy (PD). The ICG fluorescence imaging system in laparoscopic surgery could identify the biliary. Nevertheless, to date, there have no report of ICG enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). In this article, we reported the technique of LDPPHR with video by the assist of real-time ICG fluorescence imaging system. Methods: A 29-year-old woman was diagnosed with chronic pancreatitis and an inflammatory mass in the head of the pancreas. CT scan showed atrophy of pancreas, dilatation of main pancreatic duct and heterogeneous enhancement of pancreatic head parenchyma. Her other preoperative examinations were normal except for high blood sugar. To avoid an extended PD for this young patient, LDPPHR was performed.The upper part of the pancreatic head was separated to expose the common bile duct (CBD) with the help of real-time ICG fluorescence imaging. Results: Operation time was 251 min, and estimated blood loss was 150 ml. The postoperative course was uneventful with a hospital stay of 13 days. Conclusions: Indocyanine green enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection was safe and may be benefit for maintaining the integrity of the biliary system. |
VP02-03 | Panico Mesopancreas Approach Vittoria Barbieri, Italy
V. Barbieri, M.T. Mita, A. Altamura, M. Gregori, G. Giaracuni, M.G. Viola Azienda Ospedaliera 'Cardinale G. Panico', Italy
The aim of this video is to report our experience with our new approach of the SMA. The middle colic vein and right gastroepiploic vein can be traced down to the superior mesenteric vein for rapid identification. The anterior surface of the vein is separated by blunt dissection from the pancreas ceating a tunnel behind the pancreatic neck. The duodenum and the head of the pancreas are separated from the posterior bed medially past the aorta and distally to the ligament of Treitz. Following a wide Kocher manouvre, the SMA origin can be identified above the left renal vein. The first part of the dissection begins along the posterior wall of the vascular axis of the SMA. After duodenum section with the stapler, the dissection of the SMA is continued on uts anterior margin. The gastroduodenal artery is ligated to minimize the bleeding and lymph nodes anterior to the proper and common hepatic artery are taken with the specimen. Transection of the pancreas in front of the portal vein is next. Here begins the second phase of our mesopancreas dissection. Anteriorly, after the ligation of the portal vascular afferents, the SMA is exposed anteriorly. The dissection started on the posterior plane circumferentially to the origin is completed. Then we move distally to the origin of the SMA, along its vascular axis. After Treitz dissection, jejunal section and duodeno-jejunal axis derotation, the specimen is connected only by the mesopancreas and the final dissection follow the lateral margin of the SMA |
VP02-04 | Full Robotic Kimura Distal Pancreatectomy for IPMN Emanuele Felli, France
E. Felli1,2,3, E.M. Muttillo4, D. Mutter2,3,4, J. Marescaux2,3, P. Pessaux2,3,4 1HPB Unit, Nouvel Hopital Civil, France, 2IHU Strasbourg, France, 3IRCAD, France, 4Nouvel Hôpital Civil, University of Strasbourg, France
We present a total robotic Kimura distal
pancreatectomy for an IPMN of the pancreatic tail. A 58-year-old patient
affected by a 35mm kystic lesion diagnosed
fortuitously after a systematic CT scan during a preoperative wall hernia
repair work-up. In his past medical
history we notice obesity, diabetes, sleeve gastrectomy, blood hypertension and
dislypidemia. A pancreatic MRI was
performed and confirmed the presence of a distal lesion communicating with the
main pancreatic canal associated to a non enehancing intramural nodule. Initial
surveillance was indicated. The first control MRI showed an increas in size of
the lesion so resection was indicated. Biology was normal, CEA and Ca 19.9 either. After
robot docking initial adhesions section is performed with hook and bipolar
forceps, the lesion is then visualized.
Dissection was conducted according the original Kimura technique with isolation
and section of small venous and arterial branches of the splenic artery and
vein. Pancreas transection
is performed at the body-tail junction
with ENDO-GIA 60 through a 12mm assistant trocart. Accurate hemostasis is performed with
application of an hemostatic patch. Epiploplasty and drainage are finally
performed. Pathologic results showed a gastric typ IPMN with low grade dysplasia. Postoperative course was
uneventful and the patient was discharged at POD 8. |
VP02-06 | Laparoscopic Distal Pancreatectomy with Spleen And Splenic Vessel Preservation (Kimura Procedure) Using Pure Ultrasonic Shear Technique Peng Soon Koh, Malaysia
P.S. Koh, Y.S. Lee, J.K. Koong, B.K. Yoong Department of Surgery, Faculty of Medicine, University of Malaya, Malaysia
Spleen and splenic vessel preservation in distal pancreatectomy is gaining popularity and performed only for benign pancreatic lesion, low grade tumour and chronic pancreatitis. Unlike the conventional laparoscopic distal pancreatectomy with splenectomy or spleen preserving with non-splenic vessel preservation distal pancreatecomty (Warshaw Technique), spleen and splenic vessel preservation distal pancreatectomy (Kimura Procedure) is considered more technically difficult and challenging. This video presentation demonstrates Kimura Procedure being performed for a 29-year-old lady who presented with left sided abdominal pain and had a computer tomography (CT) scan performed revealing a 3.4cm pancreatic tail cyst. An endoscopic ultrasound (EUS) was also performed showing likelihood of branch duct IPMN. Patient was counseled for surgery and did not receive splenic vaccination. Intra-operative was uneventful and surgery was performed solely on using the ultrasonic shear (Harmonic Ace ®) as the energy device. Minimal bleeding was encountered during tissue dissection and hemostasis of small vessels was effective. Surgery took 225 minutes with blood loss of 200ml. No blood transfusion was required. She recovered well post-operatively and was discharged home by post-operative day 6. Histopathological examination (HPE) revealed a serous cystadenoma. Spleen preservation is recommended when dealing with conditions mentioned above and advantageous in preserving patient's immunological function. However, splenic vessel preservation is known to be more technically difficult and requires experience and better learning curve before embarking on it. The Kimura Procedure preserves the normal anatomical supply to spleen whereas the Warshaw Technique is known to be associated with splenic infarct and long-term predisposition to gastric varices. |
VP02-07 | Laparoscopic Distal Pancreatectomy with Regional Lymphadenectomy through Retroperitoneal-first Laparoscopic Approach (Retlap) for Pancreatic Body Cancer Close to the Arterial Wall Gozo Kiguchi, Japan
G. Kiguchi, A. Sugioka, M. Kojima, A. Yasuda, S. Nakajima, Y. Tanahashi, Y. Kato, I. Uyama Department of Surgery, Fujita Health University, Japan
Background: Laparoscopic distal pancreatectomy (LDP) for pancreatic
body cancer close to the arterial wall is technically demanding. We previously reported
new strategy named “retroperitoneal-first laparoscopic approach (Retlap)” for LDP.
In this study, Retlap is applied to LDP for the tumor close to the arterial
wall.
Methods: This video demonstrates the case of a 77-year-old woman
with a 40-mm pancreatic body cancer. Preoperative computed tomography revealed
a tumor close to the bifurcation of the common hepatic artery (CHA) and splenic
artery (SPA) and the confluence of the splenic vein. Distal pancreatectomy with
celiac axis resection was not indicated because arterial collateral circulation
from the superior mesenteric artery to the liver was immature on angiography. To
secure an adequate margin without celiac axis resection, exposure of the
arterial wall inside the vasa vasorum was required. Using Retlap, the
layer inside the vasa vasorum of the celiac axis was exposed through the
retroperitoneal approach from the dorsal side of the pancreatic body. Without interfering
with the tumor, the bifurcation of CHA and SPA was exposed with its vasa vasorum
removed. After dividing SPA, the procedure was converted to laparoscopic
approach and portal vein resection and reconstruction was performed from small
incision.
Results: The operative time and estimated blood loss were 737 min and 60 mL, respectively. Pathological
examination confirmed a negative surgical margin, and R0 resection was achieved
despite of the tumor location.
Conclusion: Retlap was useful for achieving adequate surgical margin in the
case of the tumor close to the arterial wall. |
VP02-08 | Laparoscopic Frey Procedure with ICG Fluorescence-Guided Biliary Tract Imaging Roman Izrailov, Russian Federation
P. Agami, A. Andrianov, M. Baychorov, M. Mikhnevich, P. Tyutyunnik, R. Izrailov High Technology Surgery, Moscow Clinical Scientific Center, Russian Federation
This is the case of a 25-year-old male patient
presenting with recurrent intractable abdominal pain he has been suffering from for the last 6
months. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma and dilated main
pancreatic duct in the head and body of the pancreas up to 10 mm and 8 mm
respectively. The patient was referred for laparoscopic subtotal removal of the
head of the pancreas with longitudinal Roux-en-Y pancreaticojejunostomy - a
technique known as Frey procedure.
One of the most common complications during the
Frey procedure is the distal bile duct injury, which can be easily
misidentified within the surrounding fibrotic tissues. A method that helps to
prevent this complication is the indocyanine green (ICG) fluorescence-guided
imaging, that allows to clearly visualize the biliary tract. Two hours prior to
the surgery our patient received an intravenous injection of 25 mg of
indocyanine green. During the resection step ICG-imaging allowed us to reveal
the intrapancreatic portion of the common bile duct, thus significantly
facilitating the prevention of its injury and making the resection much safer.
The purpose of this video is to demonstrate that
laparoscopic Frey procedure is safe and feasible, and provides all the
well-known advantages of the minimally invasive approach, particularly lower
postoperative pain, earlier functional recovery, and shorter hospital stay.
Also, in this particular case, we highlight the important role of ICG
fluorescence-guided imaging in the prevention of one of the most serious
complications - the common bile duct injury. |
VP02-10 | Robotic Excision of Duodenal Tumour Andrew Kai-Yip Fung, Hong Kong
A.K.-Y. Fung, A. Cheung, C.N. Chong, K.F. Lee Chinese University Hong Kong, Hong Kong
Content: We present a 58-year-old female, who was found to have an incidental pancreatic head lesion. EUS with intravenous contrast showed a 2.7x1.8cm hyper-vascular
lesion in the aorto-caval groove, suggestive of a neuro-endocrine or hyper-vascular
tumour. PET-CT showed no distant metastases.
The patient proceeded to robotic exploration, using the DaVinci Xi robot.
The duodenum was Kocherised and intra-operative ultrasound demonstrated that
the lesion was located in the posterior part of D2/3 and anterior to the
inferior vena cava. The lesion measured 2cm with an 8mm stalk and was separate
from the pancreatic head and uncinate process. The duodenal lesion was then excised
with the endo-GIA stapler. Total operative blood loss was 1 millilitre. The
patient's post-operative recovery was unremarkable, with hospital stay of four days.
The pathology of the duodenal lesion was a gastro-intestinal stroma
tumour, with 1 mitosis per 50 high power fields and clear resection margins. The
patient was seen by the oncologist and no adjuvant therapy was required.
Novelty: This video presentation illustrated a case of an incidental cystic
lesion around the pancreatic head. Surgical dissection with the DaVinci Xi
robot showed that the lesion could be excised without need for
pancreatico-duodenectomy.
Clinical relevance: The DaVinci Xi robotic platform minimal access approach for this
case could spare the patient from the considerable post-operative morbidity of
an open surgical exploration. |
VP02-12 | External Retraction Techniques for Robotic Pancreatoduodenectomy Naruhiko Ikoma, United States
N. Ikoma, M. Kim, C.-W. Tzeng, J. Lee, M. Katz UT MD Anderson Cancer Center, United States
In this video, we introduce novel external retraction
techniques that improve exposure of critical surgical views during robotic
pancreatoduodenectomies. First, a 10-cm-long half-inch-wide Penrose drain, with
a 3-0 Vicryl suture tied in the middle and 0 silk suture tied at the ends, is
used for liver retraction. The midpoint of a Penrose drain is sutured to the
diaphragmatic crus, and silk sutures at the ends of the drain are externally
retracted with use of a suture passer at each side of the xiphoid process. This
maneuver exposes the anterior stomach and the porta hepatis for the entire procedure.
Second, a 3-0 Vicryl suture placed at the posterior stomach is externally
retracted to help expose the anterior and inferior pancreas. This exposure is
helpful during dissection of the inferior pancreas and the superior mesenteric
vein (SMV), until the antrum is divided. Finally, vessel loops encircling the SMV
are ligated with Endoloops, and the ends of the Endoloops are carefully
retracted externally on the patient's left side. This maneuver provides
critical exposure of the superior mesenteric artery (SMA) that allows safe,
high quality oncologic dissection. In summary, the external retraction
techniques described in this video presentation are helpful to mitigate limitations
of the current robotic surgery platform and can improve the safety and quality
of robotic pancreatoduodenectomy. |
VP02-14 | Laparoscopic Resection of the Uncinate Process of Pancreas
W. Chen, X. Bai, T. Liang Zhejiang University, School of Medicine, the First Affiliated Hospital, Hangzhou, China
Objective: Laparoscopic resection of the uncinate process of pancreas is a very challenging procedure. It not onlyshould resect the neoplasm but also preserve the organ function. This video presents technical details of a laparoscopic uncinectomy in a patient with branch duct IPMN. Methods: A 63-year-old man had a 32-mm IPMN in the uncinate pancreas, with the dilation of main pancreatic duct having a size of 0.6 cm. The patient was placed in the supine position with legs spread open. One 10-mm, two 5-mm, and two 12-mmtrocars were used. Firstly, the gastrocolic ligament was opened and the pancreas exposed.Then the uncinate process was carefully dissected from the horizonal portion of the duodenum and superior mesenteric vein. Blood supply of the duodenum was preserved and common bile duct was identified without injury. It was most important that the junction of the branch duct of IPMN and the main pancreatic duct was dissected and ligatured with a clip. Lastly, a hemostatic absorbable tissue was placed in the cutting pancreatic surface, and a drainage tube was left in place. Results: Operative time was 180 minutes. Intraoperative blood loss was about 100 ml without blood transfusion. The patient presented a grade A postoperative pancreatic fistula. Postoperative hospital stay was 6 days. Final pathological diagnosis confirmed IPMN with mild dysplasia. Conclusion: Laparoscopic resection of the uncinate process of pancreas is safe and feasible. It should be considered as a good alternative to pancreatoduodenectomy for patients with premalignant neoplasms. |
VP02-15 | Robotic Central Pancreatectomy Paolo Magistri, Italy
P. Magistri, R. Ballarin, F. Di Benedetto University of Modena and Reggio Emilia, Italy
Background: Minimally invasive approach
to pancreatic surgery may reduce complications and improve post-operative
outcomes. In particular, the use of the robot may enhance surgical skills more
than standard laparoscopy allowing to perform more complex procedures.
Methods: We report the case of
a 23 years-old female that came to our attention due to a large cyst of the
body of the pancreas incidentally diagnosed during the pre-operative study for acute
appendicitis. She underwent laparoscopic appendectomy and later CT scan and EUS
confirmed the presence of a 4x3.5 mucinous cystic neoplasm. Two months later
she was scheduled for robotic central pancreatectomy.
Results: The post-operative course was uneventful, and
the patient was discharged on p.o.d. 5 in good general conditions, tolerating a
diet and without drains. Final pathology revealed a Cystic NET G1, MIB1 < 1%.
Conclusion: Robotic pancreatic surgery is safe and feasible. The agility
of robotic instruments, the stable view and the high degree of magnification allow
to safely perform advanced procedures in dedicated high volume centers with experience
of HPB and minimally invasive surgery. |
VP02-16 | Anterior RAMPS with the Ligament of Treitz Posterior Approach Maria Teresa Mita, Italy
M.T. Mita, V. Barbieri, M. Gregori, A. Altamura, G. Giaracuni, F. Rubichi, M.G. Viola Azienda Ospedaliera 'Cardinale G. Panico', Italy
For
left-sided pancreatic ductal adenocarcinoma we standardized a laparoscopic
approach for radical antegrade modular pancreatosplenectomy. This video shows
an anterior RAMPS with a posterior approach through the ligament of Treitz.
The first step was the incision of the ligament of Treitz and the access
to the retroperitoneum with exposition of the inferior vena cava and left renal
vein. We resected Gerota's fascia under a good laparoscopic view and we proceeded
our resection behind the anterior renal fascia preserving the adrenal gland
from the right side to the left side.
The origin of the superior mesenteric artery was identified above the
left renal vein. The dissection of the neurovascular lymphatic tissue
surrounding the artery leads to the adventitial plane. The lymphadenectomy was
carried out on the left border of the superior
mesenteric artery up to its origin on the aorta and towards the origin of the celiac trunk up to the right crus of
diaphragm.
The
inferior border of the pancreas was dissected from the transverse mesocolon and
we completed the dissection from an anterior approach after division of the
gastrocolic ligament.
The splenic artery
was dissected along the plane of the adventitia and a lymphadenectomy with
skeletonization of the hepatic artery, the left gastric artery and the celiac trunk was performed,
so we reached the posterior dissection plane.
We
transected the neck of the pancreas and the splenic artery and vein. The
splenopancreatic bloc was tilted on the left side and we completed the
splenectomy. |
VP02-17 | Laparoscopic Pancreatic Head Preserving Duodenectomy - The Parenchymal Sparing Alternative to a Whipple Eduardo A. Vega, United States
E. Vega1, O. Salehi1, O. Kozyreva2, C. Conrad1 1Surgery, Tufts University, Saint Elizabeth Medical Center, United States, 2Medical Oncology, Saint Elizabeth Medical Center, Dana Farber Cancer Institute, Harvard University, United States
Background:
When
endoscopic options fail, laparoscopic pancreatic head preserving duodenectomy
(LPHPD) for benign duodenal lesions is a parenchymal sparing and safe
alternative to a pancreaticoduodenectomy. For premalignant duodenal polyps and adenomas too
large to remove endoscopically, LPHPD may be the optimal “amount” of surgery,
because such lesions are at risk for under treatment (partial endoscopic
resection associated with recurrence) or overtreatment (Whipple associated with
significant morbidity and unnecessary loss of functional pancreatic parenchyma).
Patient:
A
80-year-old healthy female patient was diagnosed on endoscopy with 2 flat,
symptomatic adenomas (7cm D2; 2cm D3). She had no family history of polyposis
and germline testing, tumor markers and colonoscopy did not show any
abnormality. Technique:
With
the patient in French position, a wide laparoscopic Kocherization was performed
past IVC and aorta. Following prepyloric gastric transection the duodenum was
carefully dissected off the pancreas. After transection of the proximal
jejunuem, a two-layer duct-to-mucosa ampullary-jejunal anastomosis and a
gastrojejunostomy were performed. Conclusion:
LPHPD
avoids under- or overtreatment of benign duodenal lesions unamendable to an
endoscopic approach. If the stepwise approach described in this video is
followed, LPHPD represents a safe and parenchymal-sparing alternative to
pancreaticoduodenectomy for benign duodenal lesions with reduced morbidity. |
VP02-18 | Dissection of Porta Hepatis in Laparoscopic Pancreaticoduodenectomy: How I Do It Hee Joon Kim, Korea, Republic of
H.J. Kim1, Y.H. Lee2, Y.H. Hur2, Y.S. Koh2, C.K. Cho2 1Division of HPB Surgery, Department of Surgery, Chonnam National University Hospital, Korea, Republic of, 2Division of HPB Surgery, Department of Surgery, Chonnam National University Hwasun Hospital, Korea, Republic of
Introduction: Porta hepatis dissection in laparoscopic
pancreaticoduodenectomy (LPD) is a very important step for safe surgery and oncologic
outcome. Herein, I share my technique of porta hepatis dissection in LPD. Method: A 47-year-old male presented with
incidentally detected ampullary adenoma, which is unsuitable for endoscopic
papillectomy on EUS finding. Five trocars are used. At first, the right gastric
vessels are divided, then, anterior surface of CBD and gastroduodenal artery is
exposed. After division of gastroduodenal artery, portal vein is exposed and
soft tissue around the hepatic artery is dissected. The common hepatic duct is
divided at right hepatic artery level. The portal vein is skeletonized, then,
upper border of hepatoduodenal ligament is resected. Dissected lymph nodes are
removed at the last step of SMA dissection with en bloc fashion. Result: Operation time was 425 minutes, and
estimated blood loss was 400 ml. The patient discharged on postoperative days 9
without any complication. Conclusion: With this technique, porta hepatis dissection
can be achieved with safety. |
VP02-19 | Robotic Simultaneous Pancreaticoduodenectomy and Distal Pancreatectomy (RSPDDP) with Preservation of Central Pancreas Shin-E Wang, Taiwan, Republic of China
S.-E. Wang1,2, Y.-M. Shyr1,2, S.-C. Chen1,2, B.-U. Shyr1,2 1General Surgery, Taipei Veterans General Hospital, Taiwan, Republic of China, 2National Yang Ming University, Taiwan, Republic of China
This
video is to present an
unique technique by robotic simultaneous pancreaticoduodenectomy and distal
pancreatectomy (RSPDDP) with preserving the central pancreas for a
68 year old female presenting two asymptomatic tumors separately in pancreatic
head and body-tail by routine health check with sonography. The lab data were not
remarkable, including CEA 4.5 ng/ml, CA-199 18.38 U/ml, amylase 141 U/L, lipase
21 U/L, fasting blood sugar 109 mg/dl, HbA1c 6.0%, C-peptide 1.59 ng/mL. CT
scan showed 2.3 cm tumor at pancreatic uncinate process and 3.4 cm tumor at
pancreatic body-tail. MRI revealed 3.6 x 2.3 cm mass at pancreatic uncinat
process and another 3 cm mass at pancreatic body-tail. Tumor growth such as
acinar cell carcinoma, neuroendocrine tumor or adenocarcinoma was considered. To
avoid total pancreatectomy, SRPD-RDP with preservation of 3.8 cm central
pancreas was successfully performed with console time 480 minutes and blood
loss 6 c.c. on August 21, 2018. The pathological examination revealed a 3.8 x 3
cm G1 NET at pancreatic uncinate process, another 3.2 x 2.5 cm G2 NET at
pancreatic body-tail, and no lymph node involvement (0/24; 0/15). Post-operative
C-peptide was 1.45 ng/mL on postoperative day (POD) 1 and 1.11 ng/mL on POD 7. Patient
recovered uneventfully and was discharge on POD 10. Patient has been under oral
medication for blood sugar control with Glucohage (Metformin)
500mg po tid and Januvia (Sitagliptin) 100 mg po qd. The 1-year follow-up
fasting blood sugar, HbA1c and C-peptide were within normal limits, 111 mg/dL,
5.6% and 1.11 ng/mL respectively. |
VP02-21 | Laparoscopic Transduodenal Ampullectomy for Ampullary Tumor Eric Herrero, Spain
E. Herrero1, M.I. Garcia-Domingo1, J. Camps1, L. Martinez1, A. Rodríguez2, E. Cugat1 1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain
Introduction: Ampullary tumors are rare and are usually treated by pancreaticoduodenectomy (PD).
In selected cases, such as benign lesions as adenomas or malignant in situ lesions, conservative resection of the ampullary tumor could be an alternative. PD should be completed if the histopathological study of the specimen shows invasive tumor.
Method: The case of a 78-year-old patient admitted for jaundice is presented. Abdominal CT and USE showed a well defined solid nodular lesion in Vater's ampula. Preoperative biopsy showed no signs of malignancy. In a multidisciplinary committe it was decided to perform a resection of the lesion and histopathological analysis of the specimen, and in case of invasive malignancy complete the PD.
Results: The video shows the surgery performed. Macroscopic characteristics of the papillary lesion can be observed through the image of the choledocoscopy and allowed to locate the papilla and perform the duodenotomy in the appropriate place.
After the duodenotomy and papilla location, a Fogarty catheter was introduced through it and allowed to pull the papilla to facilitate dissection. Ampullary resection was performed identifying the Wirsung duct at the level of the pancreatic margin and the distal bile duct. The two ducts were reimplanted into the duodenum. Postoperative course was correct being the patient discharged on the fourth postoperative day.
Definitive pathological findings were compatible with low-grade dysplasia ampullary adenoma.
Conclusions: Laparoscopic resection of ampullary tumors is feasible and safe in selected cases.
PD should be completed if the histopathological study of the specimen shows invasive tumor. |
VP02-22 | Laparoscopic Uncinate Process Excision with Infra-ampullary Segmental Duodenectomy for Pancreatic Net M Srinivasan, India
M. Srinivasan1, S. Srivatsan Gurumurthy1, P. Senthilnathan1, V. Nalankilli2, N. Anand Vijai2, C. Palanivelu1 1Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India, 2Gem Hospital, India
A 40 yr old male presented with upper abdominal
pain for 2 months. CECT abdomen revealed 1.8 x 1.3 cm hypodense lesion with
arterial enhancement in uncinate process of pancreas s/o NET. 68Ga-DOTANOC PET
CT confirmed the finding and EUS-FNB confirmed a grade 1 PNET. Hence, he was
planned for a laparoscopic uncinated process excision. Under GA, patient in
supine position, painted and draped. Pneumoperitoneum created by veress needle
(closed method). Ports placed. Findings confirmed. DJ flexure mobilized and
Gastrocolic omentum incised and lesser sac entered. Duodenum kocherized.
Inferior border of uncinate process dissected carefully. Transection of DJ
flexure done and D3, D4 dissected away from uncinate process upto D2. Uncinate
process dissected from superior mesenteric vein. Under Intraoperative USG
guidance, Localisation of tumour confirmed and uncinate process transected
using harmonic scalpel. D2-D3 junction transected. Inferior cut margin of pancreatic
head sutured with 3-0 PDS continuous suture. Duodenojejunostomy done with Endo
GIA white stapler and stapler rent suture closed with 3-0 PDS. Perfect
hemostasis secured. Specimen removed using endobag. Port sites closed. HPE was
reported as well differentiated neuroendocrine tumour. Patient had a postoperative
pancreatic leak and fistula which settled with conservative management. |
VP02-23 | Robotic Median Pancreatectomy with Distal Stump Pancreaticojejunostomy in Solid Pseudopapillary Neoplasm (SPEN) (Da Vinci Xi Surgical System) Aamir Parray, India
A. Parray, M. Bhandare, V. Chaudhari, S. Shrikhande Surgical Oncology, Tata Memorial Hospital, India
Objective: To present a
systematic approach and operative technique to Robotic Median Pancreatectomy
with Distal Stump Pancreaticojejunostomy.
Methods: We present a
case of a 39-year-old lady with no comorbidities who presented with abdominal
pain. After initial ultrasound of abdomen, triphasic CT Scan of the abdomen
(pancreas protocol) revealed pancreatic body mass 4cm x 4cm solid/cystic in
nature. CA19-9 was 4.8 and fine needle aspiration cytology revealed features of
SPEN. We performed Robotic Median Pancreatectomy with Distal Stump
Pancreaticojejunostomy.
Results: The procedure was performed in 360 minutes with a blood
loss of 100ml. Postoperatively patient developed biochemical pancreatic leak
managed conservatively. Histopathology report showed SPEN, all margins were free
of tumor (R0 resection).
Conclusions: Minimally invasive pancreas sparing surgery is preferred
option for tumours like SPEN located in pancreatic body. |
VP02-24 | 8 Tips to Make the Reconstruction Phase During Laparoscopic Pancreaticoduodenectomy Easier Dominic Sanford, United States
D. Sanford1, W. Hawkins2, H. Asbun3 1Hepatobiliary and Pancreatic Surgery, Washington University, United States, 2Washington University in Saint Louis, United States, 3Miami Cancer Institute, United States
Introduction: The reconstruction phase of laparoscopic pancreaticoduodenectomy is technically challenging. The purpose of this video is to demonstrate 8 simple steps that are independent of laparoscopic surgical ability, which can help facilitate the reconstruction phase during laparoscopic pancreaticoduodenectomy. Methods: We used operative videos with and without using these simple steps to demonstrate how these methods can greatly facilitate the reconstruction phase of pancreaticoduodenectomy. Results: These steps are as follows: 1) Cut the back wall of the bile duct longer than the anterior wall; 2) Sew the hepaticojejunostomy standing on the right side of the patient; 3) Leave a clamp on the bile duct while sewing the hepaticojejunostomy; 4) Dissect out the pancreatic duct and cut it longer than the parenchyma; 5) Use pancreatic duct stents prior to stitch placement during pancreaticojejunostomy; 6) Use stay sutures to facilitate stitch placement during pancreaticojejunostomy; 7) Split the greater omentum vertically to facilitate duodeno- or gastrojejunostomy; 8) Control the location of the duodeno- or gastrojejunostomy with a stay suture. Conclusion: We believe that these 8 simple steps can be used by any pancreatic surgeon to improve the ease of reconstruction during pancreaticoduodenectomy and improve patient outcomes. |
VP02-25 | Laparoscopic Distal Pancreatectomy and Splenectomy after Neoadjuvant Chemotherapy: New Demands in Complex Procedures Nuno D Machado, Portugal
N.D. Machado1, F. Kunzler Maia2, N. Lad3, L.M. Dominguez4, K.-W. Ma5, R.E. Jimenez3, H.J. Asbun3 1Centro Hospitalar do Tâmega e Sousa, Portugal, 2Miami Cancer Institute, United States, 3Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, United States, 4General Surgery, Hospital of Povisa, Spain, 5Queen Mary Hospital, the University of Hong Kong, Hong Kong
Introduction: Neoadjuvant therapy is being increasingly utilized in pancreatic ductal adenocarcinoma (PDAC) and significant responses to therapy have been observed. The feasibility and safety of the laparoscopic approach in this subgroup of patients is not yet established. Methods: A 77-year-old man was diagnosed with borderline resectable PDAC. The tumor was 4 cm in size, located in the pancreatic neck and proximal body, encasing the origin of the splenic artery and with significant abutment of the celiac bifurcation along with the left lateral aspect of the common hepatic artery, and the head of the pancreas. Mild encasement and narrowing of the portosplenic confluence was also noted. The patient underwent 5 cycles of FOLFORINOX with minimal response. Hence, additional 5 cycles of Gemcitabine/Paclitaxel were administered to which he responded well. A significant tumor regression was noted. After 8 months of neoadjuvant chemotherapy, he underwent laparoscopic extended distal pancreatectomy with splenectomy. Results: This video demonstrates the technical challenges and the need of significant expertise on these cases. It also illustrates the particular advantages of the magnification and exposure afforded by the laparoscopic approach, which confers a meticulous dissection to preserve the main vascular structures in a severely desmoplastic, post-neoadjuvant field. Conclusion: Minimally invasive distal pancreatectomy is feasible in patients with locally advanced PDAC who demonstrate good response and tumor regression after neoadjuvant chemotherapy. Laparoscopically enhanced visualization is particularly important in these cases. There are different techniques and methods that can be used to overcome the challenges imposed by the post-neoadjuvant fibrosis and inflammation. |
VP02-26 | Laparoscopic Pancreatoduodenectomy in Patient with Common Celiac-Mesenteric Arterial Trunk Eric Herrero, Spain
J. Camps1, E. Herrero2, M.I. Garcia-Domingo2, L. Martinez2, A. Rodríguez3, A. Pedrerol4, J.A. de Marcos4, E. Cugat2 1Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 3Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 4Radiology, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain
Introduction: Pancreatoduodenectomy (PD) is the surgical treatment of ampullary, duodenal or pancreatic tumors. Laparoscopic PD, due to its technical difficulties, is still not widely accepted . In this type of surgery, special care should be taken in vascular anatomical variants. The common origin of the celiac trunk and the superior mesenteric artery has been described in only 1% of the population. Material and methods: This is a 67-year-old patient admitted for obstructive jaundice. MRI reported dilatation of the intrahepatic and extrahepatic bile ducts, as well as the Wirsung duct to the region of the papilla without clear evidence of obstruction. Endoscopic ultrasound demonstrated a hypoechoic solid nodular lesion at duodenal papilla (18x13 mm). Abdominal CT scan showed an arterial anatomical variant with common celiac-mesenteric trunk. Results: The video show the resection and the reconstruction phase of the laparoscopic PD. Reconstruction was performed according to the Child technique with termino-lateral Wirsung-jejunostomy in 2 planes with barbed suture, termino-lateral hepaticojejunostomy, and antecolic latero-lateral gastrojejunostomy. The specimen was withdrawn by supraumbilical incision of 5cm. The postoperative course was uneventful, drains were removed after 4 days, and a hospital stay was 8 days. Pathology showed an adenocarcinoma (TNM stratification: T1 N0 / 15 M0). Conclusions: Laparoscopic PD is feasible and can be performed safely despite arterial anatomical variations. However, the same oncological principles as open surgery should be observed. This complex surgery should be performed in specialized centers with experience in both hepatobiliopancreatic surgery and minimally invasive surgery. |
VP02-27 | Pancreatic Reconstruction Techniques after Laparoscopic PD Eric Herrero, Spain
E. Herrero1, F. Pardo2, L. Martinez1, J. Camps1, M.I. Garcia-Domingo1, J. Navines2, A. Rodríguez3, E. Cugat1,2 1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2HPB Surgery Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain, 3Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain
Introduction: Pancreatic fistula remains one of the main problems in the postoperative course of pancreaticoduodenectomy (PD). Many techniques have been described for pancreatic reconstruction to minimize the risk of a pancreatic fistula. The aim of this video is to show the laparoscopic technique of pancreaticogastrostomy and pancreaticojejunostomy after PD. Method: Three diferent reconstruction techniques are presented in this video. End to side wirsung jejunostomy, mainly used in cases with dilated pancreatic duct and hard pancreatic tissue.
Double and single end to side gastrojejunostomy, which is preferred in those cases where small duct diameter and soft pancreatic tissue is present. Results: Pancreatic reconstruction after PD in open surgery may be performed in different ways according to pancreas tissue characteristics, pancreatic duct diameter and extend of the pancreas resection. The same principles should prevail when performing laparoscopic PD, so it is important to know different laparoscopic reconstruction techniques. Conclusions: Laparoscopic PD is feasible and safe. Should be performed in centers with experience both in laparoscopic and pancreatic surgery. Pancreatic reconstruction techniques should be adapted to Intraoperative pancreas characteristics. |
VP02-28 | Laparoscopic Total Pancreatectomy for Pancreatic Metastasis from Renal Cell Carcinoma Safi Dokmak, France
S. Dokmak, N. Peru, B. Aussilhou, F.S. Ftériche, O. Soubrane, A. Sauvanet HBP Departement and Liver Transplantation, Beaujon Hospital, France
Introduction: Total pancreatectomy (TP) can be indicated for metastases
from clear renal cell carcinoma (CRCC) in selected patients without distant
metastases and controlled local disease by anti-tumoral therapy or favorable
natural history (1). Extensive lymphadenectomy is not necessary because the
risk of lymph node metastasis is < 15 % (2). TP can be difficult because of
the necessity of monobloc resection
and adhesions of the pancreas in the surgical field of nephrectomy. For
malignancy, laparoscopic TP was mainly reported as cases reports because
indications are limited and technically demanding (3-5).
Patients
and methods: A 65-year old male
underwent “en monbloc” laparoscopic
TP with pylorus and spleen preservation but without splenic vessels
preservation for metastasis CRCC, 10 years after left renal nephrectomy. Surgery
lasted 300 minutes with 1000 ml of blood loss and transfusion of 1 unit of
blood.
Results: No postoperative surgical complications, 14 days of
hospital stay and discharged to diabetology department. Histology confirmed the
diagnosis of metastasis from CRCC (Fuhrman 3) involving all the main pancreatic
duct infiltrating the tail without vascular invasion Tx N0 (0/37) M1 R0.
Between 2008-2019 and among the 600 patients who had laparoscopic pancreatic
resections, four (< 1%) underwent “en
monobloc one step” laparoscopic TP for IPMN (n=2), diffuse neuroendocrine
tumor (n=1) and pancreatic metastases (n=1).
Conclusion: The laparoscopic approach is a good indication for TP
related to the absence of pancreatic anastomosis and associated complications
and the benefits because TP is indicated in patients with non-aggressive
disease and good long term prognosis. |
VP02-29 | Combined Laparoscopic and Robot-assisted Pancreaticoduodenectomy with en bloc Vein Resection and Bovine Pericardium Repair Amy Li, United States
A. Li, J. Bergquist, B. Visser Stanford University, United States
Minimally invasive pancreaticoduodenectomy (PD) has been found to be technically feasible and safe when compared to open PD. However, open approach remains the standard for PD with venous resection and reconstruction. This video presents a hybrid approach combining laparoscopy and robot-assistance to perform PD with vascular resection/reconstruction. En bloc resection of the SMV wall with patch reconstruction was performed for unexpected vascular involvement found intraoperatively. This is the case of a 57-year-old female who presented with obstructive jaundice, found to have a 3 cm stricture in the distal common bile duct, biopsy demonstrating adenocarcinoma. No focal mass or vascular involvement seen on preoperative imaging. She then underwent minimally invasive PD. Four 5mm trocars were placed at the umbilicus, right and left mid-clavicular line, and right anterior axillary line at the level of the umbilicus. A gelport and 12mm trocar were placed through a Pfannenstiel incision as the assistant port. The procedure started as expected with identification of the SMV, Kocherization and dissection of the porta hepatis. As the pylorus was adherent to the pancreatic neck, classic PD was performed. The pancreas was divided with laparoscopic scissors and selective cautery. The tumor was unexpectedly involving the right lateral wall of the SMV. En bloc resection and reconstruction was performed with robot assistance. The 5mm trocars were upsized to 8mm ports. Primary closure was not possible without tension so reconstruction was performed with bovine pericardial patch repair. Reconstruction of Blumgart-style pancreaticojejunostomy, hepaticojejunostomy and gastrojejunostomy were completed as expected. |
VP02-30 | Robotic Pancreaticoduodenectomy for Cystic Neoplasm Head of Pancreas - Rubber Band Traction Technique S Srivatsan Gurumurthy, India
S. Srivatsan Gurumurthy, M. Srinivasan, P. Senthilnathan, C. Palanivelu Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India
A 24 year old female
presented with upper abdominal pain for one month. CECT abdomen revealed a 3.5 x 3.8 cm heterogenous mass with cystic areas in Head of pancreas indenting the portal vein
possibility of SPEN / SCN / NET. Tumour markers and serum chromogranin were
normal. She was taken up for Robotic Pancreaticoduodenectomy. Under GA, patient
in supine position, ports were placed. Left lobe of liver and gall bladder
retracted by hitch-stitch technique. Da vinci Si robotic system was docked. Kocherization
done. Right posterior SMA first approach done, SMA visualised and found to be free.
Tunneling done. Pancreas mobilized. Duodenum divided with endo GIA stapler. GDA
identified, doubly clipped and divided. Jejunum divided in supra-colic
compartment with endo GIA stapler. Rubber band traction applied to cut end of
pancreas and jejunum and uncinate disection done. IPDA and IPDV. Clipped and
divided. Specimen removed after transecting CBD. Pancreatico jejunostomy was
done by modified blumgart technique. Hepatico jejunostomy was done using 4-0
PDS and Duodeno jejunostomy using 3-0 PDS continuous sutures. Wash given and DTs
placed after complete hemostasis. Patient had an uneventful recovery. HPE was
reported as well differentiated neuroendocrine tumour grade 2. |
VP02-31 | Laparoscopic Splenic Vein Preserving Distal Pancreatectomy Pravin Suryawanshi, India
P. Suryawanshi1, M. Tantia2 1Surgery, MGM Medical College & Hospital, India, 2General Surgery, MGM Medical College & Hospital, N-6, Cidco, India
Introduction: Traditionally, tumours involving distal
pancreas are treated with distal pancreatectomy which involves splenic
resection due to dense adherence to splenic vessels. Laparoscopy offers
superior access to retroperitoneal structures and increased magnification, enabling surgeons to perform spleen and
splenic vein preserving distal pancreatectomy. This procedure, results in lesser
postoperative pain and decreased hospital stay, and preserves the immune
functions of spleen.
We present a case of a distal pancreatic tumour, managed
successfully with laparoscopic spleen preserving distal pancreatectomy.
A 16 year old female
presented with c/o intermittent, epigastric pain radiating to back associated
with vomiting after meals. Examination findings were non-specific. Further investigation
with CECT was s/o a well defined cystic lesion arising from tail of pancreas
abutting and displacing greater curvature of stomach with absent vascularity
and nonenhancement. Methods: Patient
underwent Laparoscopic spleen and splenic vein preserving distal pancreatectomy
with complete excision of the tumour over
2 hours duration and intraoperative minimal blood loss. Splenic vessels,
although densely adhered to the tumour were freed and preserved with meticulous
dissection, pancreas was divided with vascular endostapler with prefiring prolong
compression. Histopathology of tumour s/o
solid pseudopapillary cyst of pancreas. Result: Postoperative
recovery was uneventful, with no pancreatic leak and patient discharged on post
op day 10, on regular follow up.
Conclusion: Laparoscopic
splenic vein & spleen preserving distal pancreatectomy is a feasible method
for treating lesions arising from the distal pancreas in the hands of an
experienced laparoscopic surgeon. |
VP02-34 | Robotic Pancreaticoduodenectomy (Open Surgery Done through Small Incisions). Totally Robotic with no Assistance (Single Surgeon at Console) Imran Siddiqui, United States
I. Siddiqui Surgical Oncology and HPB Surgery, Hartford Healthcare St. Vincent Medical Center, Bridgeport, United States
Introduction: Minimally invasive pancreaticoduodenectomy has been found to be safe and effective. Oncologic outcomes are similar to open surgery. Less pain and earlier functional recovery are advantages. Longer operative times and need for two HPB experienced surgeons are traditional criticisms. We demonstrate a simple video describing performing the procedure without need for expert bedside assistance Method: Extrapolating open whipple techniques from dividing the gastrocolic omentum to mobilizing the hepatic flexure of colon to kocherization of the duodenum to performing the porta hepatis dissection, dividing the duodenum, dissection of the inferior border of pancreas and development of retropancreatic tunnel and ligation of GDA, dividing the jejunum, SMA dissection, uncinate mobilization, periportal and peripancreatic lymphadenectomy and division of pancreas and bile duct and cholecytectomy with eventual removal of specimen and proceeding with reconstruction performing pancreticojejunostomy in a duct to mucosa fashion followed by hepaticojejunostomy and then duodenojejunostomy. The entire whipple procedure is performed meticulously using techniques identical to open surgery. This allows reproducibility and ease of teaching. It also allows true comparison of outcomes between the two types of whipple surgery. Results: The surgical procedure is demonstrated in the video and audio feed can be provided live to describe the steps. The ability to articulate using fine robotic instruments allows one to perform this complex procedure with relative ease in a minimally invasive fashion. Conculsion: Robotic pancreaticoduodenectomy can be performed using a single surgeon at console with minimal assistance and without compromising principles of open oncologic surgery. |
VP02-35 | Laparoscopic Total Pancreatectomy for a Case of Pnet in the Background of Men 1 S Srivatsan Gurumurthy, India
S. Srivatsan Gurumurthy1, M. Srinivasan1, P. Senthilnathan1, V. Nalankilli2, N. Anand Vijai2, C. Palanivelu1 1Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India, 2Gem Hospital, India
28
Yr old male, a k/c/o MEN 1 syndrome post open distal pancreatectomy with
splenectomy for NET in tail of pancreas 2 years ago presented with multiple
recurrent lesions in pancreatic head and the stump on DOTANOC PET CT on
followup. Hence, he was planned for a Laparoscopic total Pancreatectomy.
Under
GA, patient in supine position and leg split, ports placed. Adhesions released
between stomach and pancreas. Tumor nodules noted in the head, uncinate process
and remnant tail of pancreas. Duodenal Kocherization done. Pancreas stump
completely mobilized. Duodenum divided with Endo GIA stapler. GDA doubly
clipped and divided. Pancreas dissected off splenic vein. Splenic vein clipped
and divided. Proximal jejunum divided with Endo GIA Stapler. Uncinate dissection
done. Bile duct divided and specimen removed via umbilical incision. Hepaticojejunostomy
done with 4-0 interrupted sutures. Duodenojejunostomy done with 3-0 PDS and NJ
tube placed. Two DTs placed. Complete hemostasis achieved and port sites
closed. Postoperatively, he was managed in ICU for 4 days and glycemic control achieved
by insulin
infusion and 2 hrly CBG monitoring. He had ketosis for 2 days and
a transient bile leak from POD 4 which conservatively settled and was discharged on
POD 12. HPE of
the specimen revealed multiple well differentiated NET nodules in the pancreas. |
VP02-36 | Laparoscopic Total Pancreatectomy for Neuroendocrine Tumor in a Patient with Neurofibromatosis Filipe Kunzler Maia, United States
G. Verasay1, F. Kunzler Maia2, N. Lad3, R.E. Jimenez3, H.J. Asbun3 1Hospital Público Materno-Infantil, Argentina, 2Miami Cancer Institute, United States, 3Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, United States
Introduction: Neurofibromatosis is associated with an increased susceptibility to tumors, including neuroendocrine tumors. Method: A 43 y-o M patient with neurofibromatosis presented to the emergency department with abdominal pain. Imaging of the abdomen elucidated a mass in the head of the pancreas, with retrograde dilation of the main pancreatic duct and pancreas atrophy. The patient was not diabetic but the only healthy pancreatic tissue was present in the head of the pancreas and, besides having the atrophic body and tail of the pancreas, the patient also had two cystic lesions, likely representing dilatations of the main pancreatic duct. A biopsy confirmed the mass to be a low grade neuroendocrine tumor. The case was presented in tumor board, and a decision was made to proceed with a total pancreatectomy. The patient underwent preoperative diabetes trannn. Results: The patient underwent a laparoscopic total pancreatectomy and had an uneventful recovery. He was able to be discharged on the 5th postoperative day. Conclusion: Total pancreatectomy might be a valuable operation for patients that have multifocal lesions, with at least one of them confirmed for pancreatic cancer. |
VP02-37 | Laparoscopic Resection of Synchronous Gastric and Pancreatic Adenocarcinomas Ignacio Miranda, Chile
I. Miranda1, E. Buckel G2, E. Buckel Sch2, F. Puelma2, R. Funke2, N. Jarufe2 1Clinica Alemana de Santiago Las Condes, Chile, 2Clinica las Condes, Chile
The video shows a total gastrectomy + corporocaudal pancreatectomy with splenectomy, all by laparoscopy. A 62-year-old patient who consulted for abdominal pain and was studied with upper gastrointestinal endoscopy that demonstrated a Bormann III type ulcer in body of the stomach whose biopsy confirmed a gastric adenocarcinoma. In the staging study with PET CT, a solid lesion appears in the body of the pancreas compatible with pancreatic adenocarcinoma type tumor. In the video it is possible to see details of the total gastrectomy, lymph node dissection, oncological resection of the body and tail of the pancreas and the reconstruction in Roux en Y eophageal-jejunal transit. The whole procedure was done by mini-invasive way. Biopsies of the surgical specimens confirmed the presence of 2 primary tumors, gastric (T1bN0M0) and pancreatic (T2N0M0) with negative lymph nodes. |
VP02-38 | Laparoscopic Parenchyma-Sparing Enucleation for Ipmn in Uncinate Process Eric Herrero, Spain
E. Herrero1, M.I. Garcia-Domingo1, J. Camps1, L. Martinez1, L. Hernandez1, M. Arias1, A. Rodríguez2, E. Cugat1 1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain
Introduction: Intraductal papillary mucinous neoplasms (IPMN) are common cystic neoplasms of the pancreas. The development of diagnostic techniques results in an increasing number of asymptomatic patients diagnosed with IPMN. Laparoscopic parenchyma-sparing pancreatectomies (LPSP) should be taken into account in this patients.
Method: A 55 year-old woman who presented with abdominal pain. A CT scan revealed a cystic tumour located in the uncinate process of the pancreas. This was confirmed by MRI. Finally, USE showed a multiloculated cystic neoplasm suggestive of secondary branch IPMN measuring 30 mm with no signs of malignancy. In MDT committee a LPSP was decided. Results: The video shows the laparoscopic procedure of enucleation of the IPMN until the secondary branch is reached and ligated. Gallbladder stones were diagnosed by USE so a cholecystectomy was also performed. The patient developed a pancreatic leak in the postoperative period requiring a percutaneous drainage to solve it. Pathology confirmed an IPMN with low grade dysplasia.
Conclusion: Laparoscopic parenchyma-sparing pancreatic resections for non-invasive IPMN's is feasible and may avoid standard resections with better preservation of pancreatic functions. |
VP02-39 | Laparoscopic Total Pancreatosplenectomy for Diffuse Mixed-type IPMN Alejandro Brañes, Chile
A. Brañes, E. Briceño, M. Dib, J. Martínez, N. Jarufe Digestive Surgery, Pontificia Universidad Catolica de Chile, Chile
A 78-year-old patient with a past medical history of type-2 DM and morbid obesity presented with a one-month history of abdominal pain, anorexia and weight loss. Imaging study revealed a diffuse mixed-type IPMN with main pancreatic duct dilation. A laparoscopic total pancreatosplenectomy was performed. Postoperative recovery was uneventful and patient was discharged at PO day 5. Total pancreatosplenectomy is an infrequently done procedure. Minimally invasive surgery is a safe and replicable option for these patients, which may offer a shorter postoperative recovery. |
VP02-41 | Laparoscopic Pancreaticoduodenectomy: How I Do It? Safi Dokmak, France
S. Dokmak, B. Aussilhou, F.S. Ftériche, O. Soubrane, A. Sauvanet HBP Departement and Liver Transplantation, Beaujon Hospital, France
Introduction:
Laparoscopic pancreatoduodenectomy (LPD) is more frequently performed and the
surgical basis are not similar to open pancreatoduodenectomy (OPD). We present our surgical technique and results.
Patients
and methods: Vascular invasion, pancreatitis and fatty pancreas are the main
contraindications. The most important technical points include: Identification of the mesentericoportal vein
(MPV) to control and section the right gastroepiploic vein before performing
the Kocher manoeuvre. Rapid sectioning of the bile duct and traction on the
main vessels for better exposure and to facilitate lymphadenectomy. The
gastroduodenal artery is stapled after dividing the stomach and pancreas and
lymphadenectomy of the hepatic pedicle is completed. For the retroportal lamina
tissue, the specimen is completely turned to the left side to free the surgical
field and to dissect the right side of the mesenteric vessels. In complicated
cases, difficult areas are dissected at the end. Traction on MPV help to
dissect the right side of the superior mesenteric artery and the celiac trunk.
Results:
Between 2011-2018, we performed 130 LPD. Surgery lasted a mean 328 mn
(225-540), mean blood loss was 290 ml (20-1200), transfusion (11; 9%) and
conversion (9; 7%). Ninety-day mortality (5. 3.8%), PF (B and C) (40; 30%),
biliary fistula (16; 12%), bleeding (21; 16%), delayed gastric emptying (16;
12%), re-interventions (18; 14%), and a hospital stay
of 24 days (2-104).
Conclusion:
Compared to the open approach, the laparoscopic approach should be used with certain
technical manoeuvres to perform LPD with an acceptable time, low conversion
rate and acceptable outcome. |
VP02-42 | Laparoscopic Pancreaticoduodenectomy with Totally Intracorporeal Hand-Sewn Anastomoses: Feasibility and Effectiveness Andrea Benedetti Cacciaguerra, Italy
A. Benedetti Cacciaguerra1, B. Gorgec1, A. Suhool2, R. Aljarrah2, M. Abu Hilal1 1Poliambulanza Foundation, Italy, 2University Hospital Southampton, United Kingdom
Background: Whipple procedure has been described since 1935, using classic open
surgery.
Pancreaticoduodenectomy (PD) is a complex procedure, associated with a
definite risk of mortality and 30-50% risk of complications. With the rising of
minimally invasive surgery (MIS), it has been described to be feasible using
the latest technology. In this video the authors report a full Laparoscopic
Whipple procedure, performing the three anastomoses by a totally intracorporeal
method.
Video: A 65-year-old
woman who presented an ampullary carcinoma infiltrating the pancreatic
parenchyma underwent to a Laparoscopic Pancreaticoduodenectomy.
Preoperative
staging showed a tT3N1M0 tumour. The postoperative course was uncomplicated
with a regular hospital stay. The histologic findings showed an ampullary
cancer with free resection margin (R0, pT3N2M0). |
VP02-44 | Exposure of Operative Fields in Laparoscopic Distal Pancreatectomy for Pancreatic Cancer by Using Hanging Tapes and Endo Retract ⅡTM Kimitaka Tanaka, Japan
K. Tanaka, Y. Ebihara, T. Nakamura, K. Okamura, Y. Nakanishi, T. Asano, T. Noji, T. Tsuchikawa, S. Hirano Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Japan
Introduction: In laparoscopic distal pancreatectomy (LDP) for pancreatic cancer, an adequate surgical margin on the retroperitoneal side and gentle manipulation of the pancreas containing the tumor is important. Here we report how to use Endo Retract IITM (ERⅡ) to create a stable operative field, and to use a hanging tape to retract the pancreas. Settings: The camera is inserted from umbilical port. The operator stands between the patient's legs and places ports in the co-axial position. One assistant's forceps are used from the left abdomen. ERⅡ is inserted from the epigastric region. Procedures: 1) The retroperitoneum is cut at the beginning of the jejunum. The inferior vena cava, left renal vein, and adrenal vein are exposed by the ligament of Treitz approach. During this procedure, the transverse colon is kept in cranial and ventral side of the operative field using ERⅡ. 2) During lymph node dissection around hepatic and splenic arteries, the distal and proximal stomach are evacuated with a hanging tape and ERⅡ respectively for making good exposure around celiac artery. 3) After division of the pancreas and its vessels, we dissect the left side of superior mesenteric artery toward the dorsal side, and then connect it to the cavity which has already dissected in the first step. 4) The fornix of the stomach is pushed up with ERⅡ, and the splenic hilum is encircled and retracted with a hanging tape. Conclusion: By using these techniques, it was possible to reduce the operation time of LDP for pancreatic cancer. |
VP02-45 | Laparoscopic Spleen Preserving Distal Pancreatectomy for a Solid Pseudopapillary Tumour Kunal Joshi, United Kingdom
K. Joshi, R. Sutcliffe, R. Marudanayagam, J. Issac, K. Roberts, N. Chatzizacharias, D. Bartlett, P. Muiesan, D. Mirza HPB and Liver Transplantation, Queen Elizabeth Hospital University Hospitals Birmingham NHS Foundation Trust, United Kingdom
We report the case of a 17 year old girl who presented with abdominal pain and deranged liver function tests. A CT scan identified a 5.1cm heterogenous pancreatic body mass and an EUS-guided biopsy confirmed the diagnosis of solid pseudopapillary tumour. She was counselled and consented for laparoscopic spleen-preserving distal pancreatectomy. After division of the gastrocolic omentum and mobilisation of the splenic flexure colon, the stomach was hitched to the anterior abdominal wall to provide access to the lesser sac. The inferior border of the pancreas was dissected to expose the superior mesenteric vein and a tunnel was developed between the pancreatic neck and SMV/portal vein. The pancreatic neck was divided using a vascular stapler. The splenic artery was encircled and the distal pancreas was dissected off the splenic vessels using Ligasure. The specimen was removed via a Pfannelstiel muscle-splitting incision. Post operatively she had a biochemical pancreatic leak but made an otherwise good recovery. Histological examination confirmed the presence of a solid pseudopapillary neoplasm of the pancreas. |
VP02-46 | Laparoscopic Spleen-Preserving Distal Pancreatectomy Eric Herrero, Spain
J. Camps1, E. Herrero1, M.I. Garcia-Domingo1, L. Martinez1, M. Arias1, A. Rodríguez2, E. Cugat1 1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain
Introduction: Laparoscopic distal pancreatectomy is the standard procedure for a benign and malignant pancreatic tumour located in pancreatic body and tail.
Avoiding splenectomy has progressively been recommended in selected cases. Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) has become a standard technique for benign and low-grade malignant tumours in the distal pancreas. Methods: A 70 year-old woman with diabetes and nephrolithiasis consulted for casual find of cystic neoplasm of pancreatic body in a CT scan.
USE and MRI confirmed a 30 mm IPMN with pancreatic tail atrophy and pancreatic duct dilatation. Results: The video shows the laparoscopic surgical procedure and different technical issues.
A distal pancreatectomy with preservation of the spleen and the splenic vessels is performed.
Pathology confirmed an IPMN measuring 34 mm with low grade dysplasia and no signs of malignant transformation.
Postoperative course was uneventful and hospital stay was 4 days. Conclusion: Evolution of imaging technology has lead to improved detection rate of asymptomatic pancreatic tumours allowing to perform early surgical resection for pancreatic lesions before malignancy is developed. In these cases, spleen preservation must be taken into account.
LSPDP is a feasible and safe technique with low morbidity and may be the standard procedure for benign and low-grade malignant tumours. |
VP02-47 | Laparoscopic Cystogastrostomy with Pancreatic Necrosectomy Rohit Dama, India
R. Dama, R. Pradeep, G. Rao, D. Reddy Asian Institute of Gastroenterology, India
Introduction: Surgical
pancreatic necrosectomy is highly morbid surgery with also some mortality.
Minimally
Invasive Surgery (MIS) management with internal drainage is less morbid,
feasible and safe.
If needed
necrosectomy can also be added - with good outcomes without any additional
morbidity
Clinical
Scenario: 55/
female with 70 days of idiopathic pancreatic necrosis and large pseudocyst in
the lesser sac with bulge in the stomach- epigastric fullness, discomfort and
occasional fever
CECT - good bulge and
minimal necrosis
Planned for lap
cystogastrostomy,
On table significant solid
debris of necrosis detected.
All tackled by MIS safely - without any significant change of
plan
Outline of the video: Video
shows the technique of laparoscopic cystogastrostomy for pseudocyst in lesser
sac opposing the stomach.
Small
incision on stomach, aspiration of liquid contents, stapled cystogastrostomy,
hemostasis and necrosectomy of the necrotic cavity, closure of stomach in two
layers and drainage - all by 4 ports
Learning
objectives: Learn
technique of laparoscopic method of internal drainage of pseudocyst
(cystogastrostomy). Stapling and suturing techniques in MIS are highlighted
Novelty
and Conclusion: During
lap cystogastrostomy if the cyst has significant necrotic material, it can
still be tacked with MIS
Procedure
by MIS is safe and has early recovery.
MIS
can be preferred mode inspite of thick necrosis and should always be attempted |
VP02-48 | 3-Port Laparoscopic Spleen-Preserving Distal Pancreatectomy Tamara Floyd, United States
T. Floyd, M. Jacobs Surgery, Ascension Providence Hospital, United States
Introduction: Laparoscopic distal pancreatectomy is now accepted treatment for benign and certain malignant pancreatic body and/or tail processes and generally performed using four to six ports. Splenic preservation avoids inherent risks associated with the post-splenectomy state, but adds surgical complexity. Methods/Technique: A 62-year old male presented with a distal pancreatic cystic lesion, elevated CEA, and atypia on cytology warranting resection. We describe our technique of three-port laparoscopic spleen-preserving distal pancreatectomy. Two 5-mm ports, placed in sub-xiphoid and left lateral subcostal positions and one 12-mm peri-umbilical port are used. A lateral-to-medial approach to mobilize pancreatic parenchyma is performed. Splenic vessel preservation dividing small branches is carried out in a medial-to-lateral approach. An endoscopic linear stapler used for pancreatic transection. Intra-operative ultrasound, regional lymphadenectomy, intra-corporeal staple line reinforcement, and drain placement are all performed with strategic use of existing port sites. Results: Successful laparoscopic spleen-preserving distal pancreatectomy was performed using a three-port approach. Operative time was 96 minutes. Estimated blood loss was 10cc. Post-operative day(POD) 2, patient was able to advance diet and transition to oral pain medications. He was appropriate for discharge POD 3, but required six-day hospitalization due to substance abuse withdrawal. Drain was removed POD 14 with no evidence of post-operative pancreatic fistula. He suffered no complications and required no readmissions. Final pathology revealed a 2cm IPMN without dysplasia. Discussion: Laparoscopic distal pancreatectomy has been shown to improve surgical outcomes. Methods to further improve outcomes is imperative. We describe a technique for safe, successful three-port laparoscopic spleen-preserving distal pancreatectomy. |
VP02-49 | Laparoscopic Cysto Jejunostomy Dhaivat Vaishnav, India
D. Vaishnav GI and HPB Surgery, Zydus Hospital, Ahmedabad, India
A 53 year old male presented with history of recurrent abdominal pain he had acute pancreatitis 10 months back. He had acute onset of weakness and hemoglobin drop 3 month back on CT scan he had splenic artery aneurysm, which was managed by coiling. due to persistent WOPN in body and tail region of pancreas, he was taken up for cystoenterostomy drainage procedure by minimally invasive technique. |
VP02-50 | Challenges in Laparoscopic Pancreatoduodenectomy Roman Izrailov, Russian Federation
I. Khatkov, R. Izrailov, O. Vasnev, M. Baychorov, P. Tytyunnik, A. Andrianov, P. Agami High-Tech Surgery, Moscow Clinical Scientific Center, Russian Federation
Tree hundred and fifteen laparoscopic pancreatoduodenectomies were performed in a single center. Herein we demonstrate the challenging cases and situations occuring during laparoscopic pancreatoduodenectomies demanding high technical skills. Among them are procedures in patient with chronic pancreatitis, previous surgeries, serious bleedings, and presence of variant anatomy. All cases were managed laparoscopically with no need to conversion. |
VP02-52 | Laparoscopic Distal Pancreatectomy with Spleen Preserving for Serous Cystadenoma of the Pancreas Aleander Voynovskiy, Russian Federation
A. Voynovskiy1, E. Krukov2, A. Chuprina2, A. Kotaev1, A. Bobin2 1Sechenov University, Russian Federation, 2Burdenko Military Clinic Hospital, Russian Federation
Background: The aim of the video
was demonstration of the technique of laparoscopic distal pancreatectomy with spleen preserving for serous cystadenoma of
the pancreas.
Methods: Patient 57 years old, was admitted to the hospital with
complaints of pain in the epigastrium. We
performed a CT scan, in which the tail of the
pancreas found mildly
heterogeneous 48 x 37 mm pancreatic tail mass centered between the stomach and
left adrenal gland. The main pancreatic duct is not dilated.
Results: We performed laparoscopic
distal pancreatectomy with spleen preserving. We used 5 trocars technique. The
tail of the pancreas with tumor was resected by line stapler after separately
dissected splenic arteria and vena. Operative
time was 160 minute. The postoperative period was uneventful. On the tenth day
after the operation, the patient was discharged.
Conclusions: Adequate patients selection (no for cancer) and surgical Kimura technique allowed to perform
laparoscopic
distal pancreatectomy with spleen preserving with good cosmetic and clinical
result. |
VP02-53 | Pancreatic Neuroendocrine Tumor of Insulinoma in Body and Tail of Pancrease Treated by Laparoscopic Distal Pancreatectomy and Splenectomy Febiansyah Ibrahim, Indonesia
F. Ibrahim Digestive Surgery Division, Departement of Surgery, University of Indonesia, Jakarta, Indonesia
Case: This is a case report of first laparoscopic
procedure done in Cipto Mangunkusumo Hospital. A sixty-eight years old female with
the previous history of recurrent hypoglycemia of unknown cause, diagnosed with
suspected for insulinoma by history taking, insulin and glucose level, and
contrast computed tomography (CT) scan.
Procedure: The tumor sized 8x6x6cm and located in body and
tail of the pancreas, first we planned to distal pancreatectomy preserving the
spleen but intra operatively the tumor infiltrating splenic vein so we deciding
to do splenectomy as well laparoscopically as well as preserving other nearby
vascular structures. The patients also assessed for preopeative and
intraoperative blood glucose measurement, especially after resection of the
tumor and showed significant increase reflecting the success of the procedure.
Conclusion: As a new emerging standard of care
done in top referral hospital of Indonesia, laparoscopic surgery will become
the new approach in managing insulinoma. The procedure can be safely done
without any intraoperative and post-operative complication, and ready to be
applied also for the next cases. |
VP02-54 | Laparoscopic Posterior RAMPS: Tips and Tricks Kunal Joshi, United Kingdom
K. Joshi, R. Sutcliffe, J. Issac, R. Marudanayagam, K. Roberts, B.V.M. Dasari, N. Chatzizacharias, P. Muiesan, D. Mirza HPB and Liver Transplantation, Queen Elizabeth Hospital University Hospitals Birmingham NHS Foundation Trust, United Kingdom
We report the case of a 68 years old lady who was found to have an incidental pancreatic body tumour with pancreatic duct dilatation on a CT which was performed to investigate respiratory symptoms. She was counselled and consented for a laparoscopic posterior RAMPS (radical antegrade modular pancreaticosplenectomy). At the time of surgery, the tumour was found to be involving the transverse mesocolon and proximal splenic vein close to its confluence with the superior mesenteric vein. After division of the gastrocolic omentum and mobilisation of the splenic flexure colon, the inferior border of the pancreas was dissected to identify the SMV. Lymphadenectomy from coeliac axis to common hepatic artery was performed. Due to the proximity of the tumour to the splenic vein/SMV confluence, the pancreatic neck was transected early to improve exposure. The splenic vessels were divided and the dissection was continued posteriorly through Gerota's fascia to expose the left renal vein and kidney. The adrenal vein was dissected, clipped and divided. The distal pancreas, spleen, left adrenal gland and Gerota's fascia were resected en bloc and removed via a 6cm lower midline incision. The patient was discharged home after four days. Histology confirmed a T2N1 (3/10 lymph nodes involved) pancreatic ductal adenocarcinoma which extended close to the splenic vein transection margin. |
VP02-55 | Robotic Pancreaticoduodenectomy Pylorus Preserving/with Antrectomy Sharona Ross, United States
S. Ross1, I. Sucandy1, T. Bourdeau2, A. Rosemurgy1 1AdventHealth Tampa, United States, 2Surgery, AdventHealth Tampa, United States
This
video demonstrates a robotic pancreaticoduodenectomy undertaken in a 79-year-old
gentleman who presented with painless jaundice.
An
8mm trocar was placed through the umbilicus for the robotic camera and two 8mm
robotic ports were placed at the right and left midclavicular lines on the same
level as the umbilicus. A fourth 8mm robotic port was placed along the anterior
axillary line on the left side halfway between the level of the umbilicus and
the costal margin. Finally, an assistant
gel port was placed between the right midclavicular line and the umbilicus, and
a trocar was placed through a 5mm incision along the right anterior axillary
line for insufflation and liver retraction. The gastrohepatic omentum was
opened in a stellate fashion. The Kocher maneuver was undertaken and the
proximal jejunum was transected using a robotic stapling device. The
gastrohepatic ligament was divided. Dissection was continued along the common
hepatic artery, and the gastroduodenal artery was isolated, doubly clipped, and
divided with the robotic shears. The dissection continued along the gastrocolic
omentum and the duodenum was transected just distal to the pylorus. The
pancreatic neck was divided along the inferior edge over the superior
mesenteric vein and portal vein, and dissection continued along the uncinate
process of the pancreas. Reconstruction was undertaken in a single-layer
hepaticojejunostomy anastomosis followed by a two-layer pancreaticojejunostomy
anastomosis. Finally, a single-layer duodenojejunostomy was constructed just
distal to the pylorus.
The
patient tolerated the operation well and had an uneventful postoperative course. |
VP02-56 | Laparoscopic Distal Splenoplancreactectomy for a Pancreatic Intraductal Papillary Mucinous Neoplasm Jose-Luis Beristain-Hernandez, Mexico
J.-L. Beristain-Hernandez, M. Garcia-Sanchez General Surgery, La Raza National Medical Center, Mexico
Introduction: Pancreatic
surgeries for intraductal papillary mucinous neoplasm (IPMN) accounts for
approximately 5-7&% of all pancreatic neoplasms in western literatura.
Objective: to present the case of a
intraductal papillary mucinous neoplasm treated by means of minimally invasive
approach.
Methods: A 65-years-old male patient
was referred to our center. He had a previous history of 2 acute myocardial
infarctions and hypertension. He also had a previous history of 3 events of
pancreatitis during the last 5 years, with no known etiology.
He was referrred due to a
new onset attack of abdominal pain, nausea and vomiting. A diagnosis of
pancreatitis was made.
During workup, a
contrast-enhanced abdominal computed tomography showed a tumor of the tail of
the pancreas was found, measuring 6 x 5 x 4 cm. No other biochemical anomaly,
all of tumoral markers were normal.
With the diagnosis of a
tumor of the tail of the páncreas, probably an adenocarcinoma, surgery was
proposed and performed.
Results: Surgical findings showed a tumor on the tail of the páncreas, with 8 cm of
diameter; normal spleen and some lymph nodes.
A distal splenopancreatectomy was performed. Tail of the páncreas was
managed with a lineal stapler.
He was discharged on day 4th.
Histopathological report showed an intraductal papillary mucinous
neoplasia. At 2 years after surgery, he remains disease free.
Conclusion: A lot of controversia exists
regarding the surgical management of intraductal papillary mucinous neoplasias
of the pancreas, nevertheless, laparoscopic approach should be considered
whenever is feasible as a safe alternative. |
VP02-57 | Partington Rochelle Assisted with Robot da Vinci Si Enrique Jimenez-Chavarria, Mexico
E. Jiménez-Chavarría1, H.F. Noyola Villalobos2, S. Pimentel-Meléndez2 1HPB, Hospital Central Militar, Mexico, 2Surgery, Hospital Central Militar, Mexico
We
present the case of a 35-year-old male patient, with 3 years of evolution,
treated with pancreatic enzymes and opioids without achieving adequate pain
control, refers to multiple hospital admissions with weight loss and disabling
pain, in the last admission he is referred to our center, due to the suspicion
of a tumor lesion in the head of a pancreas, an MRI is performed observing an
etheric pancreas with calcifications and dilatation of the pancreatic duct of 9
millimeters establishing the diagnosis of chronic pancraetitis.
Considering
that the ideal operation must have a low mortality and morbidity, be easy to
perform, relieve pain, rectify structural anomalies improving the
symptomatology, it is decided to perform a drainage procedure for minimal
invasion, in this video the placement of the Docking and docking ports, placing
a 12 mm Hasson trocar on the umbilical scar, three 7 mm robot trocars and an
accessory port 5 cm slightly below the umbilical scar, the transcavity section
begins of the epiploons, an endoscopic USG is performed to locate the
pancreatic duct insisting with energy in its entirety by removing multiple
calcifications, a Roux and a 35 cm of treitz ligament is performed, the jejunum
is raised retrocolically, the pancreatic anastomosis is performed jejunum with
barbed suture in two planes, surgery time of 160 minutes, hospital stay 48
hours, Good evolution, in visit of asymptomatic patient control and gaining
weight. |
VP02-59 | Robotic Distal Pancreatectomy with Splenectomy for SPT Tail of Pancreas M Srinivasan, India
M. Srinivasan, S. Srivatsan Gurumurthy, P. Senthilnathan, C. Palanivelu Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India
A 18
Yr old female with left hypochondrial pain for 2 months was found to have 7 X 8
cm heterodense lesion in tail of pancreas on CECT Abdomen s/o solid
pseudopapillary tumour. She was planned for Robotic Distal pancreatectomy with
splenectomy. Under GA, patient in supine position, ports were placed after
creating pneumoperitoneum. Davinci Si robotic system was docked.
Gastro-colic omentum opened and lesser sac entered. Stomach dissected from body
and tail and pancreas. Tail of pancreas with tumor mobilised and dissected.
Splenic artery and vein dissected and individually clipped (doubly) and
divided. Short gastric vessels and gastro-splenic attachments divided. Splenic
attachments divided and spleen mobilised. Pancreas transected using Endo GIA
green stapler. Specimen (Distal pancreas with spleen) removed using endobag via
Pfannenstiel incision. Port sites closed after placing drain near pancreas
stump and ensuring perfect hemostasis. She had an uneventful recovery. The HPE
was reported as solid pseudopapillary tumour of pancreas. |
VP02-60 | Pancreatoduodenectomy Totally Assisted by da Vinci Robot, Initial Experience in Mexico Enrique Jimenz-Chavarria, Mexico
E. Jiménez-Chavarría, H.F. Noyola Villalobos, S. Pimentel-Meléndez HPB, Hospital Central Militar, Mexico
In this video, we describe a pancreatoduodenectomy with pyloric preservation, the first fully robotic case in Mexico, a 75-year-old male patient, with ichteric syndrome of obstructive pattern. Dynamic pancreatic tomography shows the presence of a solid lesion in the head of the pancreas with dilated bile duct and pancreatic duct, tumor markers CA-19.9 in 135 and normal CAE. It is decided to perform a PPDP assisted with a da Vinci SI robot, the camera and the three robotic arms are used, illustrating how to place the trocars to facilitate dissection. We describe two phases, the resective with energy use with good control of hemostasis and reconstruction using barbed suture and staplers, the anchor time of 10 minutes, console time of 480 minutes, bleeding of 100 ml, the patient goes to hospitalization , using the ERAS protocol, the patient starts mobilization out of bed at 48 hours, drains with serohematic expense are withdrawn on the third day, beginning of the oral route at 48 hours, hospital discharge on the seventh day, R-surgery is obtained 0, with the lymph node harvest of 25 nodes without tumor activity, surgery is feasible, it is recommended to perform the procedure in high volume centers by experienced surgeons, in this video you can see the advantages of the robot which allow adequate anastomosis to be performed. could influence decrease the presence of pancreatic fistula. |
VP02-61 | Laparoscopic Distal Pancreatectomy with Spleen Preservation Wan Liang Sun, China
W.L. Sun, Z. Lu The First Affiliated Hospital of Bengbu Medical College, China
A 21-year-old female without any underlying
disease was admitted to our department due to an upper abdominal mass for one
weeks. Abdomen computed tomography (CT) revealed a 7-cm low attenuating mass in
the body and tail of the pancreas. Ultrasound examination also revealed a solid
cystic mass in the body and tail of the pancreas. The preoperative
diagnosis is solid pseudopapillary tumors of the pancreas. Because it was a
borderline tumor of the pancreas, laparoscopic pancreatectomy with preservation
of spleen (Kimura method) was performed. The detailed process of the operation
showed in the video. The operation lasted for 3 hours and the intraoperative
blood loss was 100 ml. There were no postoperative complications such as
pancreatic leakage. She was discharged on the 6th day postoperative.
Postoperative pathology confirmed the diagnosis: solid pseudopapillary tumors
of the pancreas. |
VP02-62 | Laparoscopic Enucleation of a Pancreatic Cystic Tumor Jose-Luis Beristain-Hernandez, Mexico
J.-L. Beristain-Hernandez, M. Garcia-Sanchez General Surgery, La Raza National Medical Center, Mexico
Objective: to present the case of a
pancreatic cystic tumor of the neck and body succesfully enucleated with
minimally invasive techniques and provide some laparoscopic tips.
Methods: A 48-years-old female
patient was admitted to our service suffering from chronic diffuse abdominal
pain over the last two months. Her past medical history was unremarkable. On
examination the abdomen was distended and painful over the left flank. Routine
blood tests were within normal ranges.
An abdominal ultrasound was
performed revealing a pancreatic tumor. Contrast-enhanced abdominal computed
tomography showed the presence of a pancreatic head and body tumor, with mixed:
solid and cystic densities. Endoscopic
ultrasound showed multiple cystic lesions over the neck and body, and a fine
needle aspiration biopsy determined a mucinous cystic tumor.
The patient was prepared to
surgery with the intention to perform a diagnostic laparoscopy and enucleation
or pancreatectomy.
Results: Surgical findings showed a multi-cystic tumor of the gland's neck and body,
3 cm in diameter, with no affection of the head nor other structures nearby,
which was succesfully enucleated by laparoscopy.
The patient presented post-operatively a low-output pancreatic fistula
which resolved uneventfully with conservative treatment at the 21th post-op
day.
Histopathology of the resected lesion confirmed the diagnosis of a
serous multi-cystic tumor of pancreas with no evidence of malignancy. Patient
underwent radiologic consultation with CAT scans showing no further tumors
postoperatively.
Conclusion: We consider that laparoscopic enucleation of pancreatic cystic tumors
should be attempted whenever it's possible since it's a safe and feasible
therapeutical approach. |
VP02-63 | Robotic Excision of A Large Duodenal Lipoma Tamara Gall, United Kingdom
T. Gall, Z. Jawad, L. Jiao Imperial College, United Kingdom
Aims: To present an interesting video showing the excision of a large duodenal lipoma. Methods: Excision completed using the Da Vinci Robot Xi. Results: A 72 year old female had a 5 x 3 x 2 cm lipoma in D2 causing CBD dilatation detected on a CT scan. Robotic excision took 130 minutes, with 110 minutes console time. She was discharged on POD3. There was no morbidity or 90 day mortality. Conclusions: This operation would have been extremely difficult laparoscopically but was successful with the robotic technique. |
VP02-64 | Laparoscopic Enucleation of a Multifocal Pancreatic Insulinoma in Limited Resources Setting Adianto Nugroho, Indonesia
A. Nugroho, I. Jamtani, R. Saunar, A. Widarso, T. Poniman HPB Unit, Digestive Surgery, Fatmawati Central General Hospital, Jakarta, Indonesia
Background: With
regards to the reduced risks of endocrine and exocrine insufficiency,
enucleation of a pancreatic insulinoma with parenchymal preservation has been
considered as an alternative to distal pancreatectomy. Together with the application
of minimally invasive approach, it is associated with lesser operative time and
faster recovery. One of the major issues is the intraoperative localization of
the lesion, especially in the limited resources setting, where laparoscopic
ultrasound is not available.
Methods: We present a
cases of pancreatic inculinoma, in a 44-years-old female with prolonged and repeated episodes of hypoglecemia. A
multiphase CT scan allowed an accurate preoperative localization of pancreatic
nodules. During laparoscopic exploration, two distinctive
nodules were feasible in the body and tail of the pancreas, as previously shown
in CT scan. Enucleation and hemostasis was done with energy devices.
Results:
Macroscopically, lesions appear reddish-brown, in contrast to the surrounding
yellowish pancreatic parenchyma. To further increase the accuracy of
localization, a series of blood sugar measurement was performed, showing an
increased in blood glucose level after enucleation.
Conclusion: In summary,
with an accurate preoperative localization and a proper understanding of
macroscopic appearance as well as biochemical physiology, laparoscopic
enucleation is a feasible option for multifocal pancreatic insulinoma. |
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