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.
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.