VP03 Video Pancreas: Miscellaneous 
Selection of Video Presentations from Abstract Submissions
VP03-01 Technique of Tube Pancreatogastrostomy Reconstruction after Pancreatoduodenectomy - the Montenegro Binding Technique
Roland Montenegro Costa, Brazil

R. Montenegro Costa1, F. Kunzler Maia2, L. Olival3, H. J Asbun4
1Hepatobiliary and Pancreas Surgery, Clínica Montenegro, Brazil, 2Miami Cancer Institute, United States, 3Clínica Montenegro, Brazil, 4Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, United States

Introduction: The Montenegro's binding technique (MBT) is a type of pancreatogastrostomy developed in 2005 with the primary goal of decreasing POPF.
Methods: This video is an instruction on how to perform the MBT in a step-by-step fashion.
Results: Step 1. Pancreas preparation: the pancreas is freed from the retroperitoneum and splenic vein for 4 cm and the sectioned surface diameter measured. Two polyglactin pulley sutures (2-0) are placed to facilitate the mobilization.
Step 2. Gastric tube confection: the gastroepiploic arcade is ligated. Using the sectioned surface diameter as a reference, the stomach is sectioned perpendicularly to the greater curvature with a stapler. A second stapled section is made parallel to the greater curvature, 4 cm long, to produce the gastric conduit. The staple line of the tip of the tube is resected and the excess of protruding mucosa is resected. A 2-0 polypropylene purse string suture is placed on the outermost edge of the tube.
Step 3. Pancreas invagination: a 6 Fr feeding tube (5 to 8 cm long) is fixed to the main pancreatic duct with a 5-0 polydioxanone suture. Xylocaine gel is spread inside the tube and pulley sutures are pulled through an anterior gastrostomy to facilitate the pancreas slide. Once the pancreas is invaginated the purse string suture is tied and the pulley sutures are secured to the anterior gastric wall.
Conclusions: MBT is technically undemanding reconstruction and likely servers the purpose of facilitating and decreasing inter-surgeon variability in pancreatic reconstruction.
VP03-02 Intracapsular Dissection for Splenectomy - a Novel Technique for Splenic Abcess / Pseudocyst in Pancreatitis
Sakthivel Harikrishnan, India

S. Harikrishnan1, J. Sathyanesan2, S. J1, K. R3, S. Devakumar1
1Department of Surgical Gastroenterology and Liver Transplant, Government Stanley Medical College, India, 2Government Stanley Medical College, India, 3Department of Surgical Gastroenterology and Liver Transplant, government Stanley Medical College, India

Introduction: Splenic abcess is a rare entity with a reported frequency of 0.05 to 0.7 %. The mortality is expected to be around 47 % and it is expected to decrease to less than 10 % on prompt antibiotic treatment . Very often splenic abcess / splenic pseudocyst is encountered in the setting of acute pancreatitis .Here we present a video presentation of Intracapsular dissection of splenectomy in a patient with splenic abcess .splenic abcess / splenic pseudocyst is encountered in the setting of acute pancreatitis.
Case Capsule: 34 year old male previously managed for acute pancreatitis presented to us with history of high grade fever with chills for 3 months. He had mild left upper abdominal pain. He lost 8 kilograms in 3 months . He was a known diabetic on insulin treatment. On clinical examination he was afebrile , hemodynamically stable and abdomen was soft . Investigation revealed multiple well defined irregular non enhancing hypodense lesions in the spleen largest 5 x 4 cm with subcapsular collection measuring 2.9 x 1.1 cm suggestive of splenic abcess. Splenectomy was done by intracapsular dissection with intracapsular ligation of splenic vessels.
Discussion: Splenectomy by intracapsular dissection and ligation of splenic vessels is a novel technique. The main advantage is the decreased injury to the adjacent structures (Gastric, pancreatic, colonic) especially in inflammatory conditions of spleen like splenic abcess.
VP03-03 Laparoscopic Splenectomy of Lymphoma Malignum in CiptoMangunkusumo Hospital Jakarta
Ardani Syafiuddin, Indonesia

A. Syafiuddin, F. Ibrahim, T. Lalisang
Digestive Surgery, Indonesia University, Indonesia

Introduction: Splenectomy is a commonly operation for various conditions: trauma and benign and malignant hematologic disorders.1,2Although the indications for splenectomy have decreased in current trauma management and cancer, splenectomy remains a frequently surgical procedure. Splenectomy can be done by open surgery or laparoscopic. Laparoscopic splenectomy is clearly the procedure of choice when technically feasible for elective splenectomy. It should be considered in all elective splenectomy cases. Relative contraindications may be considered in certain cases of previous surgery or a large spleen.
Case: A-26th years old female with lymphoma malignum of spleen in 12th weeks gravidarum. We performed laparoscopy splenectomy in right lateral decubitus position. We used 4 ports. After entering the abdominal cavity, we found tumor in the inferior pool spleen. We cut the splenocolic and splenophrenic ligament. We identified the spleen hilus. We opened the gastrosplenic ligament. We identified the A.V gastrica brevis. We ligated it. We mobilized the spleen. We ligated the A.V. spleenica. We take out the spleen from small incision in mediana supraumbilical. The details of procedure is described in the video record.
Keywords: Laparoscopic splenectomy, lymphoma malignum
VP03-04 Duodenal Schwannoma: Enucleation and Excision of the Tumor with Partial Duodenum Wall Resection
Mert Erkan, Turkey

M. Erkan, C.B. Kulle
General Surgery, Koç University Hospital, Turkey

Case presentation: A 29-year-old-women presented with a cystic tumor between the second/third portions of the duodenum and the head of the pancreas. At the time of initial diagnosis the lesion diameter was 3,4 cm but the patient refused surgery. After doubling of the tumor size in two years patient accepted surgery. The procedure started with a transvers incision. The Cattell-Braasch and the Kocher maneuvers were performed and the gastrocolic ligament was divided. A hard, cystic tumor, approximately 7 cm in diameter was located by intraoperative ultrasound between the second and third portions of the duodenum and the uncinate process of the pancreas. The distal bile duct and the pancreatic ducts were separated from the lesion with 2mm pancreatic parenchyma. With sharp and blunt dissection techniques the tumor was dissected from the pancreas and left hanging on its attachment to the duodenal wall. Preoperative magnetic resonance imaging and operative ultrasound depicted the close proximity of the tumor to the pancreatic duct and ampulla. After placing retraction sutures at the duodenum and the tumor, the tumor was excised with partial resection of the duodenal wall. Frozen section analysis of the lesion revealed a cystic schwannoma, hence a Whipple's operation could be avoided. The duodenal wall was repaired with continuous sutures after the pancreatic and bile ducts were cannulated and exposed. Finally, the gap between the uncinate process and the duodenum was filled and covered with the greater omentum that was sutured to the pancreas and duodenum.
VP03-05 Use of Near-infrared Fluorescence Imaging with Indocyanine Green (ICG) to Guide Intraoperative Decision Making during Pancreatic Resections
Andrei Tanase, United Kingdom

A. Tanase, S. Aroori
Hepatopancreatobiliary Department, University Hospitals Plymouth NHS Foundation Trust, United Kingdom

Introduction: Near-infrared fluorescence imaging with ICG is a novel technique that can be used to assess organ perfusion. We present four cases of pancreatic resections, during which ICG imaging was used.
Case 1: A male patient with pancreatic head tumour underwent a pancreaticoduodenectomy (PD). Prior to the anastomosis, proximal jejunum appeared dusky. Following intravenous injection of 0.3mg/kg of ICG, ICG confirmed definite ischemia of proximal jejunum requiring resection prior to the anastomosis.
Case 2: In a patient requiring PD, we found that pancreatic tumour has progressed and involved middle colic vessels (MCV). Clinically, transverse colon (TC) appeared healthy, but we wanted to objectively assess the perfusion of TC prior to the division of MCV. Following clamping of MCV, ICG showed normal perfusion of the TC, therefore, the MCV was divided and a transverse colectomy was avoided.
Case 3: Patient undergoing distal pancreatectomy, splenectomy, sleeve gastrectomy, and resection of the side of the portal vein. Following resection, stomach appeared dusky and congested, and a decision to remove the rest of the stomach proved difficult. ICG showed delayed perfusion of the stomach with subsequent excretion of the ICG. The decision was made not to resect the stomach. The patient developed delayed gastric emptying but otherwise recovered well.
Case 4: We used ICG to assess the perfusion of the pancreatic stump before and after pancreatico-gastrostomy.
Conclusion: The consequences of an ischaemic organ can be disastrous especially when that organ is used in an anastomosis. ICG can help surgeons with decision making by providing an objective assessment of perfusion of the anastomotic segments.