Video
Biliary 
 
VB02 Video Biliary: Minimal Invasive Biliary Surgery 
Selection of Video Presentations from Abstract Submissions
VB02-01 Laparoscopic Excision of a Rare Type II Choledochal Cyst Arising from the Intrapancreatic Common Bile Duct in an Adult
Jun Suh Lee, Korea, Republic of

Y.-S. Yoon, J.S. Lee, H.-S. Han, J. Kim, B. Lee, J.Y. Cho, Y. Choi
Surgery, Seoul National University Bundang Hospital, Korea, Republic of

Introduction: Type II choledochal cyst is a rare pathological condition, which presents an isolated diverticulum from the bile duct. Although treatment of type II choledochal cyst is surgical resection, complete resection is technically difficult when the cyst connects with the intrapancreatic common bile duct (CBD). Moreover, laparoscopic excision has been rarely reported. This video shows a case of laparoscopic excision of type II choledochal cyst arising from the intrapancreatic CBD.
Methods: A 56-year-old female presented with an intrapancreatic cyst, which was incidentally detected 4 years ago and has grown gradually in follow-up radiologic images. CT and MRCP revealed a 4.6 cm-sized cyst mainly located within the pancreas and connection with the intrapancreatic common bile duct. We performed laparoscopic complete excision of the choledochal cyst as well as cholecystectomy.
Results: Three 5-mm and two 12-mm trocars were used. Laparoscopic inspection identified the cyst protruding out of the pancreas behind the CBD. After Kocherization, the cyst was dissected from the CBD and further dissection continued into the pancreas. As the intrapancreatic portion of the cyst was meticulously dissected from the pancreas, the stalk connecting the CBD was identified. Cyst excision was completed with ligation of the stalk using hem-o-lok clips. Laparoscopic cholecystectomy was added. The operative time was 80 minutes and the estimated blood loss was 50 ml. The patient was discharged on postoperative day 4 without postoperative complications.
Conclusions: This video demonstrates that laparoscopic excision of type II choledochal cyst arising from the intrapancreatic CBD is technically feasible.
VB02-03 Successful Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis
Sabrina Cheok Hui Xian, Singapore

S. Cheok Hui Xian1, S. Gunasekaran1, B.C. Tan1, T.J. Tan1, A. Constantinos2, X.Y. Choo1
1General Surgery, Khoo Teck Puat Hospital Singapore, Singapore, 2Gastroenterology, Khoo Teck Puat Hospital Singapore, Singapore

Situs inversus totalis is an autosomal recessive disorder with an incidence of 0.005-0.01%. It is associated with the transposition of organs to the contralateral side. Gallstone disease may present with a myriad of symptoms and furthermore the nonspecific localization of symptoms in patients with situs inversus could lead to delayed diagnosis and hence delayed intervention. ERCP and laparoscopic cholecystectomy are the gold standard of treatment for bile duct and gallbladder stones respectively. Both procedures present with its own set of technical challenges and considerations in situs inversus. There have been a few case reports of physicians detailing their experience with each individual procedure but there has been no recent case report detailing the experience with both ERCP and subsequent cholecystectomy in the same patient- latest being in 1994.
We present our experience in a patient with known situs inversus presenting with symptomatic gallbladder disease- from diagnosis to CBD clearance with ERCP to laparoscopic cholecystectomy.
VB02-04 Laparoscopic Right Hepatectomy and Lymphadenectomy for Intrahepatic Cholangiocarcinoma
Andrea Ruzzenente, Italy

A. Ruzzenente, A. Ciangherotti, S. Conci, S. Valcanover, A. Bianco, C. Iacono, A. Guglielmi
Department of General and Hepatobiliary Surgery, University of Verona, Italy

This video describes the clinical case of a 77-year-old male patient who underwent a laparoscopic right hepatectomy for a 4 cm intrahepatic cholangiocarcinoma (ICC) involving segment 5-8.
The patient had a history of arterial hypertension, type 2 diabetes and dislipidemia. Preoperative liver tests were within normal values with a ICGR15 of 4%. Future remnant liver volume for a right hepatectomy was 39%.
The video describes the surgical technique of a laparoscopic right hepatectomy and regional lymphadenectomy of the stations number 8-12-13.
The definitive histology confirmed the diagnosis of a moderately differentiated ICC without involvement of the resection margins. The retrieved lymph nodes were negative (0/9).
Final AJCC / UICC pathological stage was pT2aN0M0.
Surgical time was 365 min, the patient was discharged in 6th POD without postoperative complications.
Conclusions: Laparoscopic right hepatectomy with associated regional lymphadenectomy is an advanced technique hepatobiliary surgery, minimally invasive approach to ICC is still debated in literature but oncological principles must be satisfied.
VB02-05 Robotic Choledochal Cyst Excision with Dual Hepaticojejunostomy for a 22 Month Old Child
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 22 month year old female child evaluated for upper abdominal pain and jaundice was found to have a fusiform dilatation of extra - hepatic bile duct, GB sludge and CBD stones on MRCP. She was taken up for Robotic Choledochal cyst excision. Under GA, ports placed, diagnostic laparoscopy done. Findings confirmed. Felciform tacked, Gall bladder hitched to anterior abdominal wall. Da vinci Si system with two arms was docked. Choledochal cyst mobilized, duodenum kocherized. Inferior limit of cyst dissected off above pancreas, clipped doubly with hemolock clips and divided. Cyst separated off the portal vein, calot's delineated. Cystic duct and artery divided. Cyst divided proximally below hilum, right posterior duct identified joining cyst separately. Through small 3 cm umbilical incision, roux limb created and Jejuno Jejunostomy done using endo GIA 45 stapler. Roux limb taken to supra colic compartment. Double roux-en-y hepaticojejunostomy done to right posterior sectoral duct and to main duct with continuous, single layer, 4-0 PDS. 18 Fr DT placed after complete haemostasis. Patient had an uneventful recovery and discharged on POD 4.
VB02-06 Laparoscopic Redo Left Hepaticojejunostomy for HJ Stricture
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 23 yr old male, Post open choledochal cyst excision with left hepaticojejunostomy 10 years back, presented with recurrent jaundice and abdominal pain. On evaluation he was found to have HJ stricture with stone in LHD on MRCP. He was planned for laparoscopic exploration and Redo HJ. Under GA, patient in supine with low lithotomy position, ports were placed. He was found to have adhesions of transverse colon to inferior surface of liver. Adhesions between transverse colon and inferior surface and liver taken down. Dissection carried out at porta. Hepatic artery and its branches identified - preserved carefully. Roux limb of jejunum identified, dissected, and anastomotic site identified. Intra OP USG using laparoscopic probe done and the dilated left duct identified with calculus. LHD opened longitudinally and calculus and sludge removed and bile suctioned off. Opening made in Roux limb of jejunum at terminal end with harmonic scalpel and anastamotic stricture released. Redo anastomosis and LHD with jejunal Roux limb done using 4-0 PDS interrupted sutures. Perfect hemostasis achieved. Drain placed and port sites closed. He had an uneventful recovery.
VB02-08 Laparoscopic Resection of Intrapancreatic Type2 Choledochal Cyst with Roux-en-Y Choledochojeejunostomy
Neha Lad, United States

N. Lad1, F. Kunzler2, R. Jimenez3, H. Asbun2
1Miami Cancer Institute Cancer Institute, United States, 2Hepatopancreatobiliary Surgrey, Miami Cancer Institute, United States, 3Hepatopancreaticobiliary Surgery, Miami Cancer Institute, United States

We present a very rare case of incidentally found pancreatic head cyst which had increasing size up on surveillance imaging. MRI showed that it was actually aType II choledochal cyst in the pancreatic head and not of pancreatic origin. This is the a rare case describing thee technique of laparoscopic resection of intrapancreatic bile duct choledochal cyst with roux-en-Y choledochojejunostomy.
VB02-09 Robotic Single Plus One Port a Choledochal Cyst Excision with Roux-En-Y Hepaticojejunostomy in Adult: Early Experience
Jin Hong Lim, Korea, Republic of

J.H. Lim, D.S. Yoon, M.K. Ju
HBP, Yonsei University Health System, Korea, Republic of

Objective(s): Choledochal cysts are associated with increased incidence of cholangiocarcinoma. complete excision of cyst with Roux-en-Y hepaticojejunostomy is the best surgical treatment. Development of surgical technique and instrument has allowed laparoscopic surgery to be performed in choledochal cyst excision with Roux-en-y hepaticojejunostomy. However, reduced port procedure are challenging and sophisticated surgeries because of the difficult anastomosis.
Methods: Between June 2018 and October 2019, four patients received robotic single plus one port a choledochal cyst excision with Roux-en-Y hepaticojejunostomy. Choledochal cyst type IVa was one patient and type I was three patients.
Results: The average total operation time was 420 min. The average estimated amount of intraoperative bleeding was 250 ml. No blood transfusion was given in all patient. CT on postoperative day 7 was performed all case and there are no immediated postoperative complications. However, one patients readmitted because of A-loop obstruction. This patient received laparoscopic singe plus one port adhesiolysis and a-loop fixation.
Conclusion: Mutiple bile duct anastomosis require delicate and exquisite surgical technique. The wrist like movement of robotic system allowed single site plus one port surgery in patients with choledochal cyst.
VB02-10 Laparoscopic Bile Duct Resection with Lymph Node Dissection for Postoperatively Diagnosed Gallbladder Cancer
Sunjong Han, Korea, Republic of

S. Han1, Y.-S. Yoon2, H.-S. Han2, J.Y. Cho3, Y. Choi2
1Surgery, Chungnam National University Hospital, Korea, Republic of, 2Seoul National University Bundang Hospital, Korea, Republic of, 3Department of Surgery, Seoul National University Bundang Hospital, Korea, Republic of

A 73-year-old female visited our hospital after having undergone surgery at another hospital. She underwent laparoscopic cholecystectomy for symptomatic GB stone 2 months ago and the pathologic result revealed as 0.9x0.7cm sized T2 lesion of adenosquamous carcinoma located at cystic duct. Furthermore, high-grade dysplasia involved the cystic duct margin. We planned to perform laparoscopic resection of the common bile duct with lymph node dissection.
Initial laparoscopic views showed severe adhesion. Adhesiolysis was done carefully and Kocherization was proceeded. Then the lymph node dissection was begun from the posterior superior portion of the pancreatic head. Distal portion of the common bile duct was fully exposed and isolated. Then distal common bile duct was ligated and cut. After clearing the left gastric area, the dissected lymph nodes were pushed toward the right side through the posterior portion of the portal vein. Dissection was proceeded toward the proximal bile duct and the common hepatic duct was identified. The common hepatic duct was then transected. Then retrocolic choledochojejunostomy was performed by multiple interrupted sutures both anteriorly and posteriorly.
The operation time was 195 minutes and the estimated intraoperative blood loss was less than 300mL. The postoperative pathologic report revealed that no residual tumor with negative resection margins. Lymph node metastasis was found in one of 8 retrieved lymph nodes. The patient was discharged on the fourth day after surgery without any complications.
This case demonstrated the technical feasibility of laparoscopic extended cholecystectomy including bile duct resection for GB or cystic duct cancer.
VB02-11 Laparoscopic Trans-Jejunal ERC with Stenting for Recurrent Anastomotic Stricture Following Roux-en-Y Hepatico-Jejunostomy Bypass
Jeffrey Samuel Co, Philippines

J.S. Co, N. Salvador, V. Chan, P. Ong
Surgery, Chinese General Hospital and Medical Center, Philippines

This is a case of a 34 year old female who sustained a Strasberg type E bile duct injury during an Open Cholecystectomy last 2013. After delayed repair with a Roux-en-Y Bilio-enteric bypass, the patient was able to recover well. However, 4 years after, the patient developed progressive jaundice accompanied by abdominal pain and some degree of malabsorption. An MRCP revealed stricture of the HJ anastomosis and a re-do HJ was done. Patient again was able to recover until 6 months after when she started presenting with similar symptoms. An MRCP showed dilated intrahepatic ducts with HJ anastomotic stricture. With worsening symptoms and deteriorating liver function (Total Bilirubin 10 mg/dL; INR 1.5), She was scheduled for biliary decompression via Laparoscopic Trans-jejunal ERC. Intraoperatively, extensive adhesiolysis was done, a jejunal limb was identified and a purse-string suture laid. An entorotomy followed by insertion of a 13mm trocar direct to the jejunal segment was done. The narrowed anastomosis was easily identified with the gastroscope and multiple stones and sludges were seen. Balloon cholangiogram followed by insertion of two Fr. 7 stents. The scope together with the port were retrieved and the enterotomy sutured close. The patient was discharged the following day and her liver function improved in the few months that followed (TB 4mg/dL; INR 1).
VB02-12 Laparoscopic Bile Duct Exploration for Massive Choledocholithiasis
Alejandro Brañes, Chile

A. Brañes, R. Rebolledo, E. Buckel, C. Díaz, E. Viñuela, M. Sanhueza
HPB Surgery, Hospital Dr. Sótero del Río, Chile

A 48-year-old woman with past surgical history of cholecystectomy had three previous endoscopic attempts for choledocholithiasis with incomplete biliary drainage requiring a biliary stent. A laparoscopic bile duct exploration was indicated.
Laparoscopic bile duct exploration is an excellent minimally invasive approach after failed endoscopic treatment for choledocholithiasis. We present a simple and replicable procedure for the treatment of massive choledocholithiasis which combines laparoscopic techniques with skills learned during the open bile duct exploration era.
VB02-14 Complicated Cholecystitis with Cholecystoduodenal and Cholecystocutaneous Fistulas
Thun Ingkakul, Thailand

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

Cholecystoenteric fistula and cholecystocutaneous fistula are rare conditions of complicated cholecystitis and related to underlying gallstones. The presence of simultaneous cholecystoenteric fistula and cholecystocutaneous fistula has become even rarer. This is a 86-year old female presented with abdominal pain and palpable mass at right upper quadrant for 1 month. One week PTA she developed low-grade fever but was able to have meal normally, no history of jaundice, no weight loss and no diarrhea. She underwent ultrasound which showed hypoechoic collection at right subhepatic area which contained free air and related to gallbladder region, gallbladder and gallstones cannot be clearly identified. She had CT abdomen which showed abdominal wall collection with air-fluid level, air in gallbladder with gallstones, identification of cholecystocutaneous fistula tract and suspected cholecystoduodenal fistula. Due to the patient condition with multiple comorbidities, the initial treatment began with resuscitation and intravenous antibiotic. After stabilizing patient, she was set for open drainage of abdominal wall collection and plan for elective definite treatment of her disease. She underwent open drainage and found 30 ml of pus, culture showed E.coli ESBL and she had IV antibiotic. Two weeks later she underwent the laparoscopic division of cholecystocutaneous fistula and cholecystoduodenal fistula with cholecystectomy. The operative time was 3 hours and 30 minutes, EBL was 50 ml and the total hospital was 6 days. The pathology showed chronic cholecystitis without malignancy, for the cholecystocutaneous fistula showed acute and chronic inflammation and no malignancy seen.
VB02-15 Totally Laparoscopic Radical Resection of Gall Bladder Cancer: A Single Center Experience, Propensity Score Matching
Jung Woo Lee, Korea, Republic of

J.W. Lee
Department of Surgery, Hallym Unversity Medical Center, Anyang-si, Korea, Republic of

Background: Laparoscopic radical resection of gall bladder cancer(GBC) has been contraindicated for the following reasons: (1) treatment of GBC for risk of port site recurrence or peritoneal metastasis and (2) concerns regarding the oncologic adequacy and safety of laparoscpic radical surgery. However, for patients affected by resectable T1b or T2 GBC, laparoscopic radical resection is considered the alternative treatment option in variable article. Our aim is to describe the surgical technique and clinical-pathological results of patients underwent laparoscopic RC of GBC.
Method: Laparoscopic radical resection for primary and incidental GBC, between the years 2015 and 2020 in single center from korea. Patients in whom suspected para-aortic sampling was positive were excluded.
Results: Thirty five patents were operated.
Conclusion: Laparoscopic radical resection can be considered a safe treatment for GBC. Laparoscopic surgery for GBC is still in the early phase of the learning curve, and more evidence is required to assess this procedure.
VB02-16 Robotic Resection of a Type IIIb Klatskin Tumor
Iswanto Sucandy, United States

I. Sucandy, A. Giovannetti, G. Rivera, K. Luberice, S. Ross, A. Rosemurgy
AdventHealth Tampa, United States

This video depicts resection of hilar cholangiocarcinoma involving the biliary bifurcation and the right hepatic duct, extending into the right hemi liver, undertaken in a 65-year-old man. The patient received neoadjuvant chemotherapy and placement of a biliary metal stent into the common bile duct, extending to the right hepatic duct.
An 8mm trocar was placed through the umbilicus, and diagnostic laparoscopy was undertaken. Portal dissection and lymphadenectomy was undertaken. The common hepatic artery, common bile duct, and the periportal lymph nodes were identified, excised, and sent to pathology for frozen sections. The bile duct was skeletonized down to the head of the pancreas. The distal common duct was transected, and the metal stent was removed. The distal portion of the common bile duct was then closed.
Right total hepatic lobectomy was executed after ultrasound. The right hepatic vein and portal vein were isolated and transected. The liver parenchymal transection was carried down toward the inferior vena cava using vessel sealer. The left hepatic duct was transected. The caudate lobe was mobilized off the inferior vena cava and included in the resection. The right hepatic vein and the specimen were transected and detached from the liver remnant.
To begin the reconstruction, the ligament of Treitz was identified and the proximal jejunum was transected. A side-to-side stapled jejunojejunostomy was created. A 60cm Roux limb was constructed to the porta hepatis for the construction of the right Roux-en-Y hepaticojejunostomy. An end-to-side right-sided hepaticojejunostomy was completed. The anastomosis was buttressed with the omental flap.
VB02-17 Laparoscopic Resection of an Intrapancreatic Granular Cell Tumor of the Biliary Tract
Filipe Kunzler Maia, United States

F. Kunzler Maia1, L. Olival2, V. Jeismann3, N. Lad4, R.E. Jimenez4, H.J. Asbun4
1Miami Cancer Institute, United States, 2Clínica Montenegro, Brazil, 3University of Sao Paulo - Hospital das Clinicas, Brazil, 4Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, United States

Introduction: Granular cell tumors are benign neoplasms that likely originate from Schawnn-like mesenchymal cells. They arise in the gastrointestinal tract in 5-11% of the time, the large majority in the colon and esophagus, with only 1% in the biliary tract. Intrapancreatic biliary tract tumors, even if benign, usually require a pancreatoduodenectomy (PD).
A 39 year old female presented with jaundice and abdominal pain. She underwent ERCP for stent placement and choledochoscopic biopsy which suggested granular cell tumor. In order to avoid a PD, the patient underwent a laparoscopic intrapancreatic common bile duct resection.
Methods: Resection started with freeing the gallbladder from the liver, without sectioning the cystic duct. The common bile duct was sectioned cephalad and progressively dissected towards the ampulla. Care was taken while stripping the pancreas off the duct, with meticulous mobilization of the duct in all directions. The duct was dissected towards the ampulla and visual evaluation of the margin was performed before proceeding with the transection. Biliary duct margins were negative on frozen evaluation. Reconstruction was performed with a Roux-in-Y limb anastomosed to the hepatic duct in an end-to-side fashion.
Results: The amylase on the drain was 3,715 on POD1, and 22 on POD3. The patient fully recovered and was discharged on POD5 without complications.
Conclusion: It is feasible to perform a laparoscopic pancreas preserving biliary tract resection in order to avoid a pancreatoduodenectomy in patients with benign tumors of the biliary tract.
VB02-18 Robot Assisted Roux-en-Y Hepaticojejunostomy for Post Cholecystectomy Benign Biliary Stricture
Kalayarasan Raja, India

K. Raja, B. Pottakkat
Surgical Gastroenterology, JIPMER, India

Despite technical advancements, iatrogenic bile duct injury continues to be a significant concern in open and laparoscopic cholecystectomy. Traditionally repair of postcholecystectomy biliary stricture by tension-free Roux-en-Y hepatico-jejunostomy (RYHJ) is done through a large subcostal or midline incision. While laparoscopic RYHJ is feasible, it has many limitations. The use of the robotic platform for postcholecystectomy biliary stricture is scarcely described. The technique of robotic postcholecystectomy biliary stricture repair using the DaVinci Xi Robotic Surgical System is described in this video.
The procedure was performed with the patient in supine with a split leg position. Four 8mm robotic trocars are placed in a straight horizontal line at the level of umbilicus with at least 6-8 cm distance between trocars. One 12 mm and one 5 mm assistant trocar is placed 4 cm below umbilicus on either side of the midline. Before docking, intraabdominal adhesiolysis is performed except perihepatic adhesions as it facilitates liver retraction. Key steps are the identification of the base of segment 4, preservation of left hepatic artery, lowering of the hilar plate, the opening of the left hepatic duct, identification of right anterior and posterior sectoral duct, preparation of roux limb and construction of tension-free RYHJ. Indocyanine green facilitates the identification of the hepatic ducts. The tips and tricks to identify the hepatic ducts in patients with and without internal fistula are shown in this video.
VB02-19 Laparoscopic Roux-en-Y Hepaticojejunostomy for Bile Duct Stenosis
Ignacio Guillermo Merlo, Argentina

I.G. Merlo1,2,3, D.R. Huerta1, R. Puma3, M. Gonzalez3, G. Cervelo3, J.P. Grondona1, UNACIR
1UNACIR HPB, Argentina, 2Universidad de Buenos Aires, Argentina, 3Sanatorio San Justo, Argentina

We present a video with a case of a 38 years old male with a history of complicated cholecystectomy with conversion to open surgery, bile duct exploration and bile duct T drain placement. He is sent to our HPB unit one year and a half after the surgery with jaundice. We performed a MRI where a Strasberg E1 type injury is noted. ERCP is performed but the endoscopist couldn't surpass the stenosis. Multidisciplinary approach was made and surgery was decided. We start the procedure with exploratory laparoscopy in which multiple adherences are taken down. Trocars are placed and dissection is shown using monopolar cautery and Harmonic scalpel. Lymph node of hepatic hilum and liver biopsy are taken. The dilated bile duct is identify and opened with scissors. Intraoperative cholangiography is performed with Olsen clamp to corroborate anatomy. Stones are removed and Roux-en-Y limb is prepared. The jejunum is divided 30cm downstream from Treitz ligament with stapler. A 40cm efferent limb is prepared and side to side jejunojejunostomy is performed with a stapler. The efferent limb is ascended in a retrocolic manner and a side to side hepaticojejunostomy is performed. The posterior wall of the anastomosis is made with a running 4-0 polydioxanone suture and the same for the anterior wall. Two drains are left in place. The patient didn't have posoperative complications and was discharged at the 5th day. No malignancy was found. At one year follow up no laboratory or clinical manifestations occurred.
VB02-20 Three Anatomical Identification for Safe Laparoscopic Cholecystectomy
Adeodatus Yuda Handaya, Indonesia

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

Laparoscopic cholecystectomy is the gold standard of therapy for cholecystitis and cholelithiasis. This procedure has many advantages, but there are several complications that can occur, including billiary and non-billiary complications. Common bile duct injury is one of the common biliary complication, with the incidence reaching 0.1-0.6%. While the incidence of bleeding complications is around 0.4% - 0.49%.
We propose three anatomical marker used to prevent bile duct and vessel injury during laparoscopic cholecystectomy which consist of Rouviere Sulcus, Cystic Node of Lund, and Critical View of Safety (CVS). Rouviere sulcus is a fissure 2-5cm long on the right side of the liver hilum and anterior to the caudate lobe. This sulcus is not affected by the pathology process in the biliary system and can be found in 80% of the population. Dissection at the time operations are limited to above or anteriorly from Sulvius Sulcus because of common bile duct is at under Rouviere Sulcus. Cystic node of lund will enlarge in most acute or chronic cholecystitis and become an important anatomical marker related to cystic arteries because the positions are overlapping. While dissecting cystic artery and duct, keep the dissection limited on the lateral side of the node. It can help to reduce the risk of injury of the Calot's triangle, so the lund node can be said to be the endpoint of calot's triangle dissection. All three anatomical markers must be identified before clipping and dissecting the cystic ducts and artery.
VB02-22 Laparoscopic Assisted Endoscopic Balloon Dilatation for Post Whipple's Hj Stricture with Secondary Hepatolithiasis
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 36 Yr female, a c/o Periampullary neoplasm who had underwent a Laparoscopic Pancreaticoduodenectomy done 3 yrs back presented with jaundice. MRCP revealed a HJ site stricture with stone proximal to the stricture. It was not amenable for percutaneous dilatation. Hence, a laparoscopic assisted endoscopic balloon dilatation was planned. Under GA, patient in supine position. Parts painted and draped. Ports placed. Roux limb of jejunum for HJ identified. Adhesions to Gall bladder fossa released. Enterotomy made in Roux limb and 15 mm trocar introduced into it. Endoscope was introduced via 15 mm trocar into Roux limb and HJ site reached. Stricture dilated after passing guide wire and balloon dilatation done. Stones and sludge ball removed and free flow of bile noted. Scope removed. Enterotomy closed with 2-0 PDS in two layers continuous fashion. Perfect hemostasis. DT placed. 24 Fr DT in subhepatic space. Port sites closed. She had an uneventful recovery and no e/o recurrence of stricture at one year followup.
VB02-23 Critical View of Safety Omitted: Laparoscopic Cholecystectomy with ICG Enhancement and IOC
Jose Mari Jardinero, Philippines

J.M. Jardinero, C. Teh, K. Panganiban
Surgery Department, St Luke's Medical Center, Philippines

The laparoscopic cholecystectomy is now considered the gold standard treatment for treatment of symptomatic gallstone disease. During its introduction it is said that it was easily accepted by many due to the advantages it offers compared to the conventional open cholecystectomy. However, during its early days concerns were raised regarding it association with increased bile duct injuries. Through the years increased efforts in awareness, education and training have minimized the risk.
Bile duct injury is one of the most dreaded complication of laparoscopic cholecystectomy. In order to minimize the risk surgeons have adopted several techniques in doing the procedure. Most popular is the creation of the critical view of safety prior to ligation of the cystic duct and cystic artery. However, sometimes the creation of critical view of safety is very hard to do or may not be possible at all due to the varying anatomy of the biliary tree and inflammation surrounding the area. Thus, techniques and innovations have been developed in order to ensure a safe procedure in cases wherein critical view of safety is not possible.
This video is about a case of symptomatic gallstone disease who underwent Laparoscopic cholecystectomy. Fortunately, patient was scheduled along with ICG enhancement because during the procedure the seemingly run-of-the-mill operation turned out to be a difficult but very interesting case. We were forced to forego creation of the critical view of safety but still able ensure safe surgery due to ICG fluoroscopy.
VB02-24 Robotic-Assisted Complete Excision of Type I Choledochal Cyst and Roux-An-Y Hepaticojejunostomy
Eli Kakiashvili, Israel

E. Kakiashvili
General Surgery, Galilee Medical Center, Kiriat Iam, Israel

A 30 years old, female patient presented with recurrent right upper quadrant (RUQ) abdominal pain (during last two years), without nausea, vomiting or jaundice. Her blood laboratory examinations were within normal limits, including serum CA 19-9.
Ultrasonography (US) demonstrated a large cystic dilatation of common bile duct (CBD). An abdominal computed tomography scan (CT) and MRCP revealed a type I choledochal cyst, measuring 3.5 cm in diameter.
Patient underwent da Vinci robot-assisted excision of the type I choledochal cyst, hepaticojejunostomy and extracorporeal jejuno-jejunostomy of Roux-an-Y limb.
Total operating time (ORT) was 325 min. Three day after operation patient started regular diet and was discharged on day fife.
Pathology result confirmed choledochal cyst without evidence of malignancy.
VB02-25 Minimal Invasive Biliary Surgery Approach for Indeterminate Postoperative Bilioenteric Anastomotic Strictures: Using Percutaneous and Endoscopic Transhepatic Approaches in a Hybrid Operating Room
Alain Garcia, France

M. Gimenez1, A. Garcia1, J. Verde1, M. Palermo1, M. Pizzicanella2, E. Felli3, P. Pessaux3, J. Marescaux4
1Percutaneous Surgery, Institute of Image-Guided Surgery, France, 2Endoscopic Surgery, Institute of Image-Guided Surgery, France, 3HPB Surgery, Institute of Image-Guided Surgery, France, 4Surgery, IRCAD, France

Background: Bilioenteric anastomotic strictures after hepato-pancreaticobiliary tumor resections are common in a large number of patients. In some cases, fibrotic healing versus malignant recurrence should be determined. Due to difficulties with repeat a bilioenteric anastomosis the minimally invasive biliary percutaneous access for therapeutic purposes has become widely accepted.
Cholangioscopic transhepatic forceps direct biopsy of the site stricture has been proved to be feasible and effective for direct visualization and tissue-based diagnosis. On the other hand, the therapeutic options available include new bilioenteric anastomosis or percutaneous transhepatic biliary drainage followed by balloon dilation or stent placement in case of malignant recurrence.
Case description: Male 82 years old, past surgical history of bile duct resection and regional lymphadenectomy for cholangiocarcinoma pT3N0, in 2018. The patient is admitted with obstructive jaundice and intrahepatic bilateral bile duct dilation (Bil 8.0, TGO 137, TGP 159, CA 19-9 1981). A bilioenteric anastomotic stricture with bilateral bile duct dilation was founded in the MR assessment.
Surgical plan: In the first place, a percutaneous transhepatic bilateral bile duct drainage under fluoroscopic-guidance was performed to solve the obstructive jaundice. Seven days after the first procedure a percutaneous transhepatic cholangioscopy was used for direct evaluation and biopsy of the post-operative anastomosis site stricture. The histologic diagnosis of cholangiocarcinoma was obtained one week after, and bilateral percutaneous transhepatic self-expanding metal stents for palliation of malignant biliary obstruction were placed.
Conclusion: The minimally invasive biliary surgery is an effective approach, for diagnosis, treatment or palliative care in postoperative indeterminate bilioenteric anastomotic strictures.
VB02-26 Robotic Laparoscopic Transduodenal Ampullectomy for Ampullary Tumour
Vivyan Tay, Singapore

V. Tay1, Z. Wang1, K.P.B. Goh1,2
1Singapore General Hospital, Singapore, 2Duke-National University of Singapore (NUS) Medical School, Singapore

This video demonstrates a transduodenal ampullectomy (TDA) which was performed in a robotic assisted laparoscopic technique for a case of an ampullary tumour. TDA was first introduced in 1899 and was initially intended as treatment for ampulla of vater cancer. However, the use of this procedure failed to become widespread then as the recurrence rate of cancer was high and surgical technique had not been standardized. Hence, the Whipple's procedure has become the gold standard for the treatment of ampulla of vater cancer. In the recent past decade, studies have suggested that TDA has a role especially for benign or low grade ampullary cancers as this technique is less invasive and hence less morbid compared to the Whipple's procedure. With the advent of minimally invasive surgery, this has an added advantage to improve patient's recovery post-operatively while providing similar clinical outcomes for early ampullary cancer. The video will also help to illustrate how robotic surgery can be used to complement the conventional laparoscopic technique.
VB02-27 Laparoscopic Choledochal Cyst Resection and Reconstruction
Marcelo Enrique Lenz Virreira, Argentina

M.E. Lenz Virreira, J.P.S. Durán Azurduy, J.G. Cervantes, M.L. Del Bueno, M. Poupard, C.B. Magali, E.G. Quiñonez, F.J. Mattera
Hospital el Cruce, Argentina

Background: Choledochal cysts are benign uncommon congenital cystic dilatations of the bile duct usually associated with anomalous junction of pancreaticobiliary duct. Recurrent pancreatitis can be a possible complication in these cases resulting even in bile duct cancer if not treated.
Methods: Video of a Case report
Results: We present a case of a 25 years old female with abdominal pain. A Choledochal cyst (Todani type l C) was diagnosed. A laparoscopic approach was performed with the cyst resection and Roux-en-Y hepaticojejunostomy reconstruction. The patient had a good recovery being discharge on the fourth postoperative day. Pathological analysis confirmed our previous diagnosis.
Conclusion: Complete Laparoscopic resolution of Choledochal cysts is a feasible and acceptable approach nowadays. Although rare, physicians need to keep this diagnosis in mind, especially in symptomatic patient with choledochal duct dilatation and refer the patient to a high-volume center to be correctly treated.
VB02-28 Gunshot Wound (GSW) Bile Duct Injury Requiring Liver Operation
Iswanto Sucandy, United States

I. Sucandy, S. Ross, M. Tempest, K. Luberice, A. Rosemurgy
AdventHealth Tampa, United States

The patient's initial injury was ten months prior. He was taken to a trauma center where he underwent an exploratory laparoscopy. He subsequently developed a bile leak, retroperitoneal abscess, and right upper quadrant (RUQ) infection of the hepatic lobe. Preoperative MRI w/wo contrast showed cholelithiasis and a nondilated system within indwelling biliary stent in place.
Significant amount of inflammation and scar tissue were noted in the RUQ. The inferior border of the liver was identified and a cholecystectomy was undertaken. With careful dissection, the liver was slowly mobilized cephalad and out of the RUQ fossa. With the aid of an ultrasound, careful dissection was carried along the lateral aspect of the vena cava.
Once adequately mobilized, right hepatic lobectomy was undertaken. A transection line was made at the superficial liver parenchyma. Segments five, six, seven, and part of eight were removed. The right hepatic artery was dissected. Laparoscopic linear vascular stapler was then utilized to transect the right hepatic bile duct as well as the right hepatic vein intrahepatically. The abdomen was irrigated and hemostasis was obtained. A 10-French drain was placed. An omental pedicle vascular flap and falciform pedicle vascular flap were developed to buttress the bile duct repair.
VB02-29 First Experience Pure Laparoscopic HPD for Cholangiocarcinoma: The Feasibility and Safety of Short Term Surgical Outcomes
Jin Ho Lee, Korea, Republic of

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

Background: Recently, as laparoscopic surgery has developed, bile duct cancer surgery has also been performed with pancreaticoduodenectomy (PD) or liver resection using laparoscopic system. In some cases, bile duct cancer may require hepaticopancreaticoduodenectomy (HPD) surgery, which requires simultaneous liver Resection and PD to obtain an appropriate resection margin. However, laparoscopic HPD requires a high degree of surgical technique, so very few cases have been reported.
Methods: The patient was a 65-year-old male who underwent pure laparoscopic HPD surgery on October 16, 2019 in our hospital. The patient underwent surgery in the same trocar position as the conventional laparosocpic PPPD, and hepatectomy was performed for right hepatectomy. Since the patient was diagnosed with distal biliary tract cancer at the time of initial diagnosis, we used the same trocar position as laparosocpic PPPD and three 10mm trocars and two 5mm trocars. However, during surgery, a positive for malignancy was reported until the third frozen biopsy of the proximal bile duct margin. Subsequently, intraoperative choledochoscopy was performed and left bile duct was intact. Therefore, right hepatectomy was performed to obtain a hepatic resection for distal bile duct margin.
Results: The operation time was 741 minutes, and the amount of bleeding was 750 ml. And the length of hospital stay was 21 days due to postoperative ascites control. There was no major complication but postoperative ascites.
Conclusion: The pure laparoscopic HPD procedure is feasible and safety method though operation time takes a little longer.
VB02-30 Robotic-Assisted Extraction of Large CBD Stones and Choledochoduodenostomy
Eli Kakiashvili, Israel

E. Kakiashvili
General Surgery, Galilee Medical Center, Kiriat Iam, Israel

63 years old, female patient presented with recurrent right upper quadrant (RUQ) pain, without fever, nausea or vomiting.
30 years ago, patient underwent open cholecystectomy due to cholelithiasis. During last four years, she suffered from recurrent attacks of biliary colic or ascending cholangitis.
Patient several times underwent ERCP and extraction of stones from common bole duct (CBD).
At her last admission, ultrasound (US) revealed recurrent large stones in CBD with significant dilatation of extra and intra hepatic biliary duct (CBD up to 2 cm).
Her blood laboratory examinations showed mild elevation of bilirubin and liver functional tests (LFT'S).
Patient underwent da Vinci robot-assisted choledochotomy, extraction of CBD stones and choledochoduodenostomy.
Total operating time (ORT) was 240 min. Two days after operation patient started regular diet and was discharged home on day four.
VB02-31 Bail Out: Laparoscopic Cholecystectomy in a Gravid Patient
Jenine Joy Segismundo, Philippines

J.J. Segismundo, R.A. Ong
Department of Surgery, FEU-NRMF Medical Center, Philippines

This is a case of a 34-year-old, 8-week-pregnant patient, presenting with epigastric pain and diagnosed to have acute calculous cholecystitis. Surgery has been long avoided during the first and third trimester of the pregnancy leading to delaying the non-emergent procedure until the 2nd trimester. Recent data suggest that pregnant patient can undergo laparoscopic surgery safely during any trimester without any additional risk to the fetus and the mother.
The critical view of safety has provided numerous advantages including lowering the risk of bile duct injury. However, in severe acute inflammation, exposure of the critical view of safety is very challenging. This is due to the inflammatory fusion of the area of the hepatocystic triangle making the cystic duct resemble the common bile duct. In times of difficult operative condition, it is highly advisable not to approach this area.
Subtotal cholecystectomy fenestrating type technique will expose the important structures crucial in conducting a safe cholecystectomy. An important step in this procedure is the stripping of the serosal layer of the gallbladder. This will separate the inner layer, a plane which consists the vasculature and the fibrous tissue preventing further bleeding and resulting in safe exposure of the important structures. At the hepatocystic triangle, stripping of the serosal layer will expose the cystic duct and cystic artery in addition to the development of the shield of McEmoyle, a portion of the gallbladder wall intentionally left behind to serve as a buffer between the edge of the dissection and the dangerous hepatocystic triangle.
VB02-33 Rehepaticojejunostomy and Complex Laparoscopic Exploration of the Bile Duct
Marcelo Enrique Lenz Virreira, Argentina

J.G. Cervantes, M.L. Del Bueno, M.E. Lenz, E. Quiñonez, F.J. Mattera
Unidad Cirugía Hepatobiliar Compleja y Trasplante Hepático, Hospital el Cruce, Argentina

A percentage of patients background of excision of a type l choledochal cyst an hepaticojejunostomy with may develop long-term complications such as anastomosis stenosis, ascending cholangitis and development of intrahepatic lithiasis. In few cases where interventional therapy is unsuccessful re-operation is the only way to cure patients
We describe the case of a 30-year-old female patient with background of exision of a type l choledochal cyst and hepaticoyeyunostomy in 2003, and external percutaneous drainage for cholangitis in 2019.
3 months later in a ruting control the patient has a alteracion of the laboratory. CT scan and MRI shows dilated bile duct with multiple lithiasis images inside and normal vascular anatomy.
We use an american laparoscopic technique to place the ports.
At the beginning of the procedure we taking down adhesions anda try identify the anatomy. We dissect the jejuno using monopolar cautery and make an incision on hepaticojejunostomy. The exploration didn't revel any stricture in the anastomosis. We can then reach up into the bile duct with a variety of baskets and irrigate under a lot of pressure.
An occasion the stones were more difficult to remove and you can performance with a ballon dilatation.
We made the anastomosis reconstruction using polipropilen 5.0 suture.
Rerecovery was uneventful. Discharged on 4th postoperative day and no recurrence.
VB02-34 Laparoscopic Common Bile Duct Exploration and Choledochoduodenostomy for Totally Gastrectomized Patients with Diversed Gastrointestinal Tract
Heontak Ha, Korea, Republic of

J. Han1, H. Ha2, J.H. Park2, Y.S. Han1
1Department of Surgery, Kyungpook National University Hospital, Korea, Republic of, 2Department of Surgery, Daegu Fatima Hospital, Korea, Republic of

Traditionally, many surgeons have preferred choledochojejunostomy or hepaticojejunostomy for bilio-enteric reconstruction. Choledochoduodenostomy or hepaticoduodenostomy) was thought to increase the risk of postoperative complication such as cholangitis, pancreatitis, duodenal fistula, so-called sump syndrome, by most of surgeons. We think the patients who underwent operations that caused gastrointestinal tract diversion(such as gastrectomized patients who were reconstucted by Billroth II or Roux-en-Y anastomosis) can be applied to bilio-enteric reconstruction using their duodenal stump without worrying about sump syndrome.
A 71-year-old-man who previously had underwent total gastrectomy with Roux-en-Y esophagojejunostomy and jejunojejunostomy due to gastric cancer 18 years ago visited our department and he presented with recurrent pyogenic cholangitis caused by common bile duct stones. His CT revealed dilated CBD which was fully filled with several stones and gallbladder stones. We performed laparoscopic cholecystectomy and common bile duct exploration with choledochoduodenostomy.
The operation time was 225 minutes. The patient didn't show any specific postoperative complications. He was discharged on 8th postoperative day. On follow up, he has no special problems of biliary tract after he underwent operation 9 months ago.
CD or HD is very simple, easier and faster to perform than Roux-en-Y CJ or HJ because CD or HD has advantages such as easier accomplishment and facilitation with a laparoscopic attempt. And, there is no need to worry about sump syndrome when patients already has diversed gastrointestinal tract. Hence, we should consider using duodenal stump for bilio-enteric reconstruction by laparoscopic method for gastrectomized patients who were reconstucted by Billroth II or Roux-en-Y anastomosis.
VB02-35 Robotic Common Bile Duct Exploration with Choledochoscopy and Choledochoduodenostomy
Iswanto Sucandy, United States

I. Sucandy, S. Ross, J.-K. Dolce, K. Luberice, A. Rosemurgy
AdventHealth Tampa, United States

This video depicts a robotic common bile duct exploration with choledochoscopy and choledochoduodenostomy undertaken in a 72-year-old man. Preoperative scans revealed multiple stones, cholelithiasis, and cholecystitis.
8mm ports were placed at the umbilicus and left upper quadrant for diagnostic celioscopy. Additional 8mm ports were placed at the level of the umbilicus at the midclavicular line. An 8mm port along the anterior axillary line, cephalad of the umbilicus to the left and a 5mm port along anterior axillary line, near the costal margin of the liver. The robot was then mounted in reverse Trendleburg.
The falciform ligament was taken down, up to the hepatocaval confluence. The liver was elevated exposing the porta hepatis. A limited Kocher maneuver mobilized the duodenal C-loop to allow the proximal duodenum to reach the common bile duct without tension.
Common bile duct exploration was undertaken through a longitudinal incision. The choledochoscope viewed cephalad in the biliary tree. The right and left hepatic ducts were identified to arborization in the liver.
Choledochoduodenostomy was undertaken via longitudinal incision in the duodenum. Anastomosis was constructed by utilizing sutures starting at 6 o'clock sewing to 9 o'clock for the posterior wall. The anterior wall was sewed beginning at 6 o'clock to 3 o'clock and sutured until noon. The duodenum was then tacked to more cephalad structures.
This video illustrates how the use of robotics in common bile duct exploration and choledochoscopy with choledochoduodenostomy can be undertaken safely and efficaciously, providing the patient with salutary benefits of minimally invasive surgery.
VB02-36 Robotic-Assisted Excision of Common Bile Duct Stricture and Roux-An-Y Hepaticojejunostomy
Eli Kakiashvili, Israel

E. Kakiashvili
General Surgery, Galilee Medical Center, Kiriat Iam, Israel

29 year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy.
During last year, patient suffered from recurrent episodes of ascending cholangitis. Recently, she underwent ERCP and severe stricture of middle CBD was diagnosed. Plastic stent was inserted through the CBD. MRCP also showed severe stricture of CBD with dilatation of biliary tree, proximal to the stricture.
Due to severe and resistant (did not resolved by recurrent dilatation) structure of middle CBD, she was referred to operation.
Patient underwent da Vinci robot-assisted excision of the CBD stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of Roux-an-Y limb.
Total operating time was 320 min. Day three after operation patient started regular diet and was discharged home on day four.
Final pathology has shoved part of CBD with severe inflammation.
VB02-37 Laparoscopic Cholecystectomy for Acute Cholecystitis in Porcelain Gall Bladder with Repeated Past History of Acute Cholecystitis and Pancreatitis
Bhavin Vasavada, India

B. Vasavada, H. Patel
Hepatobiliary and Liver Transplantation, Shalby Hospitals, India

We present a surgical video of 80 year old female with porcelain gall bladder confirmed on CT presented to us with acute cholecystitis, she had multiple past history of recurrent acute cholecystitis and pancreatitis. We would like to emphasise in this video about difficulty encountered during holding and retracting the gall bladder and meticulous dissection can help in completing these cases with laparoscopic approach without need to conversion.
VB02-38 Robotic Extended Cholecystectomy in Gallbladder Cancer
Yoonhyeong Byun, Korea, Republic of

Y. Byun1, Y.J. Choi2, J.S. Kang2, Y. Han2, H. Kim2, W. Kwon2, J.-Y. Jang2
1Department of Surgery, Seoul National University Hospital, Korea, Republic of, 2Department of surgery, Seoul National University Hospital, Korea, Republic of

Background: The application of minimally invasive surgery (MIS) in advanced gallbladder cancer (GBC) requiring extended cholecystectomy is challenging, in terms of achieving clinically safe and complete oncologic resection. Recently developed robotic systems, however, may provide advantages in overcoming difficulties faced by laparoscopic MIS. The purpose of this study is to investigate the feasibility and advantages of a robotic system to assist with extended cholecystectomy.
Methods: Patients diagnosed with clinically suspected stage T2 or above, GBC (as determined by preoperative computed tomography or ultrasonography) underwent robotic extended cholecystectomy (REC). The attached video shows the detailed procedure in the following order: the positioning of the patient and the trocars, Kocher maneuver, lymph node dissection (#8, 9, 12, 13), skeletonization of hepatoduodenal ligament, ligation of the cystic duct and liver resection.
Results: Eleven patients underwent REC. Mean operation time was 185.2 minutes and the mean estimated blood loss (EBL) was 210.9ml. Eight patients (72.7%) were diagnosed as stage T2 or above, and three patients (27.3%) as N1. All cases had tumor-free resection margins, and two cases showed invasion to the hepatic parenchyma. The mean number of retrieved lymph nodes was 7.3. The mean duration of hospital stay was 6.3 days. There were no cases of mortality or recurrence within 90 days of the procedure.
Conclusions: This study suggests that robotic systems can be safely utilized in advanced stage GBC, facilitating oncologically sufficient lymph node dissection and rapid recovery.