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Focus On Hepatobiliary Surgery!

Epublication, Mar 2016;16(03). URL: http://websurg.com/doi/fc01en7
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Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
P Pessaux, R Memeo, V De Blasi, D Mutter, T Piardi, J Marescaux
Surgical intervention
2 years ago
637 views
17 likes
0 comments
16:09
Robotic left lateral sectionectomy with biliary disobstruction
We present the case of a 61-year-old woman followed up for the past 7 years for a dilation of the left biliary tract at the level of the left liver lobe with 3 episodes of angiocholitis. The robot is positioned at the level of the patient’s head. Four ports are put in place. The intervention is begun with placement of the hepatic pedicle on a tape. The liver is then mobilized and the falciform ligament is divided. The hepatotomy is performed at about 1cm to the left of the falciform ligament. The hepatotomy is begun. It is performed by means of the CUSA ultrasonic dissector, and hemostasis and biliostasis are performed using a bipolar grasper. The different elements of the portal pedicle are dissected and controlled. Once the biliary tract has been dissected, it is opened using scissors. As soon as it has been opened, an intrabiliary lithiasis is found. Each stone is progressively extracted to prevent any spillage within the peritoneum. Simple suctions are initiated. A Dormia basket is then placed through the left tract to clear both the convergence and the right biliary tract. Control intraoperative choledochoscopy is performed. New maneuvers are carried out using a series of lavage, allowing for the complete clearance of the biliary tract. Once the voiding of the biliary tract has been controlled, the left biliary tract is closed by means of a PDS 5/0 running suture. The hepatotomy is pursued in order to complete the left lateral sectionectomy. The left supra-hepatic vein is divided by means of an Endo GIA™ linear stapler. The suture and hemostasis are completed by means of different fastened stitches. The tape is removed. The bag containing the stones is extracted by means of a Pfannenstiel’s incision. The postoperative outcome was uneventful and the patient was discharged on postoperative day 6. Final pathological findings ruled out the presence of any malignancy.
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
P Pessaux, J Hallet, R Memeo, S Tzedakis, V De Blasi, D Mutter, J Marescaux, L Soler
Surgical intervention
2 years ago
1605 views
58 likes
0 comments
13:06
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
P Pessaux, R Memeo, J Hargat, S Tzedakis, D Mutter, J Marescaux, L Soler
Surgical intervention
2 years ago
2007 views
42 likes
0 comments
08:07
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
A Prado de Resende
Surgical intervention
2 years ago
1525 views
63 likes
0 comments
26:34
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
Biliary access techniques in patients with surgically altered anatomy
Iatrogenic bile duct injuries following surgery are associated with life-threatening complications.
Most injuries occur following open or laparoscopic cholecystectomies. The incidence of bile duct injury (BDI) has increased when a laparoscopic approach is used.
The current incidence of BDI using a laparoscopic approach is comprised between 0.5 and 2.7%.
The presented clinical cases include bile leakage, bilioma, peritonitis or a local abscess, and only 30% of cases are recognized intraoperatively.
The main modality of treatment is surgery. However, endoscopic management is a current alternative.
This video highlights the various methods for the management of biliary leaks and postoperative biliary strictures.
M Perez-Miranda
Lecture
2 years ago
950 views
29 likes
0 comments
26:31
Biliary access techniques in patients with surgically altered anatomy
Iatrogenic bile duct injuries following surgery are associated with life-threatening complications.
Most injuries occur following open or laparoscopic cholecystectomies. The incidence of bile duct injury (BDI) has increased when a laparoscopic approach is used.
The current incidence of BDI using a laparoscopic approach is comprised between 0.5 and 2.7%.
The presented clinical cases include bile leakage, bilioma, peritonitis or a local abscess, and only 30% of cases are recognized intraoperatively.
The main modality of treatment is surgery. However, endoscopic management is a current alternative.
This video highlights the various methods for the management of biliary leaks and postoperative biliary strictures.