Society: SSAT

We present the case of a 67-year-old woman who had two IPMN in the pancreas body (4 and 2 cm) and underwent robotic distal pancreatectomy with spleen preservation. The video's goals are twofold: to demonstrate that, even in the absence of tactile sensation, haptic adaptations combined with a tridimensional view and articulated forceps favor spleen preservation due to possible vessel dissections. Nonetheless, the main meaningful goal is to approach the vessels safely with upfront vascular control and optimize the field exposition for occasional sutures in the event of inadvertent bleeding. The patient had no complications, and the pathology confirmed the presence of IPMNs with free margins.

The iatrogenic cholecystoduodenal fistula is an unusual biliary problem that is best managed by a collaboration of surgeons and gastroenterologists. We present a case report that describes the successful interdisciplinary management of the fistula. From a technical standpoint, we highlight the dynamic use of ICG to identify biliary anatomy and assess for bile leaks, as well as, the consideration of thoughtful dissection through quality tissue planes.

This video demonstrates a patient who presented with a large pancreatic tail mass biopsy proven to be pancreatic adenocarcinoma (PDAC) and treated with a 4 trocar laparoscopic distal pancreatectomy. Due to the large size and malignant nature of the lesion, Radical Antegrade Modular Pancreatosplenectomy (RAMPS) technique was used to ensure a complete resection with radial margin clearance. In a posterior RAMPS, the left adrenal gland and retroperitoneal tissue from the left renal vein to the diaphragm is cleared. Medially, a lymphadenectomy to the left of the celiac and superior mesenteric artery is performed.

This video shows the application of the robotic approach for treatment of chronic pancreatitis in a 39-year-old. Scans showed calcifications in the pancreatic head and compression on the MPD.
After Kocherization of the duodenum severe fibrosis of the hepatoduodenal ligament was encountered. The gastrocolic omentum was divided and the pancreatic neck was transected. Dissection for control of the gastroduodenal artery was then completed. A cholecystectomy was performed and the specimen was removed. A stone was retrieved, followed by reconstruction with a choledochojejunostomy, a pancreaticojejunostomy, and a duodenojejunostomy. The patient tolerated the operation well and discharged on POD 4.

We present a video of a patient with locally advanced pancreatic cancer who underwent a modified Appleby procedure for tumor clearance following neoadjuvant chemotherapy. Technical aspects include Kocher’s maneuver to mobilize the head of pancreas, dissect SMV with tumor involvement, extended lymph nodes clearance for hepatoduodenal ligament, sub-adventitial dissection for CHA and GDA, resection of Gerota’s fascia and reconstruction of PV-SMV. With proper patient selection and preparation, LAPC with celiac axis involvement following neoadjuvant chemotherapy can be safely resected with favorable outcomes.

Duodenal adenomas are often require resection if symptomatic or if they demosntrate high-risk or malignant features. While endoscopic resection is preferred if safely feasible, sometimes surgical resection is necessary due to their size or location. Formal surgical resection often requires resection of the ampulla and head of the pancreas, even when the mass itself does not involve these structures, via Whipple procedure. However, the Whipple operation remains a highly morbid procedure, commonly complicated by pancreatic fistula. In this video, we present the laparoscopic resection of a high-risk duodenal adenoma, completely sparing the pancreas, ampulla, and common bile duct.

This video is a case presentation of a 70-year-old patient who presented with a symptomatic 1.2 cm insulinoma on the posterior aspect of the pancreas in between the pancreatic duct and splenic hilum. A successful robotic enucleation of the pancreatic insulinoma was performed and distal pancreatectomy avoided. This was aided by intraoperative ultrasound guidance as well as utilization of indocyanine green (ICG) angiography during the operation, which enhanced well at the site of the insulinoma. This video illustrates the benefits of a robotic approach to this challenging pancreatic tumor enucleation.

A 55-year-old male underwent laparoscopic cholecystectomy with choledochoscopy and ductal lavage for common bile duct clearance. The patient first underwent ERCP for stent placement, but a stone remained in the upper third of the common bile duct. During the cholecystectomy, the biliary tree was not successfully visualized, so we passed a choledochoscope through the cystic duct. We visualized dense fibrinous tissue that could not be traversed, so we utilized pulsatile lavage of injectable saline to break up the tissue and flush it into the common bile duct until the duct was cleared. We removed the scope and completed the operation. The patient experienced no complications.

We demonstrate a surgical technique involving construction of a hepaticojejunostomy (HJ) anastomosis that ensures even spacing between the sutures regardless of the size of the common bile duct. This is demonstrated via a series of illustrations followed by live demonstration of a HJ anastomosis created during a Whipple procedure. Overall, this technique results in the creation of a tension-free hepaticojejunostomy anastomosis, that typically does not require stenting, is highly reliable and replicable regardless of the size of the common bile duct.

Jesse Rappaport

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