TRANSDUODENAL SPHINCTEROPLASTY: A VISUAL CASE STUDY

Minimally invasive resection for perihilar cholangiocarcinoma is an emerging technique in HPB surgery which requires both liver resection and biliary reconstruction. Description of this method is very limited. In this video, we described a Bismuth 3A perihilar cholangiocarcinoma resection in a 77-year-old man, who presented with intrahepatic ductal dilation (Right >Left) and jaundice. ERCP/cholangioscopy shows a high-grade bismuth 3A with malignant stricture. An endoscopic preoperative drainage was achieved with a 7 French 15cm plastic stent. The robotic resection of Klatskin type 3A was completed uneventfully with adequate lymphadenectomy and unremarkable postoperative course.

A 67-year-old male patient with upper abdominal discomfort for 2 months and jaundice for 1 month. CT scan demonstrated hilar mass with portal vein invasion. PTCD was performed 10 days ago. This patient was successfully treated with right hepatectomy and caudate lobectomy together with portal vein reconstruction. The portal vein invaded by the tumor was removed and end-to-end anastomosis was performed. Then, the biliary-enteric anastomosis was completed between the left hepatic duct and the jejunum in an end-to-side way. The hospital stayed is 18 days. This patient obtained rapid recovery without severe postoperative complications. Postoperative CT and laboratory examination were normal.

A middle-aged male was admitted to the hospital with pruritus and jaundice. Enhanced computed tomography demonstrated the wide extension which involved the portal vein, and the right posterior hepatic artery originates from the mesenteric artery. According to these, I/V/VIII segment resection was scheduled. The portal vein involved was removed. Then end-to-end anastomosis was performed. Finally, biliary enteric anastomosis was completed in an end-to-side way. The scheduled R0 resection had been achieved. Surgical procedures cost 10 hours with 200ml bleeding. The postoperative course was uneventful. Pathological examination revealed that R0 resection was performed.

For gallbaldder cancer patients with T1b or higher disease, radical cholecystectomy including partial hepatectomy and porat hepatic lymph node dissection (PHLND) is recommended. PHLND is a technical demanding procedure regardless in open or minimally invasive surgery.

Author presented a novel and standardized method to demonstrate the key techniques for PHLND with robotic platform with the following goals:
1. To help fellows and junior attendings to understand and to mast the skills for porta hepatis lymph node dissection in the open approach by demonstrating the key steps and anatomy.
2. It provided a road map for those surgeons who are interested in robotic radical cholecystectomy.

Minimally invasive approach for perihilar cholangiocarcinoma is an emerging technique. The difficulty with laparoscopic bilioenteric anastomosis at or above the level of hilar plate is a limiting factor in laparoscopic technique. We describe our robotic technique in unifying right posterior and anterior sectoral duct to create a single hepaticojejunostomy anastomosis after a type 3B Klatskin tumor resection. The operative time was 8 hours with an uneventful postoperative recovery. Pathology report showed cholangiocarcinoma involving the left hepatic duct and, and proximal common hepatic duct, with microscopic invasion into the left lobe (2.1 cm). The JP drain was removed prior to discharge.

Hepatocellular adenomas (HA) are benign liver tumors, more frequently seen in women exposed to estrogenic contraception. Rupture of these tumors can be the first sign and life-threatening. We describe a 35-year-old woman with oral contraceptive use presenting to the ER after an acute onset of abdominal pain. CT scan was consistent with a 13cm left hepatic lobe mass likely from a ruptured HA. The patient underwent a successful robotic left hepatectomy with minimal blood loss and without complications. We included a series of robotic HA resection performed in the last 5 years and demonstrated the safety, feasibility, and reproducibility of robotic technique in treating hepatic adenoma.

Intrahepatic cholangiocarcinoma is an aggressive cancer requiring resection with portal lymphadenectomy. One of the limiting factors in the current adoption of robotic technology in liver resection is the absence of Cavitron Ultrasonic Surgical Aspirator (CUSA). We described our technique of hepatic vein dissection without CUSA during an anatomical left hepatectomy in a 56-year-old diagnosed with an intrahepatic cholangiocarcinoma. The workup included a pre-referral liver biopsy and a CT scan showing a 2.5 cm segment 4A mass between left and middle hepatic vein. A robotic left anatomical hepatectomy was completed with an uneventful postoperative recovery. She was discharged on POD 2.

Background
Sphincter of Oddi dysfunction (SOD) is a rare disorder. Endoscopy allows minimally invasive diagnosis and therapy. Open transduodenal sphincteroplasty (TDS) is an option for SOD.

Methods
The video shows TDS on a female with gastric bypass diagnosed with Type I SOD and choledochocele.

Results
Laparotomy and Kocher maneuver performed. Intraoperative ultrasound identifies ampulla and duodenotomy site. Pediatric feeding tube cannulates common bile duct, facilitating sphincterotomy. Sphincteroplasty is performed with absorbable suture. Feeding tube acts as a pancreatic stent during duodenotomy closure.

Conclusion
TDS is an option for SOD patients whose anatomy is unfavorable for endotherapy.