Video Presentations

V 1.01 Postpartum Haemorrhage – Still a Catastroph in Rural India Prophylactic B-Lynch Suture During LSCS – A Boon for High Risk Patients. Dr M. Vijayasree, M.D., Obg., Professor, Mamata Medical College, Khammam, Telangana State, India Introduction: Postpartum Haemorrhage is an Obstetric Emergency Which Causes Significant Maternal Mortality and Morbidity Globally Especially in Developing Countries Like India. Recently focus is on prevention of Postpartum Haemorrhage. Active management of third stage of labour with oxytocics is come into practise.If Postpartum Haemorrhage is anticipated Conservative surgical procedures like B-Llynch suture is being applied to controll bleeding. In this study prophylactic B-Lynch suture was applied in women undergoing emergency caesarean section who had high risk factors for uterine atony. the aim of the study was To evaluate the effect of elective B-Lynch suture in preventing atonic Postpartum Haemorrhage during emergency caesarian section with high risk factors for atonicity. Materials and Methods: 80 antenatal women undergoing emergency caesarean section with risk factors for atony of the uterus were selected in our study. Seventy women were selected before starting caesarian section with risk factors like general anaesthesia, chorioamnionitis, preeclampsia, prolonged labour, second stage arrest, multiple gestation and use of magnesium sulphate. Ten women were selected during the caesarean section where uterus remained atonic despite of Oxytocics. During LSCS, B-Lynch suture was applied. Need for additional intervention or use of blood transfusion was evaluated. The results were analysed by using appropriate statistical method. Results: 75% of the patients were in the age group of 18–23 years. None of them were above 30 yrs of age. 90% of the women were nulliparous, 10% were parous. Risk factors involved were Eclampsia in 40/80 (50%), multiple gestation in 12/80 (15%), hydramnios in 12/80 (15%), prolonged second stage of labour in 8/80 (10%), Chorio-amnionitis in 4/80 (5%) and use of magnesium sulphate in 4/80 (5%) patients causing uterine atony post delivery. The average haemoglobin level was 9.8 g/dl. None of the women required any other means of surgical, additional pharmacological intervention and blood transfusion. Pre and post operative haemoglobin levels differed by 0.4 to 1.8 g/dl. Majority of the patients were in the younger age group, nulliparous and had eclampsia. All patients were discharged on oral ironwithout any complications during the procedure and three months there after. All women resumed normal menstruation within 40 days after delivery. Conclusion: In conclusion elective B-Lynch suture is cheap, quick and effective in preventing atonic Postpartum Haemorrhage in women undergoing Emergency caesarian section who are at high risk for haemorrhage.


Italy
Segment resection for eolo-rectal carcinoma metastasis is seldom reported in the literature. The resection can be performed when the lesion is solitary and not adjacent to left portal branch. Neoplastic lesions can be classified into 5 types according to topographic localization (Hasegawa 1991).
The ease of a 55 year old woman with metaehronous eaudate lobe metastasis from sigma adenoeareinoma resected 2 years before is reported. The eaudate lobe lesion was type II: near the inferior side of the eaudate. The lesion was demonstated by preoperative US and porto-CT scan.
The liver was ulteriorly explored by intraoperative US. The access to the tumour was through the lesser sac aider mobilization ofthe left hepatic lobe. Division of the hepatic veins on the let side of the inferior vena eava was achieved. .Dissection of the eaudate lobe from portal and hepatic branches was made. The segment was then extirped. Hepatic segmenteetomy for colon adenoeareinoma metastasis can be easily performed in selected patients.

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CENTRAL HEPATECTOMY ANATOMIC RESECTION OF SEGMENTS 4, 5 AND 8 D. Cherquio B. Tantawi, P.L. Fagniez. Department of Surgery, Universit Paris XII H6pital Henri Mondor Crteil France Central liver tumors involving segments 4, 5 and 8 may be removed by right hepatectomy extended to segment 4 (resection of segments 4-8). However, such a resection may be too extensive when the left lobe (segments 2 and 3) is small and may lead to postoperative liver failure. We present an alternative technique in such patients consisting in anatomic resection of segments 4, 5 and 8 that we called central hepatectomy which removes the territory of the middle hepatic vein while preserving the left and right hepatic veins. The surgical technique includes: complete.liver mobilization and control of the 3 major hepatic veins division of the pedicles of segment 4 on the right border of the round ligament opening of the hilar plate and control and division of the.right anterior portal pedicle for segments 5 and 8 liver transsection along anatomic planes defined by ischemic margins liver transsection is performed without vascular clamping. If hemorrhage occurs, the portal triad is clamped with or without clamping of the major hepatic veins care is taken to preserve the right hepatic vein. In this video we present the case of a 60 year-old woman with a tumor located at the junction of segments 8 and 4, diagnosed 10 years after treatment for a T2 NO M0 breastcarcinoma. The patient underwent central hepatectomy with an uneventful outcome. Histologic examination showed a metastasis of breast carcinoma. This technique was used in 4 patients including the case shown here. Indications were secondary liver cancer in 3 cases (colorectal 2, breast 1) and hepatocellular adenoma in case. The patients did not receive any blood tranfusions, vascular clamping was required in 3 cases for 15, 18 and 20 minutes respectively and postoperative course was uneventful. The technique presented here is a safe alternative to extended right hepatectomy for resection of central liver tumors in patients with a small left lobe. Initial vascular control permits to perform a bloodless and strictly anatomic resection of segments 4, 5 and 8. The case subject of this videotape is a man 59 years old with a large tumor of the caudate lobe involving the 4 and 8 segment. The patient, accepted in our Departement after an explorative laparotomy that confirmed the diagnosis of hepatocellular carcinoma in normal liver, underwent a new operation, realizing an en bloc caudate lobe and left hepatectomy extended to the 5 and 8 segments, that is a left and medial hepatic vein lobectomy. The remaining liver( 6 and 7 segments) was supplied by the lateral (posterior) branch of the right portal pedicle and drained by the right hepatic vein. Moreover the tumor was infiltrating the anterior wall of the retrohepatic vena cava and thus the hepatectomy was associated with the remove of a little patch of this vein. Parenchimal hemostasis was obtained by early hilar dissection and control of the arterial and portal branches. This procedure was integrated in case of necessity by a Pringle manoeuvre with alternative intervals of 15 minutes of hepatic anoxia and 5 minutes of vascular release and hemostasis of bloody surfaces by pad compression. The suture of the hepatic veins was realized by stapling techniques. The postoperative course was uneventful and the patient is still living and disease free two years after the operation. This case therefore incite to a more aggressive surgical treatement of hepatocellular carcinoma. Lenght ofthe video 15 minutes.

Buenos Aires. (Argentina)
The lack of cadaveric organ donors for transplants is a worldwide problem.The situation is even worse when dealing with pediatric patients which results in a high mortality rate for those low weight patients awaiting transplantation. During the last decade, new techniques in organ resection such as liver reduction for cadaveric or living related donors (LRD), has allowed us to implement a number of programs which improve the survival rate ofthose on the waiting lists.The purpose ofthis paper is to convey our experienc at the Hospital ltaliano de Buenos Aires with LRD and its impact on the Pediatric Liver Transplant Program. Between January 1988 and March 1994 we have had a total of 83 patients on the waiting list; 45 patients were admitted during the period Jan/88-April 92 (period 1) and 38 between March92 and May94 (period ll).We performed 42 transplants in 39 patients,20 of these were transplanted during period and 19 during period [I. The average age of the 39 patients was 6.3 y.o. (range 0.9-16), 20 females and 19 males. Cadaveric donors were used for 35 transplants:19 full size and 16 reduced livers.In 10 cases during period lI we performed the liver transplantation with LRD.Eleven children have received a liver transplant from a living related donor.This procedure has resulted in a 50% decrease in the mortality rate while on the waiting list, 100% survival of the receptors and donors with only minor complications to these.Living related donor liver transplantation should improve the possibilities for small receptors with extrahepatic biliary atresia. In this tape we described the differents steps of the living related liver transplantation:donor hepatectomy, procurement of internal jugular and saphenous vein, back table, recipient hepatectomy and the implant of the new liver in the recipient with the different vascular anastomosis and biliary reconstruction. ( It is an operative technique who show the ligature ofthe inferior vena cava for thrombosis by compressive hydatique cyst offight liver.
There was an hemodynamics compensation assured by a new formed collateral circulation.
The vena eava was dissected under confluence ofrenal veins. During the dissection under diaphragm, the vena cava was injured and fastly repaired, as showed. The ligature was performed upper thrombosis with very-slow adsorbable monifilament suture. The vein wasn't seetionned. It was impossible using the "cava-clip".
The hidatique cyst was treated with any cystopedcystectomy. The ligature ofvena cava may be do ifthere is a good hemodynamic compensation. This operative technique is fight for a risk of an embolism in a patient with thrombosis secundary to the other disease.
The use of this technique prevents the development of hepatic cysts and hepatoneumonic abscesses, complications inherent in the bile-duct ligation techniques, as well as the biliary recanalization in the postoperative period.
LAPAROSCOPIC RESECTION OF LIVER SEGMENT HAEMANGIOMA. M.Filauro,C. Bagarolo, E. Ciferri, G.M. Gazzaniga 1st Surgical Dep., S.Martino General Hospital, Genoa, Italy Focal lesions of the liver are rarely treated using laparoscopic approach. Authors presents the case of a 45 years-old female, admitted inSurgical Departement with upper abdominal pain mainly left sided nausea vomiting, slight fever.
Haematological checks revealed only WBC increase and slight elevation of transaminases values. Ultrasuond examination of the abdomen showed gallbladder stones with moderate signs of cholecistitis and a large lesion of inferior lateral segment of left lobe of the liver (5 x 4 cm.) Angio-CT scan of upper abdomen confirmed the hepatic mass with typical contrast enhancement of hepatic haemangioma.
Laparoscopic approach was prevented, with the aim of left inferior lateral segmentectomy, and cholecistectomy.
Trocar placement was scheduled to obtain a good vision of the all liver and to be able to insert different laparoscopic tools. Pringle manoeuvre was realized by a soft bowel forceps. Liver section was obtained using monopolar forceps, metallic clips and major vascular pedicles were severed using 30 mm reloadble EndoGIA. Cholecistectomy was also performed, and a silastic drainage positioned near the hepatic surface. Postoperative course was uneventful, and patient was discharged after 8 days from operation. Follow-up revealed an optimal hepatic growth, with complete parenchimal regeneration at 6 month from surgical approach. Laparoscopic liver resections are technically feasible in selected cases and by the use of appropriate endosurgical instruments.
Surgical treatment of Budd-Chiari syndrome consists in portosystemic decompression or in liver transplantation. This video shows the operation on a 28-year-old man with the complete thrombosis of the hepatic veins and the incomplete thrombosis of the suprahepatic infedor vena cava, caused by a myeloproliferative disease. Hepatomegaly, refractory ascites and liver functional failure were present. There was not encephalopahty. After doppler ultrasonography, angiography, CT scan and MRI, we decided to perform a double prosthetic side to side portal-caval and caval-atdal bypass to decompress the hypertensive IVC and to shunt the entire portal venous flow. Through a bilateral subcostal laparotomy the infedor vena cava and the portal vein are dissected and isolated. The side to side portal-caval (suprarenal) bypass with a 10 mm dng reinforced PTFE graft is performed. Then, after a median stemotomy, the lateral wall of the right atdum is exposed and a side to side caval (infrarenal)-atdal shunt is achieved with a 16 mm dng reinforced graft. The graft is 50 cm long and passes anteriorly to the stomach and to the left lobe of the liver into the mediastinum through a hole made in the anterior diaphragm.
Pre-shunt pressure: IVC 22 cm H20, portal vein 33 cm H20. Post-shunt pressure: IVC 5 cm H20, portal vein 15 cm H20. There were no postoperative complications; the ascites disappeared, the liver function improved and there were no signs of encephalopathy. After 2 years, doppler ultrasonography confirms a good flow in both grafts. Total vascular exclusion of the liver allows major liver resection for hypervaseulafized tumors involving main portal or hepatic vein pedieles. However, liver isehemia is not well tolerated by cirrhotic,, eholestatic or fibrotic livers. We have previously showed that these abnormal livers could be protected using anin situ peffusion of UW, in the same way than normal liver grafts during liver transplantation.
Presentation of the case A 50-year-old man presented with an hepatocellular carcinoma developed on a fibrotie liver (hepatitis B and C). The lesion was 15 em in diameter and was developed in the right lobe of the liver and the segment 4. The portal confluence was laminated but the portal vein was not invaded. Posteriorly, the tumor laminated the right and the median hepatic veins and was in contact with the anterior side of the vena cava.
Surgical procedure A large bi subcostal incision was performed. The liver was fully mobilized by section of it's ligaments and the entire vena eava was libei'ated from the posterior face of the liver. A cannula was inserted in the right hepatic artery and was directed towards the left hepatic artery. A total vascular occlusion was obtained by clamping the portal pedicle and the supra and infra hepatic segments of the vena eava. The liver was then perfused with UW at 4 C and the effluent was drained via a small cavotomy. An extented right lobectomy was then performed with a section of the main vascular pedicles using a TA stapler. The cannula was thenremoved, the cavotomy sutured and the vascular clamps removed. The hemostasis was satisfactory and the patients did not received blood transfusion. The ischemia lasted for 90 rain.

Results
The post operative course was uneventful. The patient did not developed jaundice or encephalopathy. At postoperative day 2 the prothrombine time was at 56 %.

Conclusion
This case and others from our institution are encouraging, however the principle of protection of abnormal livers by perfusion in situ with UW remains to be demonstrated. The patient is a 56-year-old man with metastatic liver cancer from the colon. Sigmoidectomy was performed on October 1991 in the other hospital. Liver metastasis was found by US and he was referred to our hospital. Two tumors in the segment VIII and V were found and the latter one infiltrated the right anterior portal pedicle. CT volumetrydisclosed that the left liver volume was 30 % of the whole liver, so that right hemihepatectomy was abandoned and right anteior segmentectomy right paramedian sectoriectomy was selected. With J-shaped incision extended to the ninth intercostal space, laparotomy was accomplished. After cholecystectomy, the right anterior bile duct, hepatic artery and portal vein were ligated and divided. Other portal venous and hepatic arterial branches were taped. The discolored area coresponding to the right anterior segment was marked with electrocautery. Under hemihepatic occlusion of the left liver, division of the liver parenchya was undergone along the major fissure. The middle hepatic vein was completely exposed. Then, selective vascular occlusion was switched to the fight posterior segment and liver transection was camed out along the intersegmental plane between the fight anterior and posterior segments. After about the caudal half of this plane was divided, the right anterior portal pedicle was ligated and severed. Liver transection was then proceeded along the fight hepatic vein and it was completely exposed. The hepatic arteries run in contact with the bile duct, and then are often infiltrated by cancers originating from the upper or h ilar portion of the bile duct or from the gallbladde. Such cases have been traditionally cosidered unresectable when both right and left hepatic arteries were invaded, or required massive resection of the liver when the right hepoatic artery was invaded. If liver segmentectomy can be performed with resection and reconstruction of the segmental hepatic artery, it may be possible to preserve the potency of the liver. We succeeded in central bisegmentectomy with concurrent caudate Iobectomy by using the right gastroepiploic artery for reconstruction of the posterior segmental branch of the right hepatic artery. This was performed on a patient with gallbladder cancer which had infiltrated the right hepatic artery up to the bifurcation site of its anterior and posterior branches. The right gastroepiploic artery was dissected free together with its surrounding fatty tissues along the greater curvature of the stomach. The dissection was carried down to the pyloric ring on the right and up to the last bifurcation site on the left. The right gastroepiploic artery was anastomosed to the posterior branch of the right hepatic artery in end-to-end fashion using 7-0 monofilament-nylon. Celiac angiography was conducted three weeks postoperatively. This study confirmed a patent hepatic segmental arterial anastomosis.

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RIGHT TRISEGMENT PORTAL VEIN EMBOLIZATION M. Nagino, Y. Nimura, J. Kamiya, S. Kondo, M. Kanai, Y. Goto 1st Department of Surgery, University of Nagoya, Nagoya, Japan We have developed embolization of the right portal vein plus the left medial portal branch (right trisegment portal vein embolization) through the "ipsilateral" approach. Its practical technique is presented in this video. The patient was a 6 lyear-old male with hilar cholangiocarcinoma. Two percutaneous transhepatic biliary drainage catheters were placed to drain the entire biliary system and to evaluate the cancer extent. Based on the preoperative findings of several diagnostic imagings, right hepatic trisegmentectomy with en bloc resection of the caudate lobe and the extrahepatic bile duct was scheduled. However, the volume of the left lateral segment, assessed by volumetric study using computed tomography, was only 249 cm (the percentage of the liver resected was 81%). Thus, portal vein embolization was performed to increase the safety of liver resection. Two kinds of 5.5F triple-lumen balloon catheters (types and II), designed at our facilities, were used for embolization. The type catheter has one lumen connected to the balloon and two other lumens connected to the catheter tip. The type II catheter is similar to the type catheter except that the two lumens open just proximal to the balloon. Under fluoroscopic control the type catheter was advanced into the portal vein through a 7F catheter sheath introduced through an ultrasonogramguided puncture of the right anterior portal branch. The left medi.al portal branch was first embolized by using this catheter. Because this catheter is made of polyethylene," it could be curved by steam and advanced easily into the left medial branch. Then the right posterior inferior (P6) and the right posterior superior (P7) portal branches were embolized individually by the same catheter, because in this case P6 and P7 branched off at the portal bifurcation independently. After exchanging the catheter, the right anterior portal branch was embolized by the type II catheter. Fibrin glue mixed with iodized oil was used as the embolic material. The volume of the left lateral segment increased to 291 cm two weeks after the embolization. Right hepatic trisegmentectomy with caudate lobectomy was carried out as scheduled. Posthepatectomy hyperbilirubinemia occured but subsided. The patient has now been well without any signs of recurrence 15 months after the surgery. In conclusions, because right hepatic trisegmentectomy for hilar cholangiocarcinoma results in extensive resection of functional liver, right trisegment portal vein embolization is advisable as preoperative management to increase the safety of extensive liver resection Trisegment embolization is achievable only through the ipsilateral approach. This approach is safer because the portal branch designed for embolization is punctured, and consequently the catheter sheath can be removed soon after embolization.
[ We will demonstrate preoperative imagings and an operative procedure of a left hepatic trisegmentectomy with extrahepatic bile duct resection and portal vein reconstruction with intraportal tumor thrombectomy for a rare case of advanced primary malignant lymphoma of the liver originated from the segment and 2 which diffusely involved the biliary structure at the hepatic hilus from the left to the confluence of the fight anterior and posterior segmental branches. CT and portography showed marked tumor thrombus which obstructed the left intrahepatic portal branches and the right anterior segmental branch and separated the portal bifurcation of $6 and $7 branches. Percutaneous transhepatic biliary drainage (PTBD) was performed in the fight anterior and posterior segmental ducts and the operation was carried out on July 29, 1993. At laparotomy, a clear demarcation was observed at the right portal fissure and collateral portal circulation was found around the bilairy ducts. After dividing the left and middle hepatic arteries, the portal vein was extensively exposed up to the bifurcation and tumor thrombectomy was performed through the longitudinal venotomy on the main portal vein extended up above the bifurcation while preserving the portal blood flow through the above collateral veins. After removing the portal tumor thrombi, the venotomy was closed longitudinally and the left and fight anterior portal vein were ligated. After obtaining the portal blood flow into the fight posterior segment, the common bile duct and the collolateral veins were reseeted above the pancreas, and the liver was transected along the demarcation on the right portal fissure and the caudate lobe was also resected en bloc. The right posterior segmental duct was resected at the confluence of $6 and $7 ducts and reconstructed with a jejunal loop.
Postoperative histological examination revealed primary malignant lymphoma of the liver: diffuse large cell, B type. The patient, 55 year-old female, received postoperative chemotherapy and has been living quite well without tumor recurrence for 2 years and 5 months. prothesis to treat bIeeding esophageal varices. This new type of operation was weii accepted because its technicai simpIicity, efficacy to prevent esophageaI. hemorrhage and iow rate of encephaIopathy. In the iater course a rate of anastomotic thrombosis up to 30% and. encephaiopathy up to 20% was described restricting its indication. Patients and Methods: Since Jan. 1,1987 our group is using a lOmm PTFE (Goretex) -prothesis prospectiveiy. The resuits of consecutive 96 pat. faiiing endoscopic scIerotherapy (ES) up to the 1st of Jan. 1995 are described. In 97%iiver cirrhosis, mostiy aIcohoiic origin was the underiying disease. 51 pat.
beionged to the CHILD-PUGH ciassification A, 41 to B and 4 to C (emergency shunts). 58 men and 38 women had a median age of 56.3 (21-72) years. Results: There were 8 hospitai deaths, 2 of the emergency group, mainiy due to liver faiiure; thus, the total hospital mortaiity is 8.3% and 6.6% of the eIective shunt. 4 postoperative thromboses (4.2%) deveioped and 5 recurrences of hemorrhage managed by ES. Preservation  A 68 year-old woman complained of carcinoid syndrome with severe diarrhea and flush. The primary tumor was located at the ileum, while large necrotic metastases were present in the fight lobe of the liver.
A fight hemihepatectomy with concomitant small bowel resection was performed.
A Swan-Ganz catheter was inserted preoperatively and continuous infusion 0f Somatostatin was started at the beginning of the procedure. Liver resection was the first step of the procedure. Water jet dissection was used for dissection of the hepatic pedicle and removal of one large metastatic lymph node, and for selective dissection of the hepatic parenchyma under portal clamping. It was used also at the second step of the operation i.e. small bowel resection, for selective dissection Of the mesentefium and removal of lymph nodes satellite to the primary tumor. The patient underwent an uneventful recovery with complete regression of the carcinoid syndrome.
Carcinoid syndrome can be cured by concomitant resections of the primary tumor and of liver metastases when both lesions are resectable.
Hydatid disease of the liver: cystopericistectomy Rovati V., Nervetti G., Faleschini E., Colturani F.. Department of Surgery, University ofMilan, Milan, Italy The film shows a case of a voluminous echinococcus cyst localized in left liver and appearing on the surface of the parenchyma. Pericistectomy with intact cyst wall was performed; vascular exclusion, in order to avoid blood leakage, Was obtained using Pringle's manouvre. This treatment has the better outcome because it doesn't cause reduction of the functioning parenchyma and has better possibilities for radical: 1) parasite exclusion, Cholangiocarcinomas,more uncommon than hepatocellular tumors allow in the majority of cases a very poor prognosis thous influenced by various factors linked to the neoplasia. In the most differentiated histological forms,with structures that looks like the ducts of Hering,to which rather low levels of AFP are associated,the expectation of life is clearly better,compared with undifferentiated forms(35vs4 months of average survival).A right hepatectomy is presented(V,VI, VII,VIII segment)carried out for a well differe ntiated cholangiocarcinoma,in a non-carrier of Australia antigen with an AFP rate of ll5ng/ml. The decision for resection was taken on the bas is of a preoperative angiographic and morphological study(ECO,TC,lapatoguided biopsy),also th rough the extemporary valuation of the stage and grading of the neoplasia. The presence of a sing le mass on the periphery of the right lobe,the lack of satellitosis,the good quality of the he althy hepatic parenchyma, the resection with ad equate margin free of neoplasia,confirmed by the intraoperative ecography,led us to consider the regulated resection for curative purposes,technically possible and more advantageous for the life expectation of the patient,compared to a conservative treatment.After 6 months the patient was in good healt. There is few report about the feasibility of minimally invasive hepatic resection even in the laparoscopic era. We introduced a new technique of hepatic resection using laparoscopy and minithoracotomy for peripheral tumor in the right lobe. The patient was a 61-year-old man having HCC associated with liver cirrhosis due to hepatitis C. The tumor, 40 mm in diameter, was located in segment VI. He had impaired hepatic function and decreased platelet count (indocyanine green clearance rate, 0.106; and platelet count, 65000/mm3).
Procedure: The ligamental attachments of the right hepatic lobe was divided under the guidance of laparoscopy. Laparoscopic sonography revealed a small satellite, 11 mm in diameter, in segment IV. Following a skin incision of 12cm in length, anterior thoracotomy not extending to the abdominal wall was made. The fight thoracic cavity was entered through the 8th intercostal space. After dividing the diaphragm and the costal arch, the right hepatic lobe was exposed. The satellite nodule was coagulated with microwave. Parenchymal dissection was carded out using an ultrasonic surgical dissector and electrocautery without holding the liver, occluding the inflow, or dissecting the hilum. There was a slight bleeding tendency; the blood loss was 1700 ml. The resected liver volume was 135 g. The patient recovered uneventfully.
Results: This procedure provides minimal access to the dissecting plane of the liver and enables non-touch resection without vascular occlusion. The procedure of parenchymal dissection was a little demanding in terms of bleeding control due to difficulty to compress the liver. This is the case of a patient of 52 years of age, male, with upper fight abdominal pain, weight loss, asthenia, and light jaundice. The ultrasonography and C.T. scan showed the typical image of a 10 cm diameter hydatic cyst of the liver, in the right lobe, with involvement of the diaphragm, and secondary vesicles inside. During the hospitalization jaundice increased abruptly, without cholangitis, which made an early surgical treatment necessary. A bilateral subcostal incision prolonged to the sternum was performed. During the hilus hepatic dissection, involvement of the duct junction and portal bifurcation was evident, therefore a concomitant malignant pathology was suspected. Intraoperative biopsy of adenomegaly was made without evidence of metastasis. The pathology was treated radically, and the surgical procedure was right hepatectomy and the resection of: extrahepatic bile duct, bile duct juntion, portal bifurcation, partial right diaphragm, with anastomosis of the portal vein to the left portal branch, and the left hepatic duct to the jejunum. Operative time was 10 hours. Immediate evolution was satisfactory but the patient needed hemodialysis. Histopathological report of the specimen was: Hydatic cyst with surrounding fibros tissue extending from the peripheral cyst to the hepatic hilus with involvement of the bile duct junction and portal bifurcation ". Conclusions This case confirms what we think about this pathology. We consider it a benign disease with malignant behavior since it involves structures, replaces the parenchyma, makes metastasis and impaires the patient's general state. We have experienced 1,000 cases of hepatic resection for primly liver cancer for 20 years, while we are making effort to simplify the operative procedure of hepatic resection.
We devised Glisson's sheath pedicle transection method as hilum vascular preparation. In this procedure, portal triads (hepatic artery, portal vein, bile duct) are transected not one by one but as one bundle. Transection of fight hepatic vessels which flow into the liver from hepatic hilum is completed within only several minutes. For the procedure of hepatic parenchymal dissection, we developed anterior approach, which does not require mobilization of fight hepatic lobe from diaphragmatic attachments. Since this procedure does not require the blind dissection, at the back of the liver, the risk of bleeding and some other trouble are reduced. especially in cases of big tumor. Right hepatic resection in our procedure can be done within 500ml of blood loss during operation, and it takes about one hour. Vena cava resecction with graft replacement is a procedure rarely performed in the surgical practice. The majority of these resections have been partial, without the need for a prosthetic replacement. At the present time, technical modifications, technological innovations and the contribution of different .experienced specialists, allow the performance of this procedure with low morbidity and mortality rates.
This video details the presentation and course of a patient with infrarenal and retrohepatic IVC neoplastic thrombosis secondary to renal cancer, not available to thrombectomy because of infiltration of the caval wall. He underwent a inferior cavectomy from hepatic veins to iliac bifurcation and replacement with a large expanded polytetrafluoroethylene graft (ePTFE) 20 nun. in diameter and 28 cm. in length. A groin arteriovenous fistula was created between superficial femoral artery and saphenous vein.
Sixteen months after the operation, the patient remains alive, without evidence of recurrence or graft occlusion.
To our knowledge, our patient is the first case of sucessful and uncomplicated replacement of the retrohepatic and infrarenal IVC for caval thrombosis secondary to renal cancer with a large synthetic graft and not undergoing liver resection.

Madrid. Spain
Cavernous hemangioma is the most common benign tumor of the liver. Most of them are small and asymptomatie and are occasionally found at ultrasound study or laparotomy.
Giant cavernous hemangioma of the liver, although rare are more prone to spontaneous rupture or hemorrhage. Hepatic fibrosis is a rare alteration in these patients, but may occur when hepatic venous outflow obstructionis present.
The .video shows a liver transplantation procedure for giant cavernous hemangioma of the liver (maximum diameter: 30 cm) associated to chronic Budd-Chiari Syndrom. The lesion was located in the right lobe and the medial segment of the left lobe.
The video include perioperative imaging techniques and details of the surgical technique. Segment 8 hepatic resection is presented by video, using enhanced intraoperative angioechography with Glisson sheath code (portal vein, bile duct, and hepatiq artery) transection at the hepatic hilus. In this procedure, the presence or absent of tumors and satellite nodules was detected by the use of enhanced intraoperative angioechography using CO gas at the ramus in the anterior segment after taping Glisson sheath code in the right lobe. After confirming tumor-bearing Glisson sheath code, ICG (Indocyanine green) was injected into portal vein which feeds the tumor, and region stained green with ICG.
Perform resection of upper anterior segment in the liver so that the region stained with ICG can be resected from the liver surface .towards the hepatic hilus after severing the Glisson sheath code which feeds a tumor using hflar approach.
This procedure for carcinoma is important not only to reduce blood loss, but also to prevent the intraoperative We developed a new partial resection of the head of the pancreas with an end-toside pancreaticoduodenostomy (or pancreaticojejunostomy), while preserving the duodenum, the common bile duct and upper part of the head of the pancreas around the duct of Santorini. Patients Inferior pancreatic head resection was performed for three patients with intradu(tal papillary adenoma or no.n-invasive adenocarcinoma with mucin hypersecretion in the head of the pancreas. They are all male, and their ages were 60, 74, 75 respectively. Operative procedure The head of the pancreas is approached through a midline upper abdominal incision. A Kocher maneuver is not performed, for protecting the mesoduodenum and vessels to the duodenum. Size and location of the primary lesion is evaluated with intraoperative ultrasonography. Invasion of adjacent structure is also investigated. An important step of the operative procedure before the resection is the tunneling of the pancreas and the dissection of both the superior mesenteric vessels. Care must be taken to preserve arterial blood supply to the duodenum. Only pancreatic branches of the inferior pancreaticoduodenal vessels should be carefully ligated and divided to avoid injuring the inferior pancreaticoduodenal vessels a, long the entire length of the duodenum. The management of these small vessels is one of the most delicate steps in this resection. Division of the pancreas begins at the inferior margin of the neck of the pancreas toward the common bile duct. During division, bleeding points are transfixed with sutures of 5-0 nylon. is important to place four or more sutures of 4-0 absorbable monofilament in.the distal duct of Wirsung for preparing pancreaticoduodenostomy. The common bile duct is well exposed after the excision. The duct of Wirsung is anastomosed to the 3rd portion of the duodenum (or jejunum) in an end to side fashion. Mucosa-to-mucosa stented pancreaticoduodenostomy (or pancreaticojejunostomy) is performed with 4-0 or 5-0 absorbable monofilament sutures. conclusion We believe resection of the inferior head of the pancreas with an end-to-side pancreaticoduodenostomy has a significant role to play in the management of patients with benign diseases and localized malignant tumors of the pancreas. The length of the video is 10 minutes.  (46),lateral (17) and purulent-pancreatic (32) depending on their relationship with the HPD. The diagnosis of fistulae was based on findings US, fistulography, level of amylase and microbial bodies in the fistulous discharge.
Occlusion was performed under roentgenologic control using "RABROH"-an absorbable antibacterial biologic occlusive contrast medium, created on fibronectin base.The medium has a resultant density of 0,05 Pa.,and polymerisation time of 2-4 mins. Postoperatively patients received "Sandostatin" in dose of 0,1 mg four days. A cure rate of 77,9 (84 patients) was achieved,recurrence of fistulae were observed in 11 patients and now deaths occured. Patients were on admission for 5-7 days,opera tion lasted for not more than 10 mins. Occlusion of pancreatic fistulae is an effective,less invasive, economically beneficial method of treating patients. AIM The video shows the surgical approach and the technique adopted in our unit. METHODS Surgical technique consists of abdominal entrance by a bilateral subcostal incision and exposure ofthe pancreas by dividing the gastrocolic omenmm. Accurate pancreatic necrosectomy or abscess debridment is performed preserving the vital parenchyma; at the end of the operation the abdomen is let1 opened and a marsupialization of the lesser peritoneal sac is created by suturing the greater curvature of the stomach and the transverse colon respective to the posterior fascia of the superior and inferior edges ofthe laparostomy. In this way, a cavity is created trough which the pancreas is exposed. The cavity is entirely packed with gauze. Multiple silicon-rubber drains are placed in the subphrenic spaces, pouch ofDouglas and in the pancreatic bed. Our video shows subtotal duodenopancreatectomy. This is just a part of a complex protocol for the treatment of resectable pancreatic head carcinoma, which includes: subtotal (or total, when needed) pylorus-sparing pancreatic resection (according to Traverso-l,ongmire technique); regional lympheetomy extended to hepatic hilus, common hepatic artery, celiac trunk, splenic vessels, mesentericoportal trunk and interaortocaval space; intraoperative radiotherapy (IORT 10 Gy), delivered trough an electron beam (6 MeV) to an area including the portal vein, the splenomesenteric confluence, the superior mesenteric vein up to its branches, the celiac trunk, the common hepatic artery, the proximal splenic vessels, the suprarenal aorta and caval vein; the subsequent execution of end-to-side pancreaticejejunostomy, hepatico-jejunostomy and duodeno-jejunostomy, on a single intestinal loop; an external beam radiation therapy (EBRT 50 Gy), delivered using a photon beam (9 MV), about 4 weeks after surgical resection, to a target volume including tumoral and lymphatic bed.
Twenty-two patients were treated following the above mentioned protocol: we obtained a good local control (90 %), but this result. was not matched with a satisfactory long-term survival (median: 11.8 months) due to the high incidence of metastasis (67 %).
Thus, new therapeutic modalities should be tested; in this respect, neoadjuvant radio-chemotherapy seems to be the most promising. V041 V042 PANCREATICODUODENECTOMY WITHOUT PANCIATIC-JEJUNOSTOMY G. De Sena-F. Chianese-F. La Rocca-G. Picardo P. Festa Dept. of Surgery-"San G. Moscati" Hospital-Avellino It is an operative teelmique performed during seven pancreaticoduodeneetomy without pancreatic-jejtmostomy.
The pancreatic-duct is dosed with any human fibrin glue introducted with a special catheter at two way and a very-low absorbable suture placed at "U".
The biological glue is used also for the impermeabilization of residual section ofpancreas.
There was no postoperative complications and no perioperative deaths. All patients left the hospital within 2 weeks of surgery.
The median follow-up time was 24 months and no one patient showed sDnnptoms ofpancreatic failure. Longitudinal anastomosis of Wirsung's channel and ,jejunum was first used by Cattel as a palliative operation in cancer of the pancreatic head. Mercadier inaugurated a similar procedure in surgical treatment of chronic pancreatitis. The fundamental condition requiring such an operation is dilated pancreatic channel of 8-10 mm in diameter. Good longtime results of this operation consist in absence of pain, good drainage of pancreatic secretion into the jejunum and the achivement of the complete function of the gland. The video-film presents our technique of operation in its all details. It consists of identification of Wirsung's channel, its intraoperative, radiograph presentation, longitudinal transparenchymn discission of the channel in length of 8-10 cm, and performance of latero-lateral Wirsung jejunal anastomosis with an isolated winding of the jejunum by Roux. Anastomosis is stitched in two layers with slow-resorbed atraumatic material.
We are si far sat.sfied with our results, because longtime good results have shown in almost 80% of operated patients. As hheclinician knows well, patients with chronic pancreatitis have persistent difficulties follo. The sphincterotomy is performed after cholangiogram at 11 o'clock using laparoscopic straight scissors with cautery. This sphincteroplasty is achieved by interrupted suture with 4.0 monofilament absorbable sutures with intracorporeal knots between the bile duct ad the duodenal wall with a two handed technique. Closure of the duodenotomy is performed with a running suture followed by periduodenal drainage.
The patient was discharged on the fourth postoperative day without any leakage or complications. Laparoscopic transduodenal sphincteroplasty for papillary stenosis is an alternative to open surgery. The insulinoma is carefully dissected from the normal pancreatic parenchyma using a hook dissector with cautery.
The vessels behind the insulinoma are ligated with titanium clips, extraction is performed via one of the ports using an opaque laparoscopic bag. A drain is left over the pancreas behind the stomach. Patients who had proximal and distal laparoscopic pancreatic resection performed were followed and evaluated for morbidity and recurrence.
No recurrences were seen at 18 months in laparoscopic Whipple for tumors, but recurrent pain was seen in chronic.pancreatitis patients. The indications for laparoscopic distal pancreatectomy included 5 insulinomas, serous cystadenocarcinoma, and 2 gastrinomas. The average age was 48 (range 27-75). The conversion rate was 62% with a mean operating time of 4.5 hours for laparoscopic distal pancreatectomy versus 7.2 hours for the converted procedure.
Conversions were due to metastatic disease in gastrinomas (2), and inability to localize an insulinoma (1). The hospital stay was shorter for laparoscopic distal pancreatectomy (4.5 days) versus 12 days for open distal pancreatectomy. After a follow-up of 18 months of the four insulinomas and one cyst adenocarcinoma, there was no recurrence.
Although the series is small, no benefit was seen from a complete laparoscopic Whipple procedure. An extended radical operation involved pancreatectomy with almost complete resection en bloc of the lymph nodes around the porta hepatis, the coeliac axis, the origin of the superior mesenteric artery and the aorta extending from the diaphragm to the inferior mesenteric artery. The inferior vena cava and aorta were also skeletonized with all tissue being removed en bloc. Following resection, including vascular reconstruction, a dose of 30 Gy of 9-12 MeV electrons was administered to the operatived field, including the paraaortic area from the diaphragm above to the inferior mesenteric artery below. More than 50% of the patients that undergo Standard Pancreaticoduodenectomy (PD) presents Ioco-regional recurrence. This is caused by the tendency of the pancreatic carcinoma to infiltrate the retroperitoneal connective and to spread along the nerve plexus and the lymphatic channels towards the Ioco-regional nodes. The lymph nodes are divided in two groups: first and second level. First level group includes: anterior and posterior pancreaticoduodenal nodes, superior and inferior nodes of the head, common bile duct nodes, pyloric nodes and mesenteric nodes. Second group includes: common hepatic duct nodes, celiac nodes, superior and inferior nodes of the body, middle colic nodes, pare-aortic nodes. Therefore PD is considered a radical procedure when it is associated to dissection of the retroperitoneal connective of the lymphatic and nerve plexi and of the Ioco-regional lymph nodes (1st and 2nd level). The pancreas .is resected at level of the left margin of the aorta.
Extended PD is carried out en bloc with lymphadenectomy. In this way the celiac trunk, the superior mesenteric artery and the hilum of the liver are dissected free as well as the aortic segment between the celiac trunk and the inferior mesenteric artery. Benign tumors and uncertain malignant potential tumors located in the neck of the pancreas more than 2 cm in diameter or encased within the parenchima present some biological and technical problems when enucleoresection is not possible. In fact distal pancreatectomy and pancreatico-duodenectomy, that are usually performed for these kind of lesions, determine impairment of exocrine and endocrine function and digestive and immunologic disorders. Central pancreatectomy contrarly permits to save pancreatic parenchima, the anatomy of the upper GI tract, the biliary tree and the spleen.
The video shows the surgical technique: midline incision and exposition of the pancreatic surface; incision of the posterior peritoneum along the inferior and superior mergin of the pancreatic segment to be resected; the splenic artery is cleared and some minor collaterals are ligated; the posterior surface of the pancreatic segment involved by the tumor is isolated form the porto-mesenteric axis; the pancreatic segment is transected at least cm from the tumor caudally and cephalically; the cephalic stump is sutured after elective tying of the Wirsung's duct or stapled; the distal stump is anastomosed end to end with a Roux en-Y jejunal loop. Endocrine tumors of the pancreas can be cured only with a surgical approach. The treatment is mandatory either for small tumors or for large tumors involving contiguous organs that are resected with the lesion. Aggressive surgical procedures are attempted also in the cases of liver metastases, removing the primary and the secondary lesions. If resection of the hepatic metastases is not possible because of multiple lesions, a multimodal treatment is adopted with resection of the pancreatic lesion and chemoembolization and/or alcoholization of the liver masses.
The surgical options depend on the size, the Ioco-regional extension and the location of the tumor; other important factors in the choice of the treatment are benignity or malignancy of the tumor and the presence of associated MEN. Dept. of Surgery, Fujita Health University, Toyoake, Japan The duodenum-preserving resection of the head of the pancreas is an organ-saving procedure in the treatment of svere chronic pancreatitis. However, there are some problems, when the Beger's procedure is indicated to the patients with benign or low grade malignant tumor. First, tumor may remain in the paraduodenal pancreatic remnant. Second, the pancreatic fistula from the paraduodenal pancreatic remnant may be caused, because of remaining the normal gland of the pancreas, and the congenital obstruction of the accesory papilla. Third, the blood supply of the duodenum and the bile duct is disturbed, since the colaterals from the hepatoduodenal ligament and the retropancreatic space is not developped due to the normal gland. This conditions causes ishemia of the bile duct and the duodenum after the resection of the head of the pancreas, and results the early postoperative complications, such as perforation of the bile duct and the duodenum, and pancreatic fistula. For these patients, a new operative procedure is needed to prevent the forementioned problems. It is a total resection of the head of the pancreas, and the preservation of both blood supply and venous drainage of the bile duct and the duodenum. The metods of the preservation of the vessels during the total resection of the head of the pancreas is to preserve the SPDV and/or the IPDV during the exploration of the mesentericportal vein, the duodenal branches of the AIPDA and the ASPDA one by one taping between the vasa rectus, and dividing the pancreatic branches, and the pancreatic posterior menbrane. The Operative time was 429 minutes, and the mean blood loss was 810 ml. A 46 years old alcoholic male patient with calcifying chronic pancreatitis presented with marked abdominal pain due to pancreatic calcifications, duct dilatation and a pseudocyst at the tail of the pancreas. The video presents a Roux-en-y cystopancreatojejunostomy using the same jejunal loop for both the cyst and ductal anastomosis. Postoperative course was uneventful and the patient was discharged free of symptoms.
Twenty-five patients with chronic pancreatitis presenting with pancreatic cysts and duct dilatation were surgically treated at our institution with this procedure. Immediate pain relief was achieved in 96% of patients, pain recurrence was observed in 8.3% and was mostly related to alcohol abuse.
Conclusion: Pancreatic cysts in patients with chronic pancreatitis and duct dilatation may be successfully treated by means of cystopancreatojejunostomy using the same jejunal loop for the cyst and ductal anastomosis. A 64 year-old female was admitted to our hospital for obstructive jaundice. Endoscopic retrograde cholangiogram demonstrated the obstruction of ampulla of Vater. Pylorus preserving pancreatoduodenectomy (PPPD) was performed for the cancer of ampulla of Vater. Our invagination method of pancreatojejunal anastomosis in PPPD will be displayed on video. Drainage tube was inserted in the main pancreatic duct after sharp dissection of pancreas. It was fixed with 3-0 Vicryl (R). Pancreatojejunal anastomosis was done with two layer sutures with atraumatic needle Pmlene (R) (3-0) threads. The first suture layer was attached the pancreatic parenchyma to the whole layer of the jejunum by interrupted suture. The second suture layer was attached the capsule of pancreas to the seromuscular layer of the jejunum, which was 2cm distant from the first suture line and that of pancreas was-lcm distant from the first line. The pancreatic duct drainage tube was pulled out from the jejunum after the suture of posterior layer. In a follow up study of this technique is easy and secure method for pancreatojejunal anastomosis, especially for a nondilatated pancreatic duct. The length of the video is 14 minites. A 59 year-old patient complained of jaundice due to a carcinoma of the ampulla of Vater. A pylorus preserving pancreaticoduodenectomy with pancreaticogastrostomy was performed.Water jet dissection was used for pedpancreatic dissection, isolation of the portal vein and division of the pancreas. The Wirsung duct was isolated from the pancreatic parenchyma by selective dissection and divided at distance from the pancreatic surface. Anastomosis of the pancreatic remnant to the back wall of the stomach was done by running suture using transgastdc external drainage of the Wirsung duct by a 6 French catheter. Rnning suture was also used for biliodigestive and duodenojejunal end-to-side anastomoses.
The patient underwent an uneventful postoperative course. Transgastric external drainage of the Wirsung duct is used routinely in our practice when the Wirsung duct is not dilated and when the pancreatic parenchyma is not sclerotic. VHS PAL. 12 mn.
A 55 year-old female patient was referred with severe secretory diarrhea and hypokalaemia. Fasting serum level of VIP was elevated. CT-scan and selective angiography demonstrated a primary tumor at the isthmus of the pancreas with hypervascular metastases to both lobes of the liver. Octreotide therapy proved to be ineffective.
A bilateral subcostal incision is perfomed. Multiple metastases are present at both lobes of the liver. Intraoperative ultraso.nography demonstrates liver metastases, the largest of them being located in segment VII, and the primary tumor at the pancreatic isthmus. Using ultrasonic dissection, a segmental isthmic pancreatectomy with pancreatogastrostomy is carded out. Technical details include parenchymal transsection at both sides of the pancreas using ultrasonic dissection, hemostasis with bipolar coagulation, selective isolation and transsection of the Wirsung duct, temporary intubation of the anastomosis by a transgastric catheter and periananastomotic application of fibrin glue.
Cytoreduction of the secundaries combines resection of multiple metastases at the fight lobe and at segment IV with a left lateral segmentectomy.
Clinical and biological symptoms improved dramatically after operation. Fasting serum VIP returned to a normal level and Octreotid therapy was resumed.
Cytoreductive surgery is indicated for endocrine metastatic secreting tumors when the secretrory syndrome is uncotrollable by medical therapy. Pancreas divisum is a congenital anomaly due to the failed fusion of the dorsal and ventralpancreas at the end of the eighthweek ofhuman gestation. When this anomaly occurs the duct of Santorini becomes the major ductal system of the exocrine pancreas, while the duct of Wirsung drains only the inferior head of the pancreas and the uncinate process. The Authors report an extremely rare case of lithiasis of the duct of Santorini associated to pancreas divisum. The patient complained of late postprandial colicky pain radiating to the back, accompained by vomit and weight loss. U.S examination showed marked dilatation of the main pancreatic duct (apparently the duct of Wirsung) and a calcuIus, 16 mm. of diameter, within its distal tract; gall bladder and biliary tract appeared normal. ERCP shoewd a narrow, short duct of Wirsung that predicated the suspect of pancreas divisum, incannulation of the minor papilla, a few centimeters superomedial to the ampulla of Vater, showed a marked dilatation of the duct of Santorini and the presence of the stone. A CT-scan confirmed the dilatation of the duct of Santorini and the presence of the stone. At laparotomy the dilated duct o.f Santorini, easily found by intraoperative echography,was opened longitudinally, the stone was removed and a laterolateral pancreaticojejunostomy was performed on a Y-en-Roux loop. The patient, discharged in good health 10 days after the operation, was still asymptomatic at one year control.
The Authors discuss about the treatment of lithiasis of the duct of Santorini in association with pancreas divisum and conclude that in the cas that they report pancreaticojejunostomy was the best choise. In the past few years the use of PG for reconstruction after DCP has been reported more and more often. Several are the advantages of this technique: 1) gastric acidity and absence of enterokinase avoid pancreatic enzymatic activation, 2) no collection of pancreaticobiliary secretions and routine postoperative gastric decompression avoid anastomotical tension, 3) the anatomical proximity of the posterior gastric wall makes the anastomosis easy to accomplish technically without tension, 4) the excellentblood supply andthe thikness of the gastric wall mean more secure anastomosis, 5) easy 19osto.perative control of the anastomosis from the gastric, side, 6) blind.
jejunal loop is avoided m case of obstruction of the pancreatic anastomosis. Aim of this video is to try to define, on the basis of our experience, the role this technique could take in reducing morbidity and mortality after DCP.
From January 1993 to June 1995 nme pancreaticogastrostomy has been performed. Five patients had adenocarcinoma of the papilla, two had carcinoma of the distal coledocus and two had carcinoma of the head of the pancreas. Pancreaticoduodenectomy was performed with the pylorus-preserving modification. The neckof the pancreas was transected to the left side of the portal vein. The pancreatic duct was identified and individual bleeding vessels were ligatedusing single 4-0 polyglicolic suture.
The stump of the remainin , gpaiacreas was fred fr6m rtroperitoneal attachment for. 2 crn The. :p,osterior .wall of the stomach, was app.roximated., to the pancreatic s_tump without tension and the site of the gastric mcmlon was easily found on the antrum. Pancreatogastrostomy was 15erformed with two rows ofinterrupted suture, ofwhichthe externalone alwaysinnon-absorbable suture. No tube was left through anastomosis but care was taken to avoid pancreatic duct obliteration. Biliary and digestive tracts were restored by hepaticojejunal, and gastroje'unal'l anastomosis to the first je'unalj loop. Two open dramage were always left in place near PG and choledocojejunostomy up to the sixth post-operative day,' amylase level in the drainage fluid was assayed daily. Anasogastric tube was left in placeuntilthe return of intestinal activity. Octreotide was used prophylacticallypostoperativelty In our series we had an operative death unrelated to PG; the major complicationswas amassivebleeding from the gastric side ofthe anastomosis occurred 3 days after the operation, dssociated to a partial deihescence of the anastomosis that we treated surgically. Reported results after PG seems to demonstrate a sharp decline in the morbidity and mortality rates after DCP, but of course the real advantagese of this technique will be confirmed only after a greater clinical experience and, when possible, with randomised prospective studies.  Palliation of biliary or duodenal obstructions secondary to pancreaticoduodenal tumoral lesions is associated with a significant morbimortality. Surgical palliation is followed by an increased early morbidity, but nonsurgical options (percutaneous or endoscopic prostheses) are associated with a higher risk of cholangitis and obstruction, and need a replacement of the stent. Laparoscopic approach has been proposed as a feasible option, with lower incidence of early complications due its minimally invasive characteristics and a longer patent period in selected cases. Aim: To evaluate the early results of laparoscopic digestive biliary diversion in selected patients with irresectable pancreaticoduodenal tumors.
Material and methods: Between set/93 and March/95 we have treated 5 patients with an irresectable pancreaticoduodenal tumor with a laparoscopic approach. Results Mean age was 70 (50-87). 4 patients were diagnosed of pancreatic cancer and one of jaundice secondary to gastric neoplastic adenomegalies. Two patients received a cholecisto-jejunostomy alone, and in 2, a gastrojejunostomy was added. The fifth case was treated with a gastrojejunostomy, in a patient with duodenal obstruction with a prior wa,llstent cannulation of the bile duct. Technique: After an operative cholecystocholangiography that showed a patent cystic duct, a cholecysto jejunostomy was performed, using an endostapler. The anastomosis was completed with an intracorporeal running suture. Gastrojejunostomy was performed with a 65 mm endostapler, and the gastric and intestinal hole was closed with several aplication of the 35 mm endostapler. There were not major complications, but catheter sepsis and trocar site infection. No patient relapse jaundice during follow up. Mean stay was 10 days (7-17), and mean survival was 12 w (6-24). Conclusion: Laparoscopic approach should be considered as an useful alternative when considering palliative treatment of malignat jaundice, and comparative studies are needed to exactly know the potential role of this technique. Previously reported techniques for duodenumpreserving pancreatic resection differ from our procedure. Previously other techniques accomplished only a partial resection, remaining a rim of pancreas along the duodenum. With our technique, duodenal blood flow is maintained, and no pancreatic parenchyma is left on the duodenal side. Operative Procedure; After laparotomy, the posterior superior pancreatoduodenal artery is preserved by avoiding Kocher's maneuver. The superior mesenteric vein is exposed at the inferior border of the pancreas to performing a portal vein tunnelling procedure, and the pancreas is transected over the portal vein. The entire pancreatic head is resected from the cut edge towards the duodenum. The pancreas between the bile duct and the duodenum is isolated by elevating the head of the pancreas. The pancreatic duct is divided at its cofluence with the bile duct. The pancreatic ductal anastomosis is performed. To assure an adequate blood supply to the duodenum, retroperitoneal vessels must be preserved by avoiding Koches maneuver, and the posterior superior pancreatoduoduodenal artery must also be preserved. Excision of the dilated extrahepatic bile duct followed by biliary reconstruction has been recognizing as the treatment of choice for choledochal cyst. However, postoperative complications such as intrahepatic calculi developed even after the complete excision of a choledochal cyst. Since congenital stenosis of intrahepatic bile duct is more likely the cause of intrahepatic calculi, operativeprocedure for intrahepatic stenosis is reported.

VIDEO PRESENTATIONS
Thirty-year-old female with choledochal cyst underwent an operation for stenosis of the intrahepatic bile duct. Stenosis excised around the perimeter at the opening of the common hepatic duct. Stenosis that involved the intraluminal membrane could be excised from the divided end of the common hepatic duct at the hepatic hilum. Postoperative follow-up demonstrated she had been in good health.
Stenosis of the intrahepatic bile duct should be treated at the initial operation for choledochal cyst. The need for a second operation or hepatic lobectomy may thus be avoided. A 43 year old female with carcinoma of the hepatic hilus underwent 6 weeks preoperative transhepatic biliary drainage. Arteriography demonstrated the patency of both arterial and portal branches. After improving jaundice a "en bloc" resection was performed including common bile duct, lymphadenectomy and segments I, IV and V. Resection was performed under partial liver exclusion including pedicle occlusion associated with venous occlusion of both middle and left hepatic veins with preservation of caval flow. Central biliary resection resulted in 4 tumour free central bile .ducts. For reconstruction a 50 cm jejunal segment was used with end-to-side cholangiojejunostomy. No postoperative complication occurred and she was discharged from the hospital on the 17 postoperative days. She is tree of recurrence two years later. Since October 1993, we started an evaluation programme of patients with symptomatic cholelithiasis aiming to detect associated common bile duct (CBD) stones. Endoscopic retrograde cholangio-pancreatography (ERCP) was reserved for high-risk patients for CBD stones. Laparoscopic ultrasound (LU) during cholecystectomy was routinely performed to identify stones unsuspected preoperatively. One-hundred-sixty-four patients with symptomatic cholelithiasis were included into the study. 140 patients were at low-risk of choledocholithiasis, while 24 patients were at high risk: these patients were submitted to ERCP: in 12 cases CBD stones were found and removed by endoscopic sphyncterotomy. Mean time for LU examination was 8+2 rain ranging from 5 to 15 minutes. In all patients the main intra and extrahepatic ducts were well documented, while in 9 cases (5%) the distal tract of the CBD was not well-visualized. In six patients (4%), unsuspected small stones into the CBD were found. A subsequent peroperative cholangiography confirmed the diagnosis. Transcystic duct approach was attempted in three cases and successful in two, while conversion to open laparotomy was performed in two cases.
Two patients were successfully treated by postoperative endoscopic sphyncterotomy. No false positives were found. In two patients a small stone in the CBD was found during the follow-up period (two false negative): ERCP was performed in one case for bfliary colic and in the other for mild acute pancreatitis. An endoscopic sphyncterotomy solved the problem. The sensitivity of the preoperative flow-chart was 56% and the specificity was 95%. The sensitivity of the preoperative flow-chart plus LU was 88% and the specificity was 95%. In conclusion, LU may be a real alternative to cholangiography during laparoscopic cholecystectomy. Some failures can be prevented by additional experience and the use of a LU HPB Surgery Section, General Surgery Service, Hospital Italiano, Buenos Aires, ARGENTINA A video of the surgical repair of an important common bile duct and right vascular pedicle injudes is presented. It was performed in a woman of 58 years old, that was operated in other hospital with the diagnosis of simple cholelithiasis, with the video iaparoscopic procedure. During that. operation the surgeon confused the cystic duct with the common bile duct, so be cutted and then ligated it above the hepatic confluence (Bismuth IV). Further he didn't performed the intraoperative colangiography and did not advise the lesion, so he had continued the operation in a wrong way and ligated the right vascular pedicle (right hepatic artery and right portal branch). The video details the biliary duct injury approach, the hepatic confluence dissection, the use of the intraoperative ultrasound, the section of the hepatic parenquima with the cavitron ultrasonic aspirator (CUSA) and the use of argon beam and synthetic glues for hemostasia. Further the double hepatoyeyunostomy with a Roux-en-y loop in one layer with interrupted stitches with polypropilene 7/0 is showed.Transanastomotic and transhepatic catheters were placed and a feeding jejunostomy (Witzel procedure) was performed. We conclude that this technique is the best choice for the repair of these serious bile duct injuries and during ever laparoscopic cholecystectomy the intraoperative .cholangiography must be carded We report the case of a 54-year-old female patient who was admitted for right upper abdominal pain. Imagistic studies(CT scan, i.v. cholangiography) excluded gallbladder stones but revealed a well defined tumoral mass in the hepatic hilum. A laparoscopic approach was attempted. Laparoscopic cholecystectomy was performed in order to gain access to the tumoral mass. The tumoral mass was then enucleated from behind the common bile duct and extracted. Its dimensions were 35/25 mm. Pathology revealed the structure of a fibroma. The patient is simptom free at 18 month follow up. We consider this case interesting due to its rarity and due to the laparoscopic approach of the tumor. choledocolithotomy, 4 VLC with eholedoco,duodenostomy) we encountered 5 eholeeysto-duodenal fistulas. Only in case the diagnosis was pre-operatively suspected, owing to the presence of pneumobilia indicated by US scans. In 4 cases the treatment was laparoseopically performed; in case the procedure was converted to open surgery on encountering an empyema with strong pericholecystie adhesions. In 3 cases the procedure consisted of isolation of cholecysto-duodenal fistula and laparoseopic mechanical resection/suture; in case, owing to the presence of a thin hole in the duodenum, after detaching the gallbladder, we performed a suture with separated absorbable.stitches. After the cholecystectomy a subhepatic drainage tube was inserted and then removed on postoperative day 2 or 3. The patients were released between postoperative day 6 and 10. Follow-up ofthe patients is normal 32, 14, 8 and months after surgery; in particular radiographic and endoscopic examination ofthe duodenum did not show morphologic or functional pyloro-duodenal alterations. Aa. present 3 cases of common bile duct lithiasis occurred 1, 13, 20 years after eholecystectomy. The patients underwent EPT but, because of the failure to remove the stones, a videolaparoscopic treatment was performed. The first patient (7.2 year old male) underwent laparoscopic cholecystectomy year before. After the failure of endoscopic retrograde extraction, of common bile duct stones, a videolaparoscopic lithotomy (2 stones) was trans-choledocally performed. The procedure involved the use of fiberscope, Dormia basket and Fogarty balloon. A transeholedochic T tube was inserted and repair of the bile duct was completed with separated absorbable stitches. The patient was released on post-operative (p.o.) day 7 and the T tube was removed on p.o. day 19. The second patient (61 year old female) underwent cholecystectomy 20 years before via a right'transrectal scarring. After EPT and double failure of endoscopic stones extraction, the patient was laparoscopically treated: viscerolysis and fibercholangioscopy with trans-cystic lithotomy (2 stones) were performed; the cystic duct was dosed with loops. The patient was released on p.o. day 4. The third patient (80 year old female) underwent cholocystectomy 13 years before via a median xipho-umbilical scarring. After EPT and double failure of stones extraction, a videolaparoscopic lithotomy was performed (4 stones) with the use of forceps and a transcholedochic approach. Repair of bile duct was completed with separated absorbable stitches and the patient was released on p.o. day 6. Follow-up of the patients is normal 12, 6 and months after surgery. It follows from our experience that a videolaparoscopic approach is indicated before laparotomy, if endoscopic retrograde treatment is not resolutive in patients with common bile duct stones, previously subjected to choloeystectomy.
EXPERIENCE WITH PANI/XX CHOLANGIOSCOPY (PC). F.Fiocca, F Salvatori, E Grasso, M ezzi, G Scopelliti M Cristaldi, P Ricci, D Apa, P Rossi, V Speranza. II Surgical Clinic and III Dept of Radiology University "La Sapienza" Rome, Italy. 97 pts underwent PC with a 3.9 or 5.0 nn endoscope" 85 2-7 days after a transhepatic, fistula dilated up to 12 or 16 F, 12 after removal of a surgical implanted T-tube.
6 pts with biliary stones were all cleared after 1-4 treatments (mean 1.8), in 12 by means of Electrohydraulic lithotripsy, in the others with fluid flushing. 5 pts had recurrent stones and they were retreated. 21 biopsies, out of 4, confirmed a malignat stricture. Surgical stitches were removed in 8 pts. There were 4 massive bleeding that required embolization and 2 perf_o rations of the bile duct repaired with stenting. No mortality was observed. Minor complications were 18 pts with nausea and intollerance (6 fluid overload) and 15 cases of minor bleeding. We conclude that PC is a safe treatment for biliary calculi, useful alternative to surgery and for diagnosis and treatment of biliary dise_ ases, especially strictures.
This procedure should be done in strictly cooperation with an experienced radiologist, endoscopist and surgeon.
The video will last i0 minutes. Knowledge of the lymphatic flow from the gallbladder is indispensable for rational lymph node dissection of gallbladder cancer. Fine activated carbon particles (CH40) injected in the tissue (especially when injected in lymph node) are taken into the lymphatics immediately, and the lymphatic vessels and lymph node can be visualized by staining black. By this method, regional lymph nodes relating to gallbladder can be removed more easily. The lymph node dissection technique using CH 40 is shown in this video. (THE PATIENT) A 68 year old .female with carcinoma of the gallbladder associated with pancreatobiliary maljunction. OPERATIVE PROCEDURE) Before lymph node dissection, lml of CH40 was injected slowly into the paracholedochal lymph node (No.12b) which is the first lymph node station of gallbladder. Then, many lymph nodes which receive a lymphatic flow from paracholedochal node were stained in black, indicating the extent of rational lymph node dissection. The following stained lymph node were dissected "lymph node in the hepatoduodenal ligament (No. 12), behind pancreas head (No13a), along the common hepatic artery and celiac trunk (No. 8a,8p,9), at the root of mesentery (No. 14a, 14d), paraaortic lymph nodes (No.16). The dissection of paraaortic lymph nodes stained in black is thought to be mportant for curability of gallbladder cancer.

(RESULT)
The patient is alive three years after the operation.
(CONCLUSION) Lymph node staining method was useful for the radical lymph node dissection of gallbladder cancer. Recurrent Pyogenic Cholangitis is a common condition seen in the Far East. Patient can present with life threatening cholangitis and emergency laparotomy carries a significant morbidity and mortality. The use of emergency ERCP to drain the obstructed system and broad spectrum antibiotcs had reduced significantly the need for emergency operations. Majority of these patients will need a definitive drainage procedure such as choledochodoudenostomy or choledochojejunostomy when the acute situation settled. This 10 minutes video will demonstrate our technique of Endolaparoscopic approach to this condition in this era of minimal access surgery. Three patients had received this treatment so far. All had dilated common and intrahepatic ducts with severe cholangitis on admission. Emergency ERCP were performed with temporary drainage using either nasobiliary catheters or stents. Laparoscopic common duct explorations were carried out to clear the ductal system of sludge and stones. This was followed by cholecystectomy and choledochoduodenostomy using a one layer side to side anastomosis. The average operating time was 180 minutes. Postoperative recovery was uneventful. In conclusion, we are encouraged with our initial experience and feel that there is a place for this approach in selected patients with this condition. The past years have been a time great excitement in laparoscopic surgery and laparoscopic cholecystectomy in particular. Sixty nine patients suffering from acute calcular cholecystitis subjects in laparoscopic procedure were included in this study. Patients were collected at random, 41 patients were women and 28 were men, patients, aged 26 84 years with a mean age 58.5 years, laparoscopic cholecystectomy could be done in 54 cases (78.26%). Cholecystectomy was conducted safely in 42 cases (60.87%). In 18 cases iaparoscopic cholangiography through cannulation of gall bladder or cystic duct was i'nduced and it was successful in 14 casesand laparoscopic cholcystectomy was proceeded in 12 cases (17.39%). Minor complications occured in 9 cases and included bile leakage in 4 cases, umbilical sepsis in 2 cases and 3 cases of abdominal wall haematoma. Major complication in the form of duodenal perforation As well as over distended gallbladder with infected bile or pus.

I-fistological examination with evidence of acute inflammation from
June 1991 to Ma 1994. O"C group included 45 patients with the same characteristics operated upon in the same period.
Regarding the results, it was found that the mean length of the operative procedure was 75 minutes in LC and 110 minutes in OC. The mean postoperative stay was 3.2 days in LC and 12 days in OC.
LC appears to be safe and beneficial option in the management of acute eholecystitis and empyema of GB as compared to OC. The video shows the laparoscopic procedure, the diagnostic work-up and the left hepatectomy that we were obliged to perform in order to resolve biliostasis. In fact the two transected biliary segmental ducts were too small to allow a safe biliary reconstruction. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. At the follow-up she remains asymptomatic 4 months after the last procedure.
Length of the video: 15 minutes.

INDIA.
Initial success of laparoscopic splenectomy for normal sized and slightly enlarged spleens has extended its indication to large sized spleens.
Since 1993, 5 cases of large sized spleens over 20 cms were successfully treated by laparoscopic approach. Age ranging between 24-56 years. 3 were male and 2 were female. Five ports were used in all the cases and semilateral position was adopted in all cases.
Procedure Spleen was mobilised in the following steps 1) Splenic flexure mobilisation. 2) Gastrosplenic ligament was divided after clipping the short gastric vessels. 3) Ligation and division of splenic artery and vein. 4) Division of lateral peritoneal fold.
Spleen. removal Spleen was removed through minilaparotomy.
Cholecystectomy was combined in two cases. Initial ligation of splenic artery makes blood loss to minimum. Patientswere discharged between 3 to 5 days. The size of the bile stones more than 6 or 8 mms, is for some authors the point were the laparoscopic transcystic approach has to be changed to the laparoscopic choledochotomy. These dimensions are related to the size of bigest balloons employed for the dilatation of the cystic duct. However the p0sibility to perform lithotripsy inside the bile ducts, could change this principle. The technique of LTML is similar to employed for the gastroenterologist in the endoscopic approach, or for us in the percutaneous access. We use a endoscopic 4 multifilament wire soft Dormia basket with 2 x 4 open size. The total length is 220 cm and 7 French size when the basket is closed. It has a lateral way for injection of radio opaque dye. For crush the stone, we introduce a straight metallic canula in one of the lateral trocars.The basket comes in trougth this canula.The cystic duct is opened close to junction with common bile duct. Once the stone is catched by the basket, both are pulled back togheter near to the cystic duct. The metallic canula comes in the duct, and again the basket is pulled back against the canula, till the stone is broken. The result are many pieces of stones in the CBD. It is cleaned combining extraction with Dormia Basket, and flushing bile duct with saline solution; previous IV administration of mg. of Glucagon.ln this video we show first an in vitro" procedure, and late an "in vivo" procedure, of a case with a stone of 3 X 2 cms size. The combined radioscopic and laparescopic control make the procedure safer and easy to learn.In a serie of 94 cases of bile duct stones treated by laparoscopic approach, we perform LTML in 7 (7,4%) patients. In the era of laparoscopic cholecystectomy (LC), the treatment of bile duct stones associated to gallstones is still no definitively resolved, however the laparescopic transcystic choledocholithotomy (LTC),is the technique most accepted by the surgeons.In this video, different cases are presented, to descdbe the most common steps: intraoperative cholangiogram, milking of the cystic duct, dilatation of the duct with balloon, flushing of bile ducts, extraction of the stones with Dormia basket, and the control with fibrocholedochoscope. The main case, was performed under radioscopic guide, with a soft endoscopic Dormia basket. The advantages of this basket of 7 French size, are: 1. To be soft, make it safer to work, avoiding the perforation of the walls of the duct. 2. It has a lateral way for injection of radio opaque dye, making easier the control under radioscopy. 3. The size of the open basket is 2 x 4 cm, making possible to catch almost all the stones. 4. The total length is 220 cm., and the nurse how has on charge the injection of the dye and to open and close the basket, works far and confortable .$ The basket is the ideal to perform mechanical lithotripsy. In the same case, we show how resolve proximal stones to the cystic duct, using extemal manoeuvres" on the proximal bile duct, and with the "luxation" of the cystic duct. This duct was closed with a Endoloop.ln our Service, we ,perform sistematically intraoperative cholangiogram, and we resolve the bile duct stones in the same operation. We indicated the LTC in 87 cases, among 1231 patients with LC 8 %). In the last 64 consecutives cases, the aplicability was 85 %, and the effectiveness of 93%. In unsuccessful cases, we performed open surgery, or iapamscopic choledochotomy with primary closure of the common bile Conclusion: The LTC is an high effective treatment for bile duct stones asociated to gallstones.The training in the different manoeuvres, and the availability of instruments as guide wires, angioplastic balloons, baskets and scopes, increase its application and effectiveness. ( In this tape, we present a 72 years old high risk patient with acute acalculous .cholecystitis and a subfrenic abscess associated.The PC was performed with local anestesia with combined radioscopic and ultrasonic guide.Whith a Seldinger technique, a 8.3 pigtail nephrestomy catheter was placed in the gallbladder. The injection of radio opaque dye by the catheter, showed a perforation in the fundus of gallbladder. The subfrenic abscess was drained with the same technique than PC, and a 12 French pigtail catheter was placed, and 120 cc of bilious purulent fluid were obtained dudng the procedure. The patient improve the general status and didnt develop complications related to the procedure. The subfrenic catheter was retired on day 7, and the patient was out of hospital on day 8. The PC was closed the day 10, and was retired day 26.
In our sede of 61 PC, only in two cases was necessary to add to gallbladder drainage, a catheter in associated fluid collection. Conclusion:The PC is effective to resolve acute cholecystitis included the advanced cases with associated fluid collections. A close follow up is necessary, and in the cases were the patient's status doesn't improve, the open resolution must be considered.
(The tape last 10 minutes) Videofibroendoscopic evaluation of biliary tree.
The endoscopic evaluation of biliary tree ("choledochoscopy") is an effective method for evaluation of bile stones and tumors. However before the "laparoscopic era" few surgeons use routinly the scopes in the biliary procedures. The development of small video cameras, and the training with other endoscopic devices, make nowadays easier the use of this instrument by the surgeons. In this tape we describe a fibrocholedochoscope with an external diameter of 4.5 mm (15French), the instruments as Dormia Basket, Fogarty balloon, biopsy forceps, and electrode for electrehidraulic lithotdpsy (EHL).We present the four accesses were we have experience: 1. Transhepatic approach: a patient with liver transplantation and a big stone in common hepatic duct above the biliary anastomosis, was resolved by this access. Under endoscopic guide, EHL was performed. The endoscopic study showed the cystic duct of the donor and recipient, and the sutures of biliary anastomosis. The ampulla was free and the fibroscope past to duodenum. The left biliary tree was normal. 2. Laparoscopic transcystic approach: we use it selectively and without an extra port for the fibroscope. In a case of multiple stones resolved by transcystic access under radioscopic guide; the study was performed to discard residual stones. It was possible to explore the distal and the proximal biliary tree. No stones were found, the ampulla was free, and a Fogarty catheter past to duodenum.3. Open choledochotomy approach: It was used to discard intraoperative residual stqnes, and to confirm the presence of a distal tumor with mucosal invasion of biliary treeo4. Transfistular approach: The procedure was performed by the tract of a T tube, to explore the biliary tree in a case of residual stone.
Conclusion: The videofibroendoscopy is an excellent procedure for the evaluation and to assist the treatment in bile ducts. The training for the surgeons is nowadays easier, and we promote a more frecuent use of the fibroscope, dudng biliary procedures. The selection of the type of the scope, will be related to the accesses to be employed. (The tape last 11 minutes).
Biliary drainage following exploration of the common bile duct is still a subject of controversy. The development of fibroscopes, the improvement of the sutures and the techniques for closure of biliary tree, and the laproscopic approach are increased the interest for pdmary closure of thebile duct (PCB). For a safe procedure, W. Mayo and P. Midzzi stresseed four strict requirements: l.Patency of Ampulla of Vater, 2.Complete removal of all intraductal calculi, &Presence of normal pancreas; and 4.Meticulous suture of the duct. The first two conditions are confirmed with the use of a fibrocholedochoscope. The third with the selection of the patients and evaluation during surgery, and the fourth is resolved with training. In the last two years, we performed eleven open and five laparoscopic PCB. In the tape we present a case of bile duct stones, were the transcystic approach was not possible, and it was resolved by laparoscopic choledochotomy, extraction of stones and primary closure .The biliary tree was evaluated proximaly and distally, the ampulla was open and was possible to pas a Fogarty ballon to duodenum. No residual stones were found. The pancreas was normal. The closure was performed with interrupted stitches of Maxon 4/0, with intracorporeal knots. No biliary drainage was used. A subhepatic sump drainage was left in place for 48 hours. The patient left the Hospital in his' third postoperative day. No patients in our serie of PCB developed bile leaks, colepedtoneum, intraabdominal biliary collections, jaundice, residual stones or other postoperative complications.
Conclusion: The laparoscopic PCB in patients with normal intraoperative endoscopic evaluation of biliary tree, normal pancreas, and performed by surgeons with training in laparoscopic sutures; is a effective procedure for treatment of bile duct stones when the transcystic approach is unneffective or non aplicable. The ausence of biliary drainage, makes the postoperative course closer to laparoscopic cholecystectomy, than to laparoscopic choledochotomy with Ttube.
(The tape last 10 minutes) The difference between the laparotomic and the laparoscopic cholecystectomy. Results: there occured a hemorraglc ascitls, treated with peritoneal drainage with favourable evolution.
Recurrent pancreatitls was not detected. Postoperative hospitalization time was 10 days.
Discusion: Choledochal cyst is frequently associated with AP (i0-20%) but it is a rare cause of AP in our series (0.35Z:I/266). A precise diagnosis was made through IV cholanglopancreatography by M.R.I. This is safer than ERCP because there no risk of cyst infection. Radical treatment is the most approplate one to prevent cancer and recurrent AP. The aim of this study is to analyze feasibility and succes of restauration of hepaticocholedochus-HCH with synthetic tubular graft. In fifteen dogs,the authors performed a resection of the supraduodenal HCH, cm in length and arising defect was bridged over polytetrafluorethilene tubular graft a 4 ram. Fifth months living rate was 45% and most ussualy complications were leakages of the anastomoses(33%), and early rejection of the graft.(ll%). The animals were followed-up 150 days with the control of holestasis and hepatocellular necrosis parameters and amylase level, which values were increased in the first postoperative days, with normalisation, during the forth week. Histological examinations performed every 7 days showed adequate epitelisation in 22%, but intensive fibrous reactions in some cases. Intmopemtive tmnspapillmy cholangiography performed on 5 dogs after 150 days showed absolute functionality of the graft in 22%, high-percent stenosis in 11% and total obstruction in l%.Inspite of many theoretical advantages of restaurative surgery of HCH ,using synthetic tube, basic problems remains great percent of anastomofis leakage and adequate epithelisaton of the PTFE. Protection of the grafts and anastomoses using intmluminaly prothesis and omentoplasty probabily decrease rateof fibrous stenosis,what is our present experimental work in course. V090 V091 COLOR DOPPLER SONOGRAPHY IN PATIENTS VMITH ACUTE CHOLECYSTITIS AND DECISION: OPEN OR LAPAROSCOPIC CHOLECYSTECTOMY. Szymczuk J., Ladny J.R., Polak6w J., Krejza J.,Rog M., Puchalski Z.

Department of General Surgery, Medical Uneristy of Bialystok, Poland
Laparoscopic cholecystectomy (LC) has become the standard operation for symptomatic gallbladder disease. Acute cholecystitis remains a challenging problem for most surgeons, and the reported rate of conversions to open surgery is still high. The aim of this study was to analyze the color Doppler imaging features and clinical importance of inflamed pericholecystic fat. MATERIAL AND METHODS: Forty live patients with surgically and histologically proved right upper quadrant inflammatory lesions in the gallbladder or the pericholecystic space underwent color Doppler sonography (CDS). Findings in the pericholecystic space were correlated with those at computed tomography in four patients and with surgical findings in 45 patients.
RESULTS: CDS performed in 15 (33%) .of the 45 patients demonstrated echogenic pericholecystic masses greater than cm in diameter that contained internal vascularity. CT in four patients and surgical findings in all 15 patients demonstrated inflamed fat adherent to the gallbladder. All patients were submitted to early LC, whereas 15 patients were managed conservatively and underwent elective laparoscopic operations.
Conversions rate was 3/15 (20%) patients after elective operation and 1/30 (3.3%) after early operations. CONCLUSION: Identification with CDS of inflamed pericholecystic fat may provide preoperative information that-, could be pertinent in the decision to perform open or laparoscopic cholecystectomy in patients with acute cholecystitis. Cardnoma arising at the confluence o the right and left hepatic duct is problematic because of the difficulty of resection and reconstmctiorr Resection is the best aviable treatment, but long-term results of resection remain poor because of frequent intmductal andperiductaltumor spread From analyzhg of 39 resected cases, itbecame obvious that re.4dual cells of the hepatic duct after resection most important prognostic factor. Therefore radical resection should be performed, including major hepatic resection with caudal resection and occasionally cembined vascular resection. However major hepatic resection such extended right lobectomy right trisegmentectomyis lilely to result in postoperative hepatic failure. So when extended right lobectomy right trisegmentectomy undergo, perform, embelization of the right portalvein to promote regeneration of the left lobe preoperatively.
would lihe to present with video theprocedure, extendedrightlobectomy withcaudal andportal combined resection, that waslrfonned after embolization of the right portal vein for of the proximal bile duct in 71-yem-old female patienL