Subhashini Ayloo, MD, MPH, Jacob Schwartzman, MD. Rutgers, New Jersey Medical School
Objective: To demonstrate the safety and feasibility of robot-assisted left lateral segmentectomy for recurrent cholangitis due to recurrent intrahepatic lithiasis in a previously Roux-en-Y hepaticojejunostomy patient.
A 46 year old man with previous hepaticojejunostomy for common bile duct stones and intrahepatic ductal stones presents with recurrent cholangitis requiring multiple admissions for bacteremia. His diagnostic imaging shows intrahepatic lithiasis mostly in segments 2/3 with dilated ducts.
This video showcases the technical details of a minimal invasive approach to left lateral segmentectomy. A diagnostic laparoscopy is performed, showing significant adhesions. The previous hepatico-jejunostomy is identified and protected. The remnant round ligament is dissected. A stay suture is placed in the inferior portion of segment 3, to retract the left lateral lobe laterally. Intraparenchymal dissection is performed using a combination of harmonic shears and cautery. Any branches of the hilar blood vessels are suture ligated when encountered. Dilated bile ducts with stones are transected when encountered; stones are removed and the ducts are suture ligated. Dissection of the hepatic parenchyma continues until the left hepatic vein is reached. This is transected using an Endo-GIA stapler. Hemostasis is achieved, and the specimen is extracted via a Pfannensteil incision.
Conclusions: Minimally invasive Robot-assisted left lateral segmentectomy is safe and feasible even in the setting of previous hepatic-jejunostomy for recurrent intrahepatic stones. The Da Vinci system provides a stable platform with 3-D visualization and improved ergonomics, which facilitate suture ligation at difficult angles of main vessels and recruitment of non-dominant hand in performing critical dissections.
Educational/Technical Points: The camera is positioned peri-umbilically, with the left and right arms of the surgeon on either side. The robotic fourth arm is placed in a left lateral position, and a first assistant port is placed inferomedial to the surgeon’s left arm. Recruitment of the non-dominant hand in using the main instruments such as scissors for sharp adhesiolysis or harmonic shears for hepatic parenchymal dissection was performed fluidly. The degrees of freedom afforded by the robotic system allow for suturing at difficult angles, which is helpful when ligating branches of the portal vein and bile ducts.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92378
Program Number: V092
Presentation Session: Exhibit Hall Theater Video Session IV
Presentation Type: EHVideo