Lateral approach liver hanging maneuver in laparoscopic anatomical liver resections

BACKGROUND

The liver hanging maneuver is a novel technique that is widely used in open liver resection. The hanging technique has been rarely applied during laparoscopic liver resection because a blind dissection between the anterior surface of the inferior vena cava and the liver is required. Dissection between the right and middle hepatic vein is necessary in right hepatectomy, as is dissection between the middle and left hepatic vein in left hepatectomy. The aim of this study was to introduce the lateral approach liver hanging maneuver in laparoscopic anatomical liver resections.

METHOD

For this technique, the upper end of the hanging tape was placed on the lateral side of the right or left hepatic vein and the lower end of the hanging tape between three Glisson's pedicles. The pathway of the tape was situated along the lateral side of the inferior vena cava in right-sided hepatectomy or the ligamentum venosum in left-sided hepatectomy.

RESULTS

From February 2013 to October 2014, this technique was performed in 35 patients. Of these patients, ten patients underwent a right hepatectomy, 5 patients underwent a right posterior sectionectomy, 12 patients underwent a left hepatectomy, and 8 patients underwent a left lateral sectionectomy. The median operative time was 240 min (range 90-390 min), and median blood loss was 350 ml (range 60-700 ml). Blood transfusion was required in six patients (17.1 %). In two patients (5.7 %), postoperative complications were observed due to intra-abdominal fluid collection and pneumonia, respectively. No postoperative mortality was encountered.

CONCLUSION

The lateral approach liver hanging maneuver is a simple, safe, and reproducible approach as dissection of the anterior surface of the inferior vena cava and between the three major hepatic veins is not required. This technique may be useful in laparoscopic anatomical liver resections.

The experience of transumbilical endoscopic appendectomies

Minimally invasive surgery is being widely accepted in various fields of surgery. Although several appendectomy techniques have been reported but, there is no standardization. We report here the experiences of transumbilical endoscopic appendectomy in humans. Between July 2008 and September 2010, ten patients with appendicitis successfully underwent transumbilical endoscopic appendectomies. There were 7 cases of suppurative, 2 cases of gangrenous and 1 case of perforated in operative findings. The ages of the patients were 13-56 years (mean age, 32.7 ± 15.4 years). Under general anesthesia, a 15-mm port was inserted through the umbilicus and then a two-channel endoscope was inserted in the peritoneal cavity. After appendix identification, counter-traction of the appendix with a direct abdominal wall puncture using a straight round needle prolene was performed to achieve good visualization of the operative field. Tissue dissection was performed using an endoscopic needle knife. Tissue grasping and resected appendix retrieval were done with endoscopic forceps. The average operation time was 79.5 ± 23.6 minutes (range, 45 to 110 minutes). No procedures were converted to laparoscopic or open appendectomy. Hospital stay was 4-6 days. All patients completely recovered without complications. As it is highly maneuverable, we believe transumbilical endoscopic appendectomy can be a feasible method. And, as surgeons want to proceed from laparoscopic surgery to natural orifice transluminal endoscopic surgery, this procedure could be a triable method.

Common bile duct dilatation after cholecystectomy: a one-year prospective study

PURPOSE

Bile duct dilatation after cholecystectomy continues to be a matter of controversy. We aimed determine the magnitude of common bile duct (CBD) dilatation after cholecystectomy followed up to 1 year.

METHODS

Sixty-four cases (age, 47.3 ± 11.7 years; men, 28; women, 36) enrolled in this study. They received laparoscopic cholecystectomy in Chungbuk National University Hospital for symptomatic cholelithiasis or gallbladder polyps with normal bile duct, less than 7 mm. The CBD diameter was measured by one radiologist using ultrasonography at the maximum point after full length evaluation of extrahepatic bile duct. Forty-five and thirty-one cases were followed at 6 months and 1 year, respectively.

RESULTS

The CBD was dilated slightly from 4.1 mm at baseline to 5.1 mm at 6 months and 6.1 mm at 12 months after cholecystectomy. The number of cases of CBD dilatation of more than 7 mm at 6 months and at 12 months after cholecystectomy were 11 (24.4%) and 9 (29.0%), respectively. Seven cases at 6 months and 5 cases at 12 months showed bile duct dilation of more than 3 mm compared to baseline. There were no cases having bile duct dilation of more than 10 mm.

CONCLUSION

Postcholecystectomy dilatation of the bile duct occured slightly in most cases. But some cases showed more than 3 mm dilatation over baseline. Asymptomatic bile duct dilatation of up to 10 mm can be considered as normal range in patients after cholecystectomy.

Suppression of proliferative cholangitis in a rat model by local delivery of paclitaxel

BACKGROUND

Proliferative cholangitis (PC) leads to biliary stricture, which is the main cause of hepatolithiasis, recurrent cholangitis, and biliary cirrhosis. The aim of this study was to determine whether local delivery of paclitaxel, which inhibits cell proliferation by overstabilization of microtubules, prevents PC in a rat model.

METHODS

PC was induced by introducing a fine nylon thread into the bile duct in a rat. Paclitaxel (100 microl of 10, 100, and 1000 micromol/l) or solvent vehicle was administered into the bile duct for 15 min. One week after treatment, histopathologic examination and 5-bromodeoxyuridine (BrdU) labeling of the bile duct were performed.

RESULTS

In comparison with the control, the mean thickness of the bile duct was reduced by 29% in the 1000 micromol/l paclitaxel-treated group (2.61 +/- 0.31 microm vs 3.67 +/- 0.25 micro m, P << 0.05). The luminal area increased ( P << 0.0001) and the grade of epithelial-glandular proliferation was decreased ( P << 0.01) as the dose of paclitaxel increased. Ductal fibrosis and inflammatory cell infiltration were similar in both groups. The BrdU labeling index was significantly lower in the paclitaxel-treated group ( P << 0.05).

CONCLUSIONS

Local delivery of paclitaxel suppressed PC in a rat model by the inhibition of epithelial-glandular proliferation and may offer an effective therapeutic option for biliary stricture.

Symptomatic duodenal diverticulum

To determine management guidelines for symptomatic duodenal diverticulum, we reviewed medical records of 26 patients. Complicated duodenal diverticulum was the only possible cause of symptoms-abdominal pain, fever and chills, melena, vomiting-in 18 patients. Ten patients improved with conservative management, and eight patients underwent diverticulectomy with or without various other procedures. Among the eight patients, one patient who had duodenal fistula died of respiratory complications on the second postoperative day. Symptoms recurred in two patients: One had a distal common bile duct (CBD) stricture and underwent choledochojejunostomy. In the other patient a CBD stone developed 3 years later, and choledocholithotomy and choledochojejunostomy were performed. Eight patients had associated gallstone disease as well as the diverticulum. Five of the eight had a history of operation for gallstone disease; four improved with conservative treatment, and one underwent choledochojejunostomy. Two patients were thought to have an innocent diverticulum and underwent cholecystectomy and choledocholithotomy only. One patient underwent diverticulectomy and sphincteroplasty for a CBD stone and pervaterian diverticulum. In conclusion, operations for duodenal diverticulum should be reserved for seriously complicated diverticula, and the surgeon should be aware that pervaterian diverticulum can be a cause of choledocholithiasis.