2005 SAGES Abstracts

POSTER ABSTRACTS
defined borders, and with no signs of invasion into the splenic
artery or vein. EUS-guided FNA in both patients confirmed the
diagnosis of a pancreatic solid pseudopapillary tumor (SPT),
an uncommon tumor of the pancreas possessing low malignant
potential and usually cured by surgical resection alone.
Based upon this definitive preoperative diagnosis, complete
resection of both masses was accomplished by means of a
laparoscopic distal pancreatectomy. Final pathologic evaluation
of both resected specimens confirmed the diagnosis of
SPT.
Conclusions: Until laparoscopic treatment of pancreatic cancer
is proven to be comparable to open treatment, laparoscopic
resection should be limited to abnormalities that are benign,
premalignant, or of low malignant potential. These two cases
demonstrate the utility of a management algorithm that combines
preoperative evaluation by means of EUS with FNA, followed
either by laparoscopic or open resection as directed by
the EUS and FNA results.
P195–Hepatobiliary/Pancreatic
Surgery
MIRIZZI SYNDROME AFTER LAPAROSCOPIC ROUX-EN-Y
GASTRIC BYPASS, Giselle G Hamad MD, Kenneth K.W. Lee
MD,Ryan Levy MD,Adam Slivka MD, University of Pittsburgh
Medical Center
Mirizzi syndrome is an uncommon disorder characterized by
benign extrinsic compression of the extrahepatic bile duct by a
gallstone impacted in the cystic duct. Following Roux-en-Y
gastric bypass, performance of ERCP to establish the diagnosis
of Mirizzi syndrome is challenging because the distal stomach
and duodenum are excluded. A 46 year-old female who underwent
laparoscopic Roux-en-Y gastric bypass 30 months ago
presented with right upper quadrant pain and nausea.
Laboratory data revealed conjugated bilirubin 0, total bilirubin
0.5, alkaline phosphatase 975, AST 155, ALT 191. Amylase and
lipase were elevated at 193 and 785, respectively. Right upper
quadrant ultrasound demonstrated a 1.7 cm gallstone and
dilatation of the common bile duct and right hepatic duct. The
patient underwent an attempted laparoscopic cholecystectomy.
Because a calculus was impacted in the cystic duct, intraoperative
cholangiography was not possible. Intraoperative
ERCP was performed through a gastrotomy created in the
excluded distal stomach and established the diagnosis of
Mirizzi syndrome. The proximal common bile duct was dilated
and was compressed by a 2 cm stone impacted in the cystic
duct that was eroding through the distal cystic duct wall, causing
ductal necrosis. An additional 2 cm stone was identified
within the common bile duct. Endoscopic stone extraction and
lithotripsy were attempted but were unsuccessful. The procedure
was then converted to an open cholecystectomy and
common bile duct exploration. Intraoperative cholangiography
confirmed clearance of the common bile duct. The patient
recovered uneventfully. Mirizzi syndrome after Roux-en-Y gastric
bypass presents a unique challenge for both diagnosis and
surgical management. ERCP through the excluded stomach is
valuable in establishing the diagnosis.
P196–Hepatobiliary/Pancreatic
Surgery
TOTALLY LAPAROSCOPIC RIGHT POSTERIOR SECTIONECTO-
MY (SEGMENTS VI-VII) FOR HEPATOCELLULAR CARCINOMA,
Ho-Seong Han MD, Yoo-Seok Yoon MD,Yoo Shin Choi
MD,Sang Il Lee MD,Jin-Young Jang MD,Sun-Whe Kim
MD,Yong-Hyun Park MD, Department of Surgery, Seoul
National University College of Medicine, Seoul, Korea
Introduction: Localization of lesions is considered as a major
determinant for the indication of laparoscopic liver resection.
Until now, reports on laparoscopic liver resections mainly
involved the antero-lateral segments (Couinaud segments II-
VI). We report on a totally laparoscopic right posterior sectionectomy
for hepatocellular carcinoma. To our knowledge,
this is the first reported case in terms that it was totally performed
laparoscopically.
Methods and Procedures: A 57-year-old man known as a HBs
Ag carrier presented with a liver mass detected in the physical
checkup. Abdominal USG and CT revealed a 5cm sized single
nodular hepatoma located in S6-7, multi-septated cystic tumor
presumed to originate from the liver. Preoperative liver function
was Child A. A totally laparoscopic right posterior sectionectomy
was performed. Five trocars were inserted at the
proper position. After cholecystectomy, the ligaments around
the liver and right triangular ligament were dissected. Liver
was dissected from the IVC and short hepatic veins met during
dissection were controlled with double application of endoclips.
After full mobilization of the right liver, major Glissonian
cord to right post section was dissected and transected with
endo-GIA. The hepatic parenchyma was dissected with
Harmonic scalpel and Ligasure along the ischemic line. The
small branches of hepatic veins were controlled with endoclips
and large branches were transected with endo-GIA. The hepatic
veins were transected with endo-GIA. The epigastric trocar
site was extensionally incised for the removal of the specimen.
Results: The operative time was 540 minutes. The estimated
intraoperative blood loss was about 1450 cc, and 3 units of red
blood cells were transfused. The patient was discharged on
postoperative day 13 without postoperative complications.
Postoperative pathology confirmed a hepatocellular carcinoma
with 1 cm free resection margin. He remains alive without the
evidence of recurrence after follow-up of 12 months
Conclusion: This case confirms that totally laparoscopic liver
resection is a possible operative procedure in the patient with
the lesion in the right posterior section of the liver. However,
the technical problems such as long operation time and large
amount of blood loss should be resolved in order that this procedure
can be more safely accomplished.
P197–Hepatobiliary/Pancreatic
Surgery
LAPAROSCOPIC MANAGEMENT OF INSULINOMAS, Jorge
Montalvo MD,Paulina Bezaury MD,Manuel Tielve MD,Juan A
Rull MD,Juan P Pantoja MD, Miguel F Herrera MD, Department
of Surgery, INCMNSZ, Mexico City, Mexico.
Background. Laparoscopic resection of Insulinomas has been
reported with increasing frequency. Preoperative localization
and intraoperative evaluation by ultrasound have been extensively
recommended.
Patients and methods. In a 10 year period, 13 patients (pts)
with biochemical diagnosis of organic hypoglycemia were
referred for surgical treatment. In all pts laparoscopic management
was attempted. Preoperative clinical, biochemical and
radiological characteristics, surgical findings and procedures,
and postoperative outcome were reviewed and analyzed.
Results. There were 9 females and 4 males with a mean age of
37 ± 15 years. All pts presented with symptoms of neuroglycopenia.
Fasting serum glucose was low in all pts (mean value
38 ± 8.2 mg/dL). In 7 of 11 pts basal serum insulin was elevated.
C Peptide was measured in 8 pts and was abnormal in 6.
Plasma insulin/glucose ratio was abnormal in 91% pts. The
tumor was preoperatively situated by image studies in 10 pts
(76.9%). Of the 11 pts who underwent CT, the tumor was correctly
localized in 7, also in 2 of the 4 pts who underwent MRI
and in 9 of the 12 pts in whom angiography was performed.
Using the selective arterial stimulation image test the tumor
was regionalized in 5 of 6 pts. Surgical procedures included
Lap enucleation in 3 pts, and Lap distal pancreatectomy in 7,
of these, Lap splenectomy was necessary in 3 pts. In all these
cases the tumor was situated in the body or tail of the pancreas.
Conversion to open surgery was necessary in 3 pts. In 2
pts the tumor was located in the head, and in one case no
tumor was found and an open subtotal pancreatectomy was
performed. Intraoperative US was used in 10 pts. In 9 pts US
correctly localized the tumor. There were no intraoperative
complications. Two pts developed postoperative complications
(a pancreatic pseudocyst in one, and a pancreatic fistula with
an abscess that required drainage in one pt that had a conversion).
Mean tumor size was 2.2 cm ± 0.9 cm.
Postoperative glucose levels became normal in all pts. In a
mean follow-up of 21 ± 15 months, no recurrences have been
observed.
Conclusion. Laparoscopic resection of Insulinomas can be efficiently
performed in most tumors located in the body and the
tail of the pancreas.
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