Gastrointestinal Surgery Series: Minimal Invasive Hepatobiliary and Pancreas Surgery Prabin Bikram Thapa, Dhiresh Kumar Maharjan
INDEX
ABCDEFGHIJKLMNOPRSTUVWY
Page numbers followed by f refer to figure.
A
Abdomen 18
lower 7, 35
Abdominal incision 99
Abdominal procedures, repeated 43
Abdominal surgery, major 1
Achilles’ heel 6
Adenocarcinoma 23, 58
Adherent coagulated tissue 9f
Advanced bipolar vessel sealing device 14
Adventitia 92
Albumin 20
Anesthesia, choice of 1
Antecolic duodenojejunostomy, end-to-side 98
Appreciate arterial fluorescence 22
Ascites 80
Atrophic parenchyma 115
B
Balanced crystalloid 4
Basic surgical techniques 6
Berne's modification 118
Bile duct
proliferation 25
resection, indication for 51
Bile spillage 53
Biliary anatomy 27
Biliary ducts 26
Biliary tree mapping 26
Bilioenteric anastomosis 58
Bipolar coagulation 9, 10, 10f
Bipolar diathermy 7
Bipolar forceps 9f
removal of 8
replacement of 8
Bleeding control
intraoperative 6
techniques for 7
Bleeding, severe 9
Blood loss 6
increased 8
Body mass index 105
Borderline resectable disease 78
C
Cadaver training 17
Cancerous tissues 24
Caudate lobe-first approach 34f
Cause, tumor dissemination 50
Celiac axis 108
Cells, malignant 26
Central hepatectomy 37
Central venous pressure 2, 3f
Chemotherapy, preoperative 25
Cholangiocarcinoma 24, 26
Cholangiography, intraoperative 28
Cholecystectomy 51
Chronic inflammation 66
Chronic pancreatitis 57, 115, 116, 119, 120f
Cirrhosis 25
Clinical care pathways 60
Coagulation 2
Coagulogram 4
Colorectal liver metastases 37, 38, 40
posterosuperior 42
robotic resections for 44
treatment of 37
Common bile duct 27, 70, 69f, 80
lower 66
Common hepatic artery 69f, 88, 88f
Conventional laparoscopic instruments 57
Conventional radiology 60
Current laparoscopic surgery 15
D
Distal pancreatectomy 57, 105, 119, 120f
Distal pancreatosplenectomy 115
Drainage procedures 116
Duct
identification of 117f
layer, anterior 97f
Duct-pancreatic suture, anterior 93
Duodenum 67
first part of 83
mobilization of 87f
transection of 87f
E
Emergency 112
Endoscopic ultrasound 80
Energy device 81
Epidural catheter removal 1
Extrahepatic ducts 27
Extremely precise dissection 79
F
Fibrillar oxidized cellulose 10
placement of 10
Fibrosis 53
Fluorescence 22
imaging
basic principles in 20
clinical applications of 20, 21
Fluorescence
guided surgery 20
type of 23
Fluorescent regions, identification of 25
Fluorophore 21
administration 22
dye 20
Fourth robotic port 53
Frey procedure 118
G
Gallbladder 68, 69f
cancer 50
managing 50
robotic surgery in 53
surgery of 54
Gastric artery clipped and divided, right 86f
Gastrocolic ligament 83, 106
division of 84f
Gastrocolic momentum 67
Gastrocolic trunk insertion 85f
Gastroduodenal artery 69f, 70f, 83, 90f, 118
junction of 88f
Gastroenterostomy 58
Gastroepiploic artery, right 84
Gastroepiploic vein, right 83
Gastrointestinal surgeries 16
Gastrojejunostomy 65, 68, 98
Glissonean branches 32
Glissonean pedicles 34
anterior 35f
division of 35f
posterior 35f
Glissonean
tree 32
trunk 34, 34f
H
Hand-assisted system 11, 12
Healthcare system 60
Healthy liver 39
Hemihepatectomy 32
completion of right 36f
Hemorrhage, postoperative 118
Hemostasis 18, 108, 115
bipolar for 41f
Hemostatic devices 12
Hemostatic stay sutures 89
Hepatectomy
laparoscopic right 32
major 38
Hepatic artery, right 68, 69f
Hepatic hilum 32, 34, 35f
Hepatic inflow, total 4
Hepatic liver dysfunction 2
Hepatic segments
boundaries of 26
identification of 26
Hepatic tumors 25
Hepatic vein 10, 32
middle 34, 35f
Hepaticojejunostomy 65, 68, 96, 99f
Hepatobiliary surgery 22
clinical applications in 23
Hepatocellular carcinoma 6, 23
Hepatocytes, compressed 24
Hepatoduodenal ligament 18, 51, 53
lymphatic clearance of 52f
Hyper eye medical system 23
Hypochondrium 32
left 33f
I
Incidentally diagnosed gallbladder 52
Incisionless cholangiography 27f
Indocyanine green 16, 20, 21
fluorophore administration 21
role of 20
systems 22
Inflammatory adhesions 53
Inflammatory nature 115
Inflow occlusion technique 8
Infracolic compartment 67
Initiating robotic pancreaticoduodenectomy 78
Instantaneous bipolar coagulation 10
Intensive care unit 72
Intra-abdominal pressure 8, 11
increase of 8
low 8
Intracorporeal suturing 116
Intraductal papillary mucinous neoplasm 66, 110
Intrahepatic biliary anatomy 28f
Intraoperative bleeding 14
Intravascular volume, management of 40
Intravenous fluid 4
Ischemia reperfusion injury 2
Islet cell autotransplantation 119
J
Jaundice 66
Jejunal stay suture 95
Jejunal vein, first 68
Jejunojejunostomy 68
fashioned 68
side-to-side 117
K
Kidney injury, acute 1
Kocher maneuver 85
L
Laparoscopic bile duct 52
Laparoscopic bleeding control 11
Laparoscopic caudodorsal magnified view 33
Laparoscopic clarity ultrasonic surgical aspirator system 14
Laparoscopic distal
pancreatectomy 60
pancreatosplenectomy, operative technique for 106
Laparoscopic drainage pictures, port position for 117f
Laparoscopic extended
cholecystectomy 51
major hepatectomy 42
Laparoscopic hepatectomy 6, 11, 14, 15, 17, 18
initiating 14
Laparoscopic instruments 108
Laparoscopic left lateral sectionectomy 39f
Laparoscopic liver
resection 1–3, 6, 15, 16, 37, 42
surgery 6, 20
Laparoscopic major hepatectomies 40
Laparoscopic minor liver resections 38
Laparoscopic pancreatic resection 65
Laparoscopic pancreaticoduodenectomy 65, 79, 84f–86f, 88f, 90f, 95f–98f, 100
first 115
indications 66
uncinate dissection 92f
Laparoscopic pancreatoduodenectomy 65, 73
Laparoscopic parenchymal sparing 40
Laparoscopic procedure 54, 68
Laparoscopic reoperation 53
Laparoscopic resection 42, 58
Laparoscopic surgery 50, 59
concerns of 16
Laparoscopic techniques, application of 73
Laparoscopic ultrasonic sears 14
Laparoscopic ultrasound 18
Laparoscopy, staging 60
Laparotomy 66
decreases 11
Lesions, malignant 58, 109
Ligamentum teres 69f, 108
Lipoprotein 20
Liver 10f, 80
enzymes, monitoring of 4
function 1
injury, chemotherapy-induced 43
lesions 25
malignancies, secondary 23
mobilization 40
parenchyma 7, 9, 12, 22, 32, 34
resection 2, 15, 17, 17, 24, 51, 53f
laparoscopic repeated 43
open 38
partial 37
treatment option for 44
segment
negative staining technique for 27f
visualization 26
surgery 25
transection 28
tumor
identification 23
localization 23
Lobe, right 35
Local inflammation 119
Low central venous pressure, challenges of 3
Low-grade malignancies 66
Low-voltage electrical cautery 32
Lung 80
M
Malign tumors 105
Malignant disease, diagnosis of 109
Maryland bipolar forceps 81
Maryland forceps 117
Mesopancreas 100
Metastatic liver tumors 24, 25
Meticulous hemostasis 66, 118
Miami international evidence -based guidelines 111
Mid-bile duct cancer 66
Minimal access surgery, advantages of 65
Minimally invasive
distal pancreatectomy 105, 109
frey procedure 118
lateral pancreatojejunostomy 116
liver resections 44
pancreatic surgery 58, 59, 61
changing trends in 57
evidence-based indications for 59
pancreaticoduodenectomy 65, 78–80, 102
evidence for 101
procedures 37
surgery 50, 58
cost-effective 60
techniques, application of 37
treatment 37
Minimizing blood loss 7
Monopolar electrode with saline irrigation 11
Monopolar scissors, curved 81
Mucinous cystic neoplasms 66
Mucosa
anastomosis 71f
technique, duct to 68
N
Neoadjuvant chemotherapy 39
Non-anatomical segmental resection, laparoscopic marking for 52f
O
Oncological surgery 54
Ondocyanine green 20
Open distal pancreatectomy 105
Organic anion-transporting polypeptide 24
Organoscopy 57
P
Pancreas 89, 106, 107
adenocarcinoma of 59
exposure of 115, 117
neck of 67
preparation of 107f
stapler division of 107f
superior border of 88f
uncinate process of 81
Pancreatectomy, total 119
Pancreatic bed 59
Pancreatic cancer 60
staging of 60
Pancreatic diseases, diagnostic laparoscopy for 57
Pancreatic duct 93, 116, 118
cannulation of 97f
identification of 115
opening of 117
stenting of 94
Pancreatic fistula 78
postoperative 78
Pancreatic head 118
Pancreatic neck 70f
division of 89, 91f
transected 70f
Pancreatic necrosis 59
infected 61
Pancreatic parenchyma, anterior 93
Pancreatic stent 71f
Pancreatic surgeons 57, 61
Pancreatic surgery 57, 61
Pancreatic tumors, benign 59
Pancreaticoduodenal artery, inferior 93
Pancreaticoduodenal vein
inferior 68
superior 68
Pancreaticoduodenectomy 78, 119
open 68, 101
Pancreaticojejunal anastomosis, completed 72f
Pancreaticojejunal duct 71f
Pancreaticojejunostomy 65, 68, 78
Pancreatitis, acute necrotizing 59
Pancreatoduodenectomy 57, 119
popularization of 65
Pancreatojejunostomy 93, 118
lateral 116
side-to-side 116
Parenchyma 38, 118
tissue 118
transection 7, 40
Periampullary lesions 66
Peripheral portal pedicle, bleeding of 10
Periportal dissection 86
Periportal nodes, dissection of 89f
Peritoneum 80
Phlebostatic axis 3f
Photodynamic eye 23
Pneumoperitoneum 14, 32, 108
loss of 116
pressure 7
Polydioxanone 81
Porta hepatis 83
Portal lymphadenectomy 100
Portal vein
dissection 70f
injection 26
left border of 88
resection 41f
Positive end-expiratory pressure 3
Posterior duct
layer 96f
pancreatic suture 93
suture 94f
Post-hepatectomy bile leak 28f
Posthepatectomy hepatic failure, risk of 18
Potentially curative surgery 25
Preferred suture materials 81
Pringle maneuver 19f, 32
Prograsp forceps 81
Pulmonary artery hypertension 3
Pylorus 98
Pylorus-preserving pancreaticoduodenectomy 82f, 83
R
Radical surgery, goals of 51
Recurrent colorectal metastases 43
Remnant liver 35f
Renal function 4
Renal vessels 108
Resectional procedures 119
Respiratory function, preservation of 1
Retropancreatic tunnel 67
Right portal vein for pedicle control, dissection of 41f
Robot-assisted distal pancreatectomy 79
Robotic approach 53
disadvantages of 100
Robotic cholecystectomy 27
Robotic hepatobiliary surgery 26
Robotic liver
resections 44
surgery 38
Robotic pancreaticoduodenectomy 79, 84f–86f, 88f, 90f–92f, 95f–98f
evidence for 101
patient position for 81
port position for 81
surgical equipment for 81
Robotic port 81
placement 82f
Robotic pylorus preserving pancreaticoduodenectomy
operative procedure of 83
setup for 82f
Robotic reconstruction 79
Robotic surgery, advent of 79
Roux loop, creation of 117
S
Safe laparoscopic hepatectomy 7
Segmentectomy, right posterior 41f
Specimen extraction 81
Splenectomy 109
Splenic artery 107
division of 108f
Splenic vein, preparation of 107f
Stroke volume variation 3
Subcellular organelle 21
Subphrenic space, right 35
Suction catheter 10f
tip 9f
Superior mesenteric
artery 78
vein 83, 85f, 91, 92
Supplementary technique 11
Suture hitching 69f
T
T metastatic disease 80
Technical competence, achievement of 61
Technical difficulty scoring system 15f
Transfusion rates 40
Trendelenburg's position 53
Trendelenburg's Lloyd-Davis position 116
Trocar placement 33f
U
Ultrasonic dissector 93
Uncinate dissection 71f, 90
completion of 71f
V
Vascular stapler, use of 41f
Vena cava, inferior 3, 67
Viscoelastic coagulation 2
Vision, two-dimensional 79
Vitamin K 1
W
Water-soluble fluorophore 20
Winslow foramen 18
Wound infection 116
Y
Yonsei criteria 109
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Chapter Notes

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Anesthetic Viewpoints in Laparoscopic Liver ResectionCHAPTER 1

Babu Raja Shrestha,
Sushila Lama Moktan
 
INTRODUCTION
Major abdominal surgery leads to major physiological deviations. Every anesthetic endeavor should be directed to preserve the physiological balance during and after the surgical interventions associated with inherent risks of bleeding, hemodynamic fluctuations, fluid shifts, coagulopathy, and pulmonary and renal impairments including postoperative hepatic failure.
Era of laparoscopic liver resection demands meticulous anesthetic patient care perioperatively. Laparoscopic liver resection unless fine-tuned with anesthetic manipulation, the untoward effects are accentuated and even inevitable. The advent of this minimal invasive hepatic resection technique mandates anesthetic counterparts to stay in close touch with the changing physiological parameters during surgery. Growing surgical expertise and anesthetic experiences have allowed several limitations to overcome since the first laparoscopic liver resection in 1991.1
Preoperative evaluation and assessment should be tailored according to the existing liver function status and comorbidities. Detailed laboratory investigations and risk stratifications warrant preoperative optimization and perioperative planning. Liver function reserve is evaluated, and the candidate is categorized as per Child–Pugh classification. This aids to determine extent, possibility, and prognostication of liver resection.
 
CHOICE OF ANESTHESIA
Liver-friendly general anesthesia with endotracheal intubation under controlled ventilation is key in laparoscopic liver resection.
For best perioperative analgesia, thoracic epidural catheter placement is widely employed and maximum care is exercised during, and at the time of epidural catheter removal. Epidural analgesics has been claimed to be immune-protective.2 Moreover, other benefits such as reduced thromboembolism, preservation of respiratory function, and early return of gastrointestinal mobility are in favor of thoracic epidural placement.3 Postresection international normalized ratio (INR) should be <1.3 prior to epidural catheter removal. Unless the INR is normalized, fresh-frozen plasma transfusion, injection vitamin K is indicated before catheter removal.4
An important issue with regards to thoracic epidural in laparoscopic liver resection is fear of acute kidney injury (AKI) on the background of 2sympathetic truncation, peripheral vasodilatation, compromised central venous pressure (CVP) during liver resection, miser crystalloid infusion at times during parenchymal resection, and compromised hemodynamics in condition of probable torrential intraoperative bleeding.
Another effective alternative for analgesia is single shot intrathecal morphine (200–300 µg) with bupivacaine along with premedication of gabapentin. The extent of analgesia provided by this mode is comparable to epidural analgesia for early postoperative period of 48 hours.5
 
Point to Note
Perioperative opioid use might retard gastrointestinal function as liver resection might increase bioavailability of opioids due to reduced drug metabolism and subsequent accumulation. This demands vigilant postoperative respiratory monitoring to protect the patients from possible respiratory depression.
 
SOME ISSUES ON COAGULATION
Postoperative coagulopathy after laparoscopic liver resection is dependent on various factors such as previous hepatic liver dysfunction, prothrombin time (PT), INR, platelet function, extent of liver resection and remnant functional hepatic volume, duration of surgery, volume of blood transfusion, and extent of ischemia reperfusion injury.
Foundation resource management for laparoscopic liver resection enthusiasts in countries such as Nepal is arrangement of viscoelastic coagulation testing arrangement. This facility offers evaluation of both procoagulant activity and endogenous anticoagulation. Viscoelastic coagulation study demonstrates normal, hypercoagulable, and clot strength following laparoscopic liver resection enabling appropriate measures accordingly. Factors such as acidosis, hypocalcemia, and hypothermia must be regularly monitored in order not to amplify coagulation disorders.6
 
WHAT ANESTHESIOLOGISTS NEED TO DO TO MINIMIZE INTRAOPERATIVE BLEEDING DURING LAPAROSCOPIC LIVER RESECTION?
  • Keep the patient in head-up, reverse Trendelenburg position to unload the vascular beds during bleeding.
  • Increase carbon dioxide pneumoperitoneum pressure from 12 to 15–16 mm Hg. This helps compress vascular weeping from vessels other than inferior vena cava.
  • Restrict intravenous crystalloid infusion down to 1 mL/kg/h during liver parenchymal resection period.
  • Maintain CVP <5 mm Hg (Fig. 1).73
zoom view
Fig. 1: Central venous pressure (CVP) monitoring keeping at phlebostatic axis.
Hepatic valve-less veins might allow backflow of blood during hepatic inflow occlusion, thus lowering CVP significantly decreases bleeding. In order not to increase effects of bleeding, anesthesiologists may consider preoperative therapy of erythropoietin and intraoperative use of warming blankets and warm fluids to check hypothermia.
 
PITFALLS AND CHALLENGES OF LOW CENTRAL VENOUS PRESSURE IN LAPAROSCOPIC LIVER RESECTION
The first basic need is to note down the individual CVP in the beginning of the surgery. This allows us to consider the factors that might elevate or lower CVP. Risks of lowering CVP predispose patient to hemodynamic instability—decrease cardiac output, decrease mean arterial pressure, and decrease perfusion pressure to the vital organs.
These after-effects of minimized CVP are further accentuated due to the carbon dioxide pneumoperitoneum compressing the major intra-abdominal vasculatures. However, these conditions reduce the distension of the central veins aiding hepatic dissection.
All the maneuvers employed during bleeding are not in favor of maintaining hemodynamics and add on further challenges to anesthesiologists. This demands expertise, skill, and vigilance from anesthetic counterpart. Fluid restriction head-up position, epidural, nitroglycerin, and diuretics might help reduce CVP. Besides, positioning patient in left lateral tilt keeps hepatic veins superior to the inferior vena cava and venous bleeding is decreased during parenchymal dissection.
Preexisting conditions such as right ventricular pressure overload due to pulmonary artery hypertension (PAH), tricuspid valve pathology, auto-positive end-expiratory pressure (PEEP) from pulmonary pathology might change the actual CVP readings. CVP recording at mid-axillary point should also be well fixed for continuous CVP tracing. Stroke volume variation (SVV) monitoring is another monitoring technique where CVP measure loses its validity.8 Compression on liver and diaphragm by multiple surgical pads may be another point to note if CVP is persistently high despite all above-mentioned 4techniques. Intermittent total hepatic inflow clamping is another widely adopted technique for this purpose to control bleeding (Pringle technique).9
Laparoscopic liver resection poses another serious condition such as probability of gas embolism (incidence 0.2–1.5%).10 The risk of venous gas embolism during laparoscopic liver resection is likely when favorable condition of gas entrainment into venous system is created by increasing CO2 pneumoperitoneum in the background of lowered down CVP with no intention of minimizing bleeding during liver resection. However, despite positive pressure gradient between CVP and intra-abdominal pressure (IAP) (CVP > IAP), gas embolism can still occur due to volume and rate of CO2 insufflation.11,12
This raises a question that laparoscopic liver resection might have different CVP target than in open liver resection as low CVP demanded by operating surgeon might increasingly predispose CO2 gas embolism when IAP-CVP gradient is continuously positive, with negative suctioning effect transferred from the thoracic cavity. The practical solution to this issue is prevention and earlier recognition of gas embolism by comprehensive monitoring system such as transesophageal echocardiography (TEE), precordial Doppler, and capnography.
 
INTRAVENOUS FLUID
It is strongly recommended to use balanced crystalloid (Plasma-Lyte) and avoid 0.9% normal saline to avoid postoperative hyperchloremia and renal dysfunction.13
 
POSTOPERATIVE ISSUES
Closer monitoring of liver enzymes, coagulogram, and renal function is the key to early recognition and treatment. Early enteral nutrition, electrolyte correction, and avoidance of hepatotoxic agents expedites restoration of liver functionality.
 
CONCLUSION
Laparoscopic liver resection demands meticulous understanding of ongoing physiology. This allows anesthetic modification and techniques which create favorable surgical field and helps overcome untoward effects with vigilance, communication in the team for better operative outcomes, and subsequent patient recovery.
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