SOME COMPLEX HPB SURGERIES PERFORMED AT CARE HOSPITALS

OPEN LIVER RESECTION OF GIANT LIVER CANCER: OPTIONS DO EXIST, DESPITE SIZE

Mr CKR, 61 years old, presented with complaints of pain in the abdomen for 2 months. A PET/CT revealed a SOL in segment V, IV, VII, VIII suggestive of HCC. His TB: 1.4, AST: 59, ALT: 144, ALP: 168 and AFP was >6000. As the tumor involved over 6 segments of the liver he was refused surgery elsewhere. However, we carefully performed a pre-operative TACE and, after a month a diagnostic laparoscopy showed multiple lesions in seg VI to VIII. However, as we had hoped, the left lateral segment was still healthy and there was no peritoneal metastasis. In view of a non cirrhotic liver remnant and good remnant liver volume and no other options, an extended right hepatectomy was done. Duration of the surgery was 340 min, blood loss 800 ml and the patient was discharged in POD 10 after a mild liver dysfunction, which needed careful hepatology support.







WHIPPLES PANCREATICODUODENECTOMY WITH A PRE/INTRA-OP DIAGNOSTIC DILEMMA

Mr SS, 57 year old male, was a follow up patient after chemotherapyand radiotherapy for NHL completed in 2007, and declared cured. He presented with progressive jaundice; an USG abdomen showed a bulky head of pancreas, dilated MPD, IHBD and CBD with abrupt narrowing in intra-pancreatic portion. A PET CT did not show any significant FDG uptake anywhere. His CBP LFT etc was normal, CA19.9 was 2027. CT reconfirmed a dilated CBD, MPD and bulky pancreas. This presented a diagnostic dilemma as the differential diagnosis included a primary or secondary pancreatic lymphoma when surgery was not indicated and a HOP or peri-ampullary adenocarcinoma where, without surgery, he had very limited survival chances. Following a full assessment and various discussions with experts in other fields (oncology) surgery was planned. Intra op frozen sections from peri-choledochal lymph nodes, pancreatic head, etc, were negative for malignancy/lymphoma. A pylorus preserving pancreatico-duodenectomy was done, the intraoperative liver was noted to be firm with a granular surface (previous chemo and HBsAg+ve). The post-op histopathology report confirmed an adenocarcinoma of the Ampulla of Vater. He had an uneventful recovery.


OPEN LIVER RESECTION––OPTIONS DO EXIST, DESPITE AGE AND CIRRHOSIS

Mr LM, 70 years old, HCV positive male presented with pain in the right side for 15 days. He was evaluated outside and found to have liver SOL. His CBP, LFT was normal but the AFP was 517. On CT he was found to have a 9x8 cm Seg 8 HCC that had ruptured. Therefore, to ensure that there was no peritoneal disease we decided to delay surgery by 6 weeks, repeated a CT and then proceeded to resection. In the meantime, to minimize the risk of tumor progression, we performed TACE and put him on Sorafinib. In view of the cirrhosis a non-anatomical (limited Seg 5, 6 & 8) liver resection of tumor was done. Post op he recovered well and was discharged on POD 6.



ANATOMICAL LAPAROSCOPIC LIVER RESECTION [RIGHT POSTERIOR SECTIONECTOMY]

Mr TB, 56 years old, HBV positive male. During a routine health check-up was found to have SOL in the liver. His lab tests were normal. Triphasic CT (liver) showed 5 x 3 cm lesion in segment 7 with typical enhancement and delayed washout suggestive of a HCC. Following assessment and diagnostic laparoscopy, a fully laparoscopic Right Posterior Sectionectomy was performed, despite a slightly coarse liver. The operative time was about 6 hours and intra-op blood loss about 650 ml. However, he did not require any blood products. Post-operatively, Mr TB recovered well and was discharged on POD 6.


LAPAROSCOPIC LIVER RESECTION FOR BENIGN DS (OPTIONS DO EXIST FOR EVEN MULTIPLE SITES)

Mrs ARB, 34 years old, presented with pain in the right upper quadrant for 5 months. A CT scan revealed multiple hemangiomata in seg 6 (6.8 x 4.2 cm), seg 8 (2 x 1.3 cm) and seg 2/3 (5.8 x 4.3 cm) of the liver. She had had 2 LSCS and a hysterectomy in the past. Given her symptoms and lesion size, a fully laparoscopic left lateral sectionectomy and seg 6 segmentectomy was done. Duration of surgery was 4 hours for both lesions and blood loss was 300 ml with no blood products being used. The specimens were retrieved through the previous pfannenstiel incision and, hence, the entire procedure of dual lobe resection was completed without a single new incision (other than port holes). Post-operative recovery was fast, pleasant and uneventful.