The anatomy of the hepatoduodenal ligament in laparoscopic sonography

Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery

Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.

The hepatoduodenal ligament revisited: cross-sectional imaging spectrum of non-neoplastic conditions

INTRODUCTION

The hepatoduodenal ligament is frequently involved by conditions affecting the portal triad and surrounding structures, including a vast array of non-neoplastic conditions. Due its unique location between the retroperitoneum and the peritoneal space, the hepatoduodenal ligament is also targeted by inflammatory conditions involving the retroperitoneum and the liver. Finally, the presence of lymphatics and of the biliary tracts makes the hepatoduodenal ligament a route of spread for a variety of infections. The purpose of this pictorial essay is twofold: to review the cross-sectional radiological anatomy and variants of the structures within the hepatoduodenal ligament, and to illustrate the non-neoplastic conditions that may arise within the hepatoduodenal ligament.

CONCLUSION

Familiarity with these specific entities and their cross-sectional imaging findings is fundamental for a more accurate diagnosis.

Vascular occlusion to decrease blood loss during hepatic resection

BACKGROUND

Historically, the primary hazard with liver surgery has been intraoperative blood loss. This led to the refinement of inflow and outflow occlusive techniques. The utility of the different methods of inflow and outflow techniques for hepatic surgery were reviewed.

METHODS

A search of the English literature (Medline, Embase, Cochrane library, Cochrane clinical trials registry, hand searches, and bibliographic reviews) using the terms "liver," "hepatic," "Pringle," "total vascular exclusion," "ischemia," "reperfusion," "inflow," and "outflow occlusion" was performed.

RESULTS

A multitude of techniques to minimize blood loss during hepatic resection have been studied. The evidence suggests that inflow occlusion techniques are generally well tolerated. These should be used with caution in patients with cirrhosis, fibrosis, steatosis, cholestasis, and recent chemotherapy, and for prolonged time intervals.

CONCLUSIONS

Harmful effects of intraoperative blood loss and transfusion occur during hepatic resection. Portal triad clamping (PTC) is associated with less blood loss compared with no clamping. In procedures with ischemic times <1 hour in length, PTC-C (continuous) is likely equal to PTC-I (intermittent). In patients with chronic liver disease or undergoing lengthy operations, PTC-I is likely superior to PTC-C. PTC is superior to total vascular exclusion except in patients with tumors that are large and deep seated, hypervascular, and/or abutting the hepatic veins or vena cava and in patients with increased right-sided heart pressures.

Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography

BACKGROUND

Laparoscopic ultrasonography (LUS) has been used increasingly over the last several years as a new imaging modality. To define the role of LUS during laparoscopic cholecystectomy, we evaluated LUS by prospectively comparing it with operative cholangiography (OC), by reviewing the literature on LUS, and by retrospectively comparing it with intraoperative ultrasonography performed during open cholecystectomy.

STUDY DESIGN

LUS and OC were compared prospectively in 100 consecutive patients during laparoscopic cholecystectomy. The success rate of examination, the time required, the accuracy in diagnosing bile duct calculi, and the delineation of biliary anatomy were evaluated.

RESULTS

The success rate of examination was 95% for LUS and 92% for OC. The main reason for unsatisfactory LUS was incomplete visualization of the distal common bile duct. The time required was 8.2 minutes for LUS and 15.9 minutes for OC (p<0.0001). Nine patients had bile duct calculi. LUS had one false-negative result and OC had two false-positives and one false-negative. The accuracies of LUS and OC were comparable except for a slightly better positive predictive value of LUS (100% versus 77.8%; p>0.1). In a literature review, 12 recent prospective studies comparing LUS and OC and three studies on open intraoperative ultrasonography were reviewed. Twelve studies of LUS with a total of 2,059 patients demonstrated results similar to the present study. The success rate was 88% to 100% for both tests. The time for LUS was approximately 7 minutes, about half of the time needed for OC. Overall, LUS was associated with fewer false-positive results than OC; the positive predictive value and specificity of LUS were better, while the sensitivity and negative predictive value of LUS and OC were comparable. OC detected ductal variations or anomalies more distinctly than LUS. Compared with open intraoperative ultrasonography, LUS had a slightly lower success rate and required a slightly longer time because it was technically more demanding, but the two procedures had a similar accuracy for diagnosing bile duct calculi.

CONCLUSIONS

Because of their different advantages and disadvantages, LUS and OC can be used in a complementary manner. There is a learning curve for LUS because of its technical difficulty. Once learned, however, LUS can be used as the primary screening procedure for bile duct calculi because of its safety, speed, and cost-effectiveness. OC can be used selectively, particularly when ductal anatomic variations or anomalies or bile duct injuries are suspected.

Is growth influencing diameter and function of laparoscopic TESA hepaticojejunostomy? A comparison of adult minipigs and juvenile domestic swine

Current treatment of obstructive jaundice includes endoscopic stenting and open surgical bypass. To combine the advantages of surgical bypass with the minimal invasive approach of endoscopic stenting we developed a laparoscopic technique, transient endoluminally stented anastomosis (TESA). As shown previously, small-diameter anastomoses (e.g., hepaticojejunostomy) by TESA technique can be performed reliably in growing domestic swine. This further preclinical trial was designed to exclude growth of the animals as the main reason for these excellent results. After ligation of the common bile duct, a laparoscopic Roux-en-y hepaticojejunostomy was performed 7 days later by TESA with a reabsorbable radiopaque polyglycolic acid stent. In group A (n = 7) growing domestic pigs and in group B (n = 5) adult minipigs were operated on. Laboratory parameters were controlled weekly. Stent degradation was followed by weekly abdominal x-ray. At necropsy 6 months after surgery, cholangiography was performed and the anastomoses were measured. Mean weight gain was 140.7 +/- 10.9 kg in domestic pigs versus 5.8 +/- 1.6 kg in minipigs. Cholestasis normalized within 7 days postoperatively. Duration of stenting was not significantly different between groups. Cholangiography at necropsy showed immediate runoff through the anastomoses in both groups. The diameter of the anastomosis was 4.7 +/- 0.5 mm in group A versus 3.0 +/- 0.4 mm in group B (p = 0.03). In conclusion, functionality of the small-diameter TESA hepaticojejunostomy is not related to age and growing factors in pigs, justifying its application in human as the next step of investigation.

The utility of ultrasonography for screening the common bile duct during laparoscopic cholecystectomy

Since the introduction of laparoscopic cholecystectomy, the means by which the common bile duct is evaluated, if performed at all, has been debated. When the common bile duct is to be screened, two primary modalities have emerged. These techniques are fluoroscopic cholangiography and intracorporeal ultrasonography. Fluoroscopic cholangiography during laparoscopic cholecystectomy has been shown to be effective and accurate for demonstrating ductal stones and anomalies. More recently, laparoscopic ultrasonography has been utilized for screening the common bile duct. Ultrasonography is probably more sensitive than cholangiography for demonstrating intraluminal common bile duct stones or sludge and can be performed more rapidly and at less cost than cholangiography. However, ductal anomalies may not be as readily visualized. The two techniques, therefore, appear to be complementary for evaluating the common bile duct during laparoscopic cholecystectomy, and both techniques should be taught to today's surgical trainees.

Laparoscopic Roux-en-Y choledochojejunostomy

OBJECTIVE

Although surgical biliary bypass for nonresectable periampullary tumors is superior to endoscopic stent placement, the latter has become popular because of the "minimally invasive" approach. Laparoscopic biliary bypass would appear to offer the advantages of both. However, this technique remains technically difficult using existing instrumentation. This study investigates the efficacy of a new endoscopic device designed for rapidly completing a small-diameter intestinal anastomosis under laparoscopic guidance.

METHODS

Eighteen female pigs (mean weight 35 kg, range 31 to 44) were randomly divided into three groups: animals undergoing handsewn (group H) or instrumental transient endoluminally stented anastomosis (TESA; groups P and D) laparoscopic Roux-en-Y choledochojejunostomy. For TESA two different reabsorbable stents were used, polyglycolic acid (PGA; group P) and polyurethane ester (Degrapol; group D). Blood chemistry, weight gain, and abdominal X-rays were taken weekly to document any possible migration or reabsorption of the radio-opaque stents. After 3 months, necropsy was performed. Patency of the biliary bypass and choledochojejunostomy were examined using fluoroscopy and measured by introducing graduated dilators into the anastomosis.

RESULTS

Fluoroscopy revealed immediate passage of contrast through the anastomosis in all animals. Weight gain, bilirubin, and alkaline phosphatase were within normal range in all groups. Diameter of the bile duct (group H 10.7 +/- 2.9 mm/group P 9.5 +/- 3.6 mm/group D 11.0 +/- 4.6 mm) and choledochojejunostomy (group H 4.5 +/- 1.1 mm/group P 4.7 +/- 1.8 mm/group D 3.6 +/- 1.9 mm) did not differ. The time required to complete the biliary bypass was significantly decreased when TESA was applied (group H 152 +/- 13 min/group P 86 +/- 14 min, P <0.001/group D 110 +/- 20 min, P <0.002).

CONCLUSIONS

Applying TESA, laparoscopic choledochojejunostomy can be performed rapidly and safely, revealing good bypass function over a period of 3 months. With regard to treatment for nonresectable periampullary tumors, TESA may offer a new therapeutic approach combining the benefits of minimally invasive endoscopic stent placement with the functional results and lower readmission of conventional Roux-en-Y choledochojejunostomy.

Laparoscopic ultrasonography during cholecystectomy

The routine use of intraoperative cholangiography during cholecystectomy has been debated extensively. Intraoperative ultrasonography was a quick, efficient alternative in open cholecystectomy. A prospective controlled trial to evaluate its usefulness in laparoscopic cholecystectomy is reported. Two groups of 100 patients each were examined during operation with laparoscopic ultrasonography and intraoperative cholangiography. In the first group an adapted urethral probe was used and in the second group a new specialized laparoscopic probe. Intraoperative cholangiography followed immediately after laparoscopic ultrasonography in each patient. In group 1 bile duct stones (n = 4) were detected with a sensitivity of 100 and 75 per cent, a specificity of 98 and 99 per cent, and an overall accuracy of 98 per cent for both ultrasonography and cholangiography. In group 2, 11 patients demonstrated common duct calculi. The sensitivity, specificity and overall accuracy for laparoscopic ultrasonography and intraoperative cholangiography were 91 and 64 per cent, 100 and 100 per cent, and 99 and 96 per cent respectively. The differences between groups 1 and 2 and between ultrasonography and cholangiography were not significant. Variations in the anatomy of the bile duct were observed in 21 patients in group 1 by laparoscopic ultrasonography and in 20 by intraoperative cholangiography. In group 2, 64 variations were demonstrated in 50 individuals by ultrasonography and 61 variations in 47 patients by cholangiography. Vascular variations were seen with ultrasonography in 22 and 24 patients in groups 1 and 2 respectively. In conclusion, laparoscopic ultrasonography (with either probe) proved as accurate as intraoperative cholangiography in detecting bile duct stones, and the specialized probe detected significantly more variations of the bile duct than the adapted probe.

Intraoperative ultrasonography (IOUS) during laparoscopic cholecystectomy

BACKGROUND

The purpose of this study was to evaluate the usefulness of intraoperative ultrasonography (IOUS), a new method of imaging the biliary tree and related structures, during laparoscopic cholecystectomy.

METHOD

An IOUS probe (Aloka, Tokyo, Japan) with a 7.5-MHz linear-array transducer was used during cholecystectomy in 124 patients with symptomatic cholelithiasis (45 men, 79 women; mean age, 48 +/- 14 years).

RESULTS

The examination of the common bile duct (CBD) was excellent in 117 patients but unsatisfactory in 7 cases (5.6%) at the level of the head of the pancreas. In 5 patients, IOUS showed unsuspected choledocholithiasis: a subsequent intraoperational cholangiogram confirmed this. In five cases IOUS was able to help the surgeon to localize a Calot area obscured by inflammation. Postoperatively, one patient had an injury of the cystic duct stump: a nasobiliary tube resolved the bile leakage after 7 days. Another patient was submitted to postoperative endoscopic retrograde cholangiopancreatography (ERCP) for a choledocholithiasis recognized by a trans-cystic-tube cholangiography: the stone was suspected but not demonstrated either by laparoscopic IOUS or by intraoperative cholangiography. During the follow-up period, one patient had an episode of acute pancreatitis. ERCP showed a small stone wedged in the sphincter of Oddi.

CONCLUSIONS

IOUS may be a real alternative to cholangiography during laparoscopic cholecystectomy since it is safer and offers a complete examination of the biliary tree. It has some disadvantages which can solved by additional experience.

Appraisal of intraoperative ultrasonography during laparoscopic cholecystectomy

BACKGROUND

The usefulness of intraoperative ultrasonography during laparoscopic cholecystectomy (LC) has yet to be evaluated fully.

METHODS

In 50 patients who underwent LC, the intraoperative ultrasonography findings were compared with those of preoperative ultrasonography, intraoperative cholangiography, and histology, and then its usefulness for examining anatomic relationships in the hepatoduodenal ligament, detecting bile duct stones, diagnosing gallbladder polyps and abnormally thickened walls, and determining the propriety of LC was appraised.

RESULTS

The preoperative ultrasonography diagnoses were gallstones in 38 patients, polyps in 10, and cancer and adenomyomatosis in one each. In four patients endoscopic retrograde cholangiography showed bile duct stones. In all 50 patients intraoperative ultrasonography was useful for examining the anatomic relationships between the bile duct and vessels, such as the portal vein and hepatic artery, and showing the presence or absence of bile duct stones. On the basis of the intraoperative ultrasonography findings, gallstones were diagnosed in 38 patients, in five of whom bile duct stones were shown clearly, cholesterol polyps in eight, early-stage cancer or adenoma in two, and adenomyomatosis in two, and subsequently LC was performed. Histologic diagnoses of cholesterol polyps were made in eight of ten patients with polyps, and intramucosal cancer and an inflammatory polyp in one each. In one patient with a preoperative diagnosis of cancer the apparently elevated flat lesion was found to be partial thickening of the gallbladder wall, which was diagnosed as adenomyomatosis, and LC was chosen as the operative procedure.

CONCLUSIONS

Intraoperative ultrasonography during LC is useful for detecting bile duct stones, diagnosing gallbladder polyps and abnormally thickened walls, and deciding whether LC is adequate for resection of the gallbladder.

New, mobile-tip ultrasound probe for laparoscopic sonography

A new ultrasound probe (type 8555) especially constructed for laparoscopic sonography has been developed in collaboration with B&K Medical A/S, Naerum, Denmark. The probe is 9.5 mm in diameter and the usable length of the rod is 39 cm. At the tip a convex scanner of 5-7.5-MHz frequency can be angled 90 degrees up and 45 degrees down. The scanner is capable of both real-time sonography and color-flow doppler. Our first trials showed that the scanner not only facilitates sonographic examination of the biliary tree but also permits visualization of the entire liver, the pancreas, the spleen, and other intraabdominal organs.