Identification of Abnormal Biliary Anatomy Utilizing Real-Time Near-Infrared Cholangiography: A Report of Two Cases.Case Rep Gastrointest Med. 2017;2017:8628206. [PMID: 28536662 DOI: 10.1155/2017/8628206]

Total robotic choledochal cyst excision with Roux-en-Y hepaticojejunostomy in adults

INTRODUCTION

Choledochal cyst (CDC) excision with bilio-enteric anastomosis has been reported by a laparoscopic approach. With the advent of robotic surgery, it is likely to simplify the performance of such complex procedures. Herein, we present our technique of total robotic CDC excision with intra-corporeal Roux-en-Y hepaticojejunostomy (RYHJ).

METHODS

The patient was placed in a reverse Trendelenburg position. The robotic ports were placed in a "C"-shaped manner, with the camera port placed ~2 cm below the umbilicus. A 12-mm assistant port was placed in between the camera and the left-sided robotic port. Robotic dissection and excision of extrahepatic part CDC were performed, and subsequently, intra-corporeal robotic RYHJ with jejunojejunostomy was completed. Intra-operatively, indocyanine green dye was used to delineate the biliary anatomy and to check the anastomotic integrity.

RESULTS

All three patients were female with a median age of 21 (18-34) years. Two patients had type IVa, and one had a mixed variant of type I(C) with type VI. The median operative time was 420 min, whereas docking and console time was 22 (20-25) min and 400 (360-450) min, respectively. The median blood loss and length of hospital stay were 50 (50-100) ml and 6 (5-6) days, respectively. One patient has mild acute pancreatitis in the post-operative period, which was managed conservatively.

CONCLUSION

Robotic CDC excision and reconstruction seem to be a safe, feasible, and effective surgical option that provides the benefits of minimal access surgery but also greatly aids in complex dissection and reconstruction.

Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Laparoscopic cholecystectomy (LC) is one of the most frequently performed gastrointestinal surgeries worldwide. Bile duct injury (BDI) represents the most serious complication of LC, with an incidence of 0.3%-0.7%, resulting in significant perioperative morbidity and mortality, impaired quality of life, and high rates of subsequent medico-legal litigation. In most cases, the primary cause of BDI is the misinterpretation of biliary anatomy, leading to unexpected biliary lesions. Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings. The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

Laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System with intraoperative fluorescent imaging for acute cholecystitis: A case report

We report on a laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) using the bright field/full-color fluorescence laparoscope system PINPOINT^® (Novadaq, Mississauga, ON, Canada).

The patient was an 85-year-old man who was diagnosed with moderate AC. Indocyanine green (ICG) was administered just before surgery, and we used only PINPOINT^® to perform the LC. The advantage of this procedure is that it can be performed while viewing ICG fluorescence in the cystic duct. Since the gallbladder is imaged with this technique, it is also advantageous from the perspective of deciding at which layer to detach the gallbladder from the liver. The operative time was 81 minutes, and blood loss was 5 ml. There were no perioperative complications, and the patient was discharged on post-operative day 6.

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The PINPOINT system is safely and effectively at laparoscopic cholecystectomy.

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We were able to identify a cystic duct with a common bile duct, and we completed the surgery without perioperative complications.

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We concluded that PINPOINT^® might help avoid bile duct injury, which can be a serious complication when performing laparoscopic cholecystectomy for acute cholecystitis.