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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
 ¤ Conclusion
 ¤  References
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 Table of Contents     
UNUSUAL CASE
Year : 2016  |  Volume : 12  |  Issue : 4  |  Page : 382-384
 

Hepatic artery reconstruction following iatrogenic injury during laparoscopic distal pancreatectomy: Minimal access surgery is new horizon


Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India

Date of Submission06-Nov-2015
Date of Acceptance19-Nov-2015
Date of Web Publication8-Sep-2016

Correspondence Address:
Biswajit Deuri
GEM Hospital and Research Centre, 45, Pankaja Mill Road, Ramanathapuram, Coimbatore - 641 045, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.181330

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 ¤ Abstract 

Although minimally invasive surgery has evolved in every field of surgery, its use in vascular surgery is limited to major vessel diseases only. A 23-year-old female presented with a cystic lesion in the distal body and the tail of the pancreas. Triphasic computed tomography (CT) abdomen revealed a 4.5 cm × 3.2 cm-sized mass with calcifications. A diagnosis of the mucinous cystic neoplasm in the distal body and the tail of the pancreas was made and the patient was planned for laparoscopic distal pancreatectomy. During the procedure, hepatic artery was accidentally injured due to its anomalous course. The artery was then reconstructed laparoscopically using left gastric artery as conduit. The time duration of the procedure was 45 min and blood loss was approximately 75 mL. The patient recovered well and the postoperative Doppler study revealed normal blood flow. Medium-vessel surgery through laparoscopic approach is feasible and safe in select cases, while availing benefits of laparoscopy.


Keywords: Hepatic artery, iatrogenic injury, left gastric artery, medium-sized vessel, minimally invasive surgery, vascular reconstruction


How to cite this article:
Palanisamy S, Deuri B, Naidu SB, Palanisamy NV, Natesan VA, Chinnusamy P. Hepatic artery reconstruction following iatrogenic injury during laparoscopic distal pancreatectomy: Minimal access surgery is new horizon. J Min Access Surg 2016;12:382-4

How to cite this URL:
Palanisamy S, Deuri B, Naidu SB, Palanisamy NV, Natesan VA, Chinnusamy P. Hepatic artery reconstruction following iatrogenic injury during laparoscopic distal pancreatectomy: Minimal access surgery is new horizon. J Min Access Surg [serial online] 2016 [cited 2021 May 6];12:382-4. Available from: https://www.journalofmas.com/text.asp?2016/12/4/382/181330



 ¤ Introduction Top


Minimally invasive vascular surgery is currently applied to the reconstruction of major vessels only, i.e., aorta, pelvic vessels and renal artery.[1],[2] Advancement in instruments, optics and gaining experience in laparoscopy will help in establishing laparoscopy as a novel technique for vascular surgery involving medium-vessels too. We report a case of laparoscopic hepatic artery reconstruction following iatrogenic injury.


 ¤ Case Report Top


A 23-year-old female presented with a cystic lesion in the distal body of the pancreas. No mass was palpable through abdomen examination. Her serum carcinoembryonic antigen (CEA) was 2.5 ng/dL and serum carbohydrate antigen (CA) 19.9 was 6.7 IU/dL. Triphasic computed tomography (CT) abdomen showed a 4.5 cm × 3.2 cm cystic lesion in the body of the pancreas with calcifications. The diagnosis of a mucinous cystic neoplasm was made and the patient was planned for laparoscopic distal pancreatectomy.

She was placed in supine position with a 30° right lateral tilt. Pneumoperitoneum was created using a Veress needle and four ports were placed (supraumbilical for camera, epigastric, left mid-clavicular and left midaxillary as working ports). After assessing for metastatic disease, gastrocolic ligament was divided and access was gained to a lesser sac. Resectability of the lesion was assessed. Splenic flexure was mobilised to expose the inferior edge of the tail of the pancreas. Peritoneal incision was made along the inferior edge of the pancreas from body to tail. The pancreas was then dissected off from the retroperitoneum. After completing inferior and retroperitoneal dissection, dissection was started in the superior aspect of the pancreas. During the mobilisation, the common hepatic artery was accidentally clipped and divided, assuming it as the splenic artery. The common hepatic artery was densely adherent to the pancreatic body and had an anomalous course (i.e., after arising from the coeliac axis, it was running to the left side just adjacent to the superior border of the body of the pancreas for a few centimetres and hence mistakenly interpreted as splenic artery). Abnormal course of the common hepatic artery was confirmed and primary reconstruction was planned using the left gastric artery as conduit. Distal pancreatectomy was completed, after which the distal part of the hepatic artery was mobilised. Bolus dose of heparin was given. Left gastric artery was skeletonised and mobilised. Its proximal part was occluded using endo bulldog clamp while the distal part was doubly clipped and divided, keeping adequate stump for reconstruction. Distal stump of the hepatic artery that was clipped, was exchanged to endo bulldog clamp and the edges were refashioned [Figure 1]. An end-to-end anastomosis was done using a 7-0 prolene suture in an interrupted fashion using a 3 mm endo needle holder [Figure 2]. Hepatic artery blood flow was ascertained by intraoperative laparoscopic Doppler study. The total duration of reconstruction was 45 min and the estimated blood loss was 75 mL. Postoperatively, the patient was observed in the intensive care unit (ICU) for 2 days. Liver enzymes were transiently elevated on the 1st postoperative day; they became normal by the 4th postoperative day. She received heparin infusion for 5 days and then was switched to aspirin. She was discharged on the 7th postoperative day with an advice to continue aspirin for 90 days.
Figure 1: Refashioned ends of the hepatic and the left gastric artery

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Figure 2: At the completion of the anastomosis

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 ¤ Discussion Top


The first laparoscopic-assisted technique was performed for aortoiliac disease in 1993[1] and purely laparoscopic aortic end-to-end repair was done in 1995.[2] With the advancement in instruments and gaining experience in vascular surgery, laparoscopic repair for aortoiliac disease has become the standard of care while availing benefits of minimally invasive approach, i.e., shorter hospital stay; less postoperative pain; faster return to regular diet, ambulation and work; lower incisional hernia rates; and better cosmetic results.[3],[4],[5] The role of laparoscopy till date is limited only to the reconstruction of major vessels, i.e., aorta, pelvic vessels and renal artery.[1],[2] We are reporting the first case so far in the literature on laparoscopic reconstruction of a medium-sized vessel.

Although magnification in laparoscopy is 15-20 times more than what appears to the naked eye, which helps in vascular reconstruction, it still remains to be used for surgery on major vessels only. The prime limitation for laparoscopic vascular surgery is time consumption, demand for highly skilled and precise movements.


 ¤ Conclusion Top


Although laparoscopic vascular reconstruction is a complex procedure and requires high skills, it is feasible and safe in select patients. The unique exposure and magnification afforded by laparoscopy may demonstrate advantages of this approach.

Acknowledgement

We had no financial support for this case presentation. The authors declare that they have no competing interests.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

Authors declare that they have no competing interests.

 
 ¤ References Top

1.
Dion YM, Katkhouda N, Rouleau C, Aucoin A. Laparoscopy-assisted aortobifemoral bypass. Surg Laparosc Endosc 1993;3:425-9.  Back to cited text no. 1
[PUBMED]    
2.
Dion YM, Gaillard F, Demalsy JC, Gracia CR. Experimental laparoscopic aortobifemoral bypass for occlusive aortoiliac disease. Can J Surg 1996;39:451-5.  Back to cited text no. 2
[PUBMED]    
3.
Alimi YS, Di Molfetta L, Hartung O, Dhanis AF, Barthèlemy P, Aissi K, et al. Laparoscopy-assisted abdominal aortic aneurysm endoaneurysmorraphy: Early and mid-term results. J Vasc Surg 2003;37:744-9.  Back to cited text no. 3
    
4.
Fourneau I, Sabbe T, Daenens K, Nevelsteen A. Hand-assisted laparoscopy versus conventional median laparotomy for aortobifemoral bypass for severe aorto-iliac occlusive disease: A prospective randomised study. Eur J Vasc Endovasc Surg 2006;32:645-50.  Back to cited text no. 4
[PUBMED]    
5.
Kolvenbach R, Puerschel A, Fajer S, Lin J, Wassiljew S, Schwierz E, et al. Total laparoscopic aortic surgery versus minimal access techniques: Review of more than 600 patients. Vascular 2006;14:186-92.  Back to cited text no. 5
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]



 

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