Pre-peritoneal tissue transfer: a novel laparoscopic and open surgical technique for resection margin and anastomotic reinforcement

Abstract

Presenter: Casey J Ward MD | University of California, San Francisco Background: Vascularized tissue flaps are useful adjuncts in hepatopancreaticobiliary (HPB) surgery for both enteric and vascular anastomotic reinforcement. One of the most commonly used tissue flaps includes the ligamentum teres hepatis and falciform ligament. The aim of this video is to describe a novel technique, in both open and laparoscopic surgery, wherein the full pre-peritoneal fat pad is dissected in addition to the ligamentum teres hepatis. The supplementary vascularized and peritoneal tissue obtained by this technique can be utilized for a broad array of anastomotic and resection margin reinforcements. Methods: We performed a totally laparoscopic left lateral sectionectomy for a 73 year old male with a segment 2 hepatocellular carcinoma. We utilized a combination of laparoscopic harmonic scalpel, Bovie electrocautery, bipolar coagulation and 1.5-2.25mm laparoscopic staple loads in order to dissect our pre-peritoneal fat pad and perform our hepatic parenchymal transection. The pre-peritoneal fat pad was utilized to reinforce our hepatic resection margin and secured using endoclips. Results: After completion of a totally laparoscopic left lateral sectionectomy, the fully mobilized pre-peritoneal fat pad vascularized tissue flap is used to reinforce the hepatic resection margin under no tension. No drains were placed at the completion of the procedure. Routine follow-up CT scan showed no evidence of post-operative fluid collection and the patient was discharged home with no post-operative complications on post-operative day number five. Conclusion: We describe a novel surgical technique, for use in both open and laparoscopic surgery, wherein the full pre-peritoneal fat pad is dissected in addition to the ligamentum teres hepatis in order to provide supplementary vascularized and peritoneal tissue coverage for anastomotic and resection margin reinforcement.