Segments 4b Research Articles

Practice patterns in diagnostics, staging, and management strategies of gallbladder cancer among Nordic tertiary centers.

Gallbladder cancer (GBC) is a rare malignancy in the Nordic countries and no common Nordic treatment guidelines exist. This study aimed to characterize the current diagnostic and treatment strategies in the Nordic countries and disclose differences in these strategies. This was a survey study with a cross-sectional questionnaire of all 19 university hospitals providing curative-intent surgery for GBC in Sweden, Norway, Denmark, and Finland. In all Nordic countries except Sweden, neoadjuvant/downstaging chemotherapy was used in GBC patients. In T1b and T2, majority of the centers (15-18/19) performed extended cholecystectomy. In T3, majority of the centers (13/19) performed cholecystectomy with resection of segments 4b and 5. In T4, majority of the centers (12-14/19) chose palliative/oncological care. The centers in Sweden extended lymphadenectomy beyond the hepatoduodenal ligament, whereas all other Nordic centers usually limited lymphadenectomy to the hepatoduodenal ligament. All Nordic centers except those in Norway used adjuvant chemotherapy routinely for GBC. There were no major differences between the Nordic centers in diagnostics and follow-up. The surgical and oncological treatment strategies of GBC vary considerably between the Nordic centers and countries.

Liver Segment Disposition of Hepatocellular Carcinoma Predicts Microvascular Invasion.

Hepatocellular carcinoma (HCC) is a leading cause of cancer morbidity and mortality. Findings of microvascular invasion (MVI) in patients with HCC have emerged as an important prognostic factor for poor survival after tumor resection. This study evaluated the relation between MVI and HCC within various anatomical Couinaud's segments of the liver. A multicenter retrospective review of HCC records was conducted from 2012 to 2017. HCC cases were identified using ICD-9 and 10 codes 155, C22.0, and C22.8. HCC patients who underwent liver transplants were included in this study. Liver segment of the location of HCC was obtained from radiographic records, and MVI information was obtained from pathology reports. Segmental distributions of HCC in MVI versus non-MVI groups were compared using Wilcoxon rank sum tests. p value was set at <0.05. We analyzed 120 HCC patients who underwent liver transplantation. The mean age of our cohort was 57 years, and the most common etiology of liver disease was hepatitis C at 58.3%. The median HCC size was 3.1 cm, and MVI was present in 23.3% of the explanted specimens. MVI was 2 to 3 times significantly higher in patients with HCC affecting segments 2 and 3 and segments 4b and 5 (p = 0.01). Moreover, median survival was significantly lower in patients with MVI versus those without MVI (50 vs. 137 months, p < 0.05). MVI was significantly higher in HCC tumors located in liver segments 2 and 3 and 4b and 5, and survival was lower in patients with MVI compared with those without.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

A Case of Simultaneous Resection of Recurrent Colorectal Liver Metastases as part of Colorectal Cancer Treatment Journey

Combining systemic treatments with liver resection in patients with colorectal liver metastases has been proven to be successful in delivering favorable survival outcomes. We describe a 68-year-old man who underwent six cycles of chemotherapy before developing recurrent colon cancer with liver metastases. Prior to this, he underwent a Hartmann’s procedure for obstructive malignant rectal cancer. Shortly after the initial procedure, he underwent a Hartmann’s reversal. Imaging revealed locoregional recurrence with increased CEA as well as metastatic lesions in segments 4b and 8 of the liver at the time of recurrence. After a complete multidisciplinary evaluation, the simultaneous resection of the liver metastasis and the bowel recurrence was carried out without incident, and adjuvant therapy was then administered. This case report detailed the patient’s experience with many chemotherapy treatments and an early recurrence of CRLM, followed with surgical resection of recurrent primary and liver metastatasis. As part of multidisciplinary therapy, we propose that simultaneous excision of the recurring bowel location and the liver metastases offers the potential for superior care.

Robotic radical resection for incidental gallbladder cancer using Glissonian approach

Background: Gallbladder cancer is suspected preoperatively in about 30 % of patients, while the remaining 70 % of cases are incidentally discovered. The increasing rate of cholecystectomies via laparoscopy has led to the detection of more gallbladder cancers in an early stage, and extended resection with regional lymph node dissection has been suggested. We present a video of a robotic liver resection (segments 4b and 5) with hilar lymphadenectomy in a patient with an incidental gallbladder cancer.

Extended radical cholecystectomy with curative potential for well selected locally advanced carcinoma gall bladder: a case report and review of literature

Gallbladder cancer is an aggressive malignancy that is associated with a poor prognosis. While surgical resection provides the only curative option, the majority of patients are not considered resectable due to locally advanced disease and presence of metastatic disease at the time of presentation. Here we presented a case of 46-year-old female with symptoms and initial workup suggestive of obstructive jaundice with cholestasis. PET-CT demonstrated heterogeneously enhancing mass lesion arising from neck of gallbladder and involving adjacent liver parenchyma with FDG avid para-aortic nodes. Liver biopsy confirmed adenocarcinoma, ERCP revealed tight hilar structure and CBD stent was placed. Patient was diagnosed with cT4, N2 carcinoma gall bladder and received two cycles of neoadjuvant chemotherapy (NACT) with gemcitabine and cisplatin. In view of localized and stable disease following NACT, patient underwent radical cholecystectomy with wide liver resection involving segment 4b and 5 with hepatoduodenal, portocaval and aortocaval lymph node dissection. Patient had post-operative complications, managed conservatively. On follow up patient had improved appetite, gained weight adequately, received adjuvant chemotherapy and is disease free till date. Carefully selected patients may benefit from an aggressive surgical approach following upfront systemic chemotherapy.

Primary hepatic mucosa‐associated lymphoid tissue lymphoma: Case report and literature review

AbstractPrimary hepatic mucosa‐associated lymphoid tissue lymphoma (MALToma) is a very rare disease and the diagnosis is often only made after histologic examination. To date, there is no consensus on its treatment modalities. In this paper, we report a case of primary hepatic MALToma and literature review of this rare disease. Our patient was a 72‐year‐old woman who presented with elevated alkaline phosphatase level. She was neither a hepatitis B nor C carrier. The alpha‐fetoprotein level was normal. Ultrasound of the abdomen found two hypoechoic liver lesions. Triphasic contrast computed tomography of the liver showed two arterial enhancing lesions with portovenous and delayed washout at segment 2 (1.7 cm) and segment 4b (2.5 cm), respectively. Fluorodeoxyglucose‐positron emission tomography showed two hypermetabolic foci in segments 2 and 4b of the liver, respectively, compatible with hepatocellular carcinoma. There was diffuse fluorodeoxyglucose uptake in the stomach. Oesophagogastroduodenoscopy (OGD) was performed, which showed diffuse gastritis only. Laparoscopic left hepatectomy was performed for the suspected hepatocellular carcinoma. Histological examination demonstrated the diagnosis of MALToma. Further bone marrow trephine did not show any bone marrow involvement by the lymphoma. The patient refused adjuvant chemotherapy.

Simultaneous Laparotomy Resection of Recurrent Colorectal Cancer and Liver Metastases Followed by FOLFIRI Adjuvant Chemotherapy: A Case Report

Background: Colorectal cancer is one of the most common cancers in the world. Combination of systemic therapies with liver resection in colorectal liver metastasis has been shown to be effective in providing promising survival benefits. Here, we present a case of colorectal liver metastases in which we devised a multidisciplinary treatment plan for a better prognosis Objectives and methods: We report a case of a 68 year old male who developed recurrent colorectal cancer with liver metastases after six cycles of chemotherapy one year previously. Radiological examination before liver resection demonstrated evident tumor from metastatic lesion in segment 4b and segment 8 of the liver (figure 1). Simultaneous laparotomy resection of the colorectal cancer and the liver metastasis was performed. The patient is now undergoing adjuvant combination chemotherapy with folinic acid, fluorouracil, and irinotecan (FOLFIRI) and has no signs of recurrence. Results: Time interval from the initial colorectal surgery to first hepatic surgery has a median 11 months. Tumor recurrence after resection of colorectal metastasis remains a major problem, about 50% to 75% of the patients develop a recurrence of the disease within two years. A multidisciplinary approach including systemic chemotherapy with or without biologic agents in combination with colorectal liver metastases resection are recommended for all patients, unless there are some contraindications Conclusions: The combination of surgery and adjuvant chemotherapy is a possible treatment of choice to cure colorectal liver metastases. Planned surveillance after metastasectomy may be necessary for the early detection of recurrence.

‘Invasive’ Gallbladder Fundus Mass Masquerading as Cancer

Background: Gallbladder perforation (GBP) is an uncommon but serious complication of cholecystitis with mortality rates between 12-16%. In 1934, Niemeier described three classifications; chronic perforation with fistula communication, subacute perforation with walled off abscess, and acute perforation into the free peritoneal cavity. Almost 90 years later, GBP remains poorly understood with varying clinical pictures. In this case report of GBP, the overlapping clinical and radiological picture with Gallbadder Cancer (GBC) presented a diagnostic dilemma for radiologists and surgeons. Case: A 77-year-old woman was admitted to The Canberra Hospital, Australia, reporting a 4-month history of weight loss, fatigue, diarrhoea, anorexia, abdominal pain and a firm mass in the right upper quadrant. CT scan demonstrated a mass arising from the gallbladder fundus with invasion into the right sided rectus abdominis and adjacent edge of segment 4b of the liver suggesting malignancy. Surgical resection of the presumed T3 GBC was performed, and surprisingly the histopathology report revealed a gallbladder perforation on a background of acute on chronic cholecystitis, chronic fibrosis at the abscess sites and no evidence malignancy. Conclusion: This rare case illustrates that GBP can have an insidious presentation and with striking clinical and radiological features of malignancy. As gallbladder perforations are uncommon, there is a lack of large studies evaluating clinical and radiological characteristics, especially in the chronic setting. This case exemplifies how complex the evaluation of such patients is for clinicians, and the care needed to confirm diagnosis, especially in an era of evolving neoadjuvant treatment options for GBC.

Total Hilar Exposure Maneuver for Repair of Complex Bile Duct Injury.

The reconstruction of high‐level bile duct injury is challenging because exposure of the hilar area is limited and sometimes inaccessible by the Hepp–Couinaud approach. We describe a maneuver for total hilar exposure to perform complex bile duct injury reconstruction. After adhesions surrounding the liver are divided, intraoperative ultrasonography is used to delineate the hilar and intrahepatic biliary anatomy. Surgical exposure of the biliary system is achieved by our maneuver, which consists of four steps: (1) identification of landmark structures, such as the base of the umbilical fissure, the inferior edge of segment 4b, the cystic‐hilar plate junction, and the right anterior portal pedicle; (2) lowering of the hilar plate; (3) hepatotomy along the right anterior pedicle; and (4) connection of the hepatotomy to the base of segment 4b. This maneuver allows the liver to be flipped upward, which facilitates clear exposure of the hilar duct and preserves the liver parenchyma. The anterior parts of the right and left hepatic duct are then opened, a wide‐hepaticojejunostomy anastomosis is achieved for biliary reconstruction, and a jejunal subcutaneous limb is created. We used this maneuver for treating complex bile duct injury in six cases; none of the patients has died, and two had Clavien–Dindo grade III complications, including surgical site infection and intra‐abdominal collection. The total hilar exposure maneuver is thus feasible and safe. It provides excellent exposure of both hepatic ducts and is a good surgical alternative to the Hepp–Couinaud approach in cases of high‐level injury.

Extended hepatectomies: Our experience from low volume center

Improved perioperative care combined with proper training has helped in achieving excellent outcomes following liver surgery even in low volume centers. Extended resections require additional surgical skills as well as perioperative care and when done in proper has equally good results. Here, we present the outcome of extended liver resections performed in developing HPB unit of low volume center. Retrospective review of the medical records of all the patients undergoing extended hepatectomies were analyzed. Total 86 liver resections were performed, out of which 61 were major liver resections (three or more segments) performed over 6 years period. Out of them, total 11(18% of major liver resections) extended hepatectomies have been performed. All were right extended hepatectomies only. For liver augmentation, 2 underwent successful right side and segment 4b portal vein embolization, 2 patients had open right side portal vein ligation and one had ALPPS procedure. Rest of the patients didn't require any augmentation procedures. Postoperatively, 1 patient had grade 3 PHLF, 2 grade 2 PHLF and resolved, 2 bile leaks and resolved. Patient with ALPPS procedure had grade 3 PHLF has died on 3rd postoperativ week. Rest 10 patients were discharged on average of 12 hospital days. Better patient selection combined with proper training and improved perioperative care, extended hepatectomies can also be safely performed with acceptable outcomes even in low volume centers of developing nations.

Long-term outcomes in the repair of intrahepatic iatrogenic bile duct lesions using a combined intraglissonian and extraglissonian approach.

Iatrogenic bile duct injuries (IBDI) with intrahepatic involvement are a serious and challenging surgical complication that can have disastrous consequences in terms of morbidity and mortality. We collected the patients with IBDI type (E4) between January 1991 and March 2020 in our hospital. The objective of the study was to present the long-term results of a extraglissonian approach and intraglissonian biliary reconstruction in a series of patients with intrahepatic bile duct injuries after cholecystectomy. We also detail our preoperative management and the standardization of the technique. An extraglissonian approach with partial hepatic resection of the base of segments 4b and 5 and intraglissonian Roux-en-Y hepaticojejunostomy for biliary reconstruction using to several branches was performed in 10 patients with E4 Strassberg type intrahepatic lesions. Only one patient had postoperative bile leak (Clavien 3a). Surgical time was 260 min (IQR, 210-490). We left transanastomotic catheter (between 2 and 5) in situ for 3 and 6 months after surgery. The patients remained asymptomatic over a median follow-up of 169 months (IQR 129-234). This biliary reconstruction technique obtains positive long-term outcomes in patients with severe intrahepatic lesions.

Hepatectomy type determines long term outcomes in patients with T1/T2 gladder bladder cancer

Presenter: Muhammad Khan MD | University of Southern California, Westchester Medical center Background: Optimal surgical treatment for T1 and T2 gallbladder cancer is not well defined in the literature. We utilized a national database to assess clinical outcomes based on the hepatectomy strategy - segment IVb and V resection versus wedge resection, in patients with T1 and T2 gallbladder cancer. Methods: We utilized the 2004-2017 national cancer database to select patients with T1 and T2 gallbladder cancer. We then stratified them based on the type of the hepatectomy – wedge resection vs segment 4b and 5 resections. The two groups were assessed for differences in 30-day outcomes, and 5-year survival rates. Results: A total of 5,047 patients were included in the analysis. T1 and T2 stage gallbladder cancer patients were more likely to have a wedge resection than a segment IVb & V liver resection (94.8% vs 5.3%: p-0.01). We found no difference in 30-day mortality and readmission rates based on the surgical approach. Segment IVb & V liver resection was associated with improved 5-year survival in T1 (92 months vs 74; p-0.01) and T2 disease (75 months vs 55; p-.001). Conclusion: T1 and T2 gallbladder cancer patients undergoing segment IVb and V resection rather than wedge resection have improved 5-year survival.

Robotic redo hepatectomy: resection SG 4B seven years after open right hemihepatectomy

Purpose: Evidence shows that repeat liver resection is often the best treatment option for recurrent colorectal liver metastases. Although repeat resections can be complex due to adhesion and altered liver anatomy, laparoscopic liver resection has been shown to be feasible in selected patients, and has been associated with shorter operative time, less blood loss, and shorter hospital stay. Compared to laparoscopy, robotic liver surgery has the advantage of 3D visualization and a larger range of motion thanks to endowrist technology. This video aims to demonstrate the experience of a hepatopancreaticobiliary surgeon with robotic redo hepatectomy. Methods: This report describes a robotic segment 4B resection, seven years after open right hemihepatectomy, in a patient with a solitary colorectal liver metastasis. Surgical risk was assessed by the Southampton laparoscopic liver resection difficulty score, and was classified as extremely high-risk. The patient was placed in supine position with 12 degrees anti-Trendelenburg. Four robotic 8 mm ports were placed, and one assistant 12 mm port. Extensive adhesiolysis was performed with monopolar scissors and a bipolar sealing device. Intraoperative ultrasound was used to demarcate the transection line. The Pringle maneuver was applied by the Huang loop technique. Liver parenchyma transection was done by a bipolar sealing device. Locking polymer clips, hemostatic matrix and fibrillar absorbable haemostat were used to counter blood loss. Results: The Pringle maneuver was performed for 18 minutes. Operative time was 170 minutes, and blood loss was 30 cc. Pathology confirmed a R0 resection of the colorectal liver metastasis. There were no intraoperative complications encountered. The postoperative course was uneventful, and the patient was discharged on postoperative day 2. Conclusion: Robotic redo hepatectomy is feasible after previous open extensive liver surgery for repeat metastatic liver disease in selected patients.

S2662 An Unexpected Cause of Refractory Liver Abscesses

INTRODUCTION: We report a case of multifocal liver abscesses with recurrent fevers refractory to prolonged antibiotic therapy and catheter drainage due to penetration of a toothpick into the portal vein. CASE DESCRIPTION/METHODS: A 72-year-old male with type II diabetes presented with fever, confusion, and right upper quadrant pain associated with malaise and unintentional weight loss. Objective findings were consistent with septic shock and acute liver injury. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) showed a 6.9 × 8.0 × 5. hepatic abscess and several scattered fluid collections (Figure 1). Immediate broad-spectrum antibiotics and percutaneous catheter drainage resulted in clinical improvement. Abscess fluid and blood cultures grew actinomyces odontolyticus and streptococcus viridans, respectively. Amebic serology was negative. Transition to appropriate outpatient antibiotics resulted in two readmissions for recurrent fevers with persistent drainage output for weeks. A repeat CT showed a shrunken abscess and a 4.6 cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (Figure 2). Review of previous imaging confirmed the foreign body was present since first admission. Upper endoscopy showed a patch of erythematous mucosa in the antrum encircling a pinpoint opening to a fistulous tract and exuding purulent fluid (Figure 3). Exploratory laparotomy revealed a 4.5 cm wooden toothpick in the portal vein surrounded by a dense fibrotic scar. Foreign body removal and porto-enteric fistula repair were performed. Follow up CT showed complete resolution of the abscess. DISCUSSION: Penetrating foreign body is a rare cause of liver abscess. To our knowledge, penetration of a foreign body into the portal vein resulting in liver abscesses has never been reported. Discovery of foreign body requires a high index of suspicion as patients rarely remember ingesting the object, and it can be easily missed on CT. When suspected, a non-contrast CT is recommended with attention to coronal/sagittal views with signs such as thickened antral wall and fistulous tract. Non-specific clinical features such as hematemesis, subacute/chronic abdominal pain, and failure of antibiotic therapy can be suggestive. In the setting of any of these findings, foreign body should be considered in patients with unexplained liver abscess.Figure 1.: A large dominant hepatic abscess measuring 6.9 × 8.0 × 5.3cm, involving segments 4A and 4B of the liver, extending to and involving the anterior wall of the gallbladder, as well as several scattered small fluid collections (MRI of liver without contrast).Figure 2.: A 4.6cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (CT of abdomen and pelvis without contrast).Figure 3.: A patch of erythematous mucosa in the pre-pyloric antrum encircling a pinpoint opening to a fistulous tract and scant purulent liquid; the foreign body was not visible (upper endoscopy).

Pure Laparoscopic Anatomical Resection of Segment 4b for Hepatocellular Carcinoma Using the Transfissural Glissonean Approach

BackgroundAnatomical segmentectomy is a technically challenging procedure because tertiary portal pedicles are multiple, variable, and deep inside the liver.1 Anatomical segmentectomy can be performed using the transfissural Glissonean approach through the opening main portal fissure or umbilical fissure.1-3 We present laparoscopic anatomical resection of segment 4b using the transfissural Glissonean approach. MethodsA 67-year-old man was referred for treatment of single nodular mass in segment 4b. The surgical procedure involved the following steps: (1) Opening of the umbilical fissure along the umbilical fissure vein (2) Dissection of Glissonean pedicle 4b (3) Identification of ischemic territory of segment 4b (4) Right-side parenchymal transection along the ischemic line. ResultsThe operative time was 230 min, and the estimated blood loss was 100 mL. The final histopathological diagnosis was hepatocellular carcinoma. The tumor size was 30 mm and the resection margin was 25 mm. The patient had an uneventful postoperative recovery, and he was discharged on postoperative day 6. ConclusionThe transfissural Glissonean approach for laparoscopic anatomic resection of segment 4 b is a feasible and effective technique. The opening of the umbilical fissure allows the surgeon to dissect the target portal pedicles of segment 4b directly.

Bilioptysis due to a single transcavitary thoracoabdominal gunshot wound

A 27-year-old man was transported to our trauma center after sustaining a single gunshot wound. On arrival, he was hemodynamically stable and neurologically intact, with a non-tender abdomen and negative...

Primary biliary neuroendocrine carcinoma: A rare presentation

Presenter: Frances McCarron MD | St. Elizabeth Youngstown Hospital Background: Biliary neuroendocrine carcinomas make up approximately 0.2% of neuroendocrine neoplasm cases per the most recent WHO classification. Previous reports document tumors in the gallbladder and extra-hepatic bile ducts. There has been very little documentation of hepatic involvement of biliary NECs and even fewer reports of intra-hepatic biliary NENs. Given the rarity of these tumors, diagnosis can be mistaken for other malignancies such as cholangiocarcinoma, hepatocellular carcinoma or metastasis. Formal diagnosis, and thus targeted treatment, is usually delayed until post-operative pathology identifies the tumor. We present a rare case of poorly differentiated biliary neuroendocrine carcinoma (G3) with extensive hepatic involvement without evidence of distant metastasis. Methods: A 59-year-old female presented to her primary care office with symptoms of diverticulitis which was confirmed by CT of the abdomen and pelvis. An incidental 9.1cm lesion was identified involving segments 4B, 5, and 8 of the liver. The mass appearing hypodense on non-contrasted phase, with peripheral enhancement in the portal venous phase, was initially concerning for a pyogenic liver abscess secondary to diverticulitis. Differential diagnosis also included intra-hepatic cholangiocarcinoma, and less likely hepatocellular carcinoma or metastasis. A CT guided core biopsy of the lesion suggested a moderately differentiated adenocarcinoma of unknown primary. PET-CT scan showed hypermetabolic uptake of the mass without additional activity to suggest metastatic disease or alternate primary malignancy. Preoperative tumor markers were: CEA = 1.6, Ca 19-9 = 65, AFP = 6. The patient was referred to hepatobiliary surgery for resection. She underwent an en bloc cholecystectomy with central hepatectomy and intra-operative cholangiogram. Total operative time was 346 minutes, estimated blood loss = 600mL, pringle time = 15 minutes with a length of stay of 6 days. Her drain was removed on postoperative day 6. Results: Final pathology revealed a 12.5cm large cell neuroendocrine carcinoma involving the liver of biliary origin. Ki-67 uptake was present in 90% of tumor cells with 25 mitoses per 10 high power fields. An R0 resection was obtained. Pathology was also sent to University of Pittsburgh Medical Center whom concurred with our pathologists. She completed 4 cycles of adjuvant cisplatin and etoposide with no evidence for Conclusion: Biliary tract neuroendocrine neoplasms are exceedingly rare entities. It is estimated that approximately 0.5% of all NENs are of primary gallbladder origin and NEC make up 0.5% of all gallbladder carcinomas. Minimal reports of these tumors, make it difficult to identify the proper treatment modalities. In general, a poor survival rate and increased incidence of metastasis has been associated with G3 biliary NEC. We introduce a case of a rare presentation of a 12.5 cm large cell neuroendocrine carcinoma (G3) of biliary origin with hepatic involvement, no distant metastasis and good response to an R0 resection with 4 cycles of adjuvant chemotherapy. Further research, with long term follow up is needed to identify the optimal treatment plan for these rare tumors. However, this case poses a potential benefit for R0 resection with adjuvant chemotherapy.

Outcome of Robot-Assisted Radical Cholecystectomy in a High-Volume Tertiary Cancer Center in India.

Introduction: Minimally invasive radical cholecystectomy is a complex laparoscopy. Robotic surgery is now an option to complete a radical cholecystectomy because of its high definition, magnified three-dimensional view of the operative field, and articulating instrumentation.1–3 Robotic surgery enables a safe dissection in otherwise difficult to access areas such as the porta hepatis. This video reviews the role of robotic surgery in the management of gall bladder (GB) malignancy.Methods: A 28-year-old lady, with no comorbidities, presented with abdominal pain and underwent an evaluation with a contrast-enhanced CT scan of chest and abdomen. The CT scan revealed a mass in the GB with no evidence of distant metastases. Liver function tests were normal and a CA19-9 was 898 U/mL. A robotic radical cholecystectomy using five ports (four robotic and one assistant port) was performed. The procedure started by clearing the hepatoduodenal ligament nodes (stations 8, 12, and 13 with interaortocaval node sampling). The triangle of Calot was then dissected and secured with clips. Next a wide excision of segments 4b and 5 was performed including the GB. The complete specimen was extracted in a bag from a small incision at the assistant port.Results: The procedure was performed in 330 minutes with a blood loss of 200 mL. There were no perioperative complications and the postoperative stay was 3 days. Final histopathology report revealed moderately differentiated adenocarcinoma of GB invading serosa (pT3) with negative margins and 4 out of 14 lymph nodes showed presence of metastases. The overall cohort shows 22 robotic radical cholecystectomies for GB malignancy. The median age was 53 years. The average duration of surgery was 270 minutes with a median blood loss of 120 mL. The median postoperative stay was 4 days and the median nodal yield for radical cholecystectomy was 8. The overall median survival at 18 months was 100% with one recurrent hepatic lesion.Discussion: Robotic radical cholecystectomy may offer technical superiority over laparoscopic surgery and is an oncologically acceptable approach with good short-term oncologic outcomes. This type of surgery may require a highly specialized center with adequate experience in hepatopancreatobiliary surgery. No competing financial interests exist. Runtime of video: 9 mins 5 secs

28. Robotic Radical Cholecystectomy for Locally Advanced Carcinoma Gall Bladder – A Case Report

Background and Aims: Gallbladder cancer is the most common malignant tumor of biliary system. The only potentially curative option for patients with gallbladder cancer is radical resection. We aim to describe the robotic radical cholecystectomy with segment 4b and 5 resection in a locally advanced gallbladder cancer. Case Summary: A 46-year gentleman presented with dull aching right hypochondrial pain for 1 month. His per abdomen examination, liver function and renal function tests were normal. CECT abdomen showed locally advanced mass in gallbladder infiltrating segment 4b and 5. With this he was diagnosed to have locally advanced gallbladder carcinoma. Robotic radical cholecystectomy was contemplated with lymphadenectomy. On staging laparoscopy no evidence of intra-abdominal metastasis was found. Cystic duct arose from right hepatic duct. Frozen section of cystic duct showed no evidence of malignancy. Segment 4b and 5 of liver resected with CUSA and bipolar diathermy. A right sub hepatic drain was placed. The procedure was successfully completed in 320 min. Blood loss was 150 ml. There were no intraoperative complications and drain was removed on postoperative day 5, and then discharged on the same day. Histopathology report revealed – moderately differentiated squamous cell carcinoma with no malignancy in 7 lymph nodes examined (pT3N0M0). He was subjected for adjuvant therapy. On 1-year follow-up he had no recurrence. Conclusions: Robotic radical cholecystectomy is safe and feasible in locally advanced carcinoma gallbladder. The authors have none to declare.