Technique of Robotic Repair of Postcholecystectomy Bile Duct Stricture

( Kalayarasan Raja ) 대한간학회 2020 춘·추계 학술대회 (KASL) Vol.2020 No.1

Aims: Despite technical advancements, iatrogenic bile duct injury continues to be a major concern in open and laparoscopic cholecystectomy. Traditionally repair of postcholecystectomy biliary stricture by tension-free Roux-en-Y hepaticojejunostomy (RYHJ) is done through a large subcostal or midline incision. While laparoscopic RYHJ is feasible, it has many limitations. The use of the robotic platform for postcholecystectomy biliary stricture is scarcely described. The technique of robotic postcholecystectomy biliary stricture repair using DaVinci Xi Robotic Surgical System is described in this video Methods: With the patient in a supine position, four 8mm robotic trocars 6-8cm apart are placed in a straight horizontal line at the level of the umbilicus. One 12 mm assistant trocar is placed 4 cm below umbilicus between arm 1 and 2. Before docking intraabdominal adhesiolysis is performed except perihepatic adhesions as it facilitates liver retraction. Key steps are the identification of the base of segment 4, preservation of left hepatic artery, lowering of the hilar plate, the opening of the left hepatic duct, identification of right anterior and posterior sectoral duct, preparation of roux limb and construction of RYHJ. Results: Five patients (type II stricture(n=3), type III(n=2) ) underwent robotic repair. The median (range) operative time, blood loss, and postoperative hospital stay were 280(260-300) min, 125(100-150)mL, and 5(4-7) days respectively. At a median follow-up of 12 months, all are asymptomatic with normal liver function tests. Conclusions: Robotic postcholecystectomy biliary stricture repair is safe and feasible in expert hands. The long-term outcome needs to be evaluated in a larger series.

Robotic revision surgery for type IV choledochal cyst

Raja KALAYARASAN 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.-

Robotic hepatopancreatoduodenectomy for locally advanced gall bladder cancer

Raja KALAYARASAN 한국간담췌외과학회 2022 Annals of hepato-biliary-pancreatic surgery Vol.26 No.-

Robotic Pancreatoduodenectomy for Large Solid Pseudopapillary Tumor of the Pancreas Using Precise and Systematic Vascular Control Technique

( Kalayarasan Raja ) 대한간학회 2021 춘·추계 학술대회 (KASL) Vol.2021 No.1

Splenoadrenal Shunt for Noncirrhotic Portal Hypertension

( Kalayarasan Raja ),( Biju Pottakkat ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Portosystemic shunt surgery is an established treatment option for preventing variceal rebleeding in patients with noncirrhotic portal hypertension(NCPH). The proximal splenorenal shunt is a widely performed procedure in these patients. In this study, the use of adrenal vein as an alternative conduit has been investigated. Methods: A retrospective analysis of patients with NCPH who underwent proximal splenoadrenal and splenorenal shunt between 2011 and 2015. clinical presentation, intraoperative findings, postoperative morbidity, and shunt patency were studied and compared between the two groups. All patients were followed up for a minimum of 12 months. Results: 97 patients with NCPH underwent shunt surgery (proximal splenoadrenal shunt,8; proximal splenorenal shunt,74; and interposition mesocaval shunt,15). Anomalous anatomy of the left renal vein was the main indication(5/8 patients) for a splenoadrenal shunt. Median fall in portal pressure in patients who underwent splenoadrenal shunt was 11.5 mmHg(range, 2-14 mmHg). The median (range) operative time was 4.5 (3-6) hours and median(range) intraoperative blood loss was 160(100-200) mL. During a median (range) follow-up of 32(12-48) months, shunt thrombosis developed in one patient. Comparison of intraoperative parameters and postoperative outcomes showed no significant difference in median fall in portal pressure( P=0.39), median operative time (P=0.51), median blood loss( P=0.80), Grade III/IV postoperative complications (P=0.56), shunt thrombosis (P=0.93), and varices regression rate (P=0.72) between patients undergoing proximal splenorenal and splenoadrenal shunt. Conclusions: Left adrenal vein is a suitable vascular conduit for porto-systemic shunt surgery, particularly if the performance of splenorenal shunt is precluded because of anatomic abnormality of the renal vein.

Robotic pancreatoduodenectomy for large solid pseudopapillary tumor of the pancreas using precise and systematic vascular control technique

Raja KALAYARASAN 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.-

The drain fluid amylase level on the first postoperative day predicts pancreatic fistula in chronic pancreatitis patients undergoing Frey procedure

Vijayaraj Pavankumar,Raja Kalayarasan,Senthil Gnanasekaran,Biju Pottakkat 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.4

Backgrounds/Aims: Abdominal drains are routinely placed following Frey procedure for chronic pancreatitis (CP) despite the low incidence of pancreatic fistula (PF). The utility of the first postoperative day (POD1) drain fluid amylase (DFA) value in predicting PF in CP patients undergoing Frey procedure has not been previously reported. Methods: A prospective study of patients with CP who underwent Frey procedure between August 2014 and April 2018. A standard technique of head coring with single layer continuous pancreatojejunostomy was done in all the patients. Amylase level of the drain placed close to the pancreatojejunostomy was recorded on POD1 and 3. Postoperative PF was defined and graded as per the updated International Study Group of Pancreatic Fistula (ISGPF) guidelines. Results: Fiftyfive patients with CP who fulfilled the inclusion criteria were included in the study. All had normal preoperative serum amylase level. Three patients developed a biochemical leak and four patients developed postoperative PF (Grade B - 3 and Grade C - 1). Receiver operating characteristics (ROC) curve identified a POD1 DFA cut-off value of 326 U/L that predicted a postoperative PF with sensitivity, specificity and negative predictive value of 100%, 70%, and 100% respectively. Conclusions: The POD1 DFA is a reliable predictor of postoperative PF in CP patients who have undergone Frey procedure. The PF can be confidently excluded in patients who have a POD1 DFA less than 326 U/L.

Frey’s plus versus Frey’s procedure for chronic pancreatitis: Analysis of postoperative outcomes and quality of life

Gunasekaran Gopalakrishnan,Raja Kalayarasan,Senthil Gnanasekaran,Biju Pottakkat 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.4

Backgrounds/Aims: Additional surgical procedures are often required in patients with chronic pancreatitis (CP) related complications. The present study aims to analyze the type of additional procedures required in patients who underwent Frey’s procedure (Frey’s plus) and to compare the short-term outcomes and quality of life with patients who underwent only Frey’s procedure. Methods: Retrospective analysis of a prospectively maintained database of patients who underwent surgery for CP between January 2012 and February 2018 and completed at least one year of follow-up. Patients who underwent non-Frey’s surgical procedures were excluded. Clinical parameters, postoperative pain relief (using Izbicki pain score) and functioning scale score (EORTC QLQ C30) of patients who underwent Frey’s plus procedure and only Frey’s procedure were compared. Results: Of the 146 patients who underwent surgery for CP during the study period, 100 patients (Frey’s procedure–68, Frey’s plus procedure–32) were included in this study. Roux-en-Y hepaticojejunostomy was the commonly performed additional procedure (n=12). The demographic and clinical parameters were comparable, except for more patients with jaundice (28.1% vs. 2.9%, p=0.01) and prolonged operative time (374.6 mins vs. 326.3 mins, p=0.01) in Frey’s plus group. However, there was no significant difference in mean intraoperative blood loss, postoperative morbidity or duration of hospital stay. At median (range) follow up of 34 (12-86) months, there was no significant difference in the pain control and quality of life between two groups. Conclusions: Frey’s plus procedure for chronic pancreatitis can be safely performed wherever indicated without adversely affecting the postoperative outcome or quality of life.

Early experience with robot-assisted Frey’s procedure surgical outcome and technique: Indian perspective

Ankit Shukla,Senthil Gnanasekaran,Raja Kalayarasan,Biju Pottakkat 대한내시경로봇외과학회 2022 Journal of Minimally Invasive Surgery Vol.25 No.4

Purpose: Robotic surgery for pancreatic diseases is currently on the rise, feasible, well-accepted, and safe. Frequently performed procedures in relation to pancreatic diseases include distal pancreatectomy and pancreatoduodenectomy. The literature commonly describes robotic lateral pancreaticojejunostomy; however, data on robot-assisted Frey’s is scarce. Methods: We herein, describe our series and technique of robot-assisted Frey’s procedure at our tertiary care center between November 2019 and March 2022, and its short-term outcomes in comparison to the open Frey’s. Patients with chronic pancreatitis having intractable pain, dilated duct, and no evidence of inflammatory head mass or malignancy were included in the study for robot-assisted Frey’s. Results: In our study, out of 32 patients, nine patients underwent robot assisted Frey’s procedure. The duration of surgery was significantly longer in robotic group (570 minutes vs. 360 minutes, p = 0.003). The medians of intraoperative blood loss and postoperative analgesic requirement were lower in robotic group, but the difference was not statistically significant (250 mL vs. 350 mL, p = 0.400 and 3 days vs. 4 days, p = 0.200, respectively). The median length of hospital stay was shorter in the robotic group, though not significant (6 days vs. 7 days, p = 0.540). At a median follow-up of 28 months, there was no significant difference in the postoperative complications and short-term outcomes between the two groups. Conclusion: Robotic surgery offers benefits of laparoscopic surgery in addition it has better visualization, magnification, dexterity, and ergonomics. Frey’s procedure is possible robotically with acceptable outcomes in selected patients.

Use of caudal pancreatectomy as a novel adjunct procedure to proximal splenorenal shunt in patients with noncirrhotic portal hypertension: A retrospective cohort study

Shahana Gupta,Biju Pottakkat,Raja Kalayarasan,Gnanasekaran Senthil,Pagadala Naga Balaji Nitesh 한국간담췌외과학회 2022 Annals of hepato-biliary-pancreatic surgery Vol.26 No.2

Backgrounds/Aims: Proximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis. Methods: This was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014–2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann–Whitney U test and χ² test. Results: Eighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group. Conclusions: CP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.