IPEG 2024 Round Table Discussion from East Asia - Dr. Shun Onishi

Sorry, Doctor Wahii. You muted Oh, OK. Oh, sorry, sorry about that. Could you start your presentation? Yeah. We can wait, of course. This one Yes. Thank you, Doctor Mirano. Uh good morning and good evening, everyone. Uh, it's a great honor to be here. I'm, uh, I'm Shun Onishi from Kagoshima, Japan. And today, I'd like to talk about, uh, successful laparoscopic hepaticojanostomy for infant congenital illary dilatation with both other and right hepatic artery and bile duct from the caudate region. A case was a 7 month old boy. Uh, he was, uh, 10 kg at the operation time. A boy with a congenital hydronephrosis underwent an ultrasonography every month for follow-up, and at 4 months of age, ultrasonography incidentally revealed a congenital biliary dilatation. Uh, we performed laparoscopic extrahepatic bile duct resection and A hepaticodennostomy. Uh, these are pre preoperative images, uh. Uh, enhanced CT and MRCP, uh, they revealed, uh, 5 centimeter type 1 ACBD. And uh I'll show the uh short video of the operation. Uh, we performed a protoscopic extra hepatic uh viaduct resection and hepaticogenostomy, uh, with 5 ports. And we, uh, the seeds were carefully, uh, dissecting using the vessel sealing system and 3 millimeter, uh, bipolar scissors. And we apply polymer clips to the distal side uh of a cyst and uh She stick the and resected it. In After dissecting the dilated common bile duct, we found that the arcading-like shaped, uh, right hepatic artery caused the front of, in front of CBD and additionally, And additionally, a tiny duct was identified below the main heptic duct. At first, uh, we thought it was a lymphatic vessel and dissected it from the main hepatic duct. But, uh, however, uh, Bile flow out, bile flow out was recognized after dissecting the tiny duct and finally, we confirmed it was, it's a, it's as an aberrant bile duct from the caudate region. So we analy most the bile ducts from the cauded region and main hepatic duct in a double-barreled fashion. The duodenum was extracted from the umbilical wound and wide jenostomy was performed. And then a hepaticogennostomy was performed below the aberrant RHA without repositioning the dorsal side of the anastomotic site, uh, due to the risk that it would compress the reposition aberrant RHA. And anastomosis was performed without stent insertion. We always use our 5-0 monofilament sutures. And the possibility of cause was uneventful. The patient was discharged on post-operative day 15. There were no intrahepatic ductal dilation and bilirubin elevation after 2 years, the operation. So, I'd like to discuss about this point. Uh, first point is what do you do if you encounter RHAA calls in front of the CBD like uh our case or leaving it as it is or repositioning to behind the CBD. And second point is, uh, do you remain bile duct stands for preventing stenosis if you encounter an aberrant bile duct from the caudate region, uh, that's like a small diameter, uh, bile duct, uh, aberrant bile duct. Uh, thank you. Uh, this is uh my last slide. Uh, thank you for your attention. Um, I'm looking forward to meeting you in Las Vegas in this year and also we are waiting for you, uh, in 20025, uh, uh, uh, in Kagoshima. Thank you. Thank you for your presentation. So, can we get the poll? So how to do it when the right hepatic artery caused in front of the common bile duct, leaving it as it is, repositioning to behind the CBD common bile duct. Of course, it's depending on the, you know, anatomical relationship. But It's almost half of it. Probably In, in my, in my experience, I may do the leave it as it is and without stunting for the, you know. In such cases, but. OK, thanks. So Is there any comments or questions from the commentators? That was really nice. I, I have a question you guys did. How do you do the anastomosis cause I, I missed it on the video. You just incorporated the, the accessory duct, the wall in between both, or you did uh end to side. I think you just did, how do you do anastomosis between the accessory duct and the main? Uh, how, uh, thank you, uh, incorporate. Yes, but it was it, cause I saw it next to the wall. You did like end to side or part of your wall. 00, parallel. So, so right hepatica, so the, you, did you move the uh posterior wall of the common bile ducthi uh in front of the right hepatic artery, right? Uh, in front of Como Barda, yeah, below the. Below the right hippotyre. Does it make sense? Yeah, so, so, did you move the uh posterior wall of the common bile duct? In front of, No, we, we didn't know that. So that's yeah, OK, and you didn't end to side. And end to side or end to end. Oh well, no, no, uh, into, into side out. And to side anastomosis. And hepaticostomy, yeah, and hepaticogenostomy, yeah. Yeah, but what about the, the, on the video start to say what your, uh, accessories and you have the video there. How do you put your accessory dot from the cottage into the common the, uh, into your uh um. Into your main dog. Yeah, yeah, yeah, we, we, we make the, uh, Cleaning, uh, double barrel. A question. Question, uh, that and actually the, uh, we, we make, uh, double barrel. Then the most just like 11 hole, OK, so you connect to the fast double barrel to the kind of the, yeah, yeah, yeah, that's right, yeah, OK, OK, that's what I mean. So I didn't understand. In this case, did you reposition the hepatic artery, right hepatic artery behind or below the common hepatic duct? Oh, we just Do you reposition the right hepatic artery or not? Uh, no, we just remain living it. Because, uh, the hepatic duct and right hepatic artery, uh, is, uh, right hepatic artery just, uh, around, just arcad side and we can, uh, We have a Uh, wrong, uh, distance with, uh, between right hepatic artery and anastomotic site. So maybe, uh, one case, uh, we had, uh, before, uh. RHA, uh, right hepatic artery was very close to, uh, common bile duct, so we reposition that in that case. Because it could be a cause of uh stenosis. And my second question is that, how did you discover this accessory duct from the corrupt region after transecting the common hepatic duct or before that? Yeah, inoperative, operatively after dissecting, uh, we found that. So according to our experience, We resect the upper part of political consists. Uh, in, in, in two steps. First step, I usually transact much lower than the, uh, preferred, than the, uh, than the, you know, future an anatommatic site. So after transacting, I just explore upper to see any anomalous, yeah, bank ducts. Accessory or apparent ducts. Then after be sure, after being sure that there is no, you know, additional orifice of other ducts, then I transect. Uh, higher, higher. So if you use this approach, you can save, uh, yeah, such a situation when you strive to transect in the, uh, you know, high place where you, uh, you know, want to runostomosis. I think this is, uh, really useful for surgeon to know that. OK, thank you. Uh, thank you. Yeah, I think that's a much safer way. OK, thank you so much, so. Can we move to the next presentation? Thanks, Doctor Onishi. Thank you so much.