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Rare variant of type V choledochal cyst masquerading as a biliary cystadenoma
Murugappan Nachiappan,Srikanth Gadiyaram Korean Association of Hepato-Biliary-Pancreatic Su 2022 Annals of hepato-biliary-pancreatic surgery Vol.26 No.3
Cystic lesions of the liver are commonly encountered in routine clinical practice with a reported prevalence of 15%–18%. They may range from a benign simple developmental cyst to a malignancy. Therefore, an accurate diagnosis is essential for adequate management. Cystic tumors of the liver are classified based on the content (mucin containing or not), presence of ovarian stroma, and biliary communication. Biliary cystadenoma are a group of hepatobiliary neoplasia which by definition must be multilocular, lined by a columnar epithelium, and have a densely cellular ovarian stroma. We report a case of a cystic lesion in the hilar region of the liver, which had features of biliary cystadenoma on the preoperative imaging. However, on exploration was found to be a diverticular variant of type V choledochal cyst arising from both hepatic ducts. We have discussed the preoperative imaging features, intraoperative cholangiogram, and the management of this cystic lesion.
Laparoscopic ‘D2 first’ approach for obscure gallbladders
Srikanth Gadiyaram,Murugappan Nachiappan 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.4
Laparoscopic cholecystectomy has a reported incidence of 4%–15% of conversion to an open procedure and one of the main reasons behind the conversion is a gallbladder (GB) wrapped with dense adhesions. It is prudent to convert the procedure to an open operation in patients with particularly dense adhesions when the GB is not visible, preventing safe dissection which carries a potential risk of duodenal or colonic injury. The technique described, namely laparoscopic ‘D2 first’ approach, enables the completion of laparoscopic procedure in patients with ‘obscure’ GBs.
Srikanth Gadiyaram,Murugappan Nachiappan 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.3
A secure pancreatic-enteric anastomosis is widely accepted as the ‘Achilles heel’ in reconstruction following a pancreaticoduodenectomy. Most morbidity following the procedure is related to the failure of this anastomosis, resulting in intra-abdominal collections, secondary haemorrhage, delayed gastric emptying, need for radiological interventions and re-operation for some patients. Of several techniques available, the ‘duct-to-mucosa’ technique is widely employed for pancreaticojejunal anastomosis. Among several refinements to facilitate this anastomosis, viz; mobilization of pancreatic stump, magnification with loupes and modifications made on the jejunal side to enable a tension free anastomosis, none seems to address the pancreatic duct in particular. The operative technique of anterior pancreatic duct split described by us enables a wider, well visualized pancreatic duct for a secure duct to mucosa pancreaticojejunal anastomosis.