Hepatic Artery Infusion (HAI) Pump Placement For Unresectable Intrahepatic Cholangiocarcinoma with Vessel Abutment and Intrahepatic Metastasis

CHAPTER 1

I'm Rushin Brahmbhatt, I'm an HPB surgical oncologist here at Penn State Hershey Medical Center. Today, we have a case of a 72-year-old woman who has an intrahepatic cholangiocarcinoma. I saw her initially with some right upper quadrant abdominal pain. And she had some imaging that demonstrated a mass that was somewhat in the center of her liver. And part of the issue with her tumor is that it was up against both the left and right portal veins, so the inflow to the liver. On subsequent MRI, we also determined that there were some other questionable lesions within the liver. On staging scans, we didn't find any extrahepatic disease. And her CA 19-9, which is a tumor marker for cholangiocarcinoma was in the 200s. In the setting where we have disease within the liver without extrahepatic disease and disease we don't think can be resected, we consider that unresectable intrahepatic cholangiocarcinoma. And in those patients, we offer at Penn State both systemic chemotherapy options, as well as hepatic artery infusion pump chemotherapy. And hepatic artery infusion chemotherapy is a type of chemotherapy which we administer directly through the hepatic artery. We know that tumors, especially intrahepatic cholangiocarcinomas and unresectable colorectal liver metastases, rely on arterial inflow to the liver. And we take advantage of that by placing a catheter into what's called the gastroduodenal artery, which can allow us to perfuse chemotherapy into the hepatic artery directly. That allows us to get chemotherapy to these tumors at a much higher dose and improve our response rate in unresectable intrahepatic cholangiocarcinomas. This operation can be done in an open fashion, as well as a robotic fashion. The open fashion has been described and is standard. And the robotic approach has also been described. They're very analogous procedures. And the robotic procedure really follows the open procedure with some modifications in order to ensure safety with the robotic approach, but also feasibility with the robotic approach. Today, we're planning a robotic approach for this patient. The first step in that is really doing a diagnostic laparoscopy. So many of these patients can have peritoneal spread of their cholangiocarcinoma, and so the first step is always to take a look with a laparoscope, make sure we do a thorough investigation of the peritoneum, make sure there's no spread of disease. If we can confirm that, then we can proceed with placement of the pump. This starts by dissection of the gastroduodenal artery. And so really to begin that dissection, we incise the pars flaccida and take down the gastrohepatic ligament to ensure that we can get to the common hepatic artery. The key steps in this procedure are to place the catheter into the gastroduodenal artery, but also do a complete dissection to ensure that there is no aberrant perfusion to other structures other than the liver. Because administration of this dose of chemotherapy to other structures can lead to significant complications. Additionally, in most instances, we also plan on doing a portal lymphadenectomy. In many cases, we also plan on removing the gallbladder. However, in this particular patient, she has already had a cholecystectomy. So today, the plan will be to incise the pars flaccida, take down the gastrohepatic ligament, take down any suprapyloric inflow to the stomach or duodenum, and then identify the station 8A lymph node or the common hepatic artery lymph node, which really serves as a window to the hilum of the liver. It allows us to, upon excising the common hepatic artery or station 8a lymph node, it exposes the common hepatic artery, especially where the gastroduodenal artery can be located. And once we have that dissection, we dissect both the common hepatic, as well as the proper hepatic artery, as well as the GDA, the gastroduodenal artery, so that we can place the catheter. After the dissection portion of the operation, then the plan will be to create a pocket for the pump, insert the catheter into the abdomen, and then prepare the GDA for acceptance of the catheter. After we place the catheter, we also want to ensure that the catheter is functioning. So we'll use our needles, specifically the special bolus needle for the hepatic artery infusion pump, to ensure that the catheter can be easily flushed. After we confirm that the catheter can be flushed, we also will do a profusion test Intraoperatively. That profusion test ensures that there's no aberrant flow and that we have adequate patency of the catheter, as well as no leakage from the catheter. And so once our catheter's in place, I'll be using two methods to demonstrate hepatic perfusion today. One is indocyanine green, which can be used in the robotic approach very easily given that we have Firefly on the robotic cameras. But it can also be used in an open fashion with a Spy system. And then I'll also be injecting methylene blue to ensure that there's no aberrant perfusion. Placement of hepatic artery infusion pump is a fairly straightforward procedure. We don't do a lot of bowel work. We don't plan on resecting any bowel. It can be done in combination with resection of the gallbladder or resection of certain tumors in the liver in order to ensure resectability at the completion of a neoadjuvant-intent chemotherapy or hepatic artery infusion chemotherapy. The procedure itself is fairly straightforward. And most patients will be able to leave the hospital fairly quickly after an operation like this. The robotic approach allows patients to leave the hospital a little bit more quickly and return to their normal activities a little bit more, a little bit sooner. This patient has straightforward conventional mesenteric arterial anatomy. And there are many other cases where we have aberrant anatomy that we need to ligate at the time of placement of this pump. Today, we won't need to do that. Given the preoperative imaging, there is a possibility that I may also perform an ablation of any of the satellite, or other metastases that I see in the liver, if I feel that by ablating those tumors I may enable the patient to undergo a resection at some point in the future. But that will really depend on my intraoperative ultrasound, which is another key component of the the operation. Final step in the procedure, after confirmation of perfusion of the hepatic artery, making sure that there's no aberrant perfusion, we can undock the robot. And then the last step is to implant the pump into the subcutaneous space. So we create a subcutaneous pocket and fix the pump to the fascia. So the patients don't have to do anything. The pump is completely subcutaneous. However, between two to four days after the placement of the pump, the patient goes to our nuclear medicine department for a study of the pump. And they inject technetium into this pump in order to, again, assess profusion, to ensure there's no aberrant profusion into any other viscera, and to ensure that the profusion is directly into the liver.

CHAPTER 2

So I wanna be able to put this pump in a place where I'm gonna be able to palpate it easily, okay? So I wanna know where the AS - anterior superior iliac spine is, right? Okay, right about there where the bottom border of the subcostal margin is, or the costal margin is. And I also don't want it at a location where there's a lot of subcutaneous fat that might impair my ability to palpate where the tip of that pump is. I want it right over the rectus muscle, usually. The pump will sit right about there. We can get in here in our normal location. I usually try to leave this at least four fingerbreadths breasts below this one. But obviously, if we're going for a Pfannenstiel, it'll go much lower, all right? Specimen is to extract today, so I'm not too worried about that. I might lower this one a little bit so we can work with it a little bit easier. Incision That's good. Oop, last little bit there, Annie. Uh huh. Here we go. Okay. All right, can we get OR lights down, please? So I usually talk through these layers. This is a optical trochar entry, so subcutaneous, sub-q, sub-q sub-q. Here, we see the fascia. As we get through the fascia, we'll see the muscle appear. Fascia. Okay. And I want you to rotate more than you push. Make sure your angle is perpendicular to the abdominal wall at that location, all right? Rotate more than you push. So now, we're past the muscle layer. And we're getting to the preperitoneal fat. So you keep going until we pop through that peritoneum. And rotate more than you push. And we'll be able to notice a change in the fat. Yeah, okay, that's... Okay, that's the peritoneum. What do you think? I think that's the peritoneum. Okay. Let's test that out. So low flow, can we start the gas, please? So this is a port that allows you to insufflate while we watch. And so, I'm gonna attach the gas and we're gonna watch. And the first thing you're gonna notice is the, that fluid that's in the tip of the, that port is gonna disappear. Thank you. And I am watching that pressure. And there seems to be an occlusion. All right. So we may not be through the layers. All right, so we're gonna stop that. We're gonna take that off. And then I'm gonna help. I'm just gonna rotate. And you see how I'm rotating more than I'm pushing, right? And I also wanna pull up. And we should be able to see that omentum fall away there, right? So we saw that omentum kinda fall away. So we probably likely we're up against and inside the omentum there, okay? So we want to hook our gas back up. And we're gonna turn it on. And we're gonna notice that omentum fall away as we slightly lift the abdominal wall up, okay? We wanna watch that site to make sure there's no bleeding. And we can tell we've gotten pneumoperitoneum, right? So I just let the abdomen fill. And now that we're in the safe location, I want you to turn the camera so it's oriented properly, and then drop your hand. And really, what we should see is parietal peritoneum. The fact that I don't means that we're probably under the omentum. So I'm gonna try to see if we can drop that. And maybe that she has adhesions, there we go. Omentum dropped there, you saw that? All right, now if you drop your hand, you'll see peritoneum there. And if you raise your hand, omentum down, right? So now, we're in free space. Can we get the gas to high flow, please? And then go ahead and insert that. So aim towards the safe black air. And then go ahead and advance the... No, advance the whole thing in until you feel it release. And then we can get our balloon up. So we were underneath the omentum on that one, okay? It's important to recognize that rather than keep going because we can get into some vessels back there, right? All right, look straight down, make sure we haven't injured anything there. All right, so now we'll do our diagnostic laparoscopy. So we'll put in another port to make sure that we can move things around. 15 degrees of reverse Trendelenberg, please. This is gonna be our air seal port. So in order to get the airs seal to initiate, we disconnect that and restart it. And that'll initiate air seal automatically, all right? Can I get a grasper, please? So first thing is we don't notice any malignant ascites. We're gonna do a thorough diagnostic laparoscopy. Is that like not calcification? It's likely because she's had a previous midline scar tissue, likely. Come over here. That doesn't look malignant necessarily. Okay, so let's look up the upper abdomen. I want you to look at the right diaphragm, peritoneum of the right diaphragm. That's good. Look at the left side then. Okay. And take a look under here. All right. Okay. All right, anybody see anything concerning? Okay, knife, please. Take a look here and here, inside. Now, I'm gonna switch the port, the gas and the ports so that we can come over. So I'm gonna open this one before I switch it over. All right, so if we can get it switched over quickly, it'll be less likely. Yep. Nice! First, first try. Put in your assistant port. The important thing is when you go in, the trajectory needs to be such that when you, the inner part of your cannula needs to be above the bowel, so that when we pass instruments that we're not catching bowel, okay? Make sure your angle is up towards the liver as much as possible. There you go. So the other thing to improve safety of this, which I don't... I'm not liking that we're not able to see it. Raytec. Can we level the patient out for a moment, please? Level the patient out, please. Yeah, go ahead. That's good. Keep coming. All right, now aim towards free space, up towards you a little bit. And just remember that with the air seal, it's gonna maintain a 15 millimeter mercury pressure. We can go back up to 15 degrees reverse Trendelenburg. Thank you for waiting. Yep, go ahead. I just wanna make sure that this port is coming in above the bowel, all right. Okay. All right. Yep, all right, we're ready to dock, Colin.

CHAPTER 3

Can you watch your IV pole? Perfect, and then can we drop the boom a little bit? All right, can you flex that number four out a little more, and number three out a little bit more? We're gonna need a 2-0 V-Loc to hold the liver up. What happened I think was that you had taken it out. So I usually use tip up in my extra arm over here. Fenestrated Bipolar in number two, let's do Cadiere in number four please. All right, Annie, Daisy, are you comfortable?

CHAPTER 4

Okay, so we can see the cholangiocarcinoma starting right there. That's the inferior surface of the liver. One of the reasons this was unresectable was because of its proximity to the left portal vein, which would've been the remnant side portal vein. And so, the first step here, we'll do a microwave ablation of the segment seven metastasis. So Daisy, I think it's gonna be easier if we port hop. I think we'll have to switch the tip up to number four. Excellent, thank you. So the segment seven lesion is a difficult one to get to, right? It's, especially minimally invasively, I mean. So I'm gonna use the round ligament and the falciform to kind of pull the liver. There we go. So I usually use the ProGrasp to control this. All right. So I'm just gonna start with an ultrasound kind of to orient ourselves. So we can see there's the main tumor. Okay, so... I'm gonna start up high. We can see the IVC there, all right? And we can see the... As I scroll... As I scroll over towards the left side, we can see the left hepatic veins coming into the IVC there. And then when I scroll that way, that's the right hepatic vein coming off the IVC and going into the right side there. And that segment seven lesion was just on top of a branch that goes up to segment seven. And you can see it right there. So Colin, can you hit the clip button for me, and let me know when you hit it? Okay, I hit it. It finished. Okay, thank you. Can you take a still shot right there? I got it. Now unfortunately, if we look at the primary mass, we... So that's the metastasis that's sitting right on that vein up top. Now, if we look at the primary mass itself, we can see quite a few satellite lesions to it. And actually, there's another one back there. Can you take a spot film there? So snowflake... There we go, perfect. Unfortunately, I see many more satellite lesions than... Can you take another clip for me? Start it now. Starting now, whenever you're ready. Started. So unfortunately, I'm seeing more lesions, hepatic lesions on the right side than we had originally anticipated, right? You see this right here? Yeah, a couple of 'em. Yeah, there's a couple, which means that this tumor is... You know, there was a question of whether we were gonna be able to use this modality as an in neoadjuvant approach to try to try to get this patient to resection. But with this many intrahepatic metastases, I don't think we'll be able to get her there. But then, you know, in that setting, ablation is not a good idea, right? And so at this point, we're gonna change strategies a little bit. And we're going to go directly to the hepatic artery infusion pump and systemic chemotherapy as the primary treatment modality. So we're going... We're not gonna do any ablation. There was a question on the MRI of a segment five metastasis, which is indeterminate. And I can see some other potential small indeterminate sites on the left side as well, which makes me even more confident that the ablation is not gonna help in our potential resection strategy in the future. Can we start the clip one more time? Let me know when you start. Starting. Stop. Okay, thank you. This is the vasculature. And so, you can see here, there's... We're gonna look for the portal structures. The portal structures are gonna have a bright hyperechoic Glissonean pedicle. And so, you can see right about there at the base of that ultrasound that we see some portal structures, right? And that's gonna be the right-sided portal vein coming this way. And then if I scroll towards the patient's left, then I'm... We can see that is the left portal vein going up. And you can see how intimately that tumor is involved with the Glissonean pedicle of the left portal vein. And I'll show you that on the other side as well. So if I go to the other side here, we can see there's the main portal vein, right there. And we can see, number one, there's potentially a met right there. You see that? Yeah. Can we freeze that there? I'm just gonna put on some labels because that would indicate left-sided disease, which is definitely gonna be unresectable. So, and then if you wanted to look at some of the vessels there, we can use our color flow. And so, you can see the left portal vein there, okay? And there's likely the main, which hopefully we'll be able to see better on this side here. There's the tumor. And you can see the left portal vein on the other side there, right, intimately involved there. And then when I come back on this side... We can again see that right down there at the base, the portal vein coming around it. So yeah, this is truly an unresectable cholangiocarc- intrahepatic cholangio, all right?

CHAPTER 5

Okay, so I'm gonna ask you to remove that ultrasound probe. Always make sure that the ultrasound probe is facing up when we're removing it, so that that little thing doesn't get caught on any omentum or bowel. All right, I'll take a needle driver in number three and the 2-0. Needle coming in. The liver retractor that I was trained on just seems to move a little bit too much throughout the case. And so, I've switched over to using this technique to just suspend the liver during these robotic cases. Yeah, you can go ahead and grab just any suture there, yeah. All right, four coming out. Bipolar, please, in two. Can I get the camera clutch to me? Thank you. And then if I could get my camera port bumped, please.

CHAPTER 6

All right, so here, we can see through our pars flaccida... The caudate lobe of the liver. I'm gonna be trying to access the GDA here. So first step is gonna be to identify my station 8a lymph node, and to take down the lesser omentum to prevent any possible aberrant for circulation. What's the white lesion on the left of the screen? Right here? Yeah. So you can see it's pretty free. This is not what malignancy would look like. It's like likely scar tissue from her previous operation. Got it. That's her vagus, where her vagus nerve would run through, the hepatic branch of her vagus nerve, right? And there's the crus of the diaphragm. There's the IVC. Okay? And so, I'm just gonna be going up here. We know that she does not have any aberrant left. However, even if she did, this is part of the procedure where I would take those abberant branches. And I also wanna make sure that there aren't any... There isn't gonna be any aberrant circulation through hepatic artery branches into the bowel there, okay? All right, and patient's had a previous cholecystectomy. So we see some adhesions to the gallbladder fossa, which we can take down very quickly. It's important to take all this down because I wanna make sure that there's no aberrant circulation to the duodenum. This is all just scar tissue, so it's not a problem. But I do want to be able to identify my lymph nodes. This is all just adhesion from the previous cholecystectomy. We can start seeing a glimpse of Rouviere's sulcus here. All right, which is a important landmark in cholecystectomies. And as I pull down the lesser sac, I'm gonna start seeing pulsations of my common hepatic artery. And we're gonna take lymph nodes. So we see the pancreas here. Common hepatic artery. And then our likely station 8a lymph node is likely right there. And GDA should be coming off underneath there. Okay, we also want to take our right gastric artery when we get to that point. So there's two ways to approach that space. One is by pulling the stomach down, which I might have to have you do through our assistant port while I work, or to go through the lesser sac here and get to it in that direction. So why don't we start with this method. All right, so can I get the hook cautery in number four, please. Okay, and I'm gonna have you come in with a bowel grasper. Annie, can I have you bump the camera port again, but up towards the ceiling? All right, so go ahead and grab the stomach right here, big bite. Right there. It is gonna be... Hold it in this area, avascular area here. That's good, that's fine. Yeah, go ahead in there.

CHAPTER 7

So usually, when I'm taking out the station 8a lymph node, I'm trying to grab the peritoneum below to lift it up that direction. Today, it's kind of given it to me from this direction. That's why I'm taking it that way. Are you still planning on doing a whole lymphadenectomy, or just the station 8? Yeah, no. The lymphadenectomy is good for pro, important for prognosis in the setting of a pump. And so, usually getting station 8, 12, and possibly 13 can be important. Can you push down towards the floor with that? So keep... Yeah, there we go. So you're still gonna try to get 12? Yeah, I mean, I'm not gonna push it, right? If I can, that'd be great but... But you're right in that, you know, given that the intent has changed from neoadjuvant to, to definitive therapy, then... And the consideration should change, right? Okay, so what we see here is the GDA right there, right? So our right hepatic, or sorry, right gastric artery coming off the hepatic artery is gonna be right in here somewhere. This is our common hepatic artery, proper hepatic artery, and GDA. And I'm just trying to make sure I understand that anatomy in my head as I move forward here. What are the chances she becomes like... Yeah, it was fairly low to begin with with an intrahepatic metastasis. So now with the progression with multiple intrahepatic metastases, it's extremely low that she gets to resectability. Got it, okay. Unfortunately. So there isn't a chance that you're coming back second time to finish up the lymphadenectomy? Yeah, it... If I were to come back, then I would try to finish the lymphadenectomy, yes. It's not important to get the entire node out, but it does make it easier subsequently for other parts of the case. Can I replace my number four? Can I replace with vessel sealer, please? Yep, good.

CHAPTER 8

Nice, so now we can see... You can see here that there are gonna be branches from the hepatic artery going to the duodenum, right? These are ones... These are pathways we want to interrupt in order to prevent any aberrant circulation. Okay? You can see the right gastric artery is in there. Do you have a small clip? Okay, why don't I take that small clip in number four. Thank you. Is Jason in here? He's gone at the moment. Okay, there we go. This wasn't closing for a second. Okay, I'll take the vessel sealer back. Okay. That's all right. That's okay. All right, good. You can see that there might be some additional branches in here. And I have to make sure there's... I'm not putting too much tension on that duodenum. I really want to ensure that I have the artery completely dissected up until about here. Aberrant circulation to the duodenum can cause pretty severe ulcers, right? We know that there are, the risk of biliary complications from placement of a pump is close to 3% that req... Meaning 3% of patients who have this procedure will have biliary issues that require some sort of endoscopic intervention. All right, so let's go back. That's one of the reasons why I tend not to try to grab... Okay, can I get a Hem-o-lok clip, please, in number four, please. Okay. Actually, I think we will need it when we're placing the, when we're opening up the GDA. So we can go ahead and open that if we need to. Let me get the hook cautery back in number four, please. And there can be small little branches that come off of this GDA. Seems like the GDA is huge. Yeah. Yeah, comparatively. So when the GDA... When we're potentially taking the GDA and you have this scenario where it looks this big, are there other considerations? Are there other things you're thinking about? Not necessarily aberrant vessel, but there is sometimes consideration about aberrant flow, right? And when we have a... Oops, sorry. When we have a particularly generous GDA, we should be thinking about median arcuate ligament syndrome, right? Because the hepatic artery may be relying on the GDA for all its flow. If the patient has an obstruction of their celiac access here, then when I clamp this GDA, it may be that we lose blood flow to the liver. And if that's the case, then it's a contraindication. At this institution at least, a contraindication for placement of the hepatic artery infusion pump. So when I'm moving this tissue around, I'm noticing that it's kind of pointing, right? It suggests that there might be a branch in here. And so, I'm just trying to dissect around that area, so that I can isolate that branch if there is a branch in there. And usually, that branch is something that I wanna get rid of, unless it's a hepatic artery branch. It could very well be an abberant branch going up this way. I don't mind, I can... If it's that... If that's the case, then I can ligate it safely. It does look like there's a branch in there, huh? We'll see, I'm gonna try to isolate it first. Okay. So I want to be able to isolate my common hepatic and proper hepatic as well. Okay, can I get the metal clip in number two, please? You want two. Two going in. Thank you. Oh, I don't think that there was a clip on that. or it might have fallen off. Can I get another clip in number two, please? All right, thank you. Usually if I'm working doing true vascular work, I don't wanna put too many clips, right? But here I just wanna... This is gonna be an excluded portion of the GDA. So I don't mind putting a clip there. So go ahead, I'll take another clip, please. I don't anticipate any placement of any clamps in this. I also dunno if there's a branch in there. I'm, you know, playing it safe. I am gonna take the vessel sealer next in number, oh boy. Can I take the vessel sealer next in number two? This may not work. Yeah. Okay, I'll need the scissors in number four, please. And they're hot? Okay. You want your hook back? I do. Okay. Yep, go ahead. You can see how I trust the hook more than the scissors for the vascular dissection. What's the vessely-looking thing right posterior? Is that just... This right here? Yeah, that... It's some vessel, I dunno. And it could be, you know... We think of it the way it's drawn in Netter's. But they could be a, you know, the superior pancreaticodoudenal artery comes off the GDA, right? There could be other branches that come to the duodenum from the hepatic. Whatever it is, I need to take it, right? Because it could represent aberrant flow. And this is actually... These are the vessels that are the reason why you can have FUDR flowing into the duodenum causing the aberrant flow issues once we start administering the FUDR. Do you want bipols in two, so you can grasp better? I do. Yeah, so what I'd like to do is put the fenestrated bipolar in number two and then I'd like the vessel sealer in number four, please. And again, as opposed to some of the, you know, MIS cases where we're trying to minimize the number of instrument exchanges, I don't mind instrument exchanges if it gets me the right instrument for the job that I'm trying to do, right? Okay. All right, can I have that hook back, please? Number four. And I want to have enough length on that GDA, so that I can put the catheter in. Those vessel loops, can I... Can I get that? Yeah, do you want them cut to 12? Sorry? Okay, I'll take that vessel loop. I think we have enough there for, for that. Okay, now I'm gonna need to pull, you to pull that towards the right foot. There we go. I think it'll be too much tension. Good thing I didn't grab it then. I think that's the station 8a lymph node, right? We haven't taken that out yet so... Okay. I'm just gonna... You want me to take it out? Daisy, can we take that out? Go ahead and let go of that. No, let's get a... All right, nevermind. Yeah, go ahead and take that. She can take it with just that, Daisy. Yeah, okay? All right, come back. Yep. Okay, coming back. Coming back, come on back in. Big bite. Good. Okay, now pull down towards the right foot. Okay, good. That's for permanent, right? Yeah, permanent only, please. Thank you. You see how that's pulling that pylorus in? Big bite. All right, now towards the right foot. There we go. I'm starting to see potentially some branches here, right? I think that'll be long enough for my catheter. So we're gonna have to pause the robotic portion for a moment 'cause we're gonna have to bring in the port. Is the pump ready? Yeah, we're ready.

CHAPTER 9

We have to be very careful of this pump, okay? Prolines, please. All right, knife, please. Thank you. Knife back. Salt. Salt, please, lap pad. So I used to sterilize these by putting 'em in salt solution. And so, in some institutions that I trained, we call them salts. So we're gonna go down so that I can see fascia. And then now, just retract. And I'm gonna lift up slightly. And I'm gonna start thinking about creating the pocket, and make sure that that pocket is hemostatic. My thumb's great, but... You might want to go deeper with both, actually. Good. Okay, okay. All right, let me feel this. Come on out. I'm gonna need some Tegaderm for right there. So I think that pocket will be big enough. We can maybe make it bigger if we need to, okay? So look at where I'm pushing right here. It's gonna be up there. Good, all right. Okay, tonsil. This is the part of the catheter that I'm gonna be removing, okay? Here you go. Let's dock our robot again. Can we get that Tegaderm? Okay. All right, let's redock. All right, can we get the OR lights down again, please? Do you have the 11 blade on the silk and everything? I do. Perfect. So tip up back in number one, fenestrated bipolar, number two. And then let's take Cadiere at number four while I work. Okay.

CHAPTER 10

I say right about there. Okay. Okay, can I get the vessel sealer back in number four, please? Can I get the hook back in number four, please? Okay, good. Towards the right foot. There we go, good. Great. Okay. Okay, can I get suction in number four, please? Actually, while we're at it, can I get the scissors first? I want there to be an angle on that. But so... Okay, good, there's a little bit of an angle. Go ahead and take that out. This right here. Now, we're gonna do a clamp test. We're gonna watch that proper hepatic artery. It's still pulsatile. Four coming in. Okay, can I get an 0 silk tie passed in. And actually, if you could pass in the 2-0 silk ties as well. All right, and then the other, the 2-0s next, please. And that's two 2-0s, right? So I'm just trying to make sure that this proximal suture, I can get around that little bit right there. If it's a branch, I'm not gonna ligate it because it's liable to bleed. Yeah, go ahead, I'll take it. Yep. And the only reason I'm suctioning here, I wanna make sure that we're hemostatic before we start tying. Because after we get the catheter, I'd like not to manipulate anything too much here. So, why don't we drop in the bulldogs as well. So let go of this, okay. And then if you could drop in the bulldog clamps. Yeah. So you can't squeeze it while you put it in. So the other way is to put a silk suture through the hole of the bulldog clamp. What I'm gonna do is I'm gonna tie off the distal GDA. I'm gonna leave that as a point I can use to manipulate the GDA. Then we're gonna put the bulldog clamps on. And then we're gonna pass in the 11 blade. And I'm gonna slice open the GDA. We're gonna put the catheter in and the two ties, tie that down. And then I'm gonna take the bulldogs off. And then number two is I wanna make sure that the 11 blade goes in safely and comes out safely. All right? And I'm gonna use a clip on this after I'm done tying. Pull a little bit more. There we go, good. Okay. All right, clip. Okay. Can I get suture cut, needle driver in number four, please? All right, can we pass in the 11 blade? I don't wanna spend too much time with the bulldogs on. So bring in the bowels grasp... Or bring in the 11 blade with the bowel grasper, please. Floppy on the string, please. Good? Yep. All right, all right. Okay, angling down. Hold on one second, let me follow you in. All right, come on in. All right, one second. I'm gonna take it, good. Okay, come on in with your bowel grasper again. Am I crossing over any sutures, or does it not matter? Yeah, don't grab the suture, but that's all right. Go ahead right there. All right, good. All right. Usually, I like these bulldogs to be going up, but they're gonna be hard to angle in that direction so... All right, can we start a timer? How long do you want it for? Just start, start us measuring time, so going forward. All right, and go ahead, start it now. All right, common hepatic artery is clamped. Okay, so we should be all the way across there, all the way across. There should be no other inflow to that, correct? Okay. Can I get suction in number two, please? Annie, have Daisy help you. I want you to maintain a retraction right now, okay? Okay. Is Charles coming in or..? He has not responded my text yet. Okay, he might be... Sorry, as I said that, he replied on his way. Okay, sounds good. Okay, we're gonna have... I'm gonna have you let go of that for the moment. Let go of my thing? Yep. Good. All right, we're gonna have you take that back. Go ahead and grab the suture and we're gonna actually go... I'm gonna follow you back. Can I regrab that suture? Uh huh, go ahead. Good. Hold on, hold on. Okay. All right, go ahead. Okay. Hold on. Okay, holding there. Okay, go ahead. All right, take it out. All right, 11 blade is out. Want me to put the yellow pick in now? Yes, please. And then can I get the fenestrated bipolar back in number two, please? Thank you. Bowel grasper next time so you can go right away to retraction. Okay. Okay. Yeah, can I get the non-suture cut? I don't want to accidentally cut this catheter. Non-suture cut in there, please. Okay. What do you think, Charles? Is that positioning okay there? Yeah, it looks good. You could probably do the proper and the common. And the common, yep. What do you think right there? I think it looks good. Okay. Did you do any resection? No, there's many more right-sided lesions than than anticipated. So this is gonna be, unfortunately, I think her definitive treatment. But you know, I was thinking if I had come in here for a possible resection, I would've opened in order to do an ultrasound, and then discovered that it was, you know, unresectable. And then I wouldn't have had been set up for a pump as a backup, you know? And so, this is actually a good, good option for her. Okay, so that's that. I might have tried to get this other one inside. There we go. I don't want it to stick out into the hepatic artery, you know, proper. I don't think it's doing that right now. Take a look at it again. I think it looks okay. So I should have made this arteriotomy a little lower I think, just so I could get some purchase on that. Right there. But I think I'll have a little bit of artery there. Right there. Is that a cystic duct looped up there? No, it's the right gastric artery. All right. This patient had had a previous cholecystectomy. And have you skeletonized the hepatic artery or do you do that next? I've done as much as I think I need to. I'll show you... I'll show you how much I've done here. That looks pretty secure. What do you think? I agree, it looks pretty secure. I would take a look to make sure that you're not puncturing into the lumen. Sorry? That I haven't gotten into the lumen. Yeah. Yeah. I think it'll come down a little bit like that. And then also when I release these, I wonder if it'll open. Open up a little bit? Yeah, exactly. So... You're just gonna do the two? Yeah, I think two there, right? Yeah. And then... And that should be the back bleed. And then... And we see a good pulse there. What do you think? Throw another one up more proximally, another suture up there. Up here or up here? If you see where the indentation is. Right here? Yeah. I think around. Because I think your, your one bumper is above a little bit. This one is too high? I just think of that suture, the second suture, that one. No, no, the one above that one is a little bit beyond... The bumper. Okay, I see what you're saying. I'd consider putting another one in there. Okay, can I get a suture cut needle driver in number four? It looks like you kinda placed in a really nice spot. I just think another, just securing it up a little bit more. Okay. Yeah, I see where it is. You see where the bumper is, a little bit up? Yep. You want me to pull the tails outta your way? No, it's all right. What's your next case in here? Gallbladder. Yeah, I like that. Okay. I mean, it's up to you, but I just... No, I agree, that's good. Okay. I don't think it looks like it's impinging on the... All right, here we go. I think I'm gonna put a separate silk on that bumper down below. I don't think I should try to get this to reach there, right? That'll kind of push it up into the hepatic artery. Yeah. That secures it nicely. Yeah. You think you need another one on that bumper? Usually, there's a suture that... This suture's supposed to go underneath that bumper, right, and to kind of keep it up. But I have to say this looks pretty secure. And also, I'm worried that if we try to secure this bumper up, it's gonna push that up into the artery a little bit. Yeah, I don't know.... I dunno what else it's gonna give you. Like there's the tip right there. It's like in perfect position, right? You've got two really good securing. All right, can I get the non-suture cut needle driver? Or sorry, can I get Cadiere a number four now, please? I think that looks pretty secure, don't you, Charles? You know, this is completely free up to there. And then, you know, I've taken the right... This is the bile duct right here. I mean, I could consider taking some more of this stuff here before I do my methylene blue and ICG. All right, and then I just wanted to make sure that this catheter was kind of pushed into the lesser sac. The other other thing I always think about is whether this should come through the greater omentum or not. And I think it probably would be better if it did, you know? That port is pulling on the outside, Daisy and Annie. Can you prevent it from pulling? Pull that pocket up towards the... Like that? Not out, but in. Yeah, I don't want there to be... Yep, good. And then I just want to fit this. So lift up towards the ceiling a little bit, Annie. There you go, good. Okay, all right, can I get vessel sealer in number four, please? So ICG and then methylene blue, and we should be done, right? All right, pull down a little bit. Thank you. It's still... Flip to like 3 o'clock. Why do you have the dissect further? There can be other small arteries that come off of the hepatic artery that come down to the duodenum. Oh, okay. And so, you want to try to prevent that, right? And... So there, you know, I'm basically approaching the portal vein here. And the bile... There's the portal vein right there. And our bile duct is right in here. You know, usually, I am doing more lymph, of a lymphadenectomy. But, when I have evidence of progressive disease in the liver, I don't know how much that's useful, you know? Yeah, so IR can try to embolize it. But what we want to do is check that way before we leave the OR. And so, we're gonna do ICG angiogram right now to demonstrate that there's no other, you know, aberrant flow. In my standard procedure for these cholangios, I would complete the lymphadenectomy. Today, I'm not gonna be doing that. But I do want to isolate. So I want to take out as much of this tissue that can potentially provide flow back to the duodenum, or the stomach, right? And I want to see and make sure that that catheter is not impinging on, into the lumen of the common hepatic. All right, watch out. What's going on with that retraction? There we go. So I think we're... So I think we're okay there. Okay. All right, let's clean up a little bit here. So first of all... Let go of that. Okay, letting go. And that pump shouldn't be under any tension now, correct? It's not, no. Okay. Can I get the Cadiere back in number four, please? Okay. So what's going on with the catheter? Can bring that pocket way up? It's still under some tension here, right? I need it off all tension. Any better? Yeah, that's better. Okay, can we clean up a little bit here? Yeah, I'll take the... Hold on one second. Let me give you some of this stuff. Of course. Yeah. Excellent, here's the bulldog. All right. Go ahead right there. Close a little bit. Push in a little more. We got one.

CHAPTER 11

Hey, Annie? Yes? I'm gonna need you to work with the port, right? So you have access to that pump? Yeah. Okay. So I'm gonna have you put a needle into it. Okay. It's gonna be a special access needle. And then can I take a three-way stopcock on that? So I first, if we could have on the three-way stopcock saline on one, and then ICG on the other. Yeah, it'll have to be injectable. And then if you could put the three-way stopcock on the end over here. It's clamped and it's off to the ICG, right? Can you make it off to the port, to the pump, I mean? You're gonna go straight through, perpendicular into the gel until you hit metal on the other side, all right? You said perpendicular? Yep. All the way to the bottom. And then you're gonna push until you hit metal. Did you hit metal? Yep. Okay. All right, now I want you to... Let me turn on the Firefly first. Sorry... Excuse me. Mm-hm. All right, so what you're gonna do is you're gonna unclamp it. And then you're gonna turn the stopcock towards the ICG. And you're gonna inject the ICG, only about two ccs or three ccs. And I'm gonna let you know when to start. Okay, we're unclamped and the stopcock is ready to turn. Okay, go ahead. ICG first. Let me know when you're injecting. Okay, we're injecting. ICG, three cc, two or three ccs. Okay, this is one. Great. This is two. Okay, you can stop there. Okay, stopped. See how the liver's lighting up? Yeah. And there doesn't seem to be duodenal filling. There's this, which is bile, which is bile duct, right? Yeah, that's bile duct. But that's okay. And then I don't see any duodenal staining. And then now, we're gonna start getting late flow, right? And so, we can... I don't see any flow in the stomach either, so that's great. Filled the liver immediately. Agreed? Yeah. All right. And then, okay, next thing is you're going to put the stopcock back. So you're gonna clamp the tubing. And you have to be very specific about the clamping because I think this is what happened last time. Make sure that that tubing doesn't fall out of the clamp. Make sure it's truly clamped. Tubing doesn't fall outta the clamp. And it's truly clamped. Okay, now go ahead and take the ICG. So turn the stopcock off to the patient, off to the pump. Take the ICG off and replace that with the methylene blue. ICG is off. All right. You wanna spray Tisseel, or just push it out? Spray would be great, thank you. All right, are you ready? Yep. So we're gonna do the same thing and you're gonna inject the methylene blue. Go ahead. All right. I'm unclamping the tubing. Unclamped. Okay. The stopcock is gonna be turned off to the heparin. Okay, how many ccs do you want? Three. All right, injecting. Yep, going in. Yep, we can see it right there. Okay, this is one. This is two. That's 2 1/2. Okay, we can see the liver turning blue. Do you want more. I have three? Nope, that's good. Okay, and I'm clamping the tubing. Okay. And I'm looking at... Hold on. And then I'm closing... All right, tubing and stopcock are both off. Great, and I'm looking at the duodenum, trying to figure out is there any methylene blue? The liver is turning nice and blue. I don't see any aberrant flow over there. What do you think, Charles? Good. Yeah, I don't see any aberrant flow anywhere, so I think that's good. All right, can you do the heparin flush, please? So full 10 cc heparin flush, please. Okay, I'm gonna unclamp the tubing. Oh, all right. Unclamped. You can't have it open to air ever, right? So even the turn of the thing, everything should be closed off, good. There is... There is definitely an air bubble. Oh, that's okay. As long as it's not open to the air, okay? So turn it open to the saline. And then go ahead and flush. Flush hard and long, the whole thing. All right, flushing. Okay, now turn it off to the pump, Daisy. Okay, now deaccesss it with the needle. Deaccesss the pump. Okay, pulling the needle out. There we go, okay, perfect. Thank you.

CHAPTER 12

All right, we can undock the robot. I'm gonna get the instruments out. And then we will put the port in the pocket. One more thing, I gotta take the liver suture out. And we gotta put the Tisseel in. So if we could get the scissors in number four, please. There we go, thank you. Okay, why don't we do our TAP blocks while we're waiting. Okay, suction in number four. Okay, come on in with the Tisseel. All right, so Annie, I'm gonna lift up. I want you to get a little bit underneath. And then I want you to cover the whole space, okay? Let's do TAP blocks then. I'm gonna show you this right side first. Okay, and we're gonna go to the other side. We're just waiting for the Tisseel. And let's go back and see if the Tisseel is thawed. So get underneath it first. And remember that when it sprays, you need to be a little bit further away from it. So I'm gonna lift up right there. Kind of get underneath there, one second. Go ahead and step on it. All right, spraying. Yep. Good. Okay, I am gonna let go. Continue spraying. Come back a little bit. I'm gonna roll this back a little bit. There we go, good. And then cover all the arterial surfaces that you see. Good, cover it right down here. Gonna let it run down. Yep, good. All right, get rid and just use... Yep, use up the rest of it, right there. Let's cover that, good. And one other thing, get it so it fixes the catheter right there is good. Go ahead. Right here? Yep. There we go, good. Uh huh, good. Okay, that's it. All right. Okay. All right, we can undock. No, we'll do a UR, 0 Vicryl UR. It's the 2-0 Vicryl running, and then the sub-q, 4-0 Monocryl, and then Dermabond, and the antibiotic solution as well. What do you mean ports come out? Just undock the robot. Don't take any ports out.

CHAPTER 13

So I wanna make sure that this catheter has a smooth course. I think this can be most likely like this where the catheter can come up, and then down, and go into the abdominal cavity. I gotta make sure that my pocket is large enough. And so, we're gonna desuflate. You don't wanna be too tight because it can be uncomfortable and cause issues. If it's not tight enough, it can form seromas and... I'll take four snaps and four Prolenes, please. And keep the needle, okay. You just parachute it down? Uh huh. You have an Army-Navy? Oh, nevermind, sorry. Thank you. Okay, we'll do this one last, or relatively last. So you can let that needle go. Just let it go completely, there we go. Because I think this port is gonna be best to be put like that, okay? Okay. And so, this one will be actually first here. But we'll put the other ones in as well while we wait. Okay. Dr. Brahmbhatt, are you okay with Ketorolac for this patient? Yep, that's perfectly fine. Yep, thank you. All right, you can let that one go and get this last one. I think the likelihood of opening is very low. Very low, okay. Yeah, all right. So go ahead and reload your needle. Rich to me, please. Okay, can I get the antibiotic solution? This is the top one. No, that's gonna be the... The one that's over here. Medial, okay. Okay, so this one's gonna go down. I would like it to sit like this, okay. Okay. Yeah, that'd be great. Thank you. All right, and then can I get a dry? Can we have suction on that port? That's all right, I'll just... It's dry. I'm gonna see how it fits. Okay. Okay, come out for a second. I think it's a little tight. So... What's this one? Bend it up or down? This is the one you just... This is one on me. I didn't take any bites on it yet. Okay, oops. Let's go ahead and take that out for a second. There we go. Can you hold onto that right there? And Amber, if I could have you hold it right there like that. Okay, I'm gonna take it from you. Do you have a bigger rich, hold that there, and tow it in a little bit. Let's make sure we're hemostatic. Dry lap pad, please. Thank you. DeBakey, all right. So this is gonna sit like that. So that's gonna be at the deepest part of that. I want you to grab a bite just like we do on the MetaPorts, but low, deep as as low as possible, meaning as caudal as possible in the pocket. So this is the medial one, right? No, so this is how it's gonna sit. So which one? Oh, you have this one, all right. Yeah, that's fine, then this one over here. Want me to... I want you to start with that one, actually. Do you have a snap? Or actually, I have a snap. So we're gonna secure this at the caudal, right? And try to get fascia. Anterior fascia only, but fascia. Still gonna be halfway down the pocket. And the lateral... That's mine. That's gonna be - no. That's gonna be yours. That's gonna be lateral, okay? Sounds good. Good. Okay, Amber, hang on to this. And I want you to go underneath the catheter, underneath the catheter first. Right here? Uh huh. A little lower, caudal, I mean. There you go, good. No, no, no muscle though. I don't want you getting that much muscle. Just fascia, okay? Okay, let go of that, Amber. That Prolene, get it underneath the... No, no, no, get it underneath. There we go. Snap, I got it, nevermind. Okay. Okay, dropping the needle. Okay, pick up on that one. All right, go ahead and let, come on out. It's all right. There you go. Here you go. DeBakey. DeBakey. Okay. All right, I'm gonna give this back to you. Army-Navy. Okay. Scissors. Okay, scissors. I got it. Thank you. Just 'cause we know you're seeing. Yep, just on that one because it's a little deep. That's all, Amber, thank you. All right, here we go. Go ahead and cut that needle off. Okay, go ahead right there. Right here? A little lower, about five millimeters. Very good. Scissors. Antibiotic solution, please. So you see all the flecks of fat, all right? And it's all set up for a infection, right? And be very careful of the catheter. Okay, good. Yep, good. Cut there, good. Hold on. Okay, can you hold this is? This is low dose heparin, correct? Okay, here, you can hold that. Okay, I'm gonna take that. It flushes great in final position. Gonna deaccess, okay, there we go. Flushes great.

CHAPTER 14

Okay, can I get the Vicryl for closure. In a 2-0. And a DeBakey? Thank you. All right. Foley in, art line in. I don't think so. I think she can go to floor status. Floor, okay. So I want to try to cover up the port, right, completely. Sure. Grab something to retract. Can I get an Army-Navy? Oh, thanks. Can you get me the other Army-Navy? Follow there. Or actually, it might be okay. Yep, it'll be all right. Okay for clears? Yes. Advance as tolerated, or just clears? Yep, advanced as tolerated. Awesome. I can't remember, was she the one on baby aspirin, or is it the next guy who's on a baby aspirin? I'll double check. Okay. But I'm okay restarting. Yep. Okay, so clears, advanced as tolerated, Foley stays in, and we'll take it out tomorrow. Art line can come out. Mm-hm. OG tube can come out. Mm-hm. No need for path and labs. Correct. Do you want a hepatic function tomorrow? No, she will be discharged, likely before that happens. Okay. If she's still here on post-op day three or four, then we will get it. Okay, but you want a set of normal morning labs tomorrow? Yes. All right, understood. And then I think okay for prophylactic Lovenox tonight? Yes. Okay. And if she's not on an aspirin... If she's not on aspirin, I would start her on a baby aspirin. before she leaves. Okay. Hey Rossi, is she on a baby aspirin at home or no? I can't remember. Addison, thank you. All right, can you hold this outta the way here? Use this for your retraction instead. I need to be able to see, I can't... It can't be that I get that catheter. It's listed in her notes, so she should be. All right, thanks. So I can't get that catheter, right? All right, then we'll restart it. Okay. Is there a special trick to those? Nope, just push it down again. It's just scar tissue. Perfect, I'll take the antibiotics solution. You know, she has scar tissue. I would've... I should've probably just closed it with the Carter-Thompson. Usually, I try to get this, just the anterior sheath here, right? There's the inferior fascia right there. You see it? Point the needle back to you. So the fascia is right there, you see it? Deep to superficial. So let go of that. Do you see the fascia there? Yeah, I felt it. Okay, so I'm gonna go down. I prefer to do this with a Carter-Thompson. Okay, hold that for a moment. Okay, and let go of that. Let go of this? Mm-hm. Okay, hold that right there. Okay. And retract that towards you. So there's fascia right there. Now, lift up on that. There you go. Pull down with that. Huh? Pull down with the S-shape more. Good. Okay, lift up with that Thompson, with the Kocher? Yep. Okay, come out with your S-shape. Yes. There. Okay. There we go, all right. Good, come on off the Kocher. Okay, good. I'll take the local. And then can I take the antibiotic solution and an asepto? All right, Amber, come on over here and you can help close the skin. If it's under tension, you can use deep dermal. Are you okay? Yeah. All right.

CHAPTER 15

Upon intraoperative ultrasound of the liver, we identified more metastases than I was expecting, which further reinforces the concept that this patient had truly unresectable intrahepatic cholangiocarcinoma. And therefore, really, the definitive therapy is going to be a combination of systemic chemotherapy and hepatic artery infusion chemotherapy. And resection is unlikely to be in her future. The case followed the normal procedure for placement of hepatic artery infusion pump. We started by taking down the gastrohepatic ligament, ensuring that there was no cross perfusion into the stomach. We identified our station 8a lymph node and our GDA underlying that. The GDA was fairly long today and fairly sizable. There are situations in which the GDA can be too small, in which case we can either use a smaller catheter or manipulate the GDA in a certain fashion to allow the catheter to be inserted. The things that make the placement of the catheter into the GDA fairly straightforward are use of that 11 blade to create a very clean arteriotomy, ensure there's no dissection of that GDA, and then using the silk that's used to ligate the distal GDA as a point of traction on the GDA as the catheter is placed. The catheter was secured so that the tip of the catheter was at the junction of the GDA to the common hepatic and proper hepatic arteries. You wanna make sure that that catheter doesn't impinge onto the hepatic artery to cause turbulent flow in that area, which can increase the likelihood of hepatic artery thrombosis. In most circumstances, the placement of the hepatic artery infusion pump is done in conjunction with a portal lymphadenectomy. In this case, since I found more diffuse disease in bi- in both lobes of the liver, I took the station 8a lymph node, but I didn't do an aggressive lymphadenectomy, as that may increase the morbidity of this operation. If the intent of this therapy was neoadjuvant, in which case we may be attempting to convert this patient from an unresectable to a resectable intrahepatic cholangiocarcinoma, then in that circumstance, I would likely pursue a more aggressive portal lymphadenectomy.