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WSHIMA - Case 25: Inpatient SurgeryPreoperative Diagnosis: Metastatic colorectal carcinomaPostoperative Diagnosis: Same, involving liver segment 4B, left iliac lymph node, right abdominal wall Operative Procedure: Laparoscopic, robot-assisted partial hepatectomy (segment 4B), Intra-operative ultrasound, Open left iliac lymphadenectomy, Right abdominal wall resection and mesh repair Indications: Pt. is a 50-year-old woman with a history of T3N1 colon adenocarcinoma s/p colectomy. She now has recurrence in segment 4B of the liver, left iliac lymph node and right abdominal wall. She also has had distant history of thyroid carcinoma. Findings: Significant adhesions from prior pelvic surgery. Normal liver parenchyma. 1.5 cm subcapsular segment 4B tumor. 2 cm left iliac lymph node. 3 cm right abdominal wall tumor.Description of Procedure: The bladder was cannulated with a foley catheter; large bore peripheral IVs for resuscitation and radial arterial catheter for invasive monitoring were placed. Access to the peritoneal cavity was obtained through a 12 mm long blunt Hassan port placed in the right paraumbilical position. The abdomen was insufflated with 12 mmHg of CO2. Laparoscopy demonstrated the above findings and significant adhesions. An 8 mm robotic port was placed under vision in the right subcostal position and adhesions were taken down using the Endo Shears. A 5 mm port was placed in the subxiphoid region to aid in the lysis of adhesions. Given that the pelvic adhesions would limit a laparoscopic approach for the iliac lymph node resection, the previous lower midline incision was opened and a gel port was placed. Two left subcostal 8 mm robotic ports were placed following clearance of adhesions. The 12 mm assistant AirSeal port was placed through the gel port. The robot was docked over the patient's head with the patient in reverse Trendelenberg position.Ultrasound confirmed the relationship of the 1.5 cm subcapsular segment 4B tumor to the vascular structures. The margins of the segment 4B tumor and its relationship to the surrounding vasculature were defined with ultrasound. The surgical margin was scored using the monopolar scissors under ultrasound guidance. The liver parenchyma was divided using the Harmonic scalpel. As the dissection progressed posteriorly, portal pedicle were visualized and divided using the hemolock clips. The remaining parenchyma was divided using the Harmonic scalpel. Hemostasis over the resection bed was achieved using the fenestrated bipolar grasper and monopolar scissors and application of Surgicel. The surgical bed was irrigated with a copious amount of warm sterile water and complete hemostasis and lack of bile leak over the resection bed was confirmed. The specimen was placed in an EndoCatch bag and removed through an extension of the upper midline robotic port incision, and sent to Pathology. There was focal abutment of the tumor to the surgical margin, and therefore, an additional rim of liver parenchyma was taken using the monopolar shears and Harmonic scalpel as an additional margin. Complete hemostasis and lack of bile leak over the resection bed was again confirmed.Through the lower midline incision, the iliac lymph node was resected with division of the lymphovascular pedicles using ties and clips. Care was taken not to injure the left iliac artery or the left ureter. Attention was then turned toward the right abdominal wall. Through a 6 cm transverse incision overlying the mass, the abdominal wall was resected with ample margins. The resulting abdominal wall defect was repaired using polypropylene mesh and interrupted 0 prolene sutures. ................
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