Open and minimally invasive HPB surgery


Our team has extensive experience in (HPB) hepatopancreatobiliary surgeries for hepatocellular carcinoma (HCC), Cholangiocarcinoma, Gall bladder cancer, Pancreatic cancer, Choledochal cyst etc. The surgeries can be done by traditional open or minimally invasive laparoscopic and robotic assisted approach. These minimal invasive approaches offer the advantage of enhanced precision during the surgery.

Liver Cancer

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. The incidence of HCC is high in countries with a high prevalence of hepatitis B and hepatitis C infection including India. Most commonly HCC occurs in the background of liver cirrhosis (end stage liver disease) resulting from viral hepatitis (B & C), alcoholism and fatty liver disease.

Sadly HCC does not produce any specific symptoms in early stages and is often diagnosed incidentally when a patient is evaluated with ultrasonography or CT scan for pain in upper abdomen or other non specific symptoms.

The detection of HCC at an advanced stage makes the management of HCC challenging. The best treatment for liver cancer is liver transplantation, especially if the HCC develops in the background of liver cirrhosis. In patients with HCC who do not have liver cirrhosis the ideal treatment is liver transplantation, however if transplantation is not feasible then a portion of the liver with cancer can be surgically removed (hepatectomy).

Since HCC is often detected at an advanced stage, sometimes surgical options for treatment of HCC may not be technically possible or safe and in such situations various non-surgical treatment modalities like radiofrequency ablation (RFA), transarterial chemoembolization (TACE), transarterial radioembolization (TARE), percutaneous ethanol injection (PEI), and stereotactic body radiation therapy are available with good results.

Patients with cirrhosis are at high risk of developing HCC and therefore decompensated cirrhotics should be advised to undergo liver transplant to remove the diseased liver. Patients with compensated cirrhosis should be under the supervision of liver specialist and screened every 3 months for evidence of HCC.

Hepatocellular carcinoma (HCC)

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. The incidence of HCC is high in countries with a high prevalence of hepatitis B and hepatitis C infection including India. HCC most commonly occurs in the background of liver cirrhosis (end stage liver disease) resulting from viral hepatitis (B & C), alcoholism and fatty liver disease.

HCC does not produce any specific symptoms in early stages and is often diagnosed incidentallywhen a patient is evaluated with ultrasonography or CT scan for pain in upper abdomen or other non-specific symptoms.

The detection of HCC at an advanced stage makes the management of HCC challenging. The
best treatment for HCC is liver transplantation, especially if it develops in the background of liver cirrhosis. In patients with HCC who do not have liver cirrhosis the ideal treatment is livertransplantation, however if transplantation is not feasible then a portion of the liver with
cancer can be surgically removed (hepatectomy).

Since HCC is often detected at an advanced stage, sometimes surgical options for treatment of HCC may not be technically possible or safe and in such situations various non-surgical treatment modalities like radiofrequency ablation (RFA), transarterial chemoembolization(TACE), transarterial radioembolization (TARE), percutaneous ethanol injection (PEI), and stereotactic body radiation therapy are available with good results.

Hilar Cholangiocarcinoma

Hilum is that portion of the bile ducts where left and right bile ducts of liver join and lies outside the liver, though closely related to it. Cancer arising from this portion of bile duct is called hilar cholangiocarcinoma. As the cancer occupies and obstructs the bile duct, jaundice is the most common presentation. It spreads in an upward direction towards the liver and therefore removal of the entire tumor, along with the involved portion of liver during surgery is needed for long term survival.

Before any surgical procedure the level of jaundice (serum bilirubin) needs to be decreased to make the surgery safe and requires either PTBD (percutaneous biliary drainage) or endoscopic stenting across the biliary obstruction.

As the surgical treatment also requires extensive liver resection, accurate estimation of liver remnant (portion of liver remaining after surgery) is essential. In case the liver remnant is not sufficient then preoperative portal vein embolization (PVE) by interventional radiologist is needed to augment the liver remnant. Thus preoperative preparation has several facets and requires a multidisciplinary approach involving HPB surgeon, interventional radiologist and gastroenterologist. Careful preoperative planning and availability of a dedicated multidisciplinary team is crucial for devising a treatment plan for patients suffering from hilar cholangiocarcinoma.

Carcinoma Gall Bladder

Carcinoma gall bladder is the most frequently encountered cancer of the biliary tract. Females are three times more likely to develop gall bladder cancer compared to men. Presence of polyps in gall bladder can lead to cancer and hence it is considered safe to remove gall bladder harbouring single polyp more than 1 cm in size, particularly in male patients and in those with family history of gall bladder cancer.

Majority of cases of gall bladder cancer are diagnosed at an advanced stage and are often incurable. 25-30% of cases of gall bladder cancer are detected following surgery for gall stone disease (incidental gall bladder cancer). In such a situation the cancer is detected at an early stage where surgical treatment is associated with very good prognosis and chance of cure.

The only curative treatment is surgery (radical cholecystectomy) wherein the gall bladder with a portion of liver and all neighboring lymph nodes are removed. Mere removal of gall bladder is thus an incomplete operation and hence patients with incidental carcinoma gall bladder require a second surgery (completion radical cholecystectomy).The treatment following surgery will depend upon the stage of the disease as ascertained by pathological examination of specimen and involves chemotherapy and radiation.

Pancreatic Cancer

Pancreas is an organ located deep within the abdomen and is principally involved in control of blood sugar levels and digestion of food by producing enzymes. It has four parts; head, neck, body and tail. Tumors can arise in any of these parts (i.e. head of the pancreas, ends of bile duct and pancreatic duct or the portion of intestine).

The pancreatic duct which brings pancreatic secretions forms a common channel with bile duct from the liver at its terminal end and thus both of them drain their secretions into the small intestine (duodenum). Tumors at this location commonly block the bile duct and cause painless progressive jaundice. The other symptoms include decreased appetite, weight loss, poorly controlled diabetes, bleeding, fever and abdominal pain.

The only available treatment with curative potential is surgery. The difficult location of such tumors necessitates surgery for removal of all structures in vicinity of the tumor. The procedure is a major undertaking and is known as Whipple’s procedure which involves removal of head of pancreas, distal stomach and proximal small intestine (duodenum and 10-15 cm of jejunum). The chances of complications in the post-operative period are high at 20-40% and therefore such patients should be managed at a tertiary care hospital with a dedicated HPB unit. The prognosis after surgery for periampullary cancer is good.

Recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis is characterized by repeated episodes of fever, abdominal pain and jaundice due to ongoing infective process in the biliary system of liver resulting in narrowing of bile ducts and deposition of stones in it. The disease is commonly seen in East Asian countries including India.

Stones and strictures are multiple and are seen both in the bile ducts within (intra-hepatic) and outside (extra-hepatic) the liver. Untreated it can result in liver abscess and atrophy (shrinking of part of affected portion of liver) generally restricted to one side of the liver. Long standing cases can cause irreversible damage to the liver leading to end stage liver disease (secondary biliary cirrhosis).

Treatment involves initial medical management with appropriate antibiotics to tide over the infective phase followed by definitive surgical procedure to prevent future recurrences and further damage to the bile ducts and liver. Depending upon the extent of involvement of liver, the surgical procedure may involve resection (surgical removal) of involved portion of liver. In presence of end stage liver disease (secondary biliary cirrhosis), liver transplantation is the only option.

Choledochal cyst

Choledochal cyst is a disease of infancy or childhood arising due to congenital dilatation of the bile duct (s); however 20% of patients present late during adulthood. This condition is often associated with cysts in other organs like liver, pancreas. It is a premalignant condition which can give rise to cancer in future and patients with choledochal cysts require lifelong surveillance for cancer. Some reports suggest that females are more likely to develop this condition. Clinically the symptoms are recurrent upper abdominal pain, fever and jaundice.

There are many subtypes depending upon the location of biliary ductal dilation, which can be determined by MRCP, but most commonly the cystic dilation is located in the portion of bile duct outside the liver and can be treated by surgical removal.

The second most common variety involves the bile ducts both within and outside the liver. In order to prevent recurrence and cancer in the diseased bile duct it is mandatory to remove the entire diseased segment of the bile ducts and therefore requires some sort of liver resection.

The most difficult variant is Caroli’s disease in which the cysts are located exclusively within the liver. It can lead to end stage liver disease and the option of liver transplantation should always be considered from the start in such group of patients as most of them will end up requiring one.

Benign biliary stricture

Benign biliary strictures are usually seen after cholecystectomy (removal of gall bladder) when bile duct is injured inadvertently. The incidence of bile duct injury during cholecystectomy is around 3 to 8 cases per 1000. In the laparoscopic era such injuries tend to be high up very close to hilum (portion of the biliary tree where left and right bile ducts of liver join) and complex. This condition can present acutely immediately following surgery as drainage of greenish bile through a drain placed at the time of surgery or as pain in abdomen with sepsis (biliary peritonitis) if bile accumulates inside the abdomen. With time the injured bile duct seals by narrowing (stricture) which prevents flow of bile and presents with jaundice and fever. Long standing poorly treated cases lead to irreversible damage and end stage liver disease (secondary biliary cirrhosis).

Definitive treatment involves surgery during which a path is created between the bile duct(s) above the stricture and the small intestine (bilio-enteric drainage).

Cystic Diseases Of The Liver (Simple Cysts and Polycystic Liver Disease)

Cysts are fluid filled sacs which can occur in any organ of the human body including liver. They are classified as simple liver cysts or can be a presentation of polycystic liver disease (PCLD). PCLD is a genetic disorder and is usually associated with cysts in the kidney as well.

Simple cysts can be single or multiple and are seen in 15-20% of the population, predominantly in elderly and in females. Generally they do not produce any symptoms, however large cysts may cause pain and rarely internal bleeding in the cyst may manifest with sudden onset of severe abdominal pain. Asymptomatic cysts, irrespective of size, do not require any treatment. Symptomatic cysts are generally treated laparoscopically wherein a large hole is made on the cyst surface (de-roofing/ fenestration) allowing the fluid to be drained into abdominal cavity from where it is absorbed.

PCLD is characterized by multiple cysts within the liver which increase in size with age. Due to the presence of multiple cysts the liver gets enlarged and patients present with abdominal swelling which can compress adjacent organs and give rise to symptoms. As in simple cysts bleeding may occur within the cysts in PCLD presenting as sudden onset of severe abdominal pain.

Operative treatment includes fenestration (as for simple cysts), liver resection or liver transplantation depending upon the extent and severity of the disease. Fenestration has high likelihood of recurrence of symptoms as all cysts cannot be addressed in one sitting. Liver resection is technically challenging as an adequate portion of liver has to be retained. Liver transplantation offers the most sustained benefit and should be considered in the management of PCLD patients. Renal transplantation may also be needed for patients with PCLD who have coexistent end stage renal disease due to multiple cysts in the kidney.

Extra Hepatic Portal Vein Obstruction (EHPVO)

Portal vein is the major blood vessel which brings blood from the intestines into the liver which is the principal organ involved in metabolism of nutrients. If the portal vein is blocked due to any reason outside the liver, alternate channels (collaterals) develop to bring blood from the intestine. This condition is known as EHPVO. However these alternate bypass vessels are weak and dilate in course of time and have a tendency to rupture and result in catastrophic bleeding.

Most of the patients with EHPVO present with repeated episodes of hematemesis (blood in vomit) which generally stops by itself. Endoscopic banding can obliterate these vessels and prevent future bleeding. Mostly it affects children who along with hematemesis also present with growth failure in their formative years and enlarged spleen (splenomegaly). Typically in EHPVO there is massive splenomegaly and patients present with left upper abdominal swelling & heaviness, anemia and low platelet counts, repeated episodes of infection and bleeding from gums, nose, etc.

While endoscopic treatment can provide temporary relief from bleeding, surgery provides definitive cure. During surgery an alternate and durable path (shunt) is created to drain the blood from the portal system into the systemic circulation. This decreases the pressure in the collateral vessels which then collapses as well as and it prevents the formation of new collateral vessels.