Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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Divide the anterior and posterior leaflets of the right triangular ligament using electrocautery. It is usually best to first extend the incision of the anterior leaflet from the right lateral margin to the midline. At this point, gentle blunt dissection will separate the diaphragmatic attachments, better revealing the posterior leaflet and facilitating division of this structure. In this fashion, the liver is mobilized to the midline, as well as in a caudal direction (Figure 44-9). With full mobilization, it is possible to bring the liver into the midline, affording a wide access to the entire liver.

Dissect the peritoneum overlying the hepatoduodenal ligament in a transverse direction. After dividing the typically filmy gastrohepatic or lesser omentum medial to the ligament, it is possible to pass your finger or an instrument into the foramen of Winslow and completely encircle the structures contained in the hepatoduodenal ligament. Pass an umbilical tape around the ligament, and using the hooked instrument with a section of rubber tubing create a Rummel loop. This safety measure is performed to permit complete inflow occlusion should this be necessary to control undue hemorrhage if encountered at any time during the procedure. Place a hemostat on the two loose ends of umbilical tape (Figure 44-10).

At approximately the mid-portion of the hepatoduodenal ligament, dissect and isolate the common bile duct laterally and the proper hepatic artery located on the medial edge of the ligament. Place a 1⁄4-inch Penrose drain around the bile duct and a vessel loop around the artery, and use traction on these two structures to reveal the portal vein positioned between and posterior to these two parallel structures. Gently tease the filmy adhesions to isolate all three structures and extend this dissection toward the hilum.

Follow the common bile duct, hepatic artery, and portal vein toward the hilum of the liver, and then isolate and encircle the right branch of each structure. Each of these will follow a course directed toward the gallbladder bed, which rises at approximately a 60-degree angle from the hilum toward the right liver.

Interrupt vascular inflow to the right liver temporarily by placing atraumatic vascular clamps on the right hepatic artery and right portal vein.

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3. CLOSING

Close the abdomen in a standard manner. We favor a horizontal mattress closure (SmeadJones) with heavy-gauge absorbable suture.

STEP 4: POSTOPERATIVE CARE

In the first 24 hours after surgery, the primary concern is hemorrhage and the related measure of coagulation status. These should be monitored by means of serial measurement of hemoglobin and coagulation factors.

In all major resections, particularly in patients with cirrhosis, one must be vigilant for any signs of hepatic failure. A particularly ominous finding is the progressive rise in bilirubin level with an enzyme pattern that supports neither obstruction nor parenchymal cell death, such as transaminase elevations. The most ominous finding is a plummeting serum glucose level, which reflects the loss of glycogen stores in the liver and by inference the loss of viable liver. Unfortunately, there is little one can do to reverse this pattern of failure. One possible cause is inadequate remaining liver after resection. This can resolve over time as the liver regenerates, which it will do to some degree.

One possibly remediable cause of this progressive demise is thrombus formation in the portal vein. This would seem to be unlikely, because coagulation is typically inadequate in these patients, but we have seen this phenomenon. It is possible that lysis of this clot may restore vital flow.

Sepsis is particularly metabolically taxing to the liver. In the compromised postoperative liver, sepsis can be catastrophic. One should monitor and obtain cultures if necessary to prevent infectious processes from progressing.

Ascites may form, and one must be aware when this phenomenon has occurred and treat as one would normally treat this entity with careful and judicious use of salt-containing intravenous fluids and with diuresis.

Remove drains if no bile is seen in the effluent.

STEP 5: PEARLS AND PITFALLS

As with all such major operative procedures, one must exercise extreme care in patient selection.

If hemorrhage occurs at any time during the procedure, the liver can be compressed into the spine or into the right flank to gain control, and another capable surgeon can be called for assistance.

Before dividing any of the major vascular structures, stop and reconfirm that the proper structure is being divided.

If ascites forms and the drains are still in place, excessive electrolyte and fluid loss can occur through actively draining liters of fluid per day. In this setting, the drains (assuming they are not bile tinged) should be removed, and the skin overlying the drain tract should be sutured.

SELECTED REFERENCES

1.Blumgart LH, Belghiti J: Liver resection for benign disease and for liver and biliary tumors. In Blumgart LH (ed): Surgery of the Liver, Biliary Tract and Pancreas, 4th ed. Philadelphia, Saunders, 2007, pp 1341-1388.

2. Liu CL, Fan, ST, Cheung ST, et al: Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: A prospective randomized controlled study. Ann Surg 2006;244: 194-203.

3. Nanashima A, Sumida Y, Abo T, et al: Anatomic resection of segments 5, 6 and 7 of liver for hepatocellular carcinoma: Prior control of right paramedian Glisson. Hepatogastroenterology 2008;55:1077-1080.

4. Shirabe K, Shimada M, Gio T, et al: Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver volume. J Am Coll Surg 1999;188:304-309.

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STEP 2: PREOPERATIVE CONSIDERATIONS

Due to the magnitude of hepatic surgery, one first consideration is the medical status of the patient and likely risk of surgery. Thus one must exclude significant coronary, pulmonary, or renal disease, or age and frailty. Of particular concern in relation to hepatic surgery is the underlying hepatic function. Because hepatocellular carcinoma is associated with prior hepatitis and cirrhosis, one must determine first whether cirrhosis exists and second what level of function is apparent. Historically, this was measured by examining synthetic and excretory functions and measures of portal hypertension (serum albumin level, coagulation profile, serum bilirubin level, ascites, and mental status/serum ammonia). More recently, the Model for End-Stage Liver Disease (MELD) score was developed as a means of segregating candidates for liver transplant. This system incorporates prior variables, but has added and places considerable significance to renal function. Particularly when one anticipates a major resection, one must establish that sufficient liver will remain to support life. Unfortunately, this estimate of “hepatic reserve” is even today an inexact science.

Nutritional status, renal function, degree of ascites, and coagulation abnormalities are all factors that may be improved by medical management before surgery. Unfortunately, we have personal experience that such patients may thereby achieve an improved functional grade but appear to carry a risk that exceeds the risk in patients who have had this improved functional status without a need for medical manipulation to achieve it.

STEP 3: OPERATIVE STEPS

1.INCISION

Several incisions have been proposed. We favor the inverted L incision, with the option to extend the incision vertically in the midline for added exposure, as well as extending farther the horizontal component of the incision either laterally into the right flank or across the midline (Figure 45-3).

Placing self-retaining retractors maximizes the exposure of the right upper abdomen. The incision should be extended if the operative view is inadequate.