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98
Right Hepatectomy
Extended Right Hepatectom
Extended Left Hepatectom
Left Hepatectomy
Surgical Therapy
Type
Right hepatectomy Resection of segments
Left hepatectomy Resection of segments
A. H. Sohail et al.
Segments involved
V–VIII
II–IV
Anatomic
resection
hepatectomy (right
trisegmentectomy)
Extended left
hepatectomy (left
trisegmentectomy)
Nonanatomic
resection
Functional liver volume (FLV)
FLV=Total liver volume−tumor volume
Extended right
Denitions
Future liver remnant (FLR): Volume of liver parenchyma remaining after liver
resection
Inadequate FLR leads to hepatic insufciency
Calculated using volumetric analysis with 3D reconstruction images (CT or MRI)
FLR% is the proportion of functional liver volume made up by the FLR
FLR%=FLR÷(total liver volume–tumor volume)
Resection of all segments
IV–VIII, and with or
without segment I
Resection of segments II–
IV, V, and VIII, with or
without segment I
Resection with uninvolved
surrounding margin
irrespective of segments
Left Lateral Sectionectomy
y
y Right Posterior Sectionectomy
Preferred FLR
Inadequate FLR
Patient Preferred FLR
Chemotherapy-naïve patients 20–25%
S/p chemotherapy or with hepatic steatosis 30–35%
Patients with cirrhosis >40%
If FLR is inadequate➔portal venous embolization can help to grow liver
parenchyma
3 Liver
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Preoperative preparation for hepatectomy
Reverse Trendelenburg position➔to achieve low central venous pressure
physiology
Pneumoperitoneum provides a tamponade effect and minimizes hemorrhage from the
hepatic veins
99
Preoperative preparation
for hepatectomy
Low CVP <5mmHg➔attenuate hemorrhage that can be most severe from the
hepatic venous system
Lower hematocrits is acceptable to minimize blood transfusion
The knowledge of relevant segmental anatomy helps to demarcate resection planes
by selectively ligating extrahepatic portal venous and hepatic arterial branches
Key steps in liver resections
Left hepatectomy
• Conrm resectability via
ultrasound/laparoscopy
• Cholecystectomy
• Identify anatomy and obtain
control of porta hepatis➔then
ligate left portal vein and hepatic
artery
• Divide liver parenchyma along the
course of middle hepatic vein (use
ultrasound)
• Perform ligation/division of left
hepatic duct
• Identify conuence of middle and
left hepatic veins, ligate left hepatic
vein
• Divide parenchymal to posterior
liver edge
• Ensure hemostasis and control bile
leaks
Right hepatectomy
• Conrm resectability via
ultrasound/laparoscopy
• Mobilize right liver by dividing
attachments to diaphragm
• Cholecystectomy
• Identify anatomy and obtain
control of porta hepatis➔then
ligate right portal vein and hepatic
artery
• Divide liver parenchyma along the
course of middle hepatic vein (use
ultrasound)➔during this step,
ensure tributaries draining segment
IV are preserved
• Perform ligation/division of right
hepatic duct
• Small vessels draining directly into
the IVC must be ligated
• Divide right inferior vena caval
ligament (which may contain liver
and vascular tissue) with vascular
stapler
• Ligate right hepatic vein
Segmental resection
• Conrm resectability via
ultrasound/laparoscopy
• Cholecystectomy
• Obtain control of porta hepatis
• Based on a combination of location
of lesion, vascular, and biliary
anatomy (use intraoperative
ultrasound), mark demarcation
plane on the surface of liver
• Ensure lesion is in specimen to be
resected based on demarcation
plane and transect parenchyma
along the plane
• Prior to ligation of segmental blood
supply, occlude vessel briey, and
conrm adequate ow to remaining
segments (use ultrasound)
• Ensure biliary drainage of other
segments, use cholangiography
• Divide segmental vessels, and
complete parenchymal dissection
• Ensure hemostasis and control bile
leaks
• Complete parenchymal dissection
• Ensure hemostasis and control bile
leaks
100
Complications of liver resections
Complications
5% perioperative mortality for partial
hepatectomy
Characteristics
A. H. Sohail et al.
Treatment
General
Portal vein and hepatic
artery thrombosis
Bile leak
Liver failure
30–50% morbidity for partial
hepatectomy
Duplex ultrasound or CT with contrast
to diagnose
Incidence: 10%
Conrm by bilirubin analysis of drain
output (drain bilirubin >3× serum
bilirubin)
Increase in INR and hyperbilirubinemia
are diagnostic
Research
Reference Findings
Ribeiro HS, Costa WL, Diniz AL, Godoy AL,
Herman P, Coudry RA, Begnami MD, Mello CA,
Silva MJ, Zurstrassen CE, etal. Extended
preoperative chemotherapy, extent of liver resection
and blood transfusion are predictive factors of liver
failure following resection of colorectal liver
metastasis. Eur J Surg Oncol. 2013;39:380–5
Therapeutic anticoagulation
Percutaneous drainage➔endoscopic
sphincterotomy expedites
resolution➔reoperation only if severe and
refractory
Detailed preoperative assessment of FLR to
avoid this complication
Management is mainly supportive
Intraoperative bleeding and the need for blood transfusion
are important predictors of post-hepatectomy liver failure
Anatomy
Duoden
Superior
Spleen
adrenal
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Anatomy
Pancreas andSpleen
4
MatthewKrell, AmirH.Sohail, CarolineE.Williams,
MeganWinner, andJohnAllendorf
Retroperitoneal organ
Stomach lies anteriorly, duodenum anterior, superior
and lateral, and the spleen laterally
Anterior to the rst lumbar vertebra
Anterior to the vena cava at the conuence of the renal
veins
Body and tail terminate within the splenic hilum
M. Krell · A. H. Sohail (*)
General Surgery Residency, NYU Long Island
School of Medicine, NYU Langone—Long Island
Hospital, Mineola, NY, USA
e-mail: matthew.krell@nyulangone.org;
amir.sohail@nyulangone.org
C. E. Williams
General Surgery Residency, University of Central
Florida/HCA Healthcare, Pensacola, FL, USA
e-mail: caroline.williams2@ucf.edu
Inferior
vena cava
Aorta
mesentric
vein
Superior
mesentric
artery
Pancreas
Left
Gall bladder
um
Common
bile duct
M. Winner
Department of Surgery, NYU Long Island School of
Medicine, Mineola, NY, USA
Robotic Surgical Oncology Program, NYU Langone
Hospital—Long Island, Mineola, NY, USA
e-mail: megan.winner@nyulangone.org
J. Allendorf
Department of Surgery, NYU Long Island School of
Medicine, Mineola, NY, USA
Division of Surgical Oncology, NYU Langone
Hospital—Long Island, Mineola, NY, USA
e-mail: john.allendorf@nyulangone.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Ajouz et al. (eds.), The ABSITE Blueprints, https://doi.org/10.1007/978-3-031-32643-1_4
101
102
Tr
of duodenum
Anatomy
Uncinate process behind superior mesenteric vein,
rests on aorta
Pancreatic body is bordered superiorly by the celiac
axis and inferiorly by the superior mesenteric vessels
Anatomic parts of pancreas
ansverse
colon
Transverse
mesocolon
Small
intestine
Pancreas
Middle
colic artery
M. Krell et al.
Superior
mesenteric
artery
Left
renal vein
Uncinate
process of
pancrease
Third portion
The pancreas is divided into ve anatomic sections:
Head, uncinate process, neck or isthmus, body, and tail
Neck overlies the superior mesenteric vein
Head proper
Uncinate
process
Ta il
Body
Neck
pancreaticoduodenal
artery & vein
Abdominal
mesenter
4 Pancreas andSpleen
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Anatomy
103
Blood supply
Arterial blood supply to the pancreas is extensive, with
multiple collaterals
Gastroduodenal artery travels anterior to the head of
the pancreas
Splenic artery travels superior and posterior to the
body and tail of pancreas
Head and neck:
Supplied by branches from:
• Celiac➔common hepatic artery➔gastroduodenal
artery➔superior pancreaticoduodenal artery
(anterior and posterior)
• SMA through inferior pancreaticoduodenal artery
(anterior and posterior) which forms the anastomosis
between the celiac and SMA
Body and tail:
Supplied by splenic artery through 8–10 branches
• Dorsal pancreatic artery arises from the splenic
artery and courses posterior to the body to become
the inferior pancreatic artery
• Superior pancreatic artery
• Great pancreatic artery
• Transverse pancreatic artery
Hepatic
artery
proper
Gastroduodenal
Anterior & posterior
superior
artery
Anterior & posterior
inferior pancreaticoduodenal
artery
artery
vena cava
Portal vein
Inferior
aorta
Celiac
trunk
Great
pancreatic
artery
Superior
mesenteric
Splenic
artery
Spleen
Venous drainage
Superior mesenteric and splenic veins converge to
form the portal vein behind the neck of the pancreas
Inferior mesenteric vein insertion is variable with
drainage into the superior mesenteric vein or splenic
vein
Venous drainage mirrors arterial supply
Right gastroepiploic vein is found at the superior
mesenteric vein conuence
Posterior superior
pancreaticoduodenal
vein
Superior
ic
vein
Right gastroepiploic
vein
Portal
vein
Right
gastric
vein
Middle
colic
vein
Splenic
vein
Inferior
mesenteric
vein
104
Common
artery from SMA (10%-15%)
Anatomy
Biliary anatomy
Bile duct runs posterior to the head of the pancreas
lateral to the portal vein. The distal common bile duct
is enveloped by the head of the pancreas
Cystic
duct
Common
hepatic
duct
Left
hepatic duct
Right
hepatic duct
M. Krell et al.
Lymphatics
Celiac, hepatic, and superior mesenteric artery nodes
Surgical anatomy
Anatomy Risk of injury
Aberrant right hepatic artery from superior mesenteric
artery runs through pancreatic head posterior to portal
vein
bile duct
Pancreatic
duct
Risk for injury during pancreaticoduodenectomy
Right hepatic artery is the origin of cystic artery and
dominant arterial supply to biliary tree
Splenic artery often takes a tortuous course superior to
the pancreas before turning forward into the
splenorenal ligament
The course of superior mesenteric artery in relation to
the uncinate process is variable
Superior mesenteric vein courses deep to the pancreatic
neck, which is the thinnest part of the gland
Replaced right hepatic
Injury to right hepatic artery➔biliary stricture
Risk of injury during longitudinal pancreatojejunostomy or
distal pancreatectomy
Risk of injury during pancreaticoduodenectomy when
resecting pancreatic head
SMV can be injured when transecting head of pancreas or
making tunnel behind the pancreatic neck
por
pancreas
Duodenum
4 Pancreas andSpleen
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Obstruction➔duodenojejunostomy
or duodenoduodenostomy (pediatric)
If pancreatitis: Endoscopic retrograde
cholangiopancreatography (ERCP)
and sphincterotomy
Excision for complications related to
heterotopic pancreas
105
Developmental Anomalies ofPancreas
Developmental anomalies of pancreas
Anomaly Characteristics Presentation Diagnosis Management
Stomach
Gastric outlet obstruction in
children
Pancreatitis in adults
Often asymptomatic
Aberrant migration of ventral bud
Associated with trisomy 21/down
syndrome, malrotation, intestinal
atresia
Annular
pancreas
Circumferential pancreas tissue
surrounding second portion of
Axial abdominal CT image with IV contrast
demonstrated an annular pancreas (arrow)
tion of
Annular
duodenum
Characteristic imaging appearances of
heterotopic pancreatic tissue is key to rendering
the diagnosis preoperatively
Often incidental nding during surgery or
autopsy
Pancreas
Often asymptomatic
Pancreatitis, pseudocyst
formation, malignant
degeneration, gastrointestinal
bleeding, bowel obstruction,
and intussusception
Most common in upper
gastrointestinal tract; duodenum,
stomach
CT showing small oval intramural
mass with micro-lobulated margins
and an endoluminal growth pattern
Heterotopic
pancreas
106
Ventral duct
If symptomatic: Endoscopic
retrograde cholangiopancreatography
(ERCP)+sphincterotomy of the
minor papilla or surgical therapy
(success rates are similar)
Dilated dorsal ducts may be
candidates for a Puestow procedure
Severely symptomatic patients who
denervation or resection
Incidental pancreas divisum➔no
fail other options➔pancreatic
additional evaluation or treatment
Mild or infrequent
symptoms➔manage conservatively
(low-fat diet and analgesia)
M. Krell et al.
Developmental anomalies of pancreas
Anomaly Characteristics Presentation Diagnosis Management
Gold standard test: Secretin-enhanced magnetic
resonance cholangiopancreatography (MRCP),
which shows a failure of ventral and dorsal duct
fusion
Magnetic resonance cholangiopancreatography
(MRCP): Pancreatic duct crossing over CBD
and inserting separately (crossing duct sign)
95% asymptomatic
Obstruction of minor papilla,
which drains the dorsal bud
(body/tail of pancreas)➔leads
to pancreatitis
Relapsing acute or chronic
pancreatitis (Santorini duct)
Dorsal duct
Common bile duct
Failure of the dorsal (Santorini)
and ventral ducts (Wirsung) to fuse
Most common congenital
pancreatic anomaly
Pancreas
divisum
Coronal MRCP image demonstrates no
connection between the main pancreatic duct
Major ampulle
(solid arrow) and the ventral duct (outlined
arrow)
4 Pancreas andSpleen
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Acute Pancreatitis
Acute pancreatitis
Most common causes in the USA are gallstones and excessive alcohol consumption
Less common causes are post-ERCP, trauma, hypertriglyceridemia, hypercalcemia, and drug side
effects (sulfonamides, azathioprine, and thiazide diuretics)
Alcohol: Can cause auto-activation of pancreatic enzymes while still in pancreas
MC genetic mutations that make individuals susceptible to pancreatitis: PRSS1 cationic
trypsinogen gene (hereditary pancreatitis); CFTR gene mutation (cystic brosis); SPINK1 gene
mutation
Characteristics
107
Gene Function Disorder
Protease serine 1 (PRSS1) gene Regulates trypsinogen
production
Serine protease inhibitor, Kazal
type 1 gene (SPINK1)
Cystic brosis transmembrane
conductance regulator (CFTR)
∆508
Symptoms Abdominal pain radiating to back, nausea and vomiting, can present as meconium ileus in a
neonate or persistent constipation in an infant
Diagnosis Clinical ndings+levation of pancreatic enzyme levels (amylase/lipase)
Lipase is also a more specic marker of acute pancreatitis because serum amylase levels can be
elevated in several conditions
CRP correlates with severity of pancreatitis. CRP>150➔severe pancreatitis
CT with IV contrast is the standard imaging modality for evaluation in acute pancreatitis to check
for necrosis
Severe acute
pancreatitis
Severe acute pancreatitis is dened as single or multiple organ failure for >48h
(Mortality rate upward of 25%)
Prevents premature
activation of
trypsinogen
Regulates the exchange
of bicarbonate and
chloride ion in the
pancreatic duct
PRSS1 mutations➔hereditary
pancreatitis
Autosomal dominant with 80%
penetrance
Tropical calcic pancreatitis and
hereditary pancreatitis
Homozygous CFTR
mutations➔cystic brosis
Heterozygous➔pancreatic
exocrine insufciency and chronic
pancreatitis
Management Enteral nutrition is safe and may be associated with a lower complication rate than TPN
Enteral nutrition decreases infectious morbidity, hospital stay, need of surgical intervention,
multiorgan failure, and mortality
Aggressive uid resuscitation with isotonic crystalloid solution
Infected peripancreatic uid collection should be excluded in all patients with recent history of
severe acute pancreatitis presenting with persistent fevers
In patients with pancreatic necrosis, the risk of infection is related to the amount of necrosis
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