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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_629_Библиотеки_им_академика_М_И_Перельмана
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1
Gallbladder and line
of resection
Left
hepatic vein
Divided
falciform
3
ligament
Left lobe
duct, vein, and
artery
2
Falciform
ligament
4
Left triangular
ligament
Ligated
cystic
artery
Left lateral lobe
Ligature on
cystic duct
Left duct
ligatures
5
243
Left
hepatic
artery
ligatures
PLATE
113
L H
(S , , ± S )
DETAILS OF PROCEDURE e le branch of the portal vein is
now exposed. e area of the bifurcation of the portal vein is carefully freed
up and the le branch mobilized for a su cient distance to permit the application of a pair of curved Cooley vascular clamps without compromising the
bifurcation of the portal vein. e le branch of the portal vein is divided a
short distance beyond the clamps to permit closure of the proximal end of
the branch of the portal vein with a continuous horizontal mattress suture of
- synthetic nonabsorbable suture that is then run back as an over-and-over
suture a er the method of Cameron (figure 6). If the caudate (Segment ) is
to be preserved, the surgeon must take care to divide the le portal vein distal
to the caudate branch at the base of the umbilical ssure. Alternatively, the
portal vein can be divided using a vascular stapler. A nal inspection determines that the blood supply to the right lobe is functioning normally.
e blood loss should be lessened if the le hepatic vein is ligated before
the liver tissue is divided. e le hepatic vein is freed of liver substance
until a su cient distance is gained to permit the application of a pair of long
curved Cooley vascular clamps. e le lateral segment (Segments and )
can be li ed to expose the ligamentum venosum. When this is divided at its
most cranial extent, a window is opened along the inferior border of the le
hepatic vein as well as the middle hepatic vein depending upon their point
of convergence. e path of the middle hepatic vein must be visualized as
separate from the le hepatic vein. e end of the vein projecting beyond the
clamps is closed rst with a continuous mattress suture and then back with
an over-and-over suture (figure 7). e clamps are removed and a nal
check is made that the proximal caval end of the divided le hepatic vein is
secure. A vascular stapler may be utilized to control the le hepatic vein.
A line of demarcation between the right and le lobes develops a er
the le hepatic vein has been ligated. is line tends to curve in a concave
manner to the le until the dome of the liver is reached. Ultrasonic dissecting instruments are available for dividing (figure 8) and aspirating the
liver tissue with easier exposure for ligation of the larger ducts and vessels,
especially the venous branches of the median hepatic vein. Alternatively, an
electrocautery or laser device may be used to divide the liver parenchyma
or an endoscopic GIA stapler can be used once the internal vascular anatomy is clearly de ned sonographically.
Some have used deeply placed absorbable mattress sutures, starting
at the anterior lower liver edge and progressing upward along the line
of demarcation. e liver tissue should be compressed with the capsule
intact and not crushed. e liver may be divided in a variety of ways but
ligatures or clips must be applied to the larger vessels or bile ducts on the
cut surface of the right lobe. Clips are usually adequate on the le lobe
side, which is to be resected. e deeply placed interrupted sutures near
the dome of the liver do not go completely through all the liver tissue in
the region of the dome.
e raw surface of the right lobe is carefully inspected for bleeding
points as well as for bile leakage, which may require a suture ligature
(figure 9). Surface coagulation may be obtained with an argon beam
electrocautery system. is may lessen the need for application of various
hemostatic materials to the cut surface of the residual liver. e omentum
can be mobilized and anchored over the divided surface of the right lobe.
Closed-system Silastic suction drains can be used.
CLOSURE A routine closure of the abdominal wall is performed.
POSTOPERATIVE CARE Antibiotics are given and the amount of blood or
bile drainage is recorded daily. e time for removal of the drains is related
to the amount and type of drainage. ■
244
6
Ligature left
hepatic duct
7
Left branch of
portal vein:
vascular clamps
8
Color
demarcation
Curved vascular
clamps on left
hepatic vein
Falciform
ligament
Line of
resection
9
Ligated
minor vessels
and ducts
Oversewn left
hepatic vein
Inferior
vena cava
245
PLATE
114
E R H
(S , , , , ± S )
INDICATIONS Malignant tumors involving a large part of the right lobe
with extension into the medial segment of the le lobe are a possible
indication for extended right hepatectomy (or trisegmentectomy). Lesions
straddling midway between the right and le lobes will require trisegmentectomy. is is a major surgical procedure that requires a highly skilled
team trained in this eld.
PREOPERATIVE PREPARATION Antibiotics are given and any blood
de ciency is corrected. Imaging scans (CT, MRI, or PET-CT) localize the
metastases in the liver. Hepatic angiography is not routinely necessary.
e lungs must be free of metastases, and studies should not have demonstrated any gross abdominal or colorectal recurrence. e patient must
be made aware that a major portion of the liver may need to be excised.
Survival of the patient can be anticipated if percent or more of normal
liver tissue remains in the le lobe. If the volume of the remaining live is
estimated by three dimensional reconstruction to be less than , then
right portal vein embolization may be performed in order to enhance the
residual liver volume through post-embolization hypertrophy of the le
lateral segment.
ANESTHESIA A general anesthetic is required with appropriate catheters
in place to provide ready access for the administration of blood, uids, and
medication. Central venous pressures should be monitored.
POSITION e patient is placed supine on the operating table in a slightly
reverse Trendelenburg position.
OPERATIVE PREPARATION e skin of the thorax and abdomen is pre-
pared, since the incision may extend from over the lower sternum to below
the umbilicus.
INCISION AND EXPOSURE A long right subcostal incision that extends
across the le subcostal region and includes a midline opening to the
xiphoid provides excellent exposure. Alternatively, a long midline incision
starting above the xiphoid and extending below the umbilicus may be used.
is procedure requires liberal exposure.
DETAILS OF PROCEDURE e extent of tumor involvement of both the
right lobe and the medial portion of the le lobe is veri ed by inspection,
bimanual palpation, and ultrasonic imaging (figure 1).
e scans are reviewed to recon rm the location of the lesion and review
the vascular supply to the liver. In patients with colorectal metastases, it is
essential to palpate and visualize the pouch of Douglas for metastases as well as
the entire colon, small bowel, mesentery, omentum, and peritoneum. Multiple
seeding would cancel the procedure, although some prefer to excise or cauterize an occasional very small metastasis and proceed with the liver resection.
e liver is mobilized by dividing the falciform and both triangular
ligaments as well as freeing up the liver posteriorly from the diaphragm
(figure 2).
When mobilization of the liver has been completed by dividing the right
coronary ligament, the procedure outlined for a right hepatectomy is followed. Ligation of the cystic artery and cystic duct is performed, and the
gallbladder is removed, resulting in a better exposure of the deeper structures that are to be divided. A clear exposure of the right hepatic duct is
essential to con rm the absence of interference with the area of bifurcation
supplying the le hepatic duct (figure 3).
A er the right duct is divided, the variable arterial supply is exposed.
e surgeon should be alerted to the possibility that the right hepatic artery
may arise directly from the superior mesenteric artery. e le hepatic
artery must be visualized to be certain it has not been obstructed or interfered with in any way. e variability of the arterial blood supply between
the right and le lobes should be kept in mind by the surgeon during the
dissection in this area. Under clear vision, the right hepatic artery is divided
and double-tied with a trans xing suture (figure 4).
e right and le branches of the portal vein are clearly exposed before
the right branch of the portal vein is doubly clamped with straight Cooley
vascular clamps. Both open ends of the portal vein are oversewn with a
continuous - nonabsorbable vascular suture. e ends of the proximal
vein are also approximated with horizontal mattress sutures. e end going
to the right lobe is doubly ligated or oversewn (figure 5). Alternatively, the
right portal vein may be divided using a vascular stapler.
CONTINUES
246
Right
triangular
ligament
Left
triangular
ligament
1
Right
hepatic vein
Gallbladder
Line of
resection
Ligated
right hepatic
duct
2
Falciform
ligament
Left
hepatic duct
4
3
Right
hepatic artery
Cystic duct
Right branch,
portal vein
Right
hepatic
artery
5
Loop about
common
hepatic duct
247
PLATE
115
E R H
(S , , , , ± S )
DETAILS OF PROCEDURE Special attention must be given
to taking down the hilar plate, followed by carefully mobilizing the le
hepatic duct, the le hepatic artery, and the le branch of the portal vein
from the undersurface of the overlying liver. ese vessels enter the liver
at the base of the umbilical ssure. A er the vessels and other structures
are gently dissected away from the liver, an area is exposed for the incision between the medial and lateral segments of the le lobe of the liver
(figure 6). e bridge of hepatic parenchyma across the umbilical ssure does not contain a major vascular structure and can be divided with
electrocautery. Branches to Segment from the le portal vein can be
individually controlled along the right border of the round ligament as it
traverses the umbilical ssure.
e right lobe is rotated medially away from the diaphragm, exposing
the small hepatic veins communicating with the inferior vena cava. ese
small vessels are carefully and securely ligated, followed by exposure of the
major right hepatic vein (figure 7). As in right hepatectomy, the caval ligament is carefully divided to expose the right hepatic vein.
A vessel loop is passed around the large right hepatic vein, and the liver
tissue gently pushed away from this large vein to permit the application of
two curved Cooley vascular clamps to the vein. Su cient vein must extend
beyond the vascular clamp to enable oversewing of the open ends a er the
vein has been divided. Two rows of nonabsorbable vascular sutures are
used to secure the end of the right hepatic vein. e middle hepatic vein
can be treated in a similar manner or its branches ligated individually as the
medial and lateral segments are divided (figure 8). e hepatic veins can
similarly be controlled using a vascular stapler.
e division of the liver lobes is made nearer the falciform ligament,
rather than in the line of the vascular demarcation between the right and
le lobes. Deeply placed stay sutures are placed parallel a few centimeters
away from the falciform ligament. ese sutures are placed on either side of
the incision and tied to control the bleeding, but care is taken not to crush
the liver substance. e liver is divided with an ultrasound dissector or electrocautery unit between the area supplied by the middle hepatic vein and
medial to the le hepatic vein. Any structures losing blood or leaking bile
are ligated with a trans xing suture or clips (figure 9). Alternatively, the
hepatic parenchyma can be transacted using multiple applications of endoscopic cutting linear stapler (GIA) with vascular loads. Great care must be
taken along the inferior border of Segment B so as not to compromise the
integrity or vascular supply of the le hepatic duct.
A er removal of the right lobe and involved portion of the le medial
lobe, the falciform ligament is reapproximated to ensure stability of the
remaining portion of the le lobe. Special care is taken to avoid injuring
the ducts and blood vessels that may be exposed as they enter the smaller
residual le lobe.
e pathologist examines the specimen to determine that adequate margins are present and free of tumor.
A variety of materials ranging from tissue glue to prepared hemostatic sterile
dressings, as well as omentum are used to cover the raw surfaces of the remaining le lobe of the liver. Closed-system Silastic suction drains may be used.
CLOSURE A routine surgical closure is used. Closed-system Silastic suc-
tion drains are inserted.
POSTOPERATIVE CARE Antibiotics are discontinued within hours.
Blood and liver function studies should be done on a daily basis postoperatively. Blood losses from drains should be replaced. Patients can do well
despite extensive hepatic resection. Meticulous attention should be paid to
minimizing infectious risks. (Leakage of uid from the wound should not
be tolerated and should be aggressively corrected.) ■
248
7
6
Divided
hepatic bridge
Line of
resection
8
Loop about left
medial duct
Venous branches
from cava
9
Falciform
ligament
Oversewn
right hepatic
vein
Vascular
clamps on
left medial
hepatic vein
Ligated minor
vessels and ducts
10
Reapproximation
249
PLATE
116
D C P
P
INDICATIONS Pseudocysts of the pancreas are not an uncommon sequela
of acute pancreatitis, chronic pancreatitis, and blunt abdominal trauma with
resultant traumatic pancreatitis. Pancreatic pseudocysts should be suspected
when the serum amylase remains elevated a er apparently satisfactory
response to treatment of the acute episode. However, the serum amylase may
be normal, and quantitative urinary amylases may establish the diagnosis.
Blood calcium levels should be followed during severe episodes. A palpable mass can usually be detected in the upper abdomen, most frequently in
the mid-epigastrium or the le upper quadrant. ese cysts do not have an
epithelial lining as do the true pancreatic cysts. ey are most commonly
found in the body and tail of the pancreas but also may be found in the neck
and head of the pancreas. Ultrasonography, computerized tomographic
scans, and retrograde cannulation of the pancreatic duct with injection of
dye and x-ray opaci cation (endoscopic retrograde cholangiopancreatography or ERCP) may demonstrate a pseudocyst. Films of the chest and abdomen may demonstrate elevation of the le hemidiaphragm with or without
basilar atelectasis or pleural e usion. Treatment of cysts that do not regress
spontaneously consists most commonly of internal drainage via the stomach, duodenum, or jejunum. External tube drainage with subsequent stula
may be rarely indicated. Alternatively, some radiologists may drain mature
pseudocysts attached to the posterior wall of the stomach using computerized axial tomography. A transgastric needle and then catheter is introduced
via a gastrostomy usually created by the percutaneous endoscopic gastrostomy technique (Plate ).
e ideal time to drain these pseudocysts internally is to weeks a er
their appearance, when the cyst is intimately attached to the surrounding
structures and the surrounding in ammatory reaction is quiescent. At this
time the cyst wall is strong enough for the technical anastomosis. External
tube drainage of the cyst may be necessary if the cyst wall is friable or if
the patient is septic or has a rapidly expanding pseudocyst. In all cases the
interior of the cyst should be thoroughly examined and the cyst wall biopsied. Externally drained cysts usually close spontaneously, but pancreatic
stulas can occur. Cysts may resolve gradually, particularly those associated
with stones in the common duct and acute pancreatitis. In general, patency
of the ampulla and the proximal pancreatic duct should be established by
ERCP prior to any operative procedure.
PREOPERATIVE PREPARATION It is most important that these patients
be in satisfactory metabolic condition before surgery. Accordingly, de ciencies in electrolytes, red cell mass, serum protein, or prothrombin levels
are corrected preoperatively, and total parenteral nutrition should be considered. A clear liquid diet is given on the day before surgery, and the colon
is emptied by the use of oral cathartics.
ANESTHESIA General anesthesia with intratracheal intubation is
satisfactory.
POSITION e patient is placed in a comfortable supine position as near
the operator’s side as possible. e knees are exed on a pillow. Moderate
elevation of the head of the table facilitates exposure. Facilities for operative
pancreatic cystogram as well as cholangiogram should be available.
OPERATIVE PREPARATION e lower thorax and abdomen are prepared
in the usual manner.
INCISION AND EXPOSURE An epigastric midline incision can be used
for this procedure. Resection of the xiphoid process will give an additional
to . cm of exposure if necessary.
DETAILS OF PROCEDURE A er the peritoneal cavity is entered, thor-
ough exploration is carried out with particular emphasis on the gallbladder
and common duct. Fat necrosis in the omentum or transverse mesocolon
is commonly found. e cysts of the pancreas are best drained into that
portion of the upper gastrointestinal tract most intimately adherent to the
cyst, as shown in figure 1a. Cystogastrostomy or cystoduodenostomy is
quite satisfactory when it can be performed easily. Loop cystojejunostomy
or Roux-en-Y cystojejunostomy may be performed also (figure 1b). e
Roux-en-Y is the preferred method for drainage unless the cyst is intimately
attached to the posterior gastric wall. It has the added advantage of preventing re ux of intestinal contents into the cyst, with less chance of leakage
about the suture line.
A er the eld is walled o by gauze pads, the omentum overlying the
cyst is opened and all bleeding points ligated (figure 2). e diagnosis of
a cyst is con rmed by needle aspiration of the suspected area. e cyst is
then partly aspirated, permitting the operator to determine the thickness of
the cyst wall and con rm the diagnosis (figure 3). Specimens of the cyst
contents are sent for culture and sensitivity, amylase and electrolyte determination. At this time operative cystography can be performed. Since the
cyst uid will dilute the contrast medium, it is better to inject to mL of
an undiluted contrast medium into the cyst.
Guide sutures A and B are placed into the wall of the cyst, and a - to
-cm opening is made at the desired level for drainage (figure 4). Suction
should be available for aspirating the cyst contents. e full thickness of the
cyst wall is biopsied (figure 4).
The surgeon should explore the interior of the cyst with the index
finger, carefully checking for coexistent neoplasm and pocketing within
the cystic cavity (figure 5). To prevent tension on the cystoduodenostomy, it is advisable to perform a Kocher maneuver to mobilize the
duodenum.
CONTINUES
250
1a
Jejunum
2
Stomach
Cyst
1b
Cyst
Middle
colic vessels
Cyst
Jejunum
Roux-en-Y anastomosis
Jejunum
Duodenum
Omentum
3
Cyst
4
Syringe
A
5
Incision
Biopsy
B
Finger inserted
into cyst
B
251
PLATE
117
D C P
P
DETAILS OF PROCEDURE Gentle tension is put on the duo-
denum with noncrushing clamps, and a posterior row of interrupted silk
horizontal mattress sutures is placed (figure 6).
Traction angle sutures are placed at the angles of the proposed opening
in the duodenum. e incision into the duodenum is made slightly smaller
than that in the cyst. All bleeding points are meticulously ligated with
silk (figure 6). e full thickness of the cyst wall is approximated
to the full thickness of the duodenal incision, using interrupted silk
sutures (figure 7). rough the duodenal incision, adequate exposure of
the ampulla of Vater can be obtained. If a sphincterotomy is considered, a
small probe or French woven whistle-tip catheter, No. or No. French,
is passed through the papilla of Vater into the duct (figure 8). e patency
of the common bile duct as well as the pancreatic duct is determined. Contrast medium is injected in a search for calculi or area of stenosis, as well as
documentation of the size of the ducts. e superior margins of the ampulla
are grasped by straight mosquito forceps. ese clamps are placed in an
anterolateral position to avoid injuring the pancreatic duct which enters on
the medial side (figure 9). A full thickness of tissue between the clamps
can be excised for a biopsy. e contents of the clamps are oversewn with
ne atraumatic sutures.
e mosquito clamps are applied again and include only several millimeters of common duct and duodenal wall at a time. e procedure is
repeated until the opening is the approximate size of the common duct.
Because of the wide range in the length of the intramural course of the
ducts, the length of the incision will vary from to mm. e opening
must be free of constriction when tested with a catheter or Bakes dilator. It
is absolutely essential that one or more gure-of-eight stitches be taken in
the apex of the incision to avoid duodenal leakage at this point.
e avascular septum between the lower end of the pancreatic duct
and the common duct is divided a er the introduction of a small catheter
into the pancreatic duct. e septum should be divided in patients who
have had recurrent pancreatitis (figure 10). A er hemostasis has been
obtained and an adequate ow of bile observed upon compressing the gallbladder, the pancreatic duct likewise is probed. e septum between the
common bile duct and the pancreatic duct may be divided if stenosis is
present. A biopsy of tissue is taken from the ampulla and ductal walls at
the time of the sphincteroplasty. A er the patency of the ducts has been
determined, the full thickness of the cyst wall and the full thickness of the
duodenum are approximated with interrupted delayed absorbable
suture as inverting sutures (figure 11). e seromuscular layer of the duodenum is approximated to the cyst wall in order to provide the outer layer
of the two-layer anastomosis (figure 12). is layer is carried well beyond
the margins of the interior anastomosis in order to prevent tension on the
anastomosis.
CONTINUES
252
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