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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
24 Liver Resection andBiliary Reconstruction
Fig. 24.6 Dissection of
the portal vein bifurcation
posterior to right hepatic
artery (RHA) and common
hepatic duct (CHD)
313
teased off the hilar plate by gently pressing the RPV posteriorly with the Maryland in
the left hand and sweeping the tissues off the vein with the scissors in the right hand.
Attention is then moved to the dissection of the posterior aspect of the RPV.The
peritoneal lining the posterior aspect of the RPV is divided and retracted posteriorinferiorly by the laparoscopic assistant. The posterior wall of the portal vein is dissected
free from the peritoneum surface until the caudate branches are visualized and dissected
free. The PV side of these branches are always ligated to avoid clips on the PV, hampering future clipping or stapling of the RPV, while the caudate side may be clipped.
Once all caudate branches are divided, the posterior RPV is then dissected off the
hilar plate, moving cephalad until the dissection plane is met from the anterior side.
Once this space is developed, the RPV is encircled with a vessel loop (Fig.24.7).
The RPV may be divided between large plastic clips or stapler at this stage. If the
RPV is particularly short, the proximal RPV inow can be clipped without division,
in which case the completion of this process is performed later in the procedure
(transection of the parenchyma and right hepatic duct increases the space around the
RPV, which will enable placement of additional clips or a stapler prior to division).
Indocyanine Green Injection andFirefly™
Demarcation of right versus left liver lobes is enhanced by indocyanine green (ICG)
dye injection (Fig.24.8). We use a 2.5 mg dose of ICG given after inow to the
relevant lobe has been ligated. The line of demarcation is marked on the liver surface using electrocautery. Injecting the dye at this stage will also allow enough time
for biliary excretion, which will assist in identication of the relevant-sided hepatic
duct during parenchymal transection.
Mobilization oftheRight Lobe
The third arm is moved to the inferior aspect of segments 5 and 6 and used to retract
these segments superior-anteriorly, exposing the inferior layer of the right coronary
and right triangular ligaments. These ligaments are divided using the scissors or
vessel sealer, taking care not to injure the diaphragm. As more of the bare area is
314
Fig. 24.7 Right portal
vein (RPV) encircled with
a blue vessel loop
Fig. 24.8 Enhancement of
right vs left lobe
demarcation using ICG
uorescence
Y. L. Cheah and C. J. Simon
exposed, the third arm is moved sequentially superiorly and posteriorly to provide
more retraction. The right adrenal gland is mobilized from the posterior surface of
the liver. Once most of the bare area has been mobilized, we turn our attention medially toward the retrohepatic inferior vena cava (IVC).
The peritoneal lining between the caudate and IVC is divided, and the short caudate and hepatic veins draining directly to the IVC are serially divided between clips
or with a vessel sealer (Fig.24.9). Dissection continues in a cephalad direction on
the anterior surface of the retrohepatic IVC, mobilizing the liver from the
IVC. Caudate lobe division at this point helps cephalad dissection of the
IVC.Laterally, the hepatocaval ligament will be encountered and can be left intact
at this stage as division of this ligament is easier after parenchymal transection. The
liver is carefully mobilized from the IVC until the area between the right and middle
hepatic veins is reached. This completes the right lobe mobilization.
24 Liver Resection andBiliary Reconstruction
Fig. 24.9 Retrohepatic
inferior vena cava (IVC)
dissection showing a short
hepatic vein branch
315
Parenchymal Transection andBile Duct Division
Intraoperative Ultrasound
An ultrasound is performed to delineate the anatomy of the liver mass and rule out
unsuspected liver metastasis prior to parenchymal transection. This examination
also ensures that transection margins are accurately marked. Location of major pedicles and segmental draining hepatic veins which will be encountered during transection can also be detected on ultrasound and marked on the liver surface.
Ultrasound images can be visualized in conjunction with the operative view on the
console using the multi-display system (Fig.24.10).
Retraction oftheLiver Using “Rubber Band” Technique
One rubber band is secured to the liver edges at each side of transection plane with
3/0 Vicryl sutures [12]. Each rubber band is then externalized on the skin of the corresponding right and left upper abdomen and clamped to the drapes. This technique
provides constant retraction of the transection plane without having to use any of the
robotic or laparoscopic arms or a liver retractor (Fig.24.11).
Parenchymal Transection
The third arm is used to gently lift the inferior surface of the liver off the hilum.
Parenchymal transection is performed with harmonic scalpel and Maryland bipolar
forceps (Fig.24.12). Small intervening vessels and oozing from the parenchyma are
controlled with bipolar electrocautery. Larger vessels including segmental veins
may be clipped and divided with the harmonic device. As more of the parenchyma
is transected, the liver edges are continually retracted due to the elasticity of the
rubber bands.
An alternative technique is to deploy the laparoscopic Cavitron Ultrasonic
Surgical Aspirator (CUSA, Integra Lifesciences, Princeton, NJ, USA) via one of the
assistant ports to transect the parenchyma. The utility of this technique is dependent
on the availability of a bedside surgeon who is facile in using the laparoscopic
316
Fig. 24.10 Multiview
display of ultrasound
showing tumor and middle
hepatic vein (MHV)
location and operative view
Fig. 24.11 Rubber band
retraction technique
Y. L. Cheah and C. J. Simon
CUSA.When the majority of the parenchyma has been transected (leaving only a
1–2cm strip of liver anterior to the IVC), the right hepatic duct (RHD) is divided.
Division ofRight Hepatic Duct
ICG cholangiogram offers visualization of the bile ducts and biliary bifurcation
using Firey™. The location of RHD division is chosen based on the surgeon’s
interpretation of the cholangiogram. The RHD with surrounding hilar plate should
be encircled with an umbilical tape. The duct is then divided between clips. The
distal duct should be doubly clipped if there is enough length; if not, the stump
should be suture-ligated above a single clip.
24 Liver Resection andBiliary Reconstruction
Fig. 24.12 Parenchymal
transection with harmonic
scalpel and bipolar
Maryland forceps
317
Final Portion ofParenchymal Transection
Once the RHD is transected, the laparoscopic assistant inserts a grasper or suction
catheter into the space previously created between the liver and retrohepatic IVC,
which is used to lift the liver away from the IVC.This portion of the parenchyma is
transected, heading cephalad toward the hepatic venous conuence. Finally, the
grasper is inserted into the space between the right and middle hepatic vein, and the
last portion of the parenchymal transection is completed.
Division oftheRight Hepatic Vein andHepatocaval Ligament,
andSpecimen Retrieval
The Maryland forceps is used to encircle the right hepatic vein (RHV) with an
umbilical tape from within the transection plane (Fig.24.13). The RHV is transected with a stapler. The hepatocaval ligament is also transected with a separate
ring of the stapler. The right lobe is then placed into a plastic retrieval bag, which
is removed via a Pfannenstiel incision. Final check for hemostasis and bile leak is
performed and a drain is placed adjacent to the cut surface and externalized through
one of the ports.
Left Hepatectomy
Falciform Dissection andMobilization oftheLeft Lobe
Falciform dissection is similar to right hepatectomy. Additionally, the left triangular
ligament is divided to mobilize the left lobe from its diaphragmatic attachments.
The left lateral segment is retracted toward the patient’s right abdomen using the
third arm, exposing the gastrohepatic ligament, which is divided up to the level of
the left hepatic vein. The Arantius ligament courses along the groove between the
left lateral segment and caudate lobe from the left portal vein to the left/middle
hepatic veins. It is divided at the superior pole of the caudate lobe, providing access
318
Fig. 24.13 Right hepatic
vein (RHV) encircled with
Maryland forceps after
completion of parenchymal
transection
Y. L. Cheah and C. J. Simon
to the posterior aspect of the left hepatic vein. Careful dissection in this area can
enable encirclement of the middle and left hepatic veins; these veins can be divided
with a stapler after the inow is taken. If encirclement is difcult, the veins can be
stapled at the end of parenchymal transection.
If the caudate lobe is to be resected as well, Spiegel’s lobe is retracted with the
tip of the third arm. It is mobilized from the IVC by incision of the peritoneal attachments and division of the hepatocaval ligament and the short hepatic veins draining
the caudate directly to the IVC.
Hilar Dissection
Since the left-sided hilar structures are not covered anteriorly by the CBD, cholecystectomy may be performed at this stage, or after completion of the liver resection. The third arm is used with a gauze pad to retract segment 4B.
Dissection oftheLeft Hepatic Artery
The peritoneum over the left side of the hilum is opened and pulsation of the left
hepatic artery (LHA) is located. This artery usually courses along the left side of the
hilar base to the umbilical ssure and it is common for the LHA to be short, as it
may divide early into the segment 4 and segment 2/3 branches. All lymphatic and
nerve tissues are dissected away from the LHA, including the station 12a node,
which is usually adherent to the left side of both the LHA and left portal vein (LPV).
The LHA is encircled and divided between clips or ties.
If there is a replaced or accessory left hepatic artery, this is usually a branch of
the left gastric artery and can be located during division of the gastrohepatic ligament. The branch is ligated and divided in this location.
Dissection oftheLeft Portal Vein
Division of the LHA will expose the anterior surface of the LPV.The plane between
the left hepatic duct or hilar plate and superior-anterior surface of the LPV is gently
24 Liver Resection andBiliary Reconstruction
319
developed by pushing the portal vein posteriorly and inferiorly off the attachments.
Dissection proceeds transversely along the base of segment 4B from the portal vein
bifurcation until the umbilical ssure. Several small segment 4B branches from the
LPV are divided in a similar manner to the caudate branches.
Attention is then moved to the dissection of the posterior LPV.The peritoneal
lining the posterior aspect of the LPV is divided and retracted posterior-inferiorly
by the laparoscopic assistant. The caudate branches are divided after ligation in a
similar manner as the right-sided caudate branches.
Once all caudate branches are divided, the posterior LPV is then dissected off the
hilar plate, moving cephalad until the dissection is met from the anterior side. Once
this space is developed, the LPV is encircled and is usually long enough to be
divided between large plastic clips or a stapler.
Lobe Demarcation andParenchymal Transection
ICG is used to demarcate the left lobe similar to the technique described with a right
hepatectomy. Once the transection line is marked, the rubber band retraction technique is used here as described above. Parenchymal transection is performed as
previously described. Intervening segmental veins are encircled and divided
between clips or with energy device (Fig.24.14). The caudate is transected from the
right lobe if it is to be included in the specimen. If the caudate can be preserved, the
transection line will change to a horizontal plane at the level of the hilum to separate
the left lobe from the anterior of the caudate lobe. Once the left hepatic duct (LHD)
has been divided (see below), the nal part of the parenchymal transection is completed. If the middle and left hepatic veins have not been ligated prior to parenchymal transection, this step can be performed now with a stapling device.
Division ofLeft Hepatic Duct
The LHD is similarly identied using ICG cholangiogram (Fig.24.15). If the bile
duct margin is not relevant, the LHD is usually divided adjacent to the umbilical
ssure to avoid injury to aberrant right hepatic duct branches.
Fig. 24.14 Segment 5
hepatic vein (HV) clipped
during parenchymal
transection
320
Fig. 24.15 ICG
cholangiogram
demonstrating common
hepatic duct (CHD), biliary
bifurcation, and site of
division of left hepatic duct
Y. L. Cheah and C. J. Simon
Pringle Maneuver
An intermittent Pringle maneuver is useful when inow control cannot be obtained
prior to parenchymal transection or to reduce bleeding during parenchymal transection [13]. Most reports of the Pringle maneuver for minimally invasive liver
surgery involve extracorporeal control of the tourniquet. In this technique, control
of the Pringle maneuver in robotic surgery is in the hands of the bedside laparoscopic assistant surgeon. One end of a long moistened umbilical tape is inserted
via a 5mm laparoscopic port, leaving the other end outside the abdomen. The
position of this port is usually on the opposite side of the lobe to be resected, i.e.,
the port is placed in the left abdomen in a right hepatic resection and vice versa.
The tape is slung around the liver hilum and the end is externalized via the same
port. The laparoscopic trocar is then removed and a small-bore chest tube or silastic catheter is slid over both strings, with the ends remaining extracorporeal. The
bedside surgeon can then control the Pringle application in the style of a Rumel
tourniquet.
Alternatively, intracorporeal Pringle maneuvers have been described, including
applying a laparoscopic Satinsky clamp across the hilum, or leaving the ends of the
tapes intracorporeal and cinching the tourniquet by inserting a large occluding clip.
The Huang’s loop is another intracorporeal technique, which uses a foreshortened
urinary catheter, forming a loop by pulling the tail through the side hole [14]. The
loop is cinched to apply the tourniquet and then secured with a clip.
Pertinent Technical Notes forOther Types ofHepatectomy
Left Lateral Sectionectomy
Port positions are similar to left hepatectomy. Parenchymal transection is usually
performed to the left of the umbilical ssure and falciform ligament. Inow control
utilizes a Glissonian technique by division of the pedicles to segments 2 and 3
24 Liver Resection andBiliary Reconstruction
during parenchymal transection. The left hepatic vein can be divided between clips
or with a stapler at the end of parenchymal transection (Video 2).
321
Right Posterior Sectionectomy
Port positions are moved slightly more to the right compared to a right hepatectomy.
The patient should be positioned with right side up at 10–15 degrees. The falciform
ligament can be looped with a suture, which is then externalized in the left abdomen
and clamped to the drapes. The suture is used to retract the liver toward the patient’s
left side. The right posterior pedicle is found in Rouviere’s sulcus in 70% of cases,
which should be conrmed on preoperative imaging [15]. Inow control is obtained
using a Glissonian technique, with dissection in this area and transection of the pedicle using a stapling device. Demarcation with ICG can be performed to conrm
isolation of the correct pedicle prior to division. The transection plane of a right
posterior sectionectomy is rather long and should be in the direction of the right
hepatic vein. The outow can be taken from within the parenchyma during transection.
Segment 7 Resection
Port positions and retraction of falciform ligament are similar to right posterior
sectionectomy. The patient may be rotated with the right side slightly up or even in
a left semi-decubitus position. The patient’s right hip may need to be lowered to
prevent restriction of movement of the robotic arms. The third arm is used on segment 6 to retract the right lobe toward the left.
Segment 8 Resection
Port positions are similar to right posterior sectionectomy but may need to be placed
more cephalad on the abdomen. Falciform ligament retraction toward the patient’s
left lower abdomen can help access to segment 8. For anatomical segment 8 resection, the conuence of the right and middle hepatic veins should be clearly visualized and accessible.
Central Hepatectomy (Segments 4a and4b +/− 5 and8)
These types of resections involve two parenchymal transection planes, which will
prolong operative time. Port positions are similar to right hepatic resection. Pedicles
to segment 4 are taken on the right side of the umbilical ssure during parenchymal
transection. The right anterior pedicles in segments 5 and 8 resection can be isolated
using the Glissonian technique prior to parenchymal transection or located during
parenchymal transection. If the tumor is not close to the hilar area, it is best to avoid
transecting down to the hilum (as long as margins are adequate) to prevent injury to
the bifurcation of the bile duct or portal vein.
Robotic Biliary Reconstruction
Biliary reconstruction, particularly anastomosis of the intra- or extrahepatic bile
ducts to the gastrointestinal tract, is commonly indicated in resection of choledochal
cysts, repair of bile duct injury, resection of bile duct tumors, and palliative bypass.
322
Flexibility of the robotic platform enables anastomosis of even small segmental
ducts to the jejunum. ICG cholangiogram on Firey™ mode can be used to highlight the biliary anatomy. One of the largest series of robotic choledochal cyst excision in adults demonstrated that robotic surgery had longer operative times but
lower complications compared to laparoscopic approaches [16]. Similarly for biliary reconstruction after bile duct injury, the robotic approach was associated with
comparable morbidity to laparoscopic surgery but a higher primary patency rate of
the hepaticojejunostomy anastomosis, though this did not reach statistical signicance [17].
Y. L. Cheah and C. J. Simon
Patient Positioning, Port Placement, andRobotic Instruments
Positioning, port placement, and instrumentation are described above throughout
the hepatectomy section. ICG is injected intravenously in the preoperative setting at
least 30minutes prior to incision to enable drainage into the biliary tract by the time
cholangiogram is performed.
Delineation ofAnatomy andResection or Division ofBile Duct
The third arm is used with a gauze pad to retract segment 4B exposing the hilum.
Choledochal Cyst
For excision of the choledochal cyst, the right and left margins of the cyst are dissected from the hilar tissues proceeding toward the duodenum. In the majority of
cases, the inferior extent of the cyst usually lies within the pancreatic head. This part
is carefully dissected to avoid injury to the pancreatic parenchyma; small vessels are
transected with an energy device. Once the inferior extent of the cyst is reached, it
is transected between clips or with a staple. The inferior end is then retracted superiorly, and the posterior wall of the cyst is mobilized. The RHA is visualized crossing posterior to the CHD (conventional anatomy) and preserved. The gallbladder is
taken down from the liver bed and cystic artery divided between clips. The gallbladder can be left attached to the cyst via the cystic duct. The common hepatic duct is
divided and the specimen is retrieved with a plastic bag at the end of the procedure.
Bile Duct Injury
In-depth discussion of the type and timing of bile duct repair is beyond the scope of
this chapter. Principles of operative repair of bile duct injury are (1) delineation of
anatomy of the biliary and vascular system (both pre- and intraoperatively), (2)
drainage of biloma, (3) debridement to healthy bile duct tissue, and (4) biliary
reconstruction.
At the beginning of these cases, lysis of adhesions is commonly required, and
any bile collections are drained. ICG cholangiogram is performed to conrm the
anatomy of bile duct injury. This can be supplemented by conventional catheter