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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
498
Y. L. Cheah et al.
Basic Robotic Instruments forParenchymal Transection
1. Harmonic scalpel
2. Camera
3. Maryland bipolar (+ electrocautery)
4. Cadiere or ProGrasp forceps
Adjunct Robotic Instruments
1. Large needle driver or suture cut
2. Small, medium, and large clip appliers
3. Vessel sealer
Laparoscopic Instruments andSpecial Items
1. Laparoscopic suction irrigator
2. Laparoscopic grasper
3. Laparoscopic needle driver
4. Ultrasound with laparoscopic or drop-in probes
5. Bulldog clamps (e.g., Scanlan® Reliance Bulldog clamps, Scanlan International
Inc., St. Paul, MN, USA)
6. Vessel loops
7. 4/0 and 5/0 polypropylene and 5/0 polydioxanone sutures
8. Surgicel™ Fibrillar™ (Ethicon, Raritan, NJ, USA)
A standardized stepwise technique is described below for right, left, and left
lateral section donor hepatectomy.
Right Donor Hepatectomy
Falciform Dissection
The ligamentum teres and falciform ligamentum are divided up to the level of the
hepatic vein-IVC conuence. The third arm is used to grasp the leaets of the falciform ligament near the conuence and a gentle inferior and posterior retraction is
used to expose the conuence. The peritoneal covering of the hepatic vein conuence is incised, exposing the three hepatic veins. The right coronary ligament lateral
to the right hepatic vein is divided. The transection line follows the principal plane
for a right donor hepatectomy; the superior end of the principal line is marked on the
liver surface with electrocautery between the right (RHV) and middle (MHV)
hepatic veins.
Hilar Dissection
The third arm cushioned by a gauze is used to retract segment 4B and gallbladder
anterosuperiorly. The laparoscopic assistant retracts the duodenum inferiorly with
blunt-tipped instrument or suction device exposing the liver hilum. A standard cholecystectomy is performed, with division of the cystic duct and artery between clips,
and the gallbladder specimen is removed from the peritoneal cavity later. The
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499
clipped cystic duct stump is now ligated with 3/0 Vicryl/Silk tie or suture-ligated
with 3/0 Vicryl/Silk sutures with tails left long. The tails are grasped by the third
arm previously positioned at segment 4B, and using the forceps as a pulley, the
cystic duct is retracted anteriorly and slightly to the patient’s left, exposing the lateral and right posterior aspect of the common hepatic duct (CHD).
Dissection ofRight Hepatic Artery
A standard right hepatic artery (RHA) usually courses posterior to the CHD and
changes course toward the cephalad direction on the right side of the CHD.Lymphatic
and nerve tissue covering the RHA are dissected free. As much of the length of the
proximal RHA is separated from the posterior wall of CHD (taking care not to
injure either the artery or the duct) to provide a good length for recipient anastomosis. If the RHA courses anterior to the duct, it will need to be dissected away from
the anterior surface of the CHD (Fig.34.5). The segment 4 hepatic artery may be
encountered if it is a branch of the right hepatic artery; it is kept out of harm’s way,
and the future division point of the RHA will be distal to its’ takeoff. Distally, the
RHA is dissected away from the CHD and the distal right hepatic duct (which will
be transected with the graft). Posteriorly, the RHA is freed from the portal vein. The
RHA is then encircled with a vessel loop.
A replaced RHA from the superior mesenteric artery courses parallel to the lateral and posterior right wall of the common bile duct (CBD) and CHD.It is usually
covered by the station 12b lymph node which may be excised to gain access to the
RHA.The length of the replaced RHA is then dissected free from the bile ducts
anteriorly and the portal vein posteriorly, and subsequently encircled (Fig.34.6).
Dissection oftheRight Portal Vein
The vessel loop of the RHA is grasped by the third arm and gentle retraction is used
to expose the anterior surface of the portal vein and its bifurcation. The plane
between the CHD and anterior surface of the portal vein (PV) is developed by
Fig. 34.5 Aberrant arterial
anatomy with RHA (red
vessel loop) coursing
anterior to CHD
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Fig. 34.6 Aberrant arterial
anatomy with replaced
RHA (red vessel loop)
running along the posterior
aspect of CBD
Y. L. Cheah et al.
pushing the portal vein posteriorly off the attachments to the duct and RHA.Dissection
proceeds cephalad until identication of the bifurcation is conrmed by visualization of the right, left, and main portal veins. The right portal vein (RPV) is then
carefully teased off the hilar plate using the Maryland forceps and scissors.
Once the anterior and superior RPV is mobilized, the dissection of the posterior
aspect of the RPV is performed. The peritoneal lining the posterior aspect of the
RPV is divided and retracted posterior-inferiorly by the laparoscopic assistant.
Caudate branches are visualized on the posterior RPV, and these are carefully encircled. The PV side of these branches are always ligated with a tie to avoid clips on
the PV, which could hamper future clipping or stapling of the RPV, while the caudate side may be clipped prior to division.
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. A 5/0 Prolene
stitch is placed supercially at the proximal RPV to mark the bifurcation (Fig.34.7).
Mobilization oftheRight Lobe
The third arm cushioned by a gauze is used to retract segments 5 and 6 superioranteriorly, exposing the inferior layer of the right coronary and right triangular ligaments. These ligaments are divided and the bare area mobilized using the scissors
or vessel sealer, taking care not to injure the diaphragm (Fig.34.8). As more of the
bare area is exposed, the third arm is moved sequentially superiorly and posteriorly
to provide more retraction. The liver is mobilized off the right adrenal. We then turn
our attention medially toward the retrohepatic inferior vena cava (IVC).
The peritoneal lining between the caudate and IVC is incised, and short caudate
and hepatic veins draining directly to the IVC are serially divided between clips or
vessel sealer. Dissection continues in a cephalad direction on the anterior surface of
the retrohepatic IVC, mobilizing the liver from the IVC.Caudate process division
from the right lobe at this point helps cephalad dissection of the IVC.Laterally, the
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Fig. 34.7 Prolene suture
placed supercially to
mark PV bifurcation
Fig. 34.8 Division of
right triangular ligament
and attachments to
retroperitoneum
501
hepatocaval ligament is left intact as division of this ligament is easier after parenchymal transection. The liver is carefully mobilized from the IVC until the area near
the right and middle hepatic veins is reached. This completes the right lobe mobilization, and the liver is returned to its anatomical position.
Demarcation
The third arm is used to retract segment 4B.The hilar plate is separated from the
liver at the area of the bile duct bifurcation, and a small ball of Surgicel™ Fibrillar™
is inserted in this space to mark the hilar endpoint of the parenchymal transection.
Bulldog clamps are placed on the RHA and RPV (Fig.34.9). Indocyanine green dye
(ICG) 2.5mg is injected intravenously, and using the Firey™ mode, demarcation
of the perfused left lobe is augmented by uorescence. The line of demarcation is
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Fig. 34.9 Temporary
clamping of RHA and
RPV for demarcation
Y. L. Cheah et al.
marked on the anterior and inferior liver surface using electrocautery. The clamps
are removed. An ultrasound may be performed to mark the course of the MHV
(which stays with the remnant) and segmental veins draining segments 5 and 8.
Parenchymal Transection
“Rubber Band” Retraction Technique
One rubber band is sutured to each side of the transection line at the tip of the liver.
Each end of the rubber band is externalized on the respective sides of the upper
abdomen and secured to the drapes. This technique takes advantage of the elasticity
of the bands to provide contact retraction of the transection plane without having to
use any of the robotic or laparoscopic arms or a liver retractor.
Parenchymal Transection
A Pringle maneuver is avoided unless necessary for hemostasis (details of a Pringle
maneuver is described in Chap. 25). During the initial part of the parenchymal transection, the third arm cushioned by a gauze 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. Small intervening vessels and oozing from
the parenchyma are controlled with bipolar electrocautery. Larger vessels including
segments 5 and 8 veins are divided between clips. If these veins are to be reconstructed in the recipient, an appropriate length of the vein stumps on the graft side
will need to be preserved to enable anastomosis.
As more of the parenchyma is transected, the liver edges are continually retracted
due to the elasticity of the rubber bands. These might need to be tightened as transection progress. Once most of the parenchyma has been transected, leaving about
2 cm of parenchyma anteriorly along the IVC, the right hepatic duct (RHD) is
divided.
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Division ofRight Hepatic Duct
The parenchyma down to the level of the biliary bifurcation should be completely
transected. An ICG cholangiogram is performed to visualize the biliary bifurcation
using Firey™. The location of RHD division is chosen based on the surgeon’s
interpretation of the cholangiogram. We usually aim to provide the recipient surgeon with as few ducts for anastomosis as possible while making sure not to impinge
on the donor’s biliary bifurcation.
There are two ways to transect the duct:
1. Clip-and-cut
The Maryland forceps is used to encircle an umbilical tape around the entire
hepatic duct with its surrounding hilar plate tissue. A large Hem-o-lock clip is
then placed on the distal RHD ensuring that it does not encroach onto the bifurcation. The proximal RHD on the graft side is then sharply divided (Fig.34.10).
The stump of the distal RHD on the donor side is suture-ligated with a running
5/0 PDS.
2. Cut-and-clip/suture
The posterior aspect of the RHD is examined to identify a crossing arterial
branch, which, if seen, should be divided between clips. The RHD is then cut at
the chosen point without cutting the hilar tissues This hilar plate tissue is divided
between two small metal clips. The stump of the distal RHD is suture-ligated
with a running 5/0 PDS.
The choice of the technique used is inuenced by the length of the RHD and the
thickness of the surrounding hilar tissue. The clip-and-cut option tends to take up an
additional ~0.5–1mm of RHD length, and it may be difcult to apply the Hem-olock clip on thick hilar tissues. The cut-and-clip/suture option may lead to fewer bile
duct openings for recipient anastomosis.
Fig. 34.10 Division of
right hepatic duct using
clip and cut technique
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Y. L. Cheah et al.
Completion ofParenchymal Transection
The remainder of the parenchyma is transected, from caudal to cephalad, with a vessel sealer while the assistant gently pushes the liver anteriorly off the IVC.The nal
piece of transection should be the parenchymal between the right and middle hepatic
veins. Once completed, the right hepatic vein is encircled with an umbilical tape.
Cross-Clamp andGraft Extraction
The middle robotic arms are undocked. A Pfannenstiel incision is made. It is important not to injure the graft during extraction and to minimize the time between crossclamp and ushing of the graft with preservation uid on the backtable. There are
two ways to extract the graft depending on the size of the graft and whether it ts in
a laparoscopic retrieval bag:
1. Fits a laparoscopic retrieval bag
The peritoneal lining at the Pfannenstiel is not opened at this point. The robot
is redocked and the right lobe is partially placed into a laparoscopic retrieval bag
that is inserted via the 12mm assistant port. Cross-clamping is performed as
described below and the graft is completely placed in the bag. The peritoneal
lining is opened, the string of the bag is grasped, and the graft is extracted.
2. Does not t a laparoscopic retrieval bag
The peritoneal lining at the Pfannenstiel is opened and a Gelport (Applied
Medical, Rancho Santa Margarita, CA, USA) is placed in the incision. The robot
is redocked and a large retrieval bag is inserted via the Gelport and the graft
partially placed in the bag. Cross-clamping is performed as described below and
the graft is completely placed in the bag. The bag is grasped and extracted via the
Gelport.
Cross-clamping commences when the RHA is doubly clipped and transected
distal to the clips while preserving as much length as possible for recipient anastomosis. The RPV is transected with a stapler just distal to the stitch marking the
bifurcation. The RHV and hepatocaval ligament are transected with separate rings
of the stapler. The graft and gallbladder are then extracted as described above.
Closure
Hemostasis of the cut surface and hilum is performed. Bile leak is ruled out. The
clips, staple, and suture lines are inspected. The left lobe is reattached to the falciform ligament to prevent torsion. A drain is placed in Morrison’s pouch and externalized via one of the ports (Video 34.1).
Left Donor Hepatectomy
Falciform Dissection andLeft Lobe Mobilization
Falciform dissection and exposure of the hepatic vein conuence is similar to the
donor right hepatectomy. The superior end of the transection line is marked between
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505
the RHV and MHV (MHV is kept with the graft). The left triangular ligament is
divided, and the left lateral segment is retracted toward the patient’s right with the
third arm exposing the gastrohepatic ligament.
If there is an accessory (10% of population) or replaced left hepatic artery (7.5%)
arising from the left gastric artery (LGA), this vessel is carefully preserved.
Oftentimes, this artery is dissected until its branch point from the left gastric artery.
The LGA in this area is also dissected free of lymphatic tissues to enable procurement of a short segment of this artery during cross-clamp to form a branch patch for
recipient anastomosis.
The Arantius ligament is located and divided at the superior pole of the caudate
lobe, exposing the junction between the left hepatic vein and vena cava, which is
marked by inserting a ball of Surgicel™ Fibrillar™. Dissection deeper into this area
can be performed to encircle the middle and left hepatic veins but this step is not
necessary. If the caudate lobe is to be procured as well, Spiegel’s lobe is mobilized
from the vena cava by incising the peritoneal attachments and dividing the short
hepatic veins between clips or with a vessel sealer.
Hilar Dissection
The third arm is used to retract segment 4B to expose the hilum. A cholecystectomy
is performed. The peritoneal covering over the left side of the hilum is opened.
Dissection oftheLeft Hepatic Artery
The left hepatic artery is dissected free from lymphatic and nerve tissue from the
proper hepatic artery until the umbilical ssure. The station 12a lymph node may be
excised to provide exposure. Medially, the artery is mobilized from the main and
left portal vein and encircled with a vessel loop (Fig.34.11). The location of the
right hepatic artery is noted at all times and dissection close to this artery is avoided.
Fig. 34.11 Isolation
of LHA
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Fig. 34.12 LHA (red
vessel loop) and LPV (blue
vessel loop) encircled
Y. L. Cheah et al.
Dissection oftheLeft Portal Vein
Gentle retraction on the vessel loop encircling the left hepatic artery toward the
patient’s left side will expose the left portal vein (LPV). The superior side of the
LPV is mobilized from the left hepatic duct and hilar plate. Small branches to segment 4B in this area are divided between clips (the LPV side is ligated with ties to
avoid clips obstructing future clipping or stapling of the LPV).
The artery is then retracted anteriorly exposing the posterior LPV.Several caudate LPV branches are usually seen near the umbilical ssure. If the caudate lobe is
not to be procured with the graft, these caudate branches are dissected free and
divided between clips (the LPV side is ligated with a tie). The LPV is then encircled
with a vessel loop (Fig.34.12). A 5/0 Prolene stitch is placed supercially at the
proximal LPV to mark the bifurcation.
Demarcation
The hilar plate is separated from the liver at the area of the biliary bifurcation, and
a small ball of Surgicel™ Fibrillar™ is inserted in this space to mark the hilar endpoint of the parenchymal transection. If preoperative imaging shows a hepatic duct
branch to the right lobe coming off the left hepatic duct (LHD), the endpoint of the
transection is shifted proximally on the left hepatic duct before the conuence of the
right duct branch, and is usually divided just proximal to the umbilical ssure.
Bulldog clamps are placed on the LHA and LPV.Similar to the right donor hepatectomy, ICG 2.5 mg is injected intravenously, and using the Firey™ mode,
demarcation of the perfused right lobe is augmented by uorescence. The line of
demarcation is marked on the anterior and inferior liver surface using electrocautery. The clamps are removed. An ultrasound may be performed to mark the course
of the MHV (which will be procured with the graft) and segmental veins draining
segments 5 and 8 (Fig.34.13).
34 Liver Transplantation
Fig. 34.13 Course of
MHV, segment 4 and 5
hepatic venous branches
marked on the surface
using ultrasound guidance
507
Parenchymal Transection
“Rubber Band” Retraction Technique
The previously described rubber band retraction technique is used.
Parenchymal Transection
Parenchymal transection is performed as described above (Figs.34.14 and 34.15).
If the caudate is not to be procured, the sagittal parenchymal transection plane ends
at the level of the caudate lobe and then curves along a horizontal plane dividing the
left lobe from the caudate. If the caudate is to be procured, the caudate lobe is split,
and the sagittal transection plane continues until the anterior IVC.
Division oftheLeft Hepatic Duct
Once all the parenchyma has been transected to the level of the biliary bifurcation,
an ICG cholangiogram is performed. The biliary bifurcation is visualized, and the
appropriate location chosen on the LHD for division (Fig.34.16). The two techniques for bile duct division are described above.