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182 Atlas of Gastrointestinal Surgery: Liver
Laparoscopic Radiofrequency Ablation
Laparoscopic RFA offers the advantage of a minimally invasive
procedure with the ability to visualize the abdominal cavity and
perform the therapy using IOUS. With this approach, patients
are treated under general anesthesia, typically in the supine
position. In most cases, the procedure can be done with two
or three ports (2). The laparoscope is placed in the periumbilical site and the laparoscopic IOUS probe is inserted through
a 12-mm port located on the right side. A working port can
be added through a 5-mm trocar if needed. The liver is typically partially mobilized, and viscera within 2 cm of the intended ablation zone are moved away. Laparoscopic cholecystectomy can be performed when a target lesion is in proximity to
the gall bladder. The RFA electrode is placed into the abdominal cavity immediately below and in parallel to the IOUS
probe, either percutaneously or through a 5-mm trocar (2).
The needle is placed within the tumor under IOUS guidance,
and ablation is performed and monitored as with the open
technique (3).
2
Ultrasound probe
Multi-electrode RFA probe
3
Hepatic Artery Infusion Pump
Operative Indications
In selected situations, a hepatic arterial infusion (HAI) pump may be implanted to deliver continuous-infusion regional
chemotherapy. Some data indicate that adjuvant regional chemotherapy (with fluorodeoxyuridine) plus systemic chemotherapy following liver resection for hepatic colorectal metastases can reduce the rate of intrahepatic recurrences and possibly
improve overall survival. In addition, some have advocated the use of HAI chemotherapy alone or in combination with
systemic chemotherapy for patients with unresectable liver-only metastases. Therefore, it is useful for the hepatic surgeon
to be facile at implantation of these devices, with or without combined liver resection or ablation.
Operative Technique
Prior to proceeding to surgical implantation of such a device, it is important to
gain knowledge of the arterial circulation to the liver. In the past, preoperative
hepatic arteriography was done in all patients. More recently, high resolution
computed tomography or magnetic resonance imaging with arterial visualization
(CTA or MRA) has replaced the need for standard arteriography.
In most cases, this procedure can be accomplished through an upper midline incision. When combined with liver resection, the choice of incision will
depend on the necessary exposure for the resection. As with other operations
for malignancy, the abdomen should be carefully examined to be certain there
is no evidence of tumor outside the liver. This is particularly important when
implanting such a device for metastatic colorectal cancer as there is little indication for HAI in patients with evidence of extrahepatic disease.
184 Atlas of Gastrointestinal Surgery: Liver
Arterial anatomy can be quite variable,
L. hepatic a.
Celiac axis
including replaced or accessory vessels
from the left gastric artery or superior
mesenteric artery. In most cases, the
R. hepatic a.
classic hepatic arterial anatomy is
present, with a common hepatic
artery arising from the celiac axis,
which gives off a right gastric artery
Cystic a.
Gastroduodenal a.
and the gastroduodenal artery
Superior
(GDA) prior to bifurcating into the
pancreaticoduodenal a.
right and left hepatic arteries (1). First,
a cholecystectomy is performed. It is imperative to remove the gall bladder in all cases
where HAI chemotherapy is being considered.
Hepatic a.
R. gastric a.
L. gastric a.
Splenic a.
Stomach
R. gastroepiploic a.
1
Gall bladder
fossa
Hepatic a.
Gastrohepatic
ligament
Lesions
Celiac axis
Stomach
Gastroduodenal a.
Common duct
Transverse colon
2
Hepatic a.
Hepatic Artery Infusion Pump 185
3
Catheter
Gastroduodenal a.
4
If not, severe chemotherapy-induced cholecystitis will occur. Next, the common hepatic artery, the GDA, and the proper hepatic artery are all dissected and encircled with vessel loops (2). It is important to divide all supraduodenal and other
arterial branches arising from the hepatic artery that do not supply the liver, in order to avoid any chance of the chemotherapeutic agents entering vessels perfusing structures other than the liver. If this is not successfully performed, significant gastritis and duodenitis will result from exposure to the chemotherapeutic agents.
Once the arterial anatomy has been identified, dissected, and made ready for catheter insertion, the subcutaneous pocket is created. To accomplish this, a small transverse incision is made at approximately the level of the umbilicus only long
enough to accommodate the device, creating a pocket inferiorly at the level above the fascia. Once the pocket has been
created, the fully primed and warmed infusion pump is inserted, bringing the catheter through the fascia within the peritoneal cavity (5). Care must be exercised to avoid redundant catheter within the pocket in order to prevent injury to the
catheter during subsequent pump accessions. The device is then anchored to the rectus fascia with non-absorbable, highstrength suture (eg, 0-polypropylene).
The pump catheter is first trimmed in order to position the flanges near the tip. The catheter is then introduced retrograde into the GDA. To accomplish this, the GDA is fully mobilized and then ligated distally close to the duodenum and
at least 2 cm from the origin. Maintaining this suture for counter-traction can be useful during catheter insertion. The hepatic artery at the junction of the GDA is then occluded with a small atraumatic curved vascular clamp (3). A small arteriotomy is then made in the GDA approximately 1 cm from the origin, and the catheter is inserted and triply ligated in place
(4). Care must be taken to place the catheter tip at the artery origin without obstructing the hepatic arterial flow. In addition, overtightening of ligatures should be avoided in order to prevent catheter occlusion.
186 Atlas of Gastrointestinal Surgery: Liver
Two of the ligatures should be placed immediately in front of and behind the first catheter flange in order to prevent
migration. Upon completion, the catheter should lie tension-free within the abdominal cavity and without kinks (5).
Replaced or accessory right or left hepatic arteries can be ligated, in most cases, provided it is not the dominant blood
supply to the liver. If present, it cannot remain patent, as non-infused circulation to the liver will limit the efficacy of the
regional chemotherapy. Following inserting and securing the catheter, the bolus port of the pump is then injected with
heparinized saline via a Huber needle to document unobstructed flow. Care should be taken to avoid backflow of blood
into the catheter and pump as this may limit the long-term flow of the device. Fluorescein dye is then injected into the
bolus port, and the liver and upper abdomen are observed under an ultraviolet (Woods) lamp. This step is used to rule
out evidence of extrahepatic perfusion and document good bilobar distribution.
Pump in
subcutaneous
pocket
5
Surgical Drainage of Liver Abscess
Operative Indications
The diagnosis of a liver abscess in any patient with fever is readily made by ultrasonography or cross-sectional imaging,
despite the fact that there may be very little in the way of physical findings. They are most commonly associated with biliary tract pathology. Colonic diverticular disease and other intra-abdominal septic processes may also produce liver abscesses and, not infrequently, they can be of unknown etiology. In most cases, liver abscesses are successfully managed using a
percutaneous approach. In some cases, however, liver abscesses are multilocular, recurrent, or fail attempted percutaneous
management. In such cases, they may require laparotomy and open drainage.
Operative Technique
Patients are generally explored through a right subcostal incision. If the
pathology is in the left lobe of the liver, the incision can be extended across
the midline. Exposure can be maximized by the use of a self-retaining retractor. The liver is exposed and any adhesions divided using the electrocautery.
188 Atlas of Gastrointestinal Surgery: Liver
Intraoperative ultrasonography can be useful in cases of deep-seated abscess in order to identify the location, extent, and
site with the closest proximity to the liver surface (1).
Deep
multiloculated
abscess
1
Abscess
Surgical Drainage of Liver Abscess 189
Anaerobic
culture
2
3
First, the abscess should be aspirated using a
syringe and sent for aerobic and anaerobic culture
(2). The abscess cavity is then opened with the
electrocautery (3) and the contents completely
suctioned out. The cavity is explored manually to
be certain that there are no undrained loculations
(4) before irrigating the cavity.
Liver
Loculations
within
abscess
4
190 Atlas of Gastrointestinal Surgery: Liver
If the remnant abscess cavity is large or deep, placement of an omental pedicle (5) should be considered to minimize the
risk of recurrence. Drains should be placed within the cavity and in the perihepatic space.
Omental pedicle
5
