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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Hanging Maneuver for Anatomic Hemihepatectomy (Including Living-Donor Liver Transplantation)
Step3
Parenchymal transsection
Slight traction on the tape allows easy identication of the right plane of parenchymal transsection.
e technique of parenchymal transsection is performed according to the surgeon’s preference.
e hanging allows elevation of the parenchyma in front of the vena cava, facilitating identication of vessels. Traction reduces the outow from the middle and le hepatic veins, representing
a localized total vascular occlusion when hanging is associated with inow occlusion. In living
liver harvesting, the inferior part of the tape is passed behind the right portal pedicle. At the end
of the transsection, the two hemilivers are completely divided, joined together only by hilar vessels
and hepatic veins (. Fig. 42.3).
. Fig.42.3
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Section III • Liver: Nontransplant Procedures
Modified Hanging Maneuver for Middle Hepatic Vein Harvesting
For the harvest of the middle hepatic vein in a living-donor procedure or for an oncologic extended resection, the hanging maneuver is adapted in order to facilitate transsection along the le
side of the vein. First, the hepatotomy is started on the top, near the median hepatic trunk, which
allows identication of the le hepatic vein and the median hepatic vein (
Once the median hepatic vein has been freed, the tape is switched to the le side of the middle
hepatic vein (. Fig. 42.4b), and the procedure is continued as described in Step3.
. Fig. 42.4a).
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. Fig.42.4
Tricks of the Senior Surgeon
Failures of this maneuver are mainly related to misplacement of the tube under the capsule
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of the liver which may cause bleeding. In these situations which account in inammatory
adhesions, in previous caval dissection or inammatory process, the maneuver should simply
be aborted and bleeding stop spontaneously.
Dissection on the upper part of the liver should be favored, because it facilitates the identi-
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cation of the right plane in front of the IVC.
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Anterior Approach for Liver Resections
See Ching Chan, Sheung Tat Fan
e anterior approach for liver resection is a no-touch technique that prevents iatrogenic rupture
or compression of liver tumors. For right liver tumors that are large, this approach is necessary
because rotation of the right liver to the le for division of short hepatic veins is not feasible. Such
rotation is also undesirable, as the inow and outow of the remnant liver will be compromised.
Avoidance of compression on the tumor also reduces the chance of shedding of tumor cells into
the circulation and thus may confer a better survival for the patient.
Hilar dissection and division of the ipsilateral inow are performed methodically and are followed by precise liver transection using the cavitron ultrasonic surgical aspirator (CUSA). Smaller
vessels are controlled by titanium clips, and larger ones are plicated with Prolene sutures. For right
hepatectomy, the transection follows the Cantlie line and may include the middle hepatic vein if
it is oncologically indicated. On approaching the inferior vena cava (IVC), the short hepatic veins
are divided between ligatures. Delivery of the liver resection specimen is preceded by division of
the ipsilateral hepatic vein(s) by endovascular staplers. In the case of extended right hepatectomy,
the middle hepatic vein is divided rst, followed by division of the right hepatic vein and the
inferior vena caval ligament, and then taking down of the right coronary ligament. Should the
right adrenal gland be adherent to the right liver, bleeding from it must be controlled by plication
with 4/0sutures. To prevent rotation of the remnant le liver to the right subphrenic space, the
falciform ligament is reconstituted by suturing with nonabsorbable sutures.
is chapter describes right hepatectomy using the anterior approach, but this approach is
also applicable to le hepatectomy.
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_43, © Springer-Verlag Berlin Heidelberg 2016
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Step1
Section III • Liver: Nontransplant Procedures
Procedure
Access to the right liver
e abdomen is opened via a right subcostal incision with an upward midline extension. Aer
division of the round ligament between ligatures, the falciform ligament is then taken down by
electrocautery. A Bookwalter retractor will provide excellent exposure of the liver. A laparotomy
is performed to identify any extrahepatic malignancies (
. Fig. 43.1).
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Step2
. Fig.43.1
Assessment of resectability by intraoperative ultrasonography
Intraoperative ultrasonography (IOUS) is carried out to delineate the extent of a tumor, to detect
the presence of multiple tumor nodules, and to exclude tumors in the le liver. Tumor involvement
by hepatocellular carcinoma of the main or le portal vein should be identied. More proximal
control of the portal inow and the le portal vein has to be anticipated in such cases. Doppler
ultrasonography will also register the patency, ow, and pulsatility of vessels in the future remnant
le liver; these should be veried on completion of the right hepatectomy, to ascertain the viability
of the le liver (. Fig. 43.2).
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. Fig.43.2
Chapter • Anterior Approach for Liver Resections
Step3
Isolation and division of right portal vein and right hepatic artery
e right liver containing the tumor is not mobilized as in the conventional approach. e liver is
gently retracted in the cephalic direction with a self-retained Dever retractor, or (even better) with
a medium-size malleable retractor. Aer ligation and division of the cystic artery, the gallbladder
is removed from its bed by cautery. e cystic duct is cannulated with a Fr3.5 Argyle catheter.
e gallbladder is then excised.
Hilar dissection is performed to expose and isolate the right hepatic artery and right portal
vein. Temporary control of these vessels will demonstrate the demarcation between the right and
le livers (Cantlie line). e patency of the le hepatic artery and portal vein is then conrmed
by IOUS. For tumors conned to the right liver, the Cantlie line will be the liver transection line
and can be marked with electrocautery. A tumor crossing the middle hepatic vein (MHV) and
involving segment4 necessitates resection of segment4. e liver transection line to be marked is
thus made with reference to the le border of the tumor as guided by IOUS (. Fig. 43.3).
e transection line on the inferior surface of the liver is marked accordingly. On approaching
the stumps of the already divided right portal vein, the planned line of transection must be on the
right side of the common hepatic duct to avoid injuring it.
. Fig.43.3
Section III • Liver: Nontransplant Procedures
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Step4
Parenchymal transection with ultrasonic dissector
Liver transection is performed using the CUSA (. Fig. 43.4a). e Pringle maneuver for inow
control is usually not required. By inserting a 4/0Maxon suture on each side of the liver transection line, gentle traction is provided to facilitate liver transection. Starting from the liver edge, the
liver transection is along the plane dened by the marking on the anterior and inferior surfaces
of the liver (
with scissors. A low central venous pressure facilitates the liver transection by reducing bleeding
and thus providing a clearer view. For right hepatectomy sparing the MHV, the right side of the
MHV is exposed without leaving ischemic liver tissue on it. e MHV serves as a guide for the
liver transection. IOUS is repeated to guide transection with an adequate margin from the tumor.
. Fig. 43.4a). Tiny vessels are cauterized and ne vessels are clipped before dividing
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. Fig.43.4
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Chapter • Anterior Approach for Liver Resections
Step5
Division of right hepatic duct
As liver transection continues to the liver hilum, the right hepatic duct surrounded by the hilar
plate will be encountered. Use of cautery for hemostasis in this area is avoided in order not to
damage the hilar plate and render the suture applied to the right hepatic duct stump in due course
insecure. Right portal vein branches with early bifurcation or in trifurcation with the le portal
vein are oen associated with a right posterior duct inserting separately into the le hepatic duct.
If the tumor is near the right hepatic duct and requires higher precision in right hepatic duct
division, an operative cholangiogram will become useful. e planned line of right hepatic duct
division is marked with a large metal clip (
Given the normal anatomy of caudate branches inserting into the hilar plate posteriorly, isolation of the right hepatic duct prior to its division is not always practical, but it is always feasible
to divide the right hepatic duct by a pair of scissors, starting anteriorly. Any arterial bleeders
encountered are plicated with 6/0Prolene in the process of duct division. e right hepatic duct
orices are sutured with 5/0polydioxanone suture (PDS).
. Fig. 43.5).
. Fig.43.5
Section III • Liver: Nontransplant Procedures
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Step6
Division of short hepatic veins
e paracaval portion of the caudate lobe is then transected with the CUSA, thus exposing the
infrahepatic portion of the IVC. With blunt dissecting forceps, the plane between the back of the
caudate lobe and the IVC is separated. By liing up the liver tissue using the dissecting forceps,
transection of the caudate lobe is expedited. e liver transection is completed, and the right side
of the IVC is exposed.
If the tumor encroaches on the caudate lobe, necessitating resection of the caudate lobe and
segment4, then, aer detachment of the right hepatic duct, the transection proceeds to the junction between the le lobe and the caudate lobe. e MHV is exposed at the junction with the le
hepatic vein and divided by an endovascular stapler. e caudate lobe is now exposed, and it is
then detached from the hilar plate and from the le and anterior surface of the IVC by dividing
the short hepatic vein branches and ligamentum venosum (Arantius ligament). e caudate lobe
is retracted toward the right side.
Continued dissection in the plane between the caudate process and the right side of the IVC
will expose the inferior right hepatic vein, middle right hepatic vein, and right hepatic vein. e
short hepatic veins and the inferior and middle right hepatic veins, if present, are ligated and
plicated as necessary (. Fig. 43.6).
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. Fig.43.6
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Chapter • Anterior Approach for Liver Resections
Step7
Division of right hepatic vein
e right hepatic vein is divided with an endovascular stapler (ATW35, Ethicon EndoSurgery,
Inc, Cincinnati, Ohio). e IVC ligament is ligated and divided on the right side of the IVC. It is
mandatory to plicate the stump of the IVC ligament with 5/0Prolene to prevent bleeding from
later dislodgement of the ligature (
When the right liver is completely disconnected from the IVC, the right liver is mobilized from
the right abdominal cavity by dividing the triangular ligament, and it is delivered. Tumor invading
or in close proximity to the right diaphragm requires resection of the portion of the diaphragm
in continuity with the right liver.
If the right liver has a large tumor with established collateral blood supply from the diaphragm,
the tumor will swell aer division of the right hepatic vein. e engorged right liver may compress
the IVC, leading to reduced venous return to the heart and hypotension. Liing up the right liver
and swily separating it from the retroperitoneum with electrocautery is necessary. If diculty is
encountered, cutting into the diaphragm will facilitate liing the specimen out of the abdominal
cavity. e diaphragmatic defect is closed with 2/0Prolene; a chest drain is not necessary.
. Fig. 43.7).
. Fig.43.7
Section III • Liver: Nontransplant Procedures
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Step8
Checking hemostasis and bile leak
At this time, the central venous volume can be restored by administering intravenous uid. Doing
so enhances the identication of bleeding from venules that have collapsed because of low central
venous pressure. Indigo carmine is instilled gently via the Argyle catheter in the cystic duct to
show any defect in the duct system (
IOUS is performed to ascertain patency of the le portal vein and le hepatic artery, as well as
good pulsatility of the le hepatic vein. e falciform ligament is reconstituted by suturing with
mattress sutures of 5/0Prolene (
e abdomen is closed; deployment of an abdominal drain is seldom necessary.
. Fig. 43.8a). e cystic duct is ligated with 2/0Vicryl.
. Fig. 43.8b).
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. Fig.43.8