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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Anterior Approach for Liver Resections
Tricks of the Senior Surgeon
Low central venous pressure (by uid restriction, muscle relaxation, head-up position, and
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deep anesthesia) minimizes blood loss during liver transection.
Adequate cooling of the tip of the CUSA by saline maintains good functioning of the instru-
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ment for ecient parenchymal transection.
Techniques of Liver Parenchyma Transection
Christoph Tschuor, Mickaël Lesurtel
Dissection of liver parenchyma may cause complications including blood loss, hematoma, infection, bile leakage, and liver failure. Various surgical techniques have been developed for careful
and safe transection of the liver parenchyma to prevent intraoperative and postoperative complications.
e aim of this chapter is to give an overview of the techniques and devices frequently used
to perform parenchyma transection of the liver.
Preparation for Parenchyma Dissection
e liver capsule is incised with diathermy on the resection line. For a better exposure, two stay
sutures (2-0 silk) can be placed at the inferior margin of the liver, one on each side of the resection line. ese stay sutures are used to li up the liver and better expose the resection line. Care
should be taken not to pull and tear the liver parenchyma, leading to bleeding.
To prevent unnecessary liver ischemia, the Pringle maneuver for continuous or intermittent inow occlusion is applied individually, depending on the intraoperative surgical situation.
Indeed, the techniques other than the clamp-crush were developed to avoid use of the Pringle
maneuver and to minimize the risk of liver ischemia.
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_44, © Springer-Verlag Berlin Heidelberg 2016
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Section III • Liver: Nontransplant Procedures
Techniques and Devices
Clamp-crush technique and bipolar forceps
A small clamp (Kelly) is used to crush parenchyma between its blades in order to isolate vessels
and bile ducts (
(< 3 mm) are coagulated using an irrigated bipolar forceps and are cut by scissors (
Bipolar forceps cautery is equipped with a channel for water dripping, which prevents adhesion of
debris to the cautery blades. Bigger identied vessels or bile ducts (> 3 mm) are ligated or clipped
on the remnant liver slice before cutting. e alternative is to use clips only to secure vessels and
bile ducts.
. Fig. 44.1a,b). Fine branches of Glisson’s tree or tiny tributaries of hepatic veins
. Fig. 44.1c).
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. Fig.44.1
Chapter • Techniques of Liver Parenchyma Transection
Water jet dissection (Helix Hydro-Jet, ERBE)
With this device, the liver parenchyma is dissected by a jet of water (. Fig. 44.2a). Saline is pressurized by a high-pressure pump and is conducted by a high-pressure hose to the nozzle. Here
the pressure is converted into kinetic energy. For liver parenchyma, pressures of 30–50 bar should
be used. e so liver tissue is washed o the more resistant vessels and bile ducts (. Fig. 44.2b).
e applicator should be used in direct contact with the tissue and moved like a paintbrush. It
can be used in combination with suction and with an electrosurgical unit. Vessels and bile ducts
are isolated and can be secured using bipolar forceps, clips, or ligatures, as with the clamp-crush
technique. ey can then be transected under controlled conditions.
. Fig.44.2
Ultrasonic dissection (Cavitron ultrasonic surgical aspirator [CUSA]
or Dissectron, Integra NeuroSciences)
e principle of ultrasonic dissection is that a cavitational eect occurs at the tip of the vibrating rod of the device. e handpiece delivers ultrasonic vibration and provides simultaneous
aspiration and irrigation (. Fig. 44.3a). e ultrasonic probe divides parenchymal cells (because
of their high water content) by the cavitational eect with less injury to structures with a high
content of brous tissue, such as bile ducts and blood vessels (
by the probe, these elements are then clipped, ligated, or coagulated, as with the other techniques. Additional electrocoagulation functions are optionally available. e ultrasonic and
high-frequency currents can be activated simultaneously to divide and coagulate vessels, ducts,
and nerves.
. Fig. 44.3b). Once skeletonized
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Section III • Liver: Nontransplant Procedures
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. Fig.44.3
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Chapter • Techniques of Liver Parenchyma Transection
Ultrasound cutting (Harmonic, Ethicon EndoSurgery)
e ultrasound cutting system includes an ultrasound generator with a foot switch, a reusable
handle for the scalpel, and the cutting device with scissors. e electrical energy provided by the
generator is converted into mechanical energy by the handpiece through a piezoelectric crystal
system. e blade or tip of the instrument being used vibrates axially with a constant frequency of
55,500 Hz (. Fig. 44.4). e longitudinal extension of the vibration can be varied between 25 and
100 mm in ve levels, by adjusting the power setting of the generator. e cutting derives from a
saw mechanism in the direction of the vibrating high-frequency blade. e intracellular generation
of vacuoles (cavitation) brings about the correct transection of the liver parenchyma. Blood vessels
up to 2 or 3 mm in diameter are coagulated on contact of the tissue with the vibrating metal. For
coagulation of larger vessels, exertion of pressure between blades for 3 to 5 is required. Especially
in the periphery, the harmonic scalpel allows the liver parenchyma to be divided without causing bleeding, bile leakage, or trauma. It is especially used for laparoscopic transection because of
its speed of action and ease of use. Its use in the depth of the liver may lead to vascular injury,
however, especially to hepatic veins. For this reason, larger vessels in depth should be secured
with clips or sutures.
. Fig.44.4
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Section III • Liver: Nontransplant Procedures
Dissecting sealer (TissueLink or Aquamantys; Medtronic; Minneapolis,
MN, USA)
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e Medtronic dissecting sealer uses proprietary technology to coagulate and seal tissue to provide
hemostasis before and aer transection. It delivers radiofrequency (RF) energy through a conductive uid (saline) to coagulate and seal tissue (. Fig. 44.5). e saline couples the RF energy into
tissue and cools the tissue so that the temperature never exceeds 100 °C. e result is hemostasis
via collagen shrinking without the tissue desiccation, smoking, arcing, and char of conventional
electrosurgery. e dissecting sealer is applied directly to the target tissue. It is important to
maintain constant contact with the liver and to move the device in a “painting” motion to ensure
eective application of energy. Vessels less than 5 mm in diameter encountered through skeletonization can be completely coagulated within 10 seconds and can thereaer be transected. Larger
vessels should be secured by clips or sutures.
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. Fig.44.5
Chapter • Techniques of Liver Parenchyma Transection
Bipolar resection device (Habib4X, AngioDynamics)
e Habib4X device is used to transmit bipolar radiofrequency energy to provide intraoperative
coagulation of tissue by a four-electrode bipolar resection device. e device creates a plane of
coagulative necrosis along the intended line of transection by heating cells, causing them to dehydrate and denaturate. e tissue can subsequently be divided with a conventional scalpel through
this zone of necrosis. e advantages of the Habib4X bipolar resection device are reduced blood
loss, shorter operating time, and the ability to perform nonclamping surgery, avoiding adverse effects from warm ischemia. ere is also a laparoscopic variant of the Habib4X device (.
Fig. 44.6
).
. Fig.44.6
Tricks of the Senior Surgeon
The dierent devices can be used in the same intervention, as they may oer dierent and
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cumulative advantages.
During laparoscopic liver resection, the harmonic scalpel is useful because it can coagulate
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and divide the hepatic parenchyma during the same application, avoiding the need to
change instruments.
Regardless of the technique used, central venous pressure must be kept low (< 5 mm Hg) dur-
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ing parenchyma transection to minimize blood loss.
Regardless of the device used, inow occlusion should be used loosely in case of signicant
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bleeding during transection.
Liver Resections
Dimitri A. Raptis, Pierre-Alain Clavien
Indications and Contraindications
Indications
Contraindications
Primary and secondary malignancy (e. g., hepatocellular carcinoma, intrahepatic cholangio-
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carcinoma, colorectal metastases, neuroendocrine tumors)
Benign neoplasia (eg, adenoma, giant hemangioma)
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Echinococcus multilocularis (alveolaris)
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Abscesses refractory to conservative management
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Other benign diseases (e. g., Caroli syndrome)
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Living-donor liver transplantation (modied technique; see ▶ Chap. 63, “Living-Donor
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Transplantation: Le Hemiliver Donor Procedure and Implantation”)
Klatskin’s tumor (modied approach to the bile duct; see ▶ Sect. 4)
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Traumatic liver lesions
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Acute hepatitis (viral or alcoholic)
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Severe chronic hepatitis
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Poor liver reserve (e.g., Child-Pugh class C cirrhosis)
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Severe portal hypertension (eg, esophageal varices, ascites, or hepatic venous pressure gradi-
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ent > 10 mm Hg)
Severe coagulopathy despite vitamin K administration
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Severe thrombopenia (platelet count < 30,000/mm3)
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Preoperative Investigation and Preparation for the Procedure
History: Alcohol, hepatitis, and hepatotoxic medication, blood transfusions, tattoos, etc.
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Clinical evaluation: Encephalopathy, ascites, jaundice, nutritional status, signs of portal
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hypertension
Laboratory tests: ALT, AST, bilirubin, alkaline phosphatase, albumin, coagulation param-
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eters (PT, platelets), tumor markers, and serologies (e. g., hepatitis, echinococcus) when
indicated
CT scan or MRI: Assessment of liver volume (for major resections) and resectability of the
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lesion
PET scan: Searching for extrahepatic lesions (e. g., colorectal metastases)
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Postoperative Tests
Postoperative surveillance in an intensive or intermediate care unit
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Coagulation parameters and hemoglobin for at least 48h
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Daily check for clinical signs of liver failure, such as jaundice and encephalopathy
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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_45, © Springer-Verlag Berlin Heidelberg 2016
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Section III • Liver: Nontransplant Procedures
Postoperative Complications
z Short-term:
Pleural eusion
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Ascites
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Liver failure
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Intra-abdominal bleeding
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Bile leak
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Subphrenic abscess
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Portal vein thrombosis
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z Long-term:
Biloma
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Biliary stricture
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Bronchobiliary stula
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