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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Section III • Liver: Nontransplant Procedures
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Step1 (continued)
. Fig.47.2
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Step2
Opening of the hepatoduodenal ligament
Cholecystectomy is usually performed, as it facilitates parenchymal dissection at the mid plane,
known as the Rex-Cantlie line; the right and le portal veins pass through the gallbladder bed
towards the vena cava. Next, the hepatoduodenal ligament is opened from the le by means of a
Kelly clamp and electrocautery, as illustrated (
the portal vein are visualized; the common bile duct is dissected sparingly, not to compromise the
blood supply from the small branches. During this step, preparation of the le hepatic duct is not
mandatory because the identication of the complete bifurcation and ligation of the le hepatic
duct are performed during parenchymal dissection (see Step 6).
. Fig. 47.3). e common bile duct, the artery, and
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. Fig.47.3
Chapter • Left Hemihepatectomy
Step3
Identification and disconnection of the arterial blood supply
to the left hemiliver
At this point, the arterial anatomy has to be claried. A possible aberrant le artery should be
secured by means of a bulldog clamp. An aberrant right artery can be identied by palpation of
the right border of the hepatoduodenal ligament. e le hepatic artery is identied le to the
common and le bile duct and can then be isolated and clamped. e patency of the arterial blood
supply to the right hemiliver can now easily be assessed by palpation of the right hepatic artery
and/or an aberrant right artery (
Once the arterial anatomy is clear, the le hepatic artery (and an aberrant artery to the le
hemiliver, if present) are divided between ties.
. Fig. 47.4).
. Fig.47.4
Section III • Liver: Nontransplant Procedures
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Step4
Preparation and ligation of the left portal vein
As the le portal vein typically is situated behind the le branch of the hepatic artery, it is easily
identied. Following convincing identication of the bifurcation, the le portal vein should be
freed from the adventitial tissue. e short branch to Sg1 on the back-le side can be divided
between ties because of the dual portal blood supply from the right and le portal vein. e vein
can now be ligated with a 1-0silk suture on both sides (
should be at least 5 mm to avoid stenosis of the remaining right portal vein. Suture ligation with
5-0Prolene or transsection by means of a vascular stapler are alternatives to a simple ligation. (See
the illustration in ▶ Chap. 46, “Right Hemihepatectomy.”)
. Fig. 47.5
). e distance to the bifurcation
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Step5
. Fig.47.5
Dissection of the Arantius’ ligament and exposure of the left hepatic
vein
e anterior walls of the le and middle hepatic vein are usually exposed by extending the dissection of the falciform and coronary ligament to the vena cava. To access the posterior wall, the
le hemiliver is lied and the lesser omentum is cut, up to the diaphragm. Next, the Arantius’
ligament (ligamentum venosum) is identied between the le hemiliver and Sg1 (
runs from the le portal vein to the le hepatic vein or to the junction between the le and the
middle hepatic veins and is divided at its portal origin between ties (a remnant of the ductus
venosus may be present). e stump of the ligament can now be grasped and dissected upward
toward the inferior vena cava until the ligament broadens into its attachment. By traction of the
ligament cephalad and to the le, an avascular plane between the le hepatic vein and Sg1 can
be seen and developed. e le hepatic vein can be isolated by means of a right angle or a Kelly
clamp. e le hepatic vein can be disconnected at this stage, but it is also possible to divide it at
the end of the parenchyma dissection, as shown in Step7.
. Fig. 47.6). It
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Chapter • Left Hemihepatectomy
Step5 (continued)
. Fig.47.6
Section III • Liver: Nontransplant Procedures
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Step6
Dissection of the liver parenchyma
As the blood supply to the le hemiliver is now interrupted, a clear demarcation between the le
and the right hemiliver is seen and identies the line of resection along the main portal plane.
Two stay sutures (2-0 silk) are placed at the inferior margin of the liver, one on each side of the
demarcation line. At this point, verify that central venous pressure (CVP) is low (below 3 mmHg).
e liver capsule is incised with diathermy a few millimeters on the ischemic side (
Pringle maneuver for intermittent or continued inow occlusion is used as needed. e dissection
starts on the inferior margin of the liver and is continued rst on the caudate lobe, then right onto
the surface of the vena cava. During the parenchyma dissection, care must be taken to protect the
mid hepatic vein. e le bile duct is isolated and carefully ligated within the parenchyma. Before
the ligation of the le bile duct, a right sectional bile duct inserting into the le hepatic duct must
be ruled out. To avoid an injury in this biliary anomaly, the le bile duct should be divided close
to the umbilical ssure.
. Fig. 47.7
). e
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. Fig.47.7
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Chapter • Left Hemihepatectomy
Step7
Transsection of the left hepatic vein
If the le hepatic vein has not been divided prior to the transsection of the parenchyma, care
should be taken while approaching the top of the liver (2–3 cm from the top). At this point, a vascular stapler can be used to transect the le hepatic vein. An alternative would be to use a spoon
clamp (
. Fig. 47.8
ne preparation of the vein can be achieved by palpation or devices such as the CUSA or HydroJet (see
▶ Chap. 44, “Techniques of Liver Parenchyma Dissection”).
). When a more accurate identication is necessary (e. g., a tumor in proximity),
Step8
. Fig.47.8
Situs at the end of the left hemihepatectomy with preservation
of Segment1.
A gauze swab is placed on the resection surface and slight compression is maintained for a few
minutes, or longer in the case of diuse bleeding. Each instance of bleeding on the cut surface
should be suture-ligated. At the end of the procedure, the gauze swab is removed and inspected
carefully. Any bile leaks (revealed by yellow spots on the gauze swab) are oversewn by PDS4-0 or
5-0. Alternatively, bile leaks can be identied by injecting methylene blue into the common bile
duct through the stump of the cystic duct (
. Fig. 47.9).
. Fig.47.9
Section III • Liver: Nontransplant Procedures
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Tricks of the Senior Surgeon
Early in the procedure, ask the anesthesiologist for a low CVP, which signicantly reduces
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overall blood loss.
Isolation and transsection of the left hepatic vein before the parenchyma dissection are not
-
absolutely required. Forcing through the parenchyma or middle hepatic vein may cause
severe bleeding. Thus, if diculty is encountered in isolating the left hepatic vein, repeated
attempts should be avoided; the transsection can be performed at the end of the parenchyma dissection. The results in terms of blood loss are the same, if a low CVP is maintained.
z Acknowledgments
We would like to acknowledge Panco Georgiev, who co-authored this chapter in the rst edition
of this Atlas.
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Extended Hemihepatectomy
Stefan Heinrich, Pierre-Alain Clavien
Extended Right Hemihepatectomy (Right Trisectionectomy)
e extended right hemihepatectomy (also called a right trisectionectomy) includes resection of
segments4 through 8. For cholangiocarcinoma of the liver hilum (Klatskin’s tumor) or carcinoma
of the gallbladder, an en bloc resection including segments1 and 9 is usually performed. is
procedure should be performed only if the remnant liver (segments2 and 3) provides sucient
liver function. erefore, preoperative assessment of liver function, a volumetric assessment of
the expected remnant liver volume, and exclusion of liver brosis or cirrhosis are essential before
extended resections.
Dependent on the vascular anatomy, two dierent approaches can be used for the anatomic
resection of Sg4 in addition to segments5 through 8. e classic anatomic resection of Sg4 is
performed by selective ligation of the pedicle to Sg4 prior to tissue transsection. Alternatively,
tissue transsection can be performed rst, with ligation of the pedicle to Sg4 during parenchymal
transsection. Here, we describe the classic approach of resection (
Steps1 through 7 are the same as for a right hemihepatectomy.
. Fig. 48.1).
. Fig.48.1
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_48, © Springer-Verlag Berlin Heidelberg 2016
Section III • Liver: Nontransplant Procedures
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Step8
Selective ligation of the pedicle to segment4
Aer mobilization of the right liver and ligation of the right branches of the hepatic artery and
portal vein, careful blunt dissection along the le portal sheath is performed (
pedicle to segment4 is then identied, is carefully dissected, and the vessels are selectively ligated
(
. Fig. 48.2b).
. Fig. 48.2a). e
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. Fig.48.2
Chapter • Extended Hemihepatectomy
Step9
Exposure of the right hepatic vein and parenchymal transsection
e right hepatic vein is isolated from below and marked with a rubber band as for a right hepatectomy. If the transection will be performed with a suspension technique, the right and middle
hepatic veins can be isolated from the top as described in
Anatomic Hemihepatectomy.”
e resection margin for the extended right hepatectomy is the right side of the falciform
ligament. Because the round ligament harbors the fetal connection of the umbilical cord with
the le hepatic vein (Arantius’ duct), it can be used as a guide. It is xed with a Kelly clamp and
retracted to the le, and a stay suture is placed to the right (.
is routinely performed to dene the exact extent of the lesion and to identify vascular anatomy.
Tissue transsection is started just to the right of the round ligament. All branches from the
right side of the round ligament into the liver need to be ligated selectively (
not done prior to the parenchymal transsection, the pedicle to segment4 can now be selectively
ligated. (is approach can be advantageous for tumors involving the le portal sheath.) e right
bile duct and the bile duct to segment4 can now be ligated safely.
▶ Chap. 42, “Hanging Maneuver for
Fig. 48.3a
). Intraoperative ultrasound
. Fig. 48.3b). If it was
. Fig.48.3