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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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Step10
Ligation of the right and middle hepatic veins
Approaching the hepatic veins, the middle hepatic vein is now isolated. e right hepatic vein
was previously prepared, so both veins can be divided at the end of the parenchymal dissection by
means of a vascular stapler (. Fig. 48.4). Of note, the middle and le hepatic veins usually share
a common trunk. Make sure that the le hepatic vein is preserved!
In addition to this extended right hemihepatectomy, the caudate lobe (segments1 and 9) can
be approached and resected en bloc, if needed.
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. Fig.48.4
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Chapter • Extended Hemihepatectomy
Step11
Reattachment of the falciform ligament
e falciform ligament must be reattached to prevent rotation of the remnant liver (. Fig. 48.5).
Rotation can result in an acute Budd-Chiari syndrome (obstruction of the venous outow of the
liver), a fatal complication aer extended right liver resections.
Step1 trough 7
. Fig.48.5
Extended Left Hemihepatectomy (Left Trisectionectomy)
e extended le hemihepatectomy includes resection of segments2, 3, 4, 5, and 8 (. Fig. 48.6).
is procedure should be performed only if the remnant liver (segments1, 9, 6, and 7) provides
sucient liver function. Preoperative assessment of liver function, volumetric evaluation of the
expected remnant liver volume, and exclusion of liver brosis or even cirrhosis are essential.
Depending on the vascular anatomy, two dierent approaches can be used for the anatomic
resection of segments5 and 8 in addition to the le liver. e classic anatomic resection of segments5 and 8 is performed by selective ligation of the pedicle to these segments prior to tissue
transsection. Alternatively, tissue transsection can be performed with ligation of the pedicle to
segments5 and 8 during parenchymal transsection. is chapter describes the classic approach
to resection.
STEPS1 through 7 are the same as for a le hemihepatectomy. To prepare an extended le
hemihepatectomy, the right liver must be mobilized as for a formal right hemihepatectomy, including the division of the short hepatic veins. (See ▶ Chap. 46, “Right Hemihepatectomy.”)
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Section III • Liver: Nontransplant Procedures
. Fig.48.6
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Step8
Selective ligation of the pedicle to segments5 and 8
e pedicle to segments5 and 8 (right anterior pedicle) is identied by careful blunt dissection
on the right portal sheath. e vessels are selectively ligated; the right posterior pedicle must be
preserved (
not be dissected in the hilum, but should be ligated during tissue transsection. Intraoperative ultrasound is a helpful tool to dene the exact extent of the lesion and to identify vascular anatomy.
. Fig. 48.7). For tumors involving the right portal sheath, the anterior pedicle should
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. Fig.48.7
Chapter • Extended Hemihepatectomy
Step9
Exposure of the left and middle hepatic veins
e middle and le hepatic veins, which usually share a common trunk, are isolated by careful
dissection from above and are marked with a rubber band for later dissection (
right hepatic vein is identied and preserved.
. Fig.48.8
. Fig. 48.8). e
Step10
Parenchymal transsection
e resection is performed along the demarcation line, which can be seen aer ligation of the
pedicles to segments5 and 8. Stay sutures allowing gentle traction are placed on each side of the
demarcation (
1 cm to the le of the right hepatic vein as dened by intraoperative ultrasound. Particular attention must be paid to the right hepatic vein; its course must be known during the whole period of
tissue transsection. e le bile duct and the bile duct to segments5 and 8 can be safely ligated at
the end of parenchyma dissection.
. Fig. 48.9). If the pedicle cannot be ligated rst, the plane of transsection is about
. Fig.48.9
Section III • Liver: Nontransplant Procedures
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48
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Step11
Ligation and transsection of the left and middle hepatic veins
At the end of tissue transsection, the le and middle hepatic veins are transected by means of a
vascular stapler and the resected part is removed, leaving segments6 and 7 and the caudate lobe
(
. Fig. 48.10). In addition to this formal extended le hemihepatectomy, the caudate lobe can be
approached and resected en bloc, if needed.
. Fig.48.10
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Tricks of the Senior Surgeon
Extended hemihepatectomies are typically performed for large tumors partially invading
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segment4 (extended right hemihepatectomy) or segments5/8 (extended left hemihepatectomy), or for hilar cholangiocarcinoma. In these cases, we do not selectively ligate the
pedicles to segment4 or segments5 and 8, respectively, but rather perform a formal hemihepatectomy and extend the resection margin into the contralateral liver (extended wedge
resection). This approach may spare liver parenchyma and operative time.
In the case of tumor involvement of the hilum, dissection and selective ligation of segmental
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pedicles should be performed during tissue transsection.
Similarly, preparation and transsection of the hepatic veins may prove dicult in some situa-
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tions. Two strategies should be considered:
– Transsection of the hepatic veins during parenchymal transsection without previous isola-
tion
– Total vascular exclusion
Portal vein embolization with delayed hepatectomy (about 4weeks) should be considered
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prior to resection if the remnant liver is judged too small.
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Segmentectomies, Sectionectomies, and Wedge
Resections
Norihiro Kokudo, Masatoshi Makuuchi
Hepatocellular carcinoma and intrahepatic cholangiocarcinoma spread via intrahepatic portal
branches. Anatomical resections of a tumor-bearing portal area or of a segment or a section are
basic procedures for treating liver tumors.
is chapter features the anatomical resection of segment 8, segment 7, and the right anterior sectionectomy as typical procedures, containing most of the basic techniques for anatomical
liver resection. Other procedures, including le lateral sectionectomy, le medial sectionectomy,
central hepatectomy, and wedge resection, are briey presented.
Anatomical Resection of Segment 8
e standard three-dimensional anatomy of Sg8 is shown in . Fig. 49.1.
e portal venous branches in Sg8 consist of two main branches, the dorsal branch (P8dor) and
the ventral branch (P8vent), in 92 % of patients. P8vent and one to three branches of Segment5
(P5) form a trunk in 62 % of patients. Between P8vent and P8dor, a thick branch of the middle
hepatic vein (MHV) runs and drains Segment8 (V8).
. Fig.49.1
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_49, © Springer-Verlag Berlin Heidelberg 2016
Section III • Liver: Nontransplant Procedures
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Step1
Access and identification of Sg8
A J-shaped thoracoabdominal incision is made entering via the 9thintercostal space. Using the
operator’s le hand, the right liver is easily lied up together with the diaphragm. is way a wide
surgical eld for the right liver is obtained (. Fig. 49.2a).
Under hepatic arterial occlusion with a so jaw clamp, P8vent and P8dor are punctured with a
22G needle using the intraoperative ultrasound. Approximately 5 mL of indigo carmine is slowly
injected into each vessel (
marked with electrocautery. Cholecystectomy and hilar dissection are performed when hemihepatic vascular occlusion is applied during hepatic parenchymal transection. No hilar dissection
is needed when Pringle’s maneuver is applied.
. Fig. 49.2b). e liver surface of Sg8 is stained blue and the border is
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. Fig.49.2
Chapter • Segmentectomies, Sectionectomies, and Wedge Resections
Step2
Hepatic parenchymal transection along the main portal fissure
Using a curved forceps, hepatic parenchymal transection begins along the main portal ssure
following the burned mark on the liver surface (. Fig. 49.3a).
e trunk of the MHV is exposed and its tributaries draining Segment8 are carefully ligated
and divided (
. Fig. 49.3b).
. Fig.49.3
Section III • Liver: Nontransplant Procedures
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Step3
Division of the portal pedicles for Segment8
e intersegmental plane between Sg8 and Sg5 is dissected and the portal pedicle for the ventral
part of Sg8 (P8vent) is isolated and divided. e dorsal portal pedicle (P8dor) is then ligated.
Hepatic parenchymal transection along the right portal ssure is done and the right hepatic vein
(RHV) is exposed (
. Fig. 49.4).
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. Fig.49.4
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Chapter • Segmentectomies, Sectionectomies, and Wedge Resections
Step4
Exposure of the RHV trunk
e root of the RHV is exposed and a thick venous tributary draining Sg8 is divided. e specimen
can now be removed, and the procedure is completed with careful hemostasis and suture ligation
of bile leaks. Aer removal of Segment8, landmarks including MHV, RHV, and stumps of P8vent
and P8dor are exposed (
. Fig. 49.5).
. Fig.49.5
Procedure: Anatomical Resection of Segment7
Access to Sg7 is gained through a straight thoracoabdominal incision via the 8thintercostal space
(le semilateral position) or through a right subcostal incision. An overview of the important
anatomical structures is shown in . Fig. 49.6.
. Fig.49.6