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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
Identification of the intersegmental plane and ligation of small
hepatic vein branches
e intersegmental plane between segments7 and 6 is identied by injecting the dye into P6 (a
counterstaining technique). A crushing method is applied using Pringle’s maneuver (.
When a peripheral branch of the RHV is exposed, it is carefully traced proximally and the trunk
of the RHV is exposed. Tiny branches of the RHV are carefully ligated with 4-0silk (.
Fig. 49.7a
Fig. 49.7b
).
).
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. Fig.49.7
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Chapter • Segmentectomies, Sectionectomies, and Wedge Resections
Step2
Division of the portal pedicles for Segment7 and exposure of the RHV
e two major portal pedicles are exposed. Both are ligated and divided (. Fig. 49.8a). e RHV is
exposed and a thick drainage vein of Sg7 is ligated (.
including the RHV and stumps of P7 are exposed.
Fig. 49.8b
). Aer removal of Sg7, landmarks
. Fig.49.8
Procedure: Right Anterior Sectionectomy (Right Paramedian
Sectoriectomy, Anatomical Resection of Segments5 and 8)
is procedure requires complete division of the main and right portal ssure, and thus the area
of parenchymal transection of this procedure is the widest among all anatomical liver resections
(
. Fig. 49.9).
. Fig.49.9
Section III • Liver: Nontransplant Procedures
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Step1
Hilar dissection and identification of the anterior section; transection
along the midplane of the liver
Aer cholecystectomy, the hepatic hilum is dissected and the right hepatic artery (RHA), the
right portal vein (RPV), and arterial and portal branches for the anterior and posterior section
(Aant, Apost, Pant, Ppost) are isolated (
of the right portal vein and right hepatic artery, see also the discussion of right hemihepatectomy
[
▶ Chap. 46] and extended right hemihepatectomy [▶ Chap. 48].)
Aer clamping Aant and Pant, the liver surface of the anterior section is discolored and the
demarcation lines are marked with electrocautery. is procedure conrms the sectional vascular
anatomy, and Aant and Pant can now be ligated and divided.
Next, under selective vascular occlusion by so vascular clamps of the le liver and anterior section, the hepatic parenchymal transection along the midplane of the liver is started (.
e MHV is exposed and tiny tributaries are carefully ligated and divided (. Fig. 49.10c).
. Fig. 49.10a). (For access to the hilum and preparation
Fig. 49.10b
).
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. Fig.49.10
Chapter • Segmentectomies, Sectionectomies, and Wedge Resections
Step2
Hepatic parenchymal transection along the right intersectional plane
Under a right hemihepatic vascular occlusion, hepatic parenchymal transection along the right
intersectional plane is started (
hand and the portal pedicle for the anterior section (Pant) is ligated and divided (
. Fig. 49.11a). e anterior section is lied with the operator’s le
. Fig. 49.11b).
. Fig.49.11
Section III • Liver: Nontransplant Procedures
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Step3
Transsection of the RHV branch
e RHV is exposed and a thick venous branch draining the anterior section is divided. Aer
removal of the anterior section, landmarks including the MHV, RHV, and the stump of Pant are
exposed (
. Fig. 49.12).
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. Fig.49.12
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Chapter • Segmentectomies, Sectionectomies, and Wedge Resections
Procedure: Left Lateral Sectionectomy (Anatomical Resection of
Segments2 and 3)
. Figure 49.13 depicts the important anatomical structures for this procedure.
Step1
Step2
. Fig.49.13
Hepatic parenchymal transection along the left edge of the falciform
ligament (the left intersectional plane)
By pulling up the le liver via the round ligament, hepatic parenchymal transection is done along
the le edge of the falciform ligament. e le wall of the portal pedicle for the umbilical portion
of the portal vein is exposed, and all of the tributaries running into the lateral section are ligated
and divided. When liver parenchyma of segment3 and 4 is connected in the visceral side of the
umbilical portion, the connecting part is divided during parenchymal transection.
Division of portal pedicles for segment2 and 3
Along the le wall of the umbilical portion of the portal vein, there are a few thick portal pedicles
for segment3 (P3). All of them are ligated and divided. Portal pedicles for segment2 (P2) are
located in the cranial edge of the umbilical portion of the portal vein. ey are usually thicker
than P3s and only 2 or 3 cm caudal to the root of the le hepatic vein (LHV). ey are ligated
and divided.
Section III • Liver: Nontransplant Procedures
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Step3
Division of the left hepatic vein (LHV)
At the end of the hepatic parenchymal transection, the root of the le hepatic vein (LHV) is exposed and divided. e stump of the LHV is ligated or is closed by running suture.
shows the situation at the end of the procedure.
. Figure 49.14
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. Fig.49.14
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Chapter • Segmentectomies, Sectionectomies, and Wedge Resections
Procedure: Left Medial Sectionectomy (Anatomical Resection of
Segment4)
. Figure 49.15a depicts the important anatomical structures for this procedure.
Hepatic parenchymal transection is done along the midplane of the liver and the right side
of the umbilical portion of the portal vein (the le intersectional plane). Aer removal of the le
lateral section, landmarks including the MHV and stumps of P4s are exposed (
. Fig. 49.15b).
. Fig.49.15
Procedure: Central Hepatectomy (Anatomical Resection of Segments4,
5, and 8)
. Figure 49.16a depicts the important anatomical structures for this resection.
Hepatic parenchymal transection is done along the right and le intersectional plane (i. e., the
umbilical portion of the portal vein). e MHV is divided at its root. Aer removal of the le lateral
section, landmarks including the RHV and stumps of Pant and P4s are exposed (. Fig. 49.16b).
For preparation of the right and anterior portal vein and right hepatic artery, and identication
of the right intersectional plane, see also the steps for Right Anterior Sectionectomy.
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Section III • Liver: Nontransplant Procedures
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. Fig.49.16
Procedure: Wedge Resection (Limited Resection)
e aim of this procedure is a non-anatomical complete removal of the tumor with sucient
margin. A wide surgical margin (e. g., > 10 mm) is not necessary, but care should be taken not to
expose the tumor on the cut surface.
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Chapter • Segmentectomies, Sectionectomies, and Wedge Resections
Tricks of the Senior Surgeon
Complete exposure of major hepatic veins, the landmarks for the intersegmental planes, is
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the key for successful segmentectomy and sectionectomy.
Before starting hepatic parenchymal transection, branching patterns of the major hepatic
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veins in each patient should be examined thoroughly with intraoperative ultrasound.
Major hepatic veins are rst exposed at their root and distal edge in the cut surface. Then the
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middle part of the venous trunks is exposed from both ends.
A tip of the Metzenbaum scissors is useful for dissecting hepatic veins, and all venous
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branches larger than 1 mm should be ligated.
Very tiny branches can be pulled out from the parenchyma (not from the venous wall) with
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vascular pickups.
Central venous pressure should be kept low (< 3 mm Hg) to reduce blood loss during the
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parenchymal transection.