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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Laparoscopic Liver Resection
Step4
Completion of transection and isolation of the left hepatic vein
Aer bile duct division, transection progresses cephalad along Arantius’ line, and complete circumferential dissection of the le hepatic vein is performed. At this stage, the gra is attached
only by its vessels (
. Fig. 50.14).
Step5
. Fig.50.14
Graft harvesting
An extraction incision is made as previously discussed, but larger (typically 8–10 cm) so as not to
compress the specimen. e le lobar arterial branch is clipped and divided. e le portal branch
is then divided, initiating warm ischemia. To preserve an adequate length of the gra portal vein,
an endovascular-TA stapler is used for the proximal transection. A bulldog clamp is placed on the
gra side to prevent bleeding. Finally, the le hepatic vein is stapled with the endovascular-TA
stapler. rough a 15-mm port, an endo-bag is placed for capture of the gra, which is extracted
aer incision of the fascia. e gra is handed to another team for perfusion with cold preservation solution. Warm ischemic time is usually less than 10min.
Tricks of the Senior Surgeon
Laparoscopic hepatectomy is a technically challenging procedure, but it can be performed
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safely for both benign and malignant lesions by those with expertise in both hepatic and
advanced laparoscopic surgery.
Patient selection and indications must be carefully assessed.
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A state-of-the-art laparoscopy suite and equipment are required.
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Ultrasonic shears or a vessel-sealing device are sucient for supercial transection (2–3 cm
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in depth), whereas an ultrasonic dissector is recommended to identify deeper structures and
avoid vascular injuries, especially of hepatic venous branches.
In cases of persistent bleeding, insucient exposure, failure to progress, risk of tumor
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rupture, or violation of margins, one should convert to an open procedure. Conversion (in
contrast to a poor outcome) is not a procedural failure.
Cryosurgery
Keh Min Ng, DavidL. Morris
e goal of hepatic cryosurgery is complete destruction of tumors for curative or palliative reasons,
as an alternative to resection when resection is not feasible.
Indications and Contraindications
Indications
Contraindications
Malignant liver tumors in the case of:
Cirrhosis, if risk of resection is excessive
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Extensive disease, where resection would not leave enough hepatic parenchyma
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Debulking of neuroendocrine tumors
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As an adjunct to resection (i. e. resect one side and cryoablate the other side)
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Edge cryotherapy, when resection margins are involved or are less than 1 cm
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Extrahepatic disease that is not amenable to surgery or ablation (except neuroendocrine
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tumors)
High number of lesions (for example, more than nine; some centers may consider more
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than ve lesions to be a contraindication)
Tumors larger than 3 cm
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Synchronous bowel resection and hepatic cryoablation (increased risk of liver abscess)
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Preoperative Investigation and Preparation for the Procedure
In addition to the preoperative investigations before liver resections:
In the case of neuroendocrine tumors: H1 and H2blockers and somatostatin (double exist-
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ing dose or 100 mg twice daily if not on it) 48hours preoperatively
Bowel preparation (facultative)
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Ensuring that there is liquid N2 in the machine
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Procedure
Step1
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_51, © Springer-Verlag Berlin Heidelberg 2016
Evaluation of the tumor
To exclude extrahepatic disease, the procedure is started with a diagnostic laparoscopy or a minilaparotomy. e liver is examined bimanually and the tumors are investigated by ultrasound with
respect to number, size, and distance from bile ducts and vascular structures. Next, the lesser sac
is opened and suspicious lymph nodes are sent for histological examination. Heated bed blankets
should be used to prevent hypothermia.
Section III • Liver: Nontransplant Procedures
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51
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Step2
Insertion of the probe and applying cryotherapy
Access to the liver is gained by a bilateral subcostal or triradiate incision. For safety reasons, the
probes need to be checked for leaks under water with liquid N
ance (
. Fig. 51.1a), the probes (3–10 mm in diameter) can be inserted at the center of the tumor
(
. Fig. 51.1b).
For larger tumors, multiple probes in a predetermined relationship are used (.
Cryosurgery can also be combined with a partial hepatectomy. In such cases, an edge probe is used
to destroy the remnant tumor at the resection surface. is probe does not need to be inserted
into the liver (
e ice ball made by cryoablation should extend at least 1 cm beyond the tumor margin, as
demonstrated with ultrasound guidance. Because it is not possible to see through the ice, the
posterior margin is visualized by ultrasound from behind the liver.
Aer demonstration of a 1-cm margin, we thaw passively, waiting for 1 cm to thaw out, and
then refreeze. Twin freeze-thaw cryotherapy lowers the local recurrence rate. A single cryoablation
cycle takes approximately 7 to 10min, depending on the size of the lesion.
. Fig. 51.2b).
running. Using ultrasound guid-
2
Fig. 51.2a
).
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. Fig.51.1
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Chapter • Cryosurgery
Step2 (continued)
Step3
. Fig.51.2
Removing the probes
Before the probe can be taken out, it must be rewarmed with warmed nitrogen gas. en the
probe can be pulled gently out of the liver, and the tract can be lled with surgical or alternate
hemostatic foams.
Section III • Liver: Nontransplant Procedures
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Step4
Cracks
e changes in temperature can cause fractures in the liver, which can cause bleeding. ese
“cracks” need to be managed by liver sutures and packs (. Fig. 51.3).
. Fig.51.3
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Postoperative Tests
Tests are performed for the prediction of cryoshock:
Full blood count, looking for thrombocytopenia particularly on day3
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Liver function test (LFT), especially aspartate aminotransferase (AST) (highest rise on
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day1)
Kidney function tests
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Postoperative Complications
Cryoshock: Cryoshock is a syndrome of multiorgan failure including renal impairment, pul-
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monary edema, coagulopathy, and disseminated intravascular coagulation. e incidence of
cryoshock is about 1 %; it is seen only with large volume distraction and especially with the
complete twin freeze-thaw technique.
Hepatic abscess: Very rare, except with synchronous bowel resection and cryoablation.
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Pleural eusion: Common, especially during right-sided hepatic ablation.
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Biloma or biliary leak.
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Biliary strictures: Biliary strictures can occur but are very rare within the liver. e main risk
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is for large lesions in segmentIV lying at the bifurcation of the portal veins.
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Chapter • Cryosurgery
Tricks of the Senior Surgeon
Do not wash the lesion or the abdominal cavity with warm saline to speed thawing; doing so
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can result in dramatic cracking.
Make sure there is liquid N2 in the machine before you start the procedure.
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Use multiple probes for multiple lesions simultaneously to increase the speed of the pro-
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cedure. However, single lesions are better treated by one large probe than by several small
probes because of the risk of cracking between small probes.
Large lesions need more than one probe.
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Before closing the abdomen, make sure the ice ball has thawed completely and there is no
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bleeding from any cracks.
Aim for a high intraoperative and postoperative urine output to prevent kidney failure.
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z Acknowledgments
e authors would like to acknowledge the contribution by Koroush S. Haghighi to the chapter
in the rst edition.
ALPPS (Associating Liver Partition with Portal Vein
Ligation for Staged Hepatectomy)
Erik Schadde, Pierre-Alain Clavien
Indications
Contraindications
Colorectal liver metastases, primarily un-resectable due to a too small liver remnant
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Non-colorectal liver metastases, primarily un-resectable due to a small liver remnant, if
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resection is oncologically indicated
Primary liver tumors like HCC and intrahepatic cholangiocarcinoma in specic situations
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in which primary resection is impossible due to remnant volume and function considerations
Patients with cholestasis
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Risk of mortality increases with older age and poor physiologic reserve
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In the eld of surgery for liver malignancies, signicant progress has been made to expand the
criteria of resectability. e importance of the size on imaging (“volumetric size”) of the future liver
remnant (FLR) that will support the patient aer resection is well established. For normal livers,
25 % to 30 % of healthy liver tissue should remain in order to support the patient hemodynamically, metabolically, and in terms of synthetic function. Several strategies have been developed
to increase the size of the FLR before resection. Portal vein embolization followed by resection
aer an interval to allow for growth of the liver became popular in the 1990s (
stage hepatectomies to allow for recovery and growth between stages were introduced 20years
ago. Adding portal vein embolization to the waiting interval between two stages (
adding portal vein ligation to the rst stage of two-stage resections (
cessfully used and reported. All these interventions have in common that the interval between
the two stages extends over several weeks, and up to one third of the patients do not progress to
the second stage operation because of tumor progression in the interval.
In 2012, a muticentric study from Germany introduced a new two-stage hepatectomy technique to obtain extensive and rapid volumetric growth of the FLR in patients requiring right
extended hepatectomies. e new technique consisted in adding a liver parenchymal partition to
the portal vein ligation in the rst step of a two-staged resection. e waiting interval was reduced
to about 1week (. Fig. 52.1d). In the inaugural study the authors presented the results of this new
technique in 25patients and reported a median volume increase of 74 % over only 1week, as assessed by CT volumetry. is complex procedure was labelled as “Associating Liver Partition with
Portal Vein Ligation for Staged Hepatectomy” (ALPPS). Other centers have been able to replicate
these results, and the relative benet of this accelerated two-stage approach compared with the
earlier methods of portal vein occlusion in two-stage operations to induce volume growth is currently a matter of debate and investigation.
is chapter presents the ALPPS procedure as practiced by the Zurich group. It explains the
surgical approach to preparation of the hepatoduodenal ligament, the hepatic veins, and parenchymal transection with preservation of arterial inow and biliary drainage during Stage1 of the
ALPPS procedure, as well as removal of the deportalized part of the liver during Stage2.
. Fig. 52.1c) has been suc-
. Fig. 52.1a). Two-
. Fig. 52.1b) or
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_52, © Springer-Verlag Berlin Heidelberg 2016
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Section III • Liver: Nontransplant Procedures
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. Fig.52.1
Chapter • ALPPS (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy)
The Concept of ALPPS
ALPPS combines portal vein ligation and parenchymal transection along the line of the deportalized part of the liver to be removed. e volumetric growth observed appears more rapid, and
generally the second-step removal of the deportalized lobe may be performed aer 1 to 2weeks.
is operation requires careful preparation of the inow structures at the hepaticoduodenal ligament, ligation of one portal vein branch, and preservation of the arterial inow and bile ducts of
both the FLR and the deportalized lobe, with meticulous avoidance of bile leaks.
ALPPS volumetric planning
For a successful ALPPS procedure, careful volumetric planning is important. e FLR is the part
of liver that will remain aer its tumor burden is removed and the deportalized part of the liver has
been removed. e size of the FLR may be expressed in dierent metrics (.
in healthy livers without cirrhosis or cholestasis is below 30 % or the ratio of FLR to body weight
is below0.5, the risk for postoperative liver failure is likely increased. For diseased livers, higher
cut-os are required (
in
. Table 52.3 in three scenarios. We observed volumetric growth of 50 % to 80 % in 1week and
120 % to 200 % aer 14days. e volumetric increase required to reach a safe FLR volume of 30 %
must be determined and the expected waiting time to reach this volume estimated.
Commonly the FLR resides within the le lateral segments2 and 3 (.
as the portal inow can be preserved and there are no tumors in segment1, segment1 may be
preserved (
preserved as well. Although the FLR more frequently resides in the le lobe, because the right lobe
is larger overall, most ALPPS procedures have been performed with the FLR on the right side.
. Fig. 52.2b). In some cases, segments 4A (. Fig. 52.2c) and B (. Fig. 52.2d) may be
. Table 52.2). e hypertrophy induced by the ALPPS procedure is shown
Table 52.1
Fig. 52.2a
). If the FLR
). As long
. Fig.52.2
Section III • Liver: Nontransplant Procedures
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. Table52.1 Denitions
FLR “Future liver remnant”
sFLR “Standardized future liver remnant”
FLR/BW ratio “Remnant to body weight ratio”
. Table52.2 Volumetric Requirements for Stage2 resection
Volume required in normal livers Volume required in injured livers (brosis, cirrhosis,
FLR/TLV> 0.3 FLR/TLV> 0.4
sFLR/TLV> 0.3 sFLR/TLV> 0.4
FLR/BW ratio> 0.5 FLR/BW ratio> 0.8
. Table52.3 Expected Volumetric Increase of FLR
FLR prior to
stage1
0.2 0.1 50 0.3 6
0.15 0.15 100 0.3 10
0.1 % 0.2 200 0.3 14
Proportion of the volume of the future liver remnant minus the tumor load to
be removed (FLR) divided by the volume of total liver measured
Proportion of the volume of the future liver remnant minus the tumor load to
be removed divided by the standardized total liver volume (sTLV) according
to Vauthey
Ratio of the volume of future liver remnant in cubic centimeters minus the
tumor load to be removed (FLR) by the body weight (BW) in kg
SOS, CASH)
Additional FLR
required (% of
TLV )
Hypertrophy
required (%)
FLR prior to
stage2
Expected time
for volumetric
increase (days)
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