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Section III • Liver: Nontransplant Procedures
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Step3
Placement of the infusion pump or of a catheter connected
to a subcutaneous port
e pump pocket is created in the right lower quadrant by making a transverse incision at the level
of the umbilicus and dissecting to the anterior rectus sheath and the external oblique fascia. e
pocket is extended laterally to near the iliac crest and inferiorly to just above the inguinal ligament.
Aer insertion of a catheter (denitive), the subcutaneous port is located in a right prethoracic
position and the catheter is connected to the port.
e pump is primed with heparinized saline and proper pump function should be established
before anchoring it to the fascia with 2-0 nonabsorbable braided suture. e arterial catheter is
passed into the pocket by direct puncture (
. Fig. 54.3).
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. Fig.54.3
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Chapter • Selective Hepatic Intra-arterial Chemotherapy
Step4
Placement of the arterial catheter
Cannulation typically should be performed with a single catheter placed in the gastroduodenal
artery (GDA). e origin of the GDA from the common hepatic artery is identied, and the proper
hepatic artery from the GDA to the liver is skeletonized. Any branches leading to intestinal viscera
are individually ligated and divided. is step prevents visceral misperfusion injuries. e GDA is
further skeletonized for approximately 2 cm distal to its origin and then ligated near the pancreas.
A noncrushing vascular clamp is used to occlude the GDA at its origin. A transverse arteriotomy
is made in the GDA approximately 1.5 cm from its origin. e beaded infusion catheter is cut such
that its port does not enter the common hepatic artery, but at least one bead is in the GDA. e
catheter tip should not enter the common hepatic artery, to lessen the risk of catheter-associated
common hepatic artery thrombosis. e GDA is secured around the catheter using 4-0 nonabsorbable suture both proximal and distal to the catheter bead, preventing advancement or retraction of the catheter (
bolused into the catheter, and the liver is observed under a Woods lamp. Alternatively, 1 to 5 cc
of methylene blue will also visually conrm adequate perfusion; this is a useful method when
placing the HAIP laparoscopically.
. Fig. 54.4). To ensure proper hepatic perfusion, 1 to 5 cc of uorescence is
. Fig.54.4
Section III • Liver: Nontransplant Procedures
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Step5
Dealing with atypical arterial anatomy
Only one catheter is implanted in the single remaining hepatic artery. When ligation of hepatic
branches is necessary, the immediate opening of intraparenchymal shunts allows a redistribution
of the arterial ow through the remaining artery. In most cases, the catheter is sited in the origin
of the GDA, and accessory or replaced hepatic arteries are ligated.
Following a hepatic resection, management of aberrant arterial anatomy is contingent upon
the arterial supply of the remnant hepatic parenchyma.
Without a liver resection, the most common arterial variant is the presence of replaced hepatic arteries (right artery originating from mesenteric superior artery, or le from the le gastric
artery); these can usually be ligated. en the liver is perfused via the typical catheter placement
(
. Fig. 54.5a).
When the replaced right hepatic artery is the only artery, the catheter must be inserted in the
le branch, which is dissected in the hilum and then distally ligated (
When there is a trifurcation anatomy, the catheter can be inserted in the GDA, and the le
branch is ligated to prevent thrombosis and unilateral preferential infusion (
. Fig. 54.5b).
. Fig. 54.5c).
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. Fig.54.5
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Chapter • Selective Hepatic Intra-arterial Chemotherapy
Postoperative Studies
Some centers routinely perform a nuclear medicine study of the HAIP on postoperative day3 to
5, to rule out extrahepatic perfusion. is study consists of a sulfur colloid outline of the liver and
then bolus injection of technetium microalbumin aggregate (MAA) via the pump bolus port. e
two images are superimposed to ensure adequate hepatic perfusion and to rule out extrahepatic
visceral perfusion. In cases of abdominal pain during infusion and/or extrahepatic perfusion,
angiography must be performed to embolize accessory arteries.
Complications
Early:
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Visceral misperfusion
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Arterial injury and postoperative bleeding
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Hematoma or seroma of the pump pocket
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Late:
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Biliary stricture
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Hepatic artery thrombosis
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Occlusion or displacement of the catheter
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Pseudoaneurysm
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Pump or port pocket infection
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Tricks of the Senior Surgeon
Prime the pump and test its function early in the case. Be familiar with the specics of the
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various pumps and the needles used to bolus/prime and ll the pump.
A postoperative MAA perfusion study is not essential and may be omitted if clear intraop-
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erative studies indicate uniform hepatic perfusion with lack of reux into the duodenum
or stomach. An MAA study or angiography should be performed before the rst infusion of
chemotherapeutic agent, to demonstrate uniform perfusion of the hepatic parenchyma.
With a port, it is possible to use any kinds of drugs, and the most frequent complication is
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dislodgment or artery thrombosis. With a pump, only FUDR can be used.
z Acknowledgments
We would like to acknowledge Ravi Chari and Christopher D. Anderson, who authored this
chapter in the rst edition of this Atlas.
Unroofing and Resection for Benign Nonparasitic Liver
Cysts
Juan M. Sarmiento, David M. Nagorney
Hepatic cysts are classied according to the presence or absence of a parasitic etiology. ey
seldom lead to hepatic dysfunction and are mostly asymptomatic. e treatment is always individualized according to the origin and presence of symptoms. e choice between unroong
versus resection is dictated by site, number of cysts, malignant potential (cystadenoma/cystadenocarcinoma), and parasitic infection (see next chapter). Malignant potential is rare and is not
a primary concern.
Indications and Contraindications
Indications
Contraindications
Pain signicantly aecting lifestyle
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Jaundice
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Infection
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Hemorrhage
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Portal hypertension
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Abdominal fullness or mass
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Asymptomatic patients
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Patients amenable to percutaneous cyst aspiration and/or alcohol sclerosis under ultrasound
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or CT guidance (simple cysts with little or no capsular extension, or cysts in segments7
and 8)
Preoperative Investigation and Preparation for Procedure
History: Polycystic disease of the kidney
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Clinical evaluation: Abdominal pain, jaundice, signs of portal hypertension
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Laboratory tests: AST, ALT, alkaline phosphatase, bilirubin, tumor markers (CEA, CA19–9)
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and serologies (hydatid)
CT scan: Location, accessibility to laparoscopic versus open approach, amount of remaining
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healthy parenchyma
Ultrasound: Location, compression of main vessels (especially hepatic veins), biliary dilata-
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tion
MRI: Polycystic liver disease or complicated cases
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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_55, © Springer-Verlag Berlin Heidelberg 2016
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Step1
Section III • Liver: Nontransplant Procedures
Procedures
Laparoscopic unroofing of a simple cyst
Access and exploration
Usually three ports are used: camera, grasper for the cyst wall, and cutting instrument (cautery,
harmonic scalpel, or scissors). Placement varies according to the anatomic location of the cyst.
One of the working ports should be 10 mm, for clip application (
. Fig. 55.1).
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Step2
. Fig.55.1
Unroofing
e dome of the cyst is elevated with a grasper. Incising the cyst and draining its contents makes
the cyst wall accid and easier to handle (.
cautery. Excision should be as close as possible to the interface between the cyst and the remnant
liver. It is very important to resect the maximal amount of the wall of the cyst to enhance retraction of the remnant edge of the cyst, thus preventing reapproximation of the rim by contraction,
with subsequent recurrence. Cytology of the aspirate is performed if indicated and if the cyst is
complex, with mural nodules. Eaced ducts or vessels at the cyst-liver interface should be stapled
or clipped. Aer removal, the cyst wall is assessed histologically.
Fig. 55.2
). e wall of the cyst is resected with electro-
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. Fig.55.2
Chapter • Unroong and Resection for Benign Nonparasitic Liver Cysts
Step3
Step1
Step2
Inspection of the cyst
Aer unroong, the residual cyst wall is inspected carefully. A biopsy should be performed on
irregularities within the concavity of the cyst. When less than 50 % of the cyst has been removed,
ablation of the remnant cyst lining directly by cautery, argon beam coagulation, or topical sclerosant may reduce the incidence of recurrence. Omentum can be placed within the cyst remnant
to prevent recurrence in this circumstance.
Open unroofing of a simple cyst
Access and approach
Cysts located superiorly in segments7 and 8 are usually unroofed in an open fashion. A right
subcostal incision is indicated in these cases; the triangular ligament and a portion of the coronary
ligaments are divided to rotate the liver (see ▶ Chap. 46, “Right Hemihepatectomy”). Using the
nondominant hand, the surgeon pulls the liver toward the midline to complete the exposure of
the cyst. e same principles dictated for the laparoscopic approach are followed, and the cyst is
unroofed. Alternatively, the cyst can be enucleated en toto.
Inspection of the cyst
ere is no cyst wall le above the level of the hepatic parenchyma. Occasionally, blood vessels
or bile ducts can be seen on the cavity. No drains are necessary aer cyst excision (
. Fig. 55.3).
. Fig.55.3
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Step1
Section III • Liver: Nontransplant Procedures
Enucleation of biliary cystadenoma
Enucleation of the cyst (. Fig. 55.4a)
Aer mobilization of the liver, countertraction is maintained by the nondominant hand of the
surgeon (
and developed; the wall of the cyst is usually thick and rarely ruptures. With deeper dissection,
compressed vessels and bile ducts become evident and should be preserved. e dissection is
completed circumferentially; the cystadenoma is enucleated and sent for histologic analysis to
exclude occult cystadenocarcinoma. Importantly, complete excision of the cystadenoma eliminates
risk of recurrence.
. Fig. 55.4b). e interface between the cyst and the hepatic parenchyma is identied
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. Fig.55.4
Chapter • Unroong and Resection for Benign Nonparasitic Liver Cysts
Step2
Repair of vasculobiliary injuries
If the bile duct is inadvertently injured, a ne (4-0 or 5-0 absorbable) interrupted suture is used
for repair. Abdominal drainage is optional (
. Fig.55.5
. Fig. 55.5).
Step1
Laparoscopic resection of cysts
Access, approach, and parenchymal transection
Laparoscopic resection is used to treat peripheral cysts, especially those in the le lateral sector
(Sg2 and 3) or in the anterior segments (Sg4B, 5, and 6). e CT scan and the picture illustrate
a simple cyst in Sg3. e approach described previously is undertaken. ree ports are usually
used, and their placement depends on the site of the cyst.
e most common instruments used for this purpose are the Harmonic scalpel, TissueLink
dissecting sealer, CUSA, and surgical staplers. e surgeon must determine the most direct route
for positioning the instrument to achieve a complete cyst resection with sparing of healthy parenchyma. Because these lesions are usually peripheral and the parenchyma is thin, at times the
stapler can tightly secure both the superior and the inferior edges of the line of transection, with
a nearly bloodless margin. Identication of individual vasculobiliary structures in this situation is
not necessary (. Fig. 55.6a). When the tissue is too thick for stapling devices, the initial transection can be done with ultrasonic shears (
and the pedicle taken with the staplers. e Pringle maneuver is usually not required for this type
of transection.
. Fig. 55.6b) or any other method of vascular sealing,
. Fig.55.6
Section III • Liver: Nontransplant Procedures
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Step2
Resection of the specimen
Aer the transection of the hepatic parenchyma is completed, hemostasis must be conrmed
by direct inspection. Sometimes it is useful to “feel” or abrade the transection line to exclude a
vessel that has stopped bleeding temporarily but may act as a site of remnant bleeding once the
pneumoperitoneum is evacuated and normal intra-abdominal pressure returns. If such a vessel
is identied, hemostasis is secured by electrocautery, surgical clips, and hemostatic agents or
devices (. Fig. 55.7).
. Fig.55.7
Postoperative Tests
Routine postoperative surveillance for most patients
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Intermediate care or intensive care units for complicated cases of polycystic disease of the
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liver
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Postoperative Complications
See ▶ Chap. 46, “Right Hemihepatectomy.”
Tricks of the Senior Surgeon
Although unroong is simple, enucleation carries risk of hemorrhage. Make certain the
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hepatic duct and ligament are accessible for a Pringle maneuver if needed.
Look for small biliary radicals after enucleation; drainage is not a good alternative to repair or
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suture ligation.
During laparoscopic resection of hepatic cysts, be aware that major pedicles may not be
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amenable to sealing devices. Surgical staplers are still the best mechanism to secure structures.
As in any laparoscopic procedure with potential bleeding, do not hesitate to open up the
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patient in the presence of signicant bleeding. Safety is still better than pride!