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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Pericystectomy for Hydatid Liver Cyst
Lucas McCormack
Patients with hydatid cysts in the liver used to present a therapeutic challenge. Although surgical techniques have improved, considerable controversy still exists regarding the most eective
operative technique. e main principle of the surgery is to eradicate the parasite and prevent
intraoperative spillage of cyst contents, to avoid peritoneal spread. Pericystectomy provides a
radical treatment, removing the whole cyst “en bloc” (including the adventitia), without resection
of healthy liver tissue.
Preoperative Treatment
Albendazole (10–14 mg/kg per day) should be administered orally 2 to 4weeks before and 2 to
4weeks aer liver surgery.
Indications
Contraindications
Step1
Indications and Contraindications
Peripheral hydatid cyst of the liver
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Intrahepatic major vascular invasion
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Invasion of right or le hepatic duct
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Deep cyst within the liver parenchyma (> 2–3 cm from liver surface)
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General contraindication of liver resections
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Procedure
Incision, exposure, and staging
Access is performed as shown in the chapters on liver resection. Careful exploration of the abdominal cavity is done to exclude extrahepatic disease. e liver should be completely mobilized,
as for a major liver resection. Because accidental opening of the cyst may occur during mobilization, always have a cup with povidone-iodine (or hypertonic saline solution) ready to use in case
of intraoperative spillage of cyst contents.
Inspection and manual exploration of both lobes of the liver must be done with caution. Intraoperative ultrasound using a 5-MHz T-shaped probe is used to assess the number and location of
the cysts. Particular attention is directed toward the relationship of the cysts with the portal veins,
major hepatic veins, and the vena cava. In addition, meticulous examination of the cyst and the
adjacent liver parenchyma can sometimes demonstrate a biliary communication.
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_56, © Springer-Verlag Berlin Heidelberg 2016
Section III • Liver: Nontransplant Procedures
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Step2
Step3
Definition of the surgical approach
Most of the cysts located in the right liver are easy to dissect away from the diaphragm. If this dissection is not safely feasible, a partial resection of the diaphragm must be performed. In patients
with major vascular involvement or invasion of the le or right hepatic duct, an anatomical liver
resection is indicated. If a cyst is located deep within the liver, liver resection is also recommended.
If the depth from the liver surface is less than 2to 3 cm, however, a hepatotomy allows the cyst to
be reached, and a standard pericystectomy can be performed. For cysts located close to the vena
cava in segments6 or 7, the liver must be mobilized as for a right hepatectomy.
Preparation prior to pericystectomy
e central venous pressure (CVP) should be below 3 mm Hg before starting the liver transection. A tourniquet is placed around the porta hepatis for inow occlusion in case of bleeding. To
prevent accidental spillage of the cyst contents, the whole space around the liver is packed using
gauze swabs. A pack placed behind the right liver usually oers better exposure. e contents of
the cyst should never be evacuated before resection. Stay sutures should not be placed in the cyst
wall, but stay sutures with silk 2-0 are placed in the liver parenchyma around the emerging part
of the cyst to enable traction and better exposure during resection (
. Fig. 56.1).
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. Fig.56.1
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Chapter • Pericystectomy for Hydatid Liver Cyst
Step4
Resection of the cyst
e liver capsule is incised with diathermy. Careful identication of the correct plane of cleavage
is crucial to avoid bleeding or spillage of the cyst contents (.
coagulated selectively with bipolar forceps or ligated with metallic clips, ties, or suture-ligatures,
depending on their diameter. Although several possible techniques for liver parenchyma dissection can be used (see
the water jet, which enables a selective and safe separation of the cyst wall from the liver parenchyma (
the exposed raw surface of the liver can be improved with an argon beam coagulator or topical
brin derivates.
. Fig. 56.2b). Small bile ducts should be carefully identied and tied. Hemostasis of
▶ Chap. 44, “Techniques of Liver Parenchyma Dissection”), we prefer
Fig. 56.2a
). Intrahepatic vessels are
. Fig.56.2
Postoperative Complications
Possible complications are the same as in liver resections (see ▶
biliary stula is less common than in partial resection.
Chap. 45
, “Liver Resections”), but
Section III • Liver: Nontransplant Procedures
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Tricks of the Senior Surgeon
Use magnication loops to control bile leaks after pericystectomy. Careful repair should be
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done with suture-ligatures with Prolene 4-0 to 5-0.
At least two drains with powerful suction should be available in case of rupture of the cyst, to
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avoid peritoneal spread of the contents.
Always have a cup with povidone-iodine (or hypertonic saline solution) ready to use in case
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of intraoperative spillage of cyst contents into the peritoneal cavity.
In case of intraoperative bleeding and technical diculties during surgery, remember that
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adequate conservative surgery (e. g., partial resection of the cyst) can also achieve excellent
results. The strategy can be changed at any time!
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Special Maneuvers in Liver Trauma
Denis Castaing, Olivier Scatton, Antonio Sa Cunha, Marius Keel
Liver injuries most oen (> 90 % of all cases) are associated with other injuries such as ipsilateral
rib fractures, lung contusions, other intra-abdominal lesions, or injuries of the extremities, the
pelvis, and the head. Hepatic injuries are graded according to the Organ Injury Scale of the American Association for the Surgery of Trauma (AAST-OIS) (. Table 57.1).
. Table57.1 Grading of hepatic injuries according to the Organ Injury Scale of the American Association for
the Surgery of Trauma (AAST-OIS)
Grade Injury description Incidence [%] Mortality [%]
I Subcapsular hematoma, < 10 % surface area 20 0
Capsular tear, < 1 cm in depth
II Subcapsular hematoma, 10−50 % surface area 55 < 10
Intraparenchymal hematoma, < 10 cm in diameter
Laceration, 1−3 cm in depth, < 10 cm in length
III Subcapsular hematoma, > 50 % surface area, expanding or
ruptured with bleeding
Intraparenchymal hematoma, > 10 cm in diameter or expanding
Laceration, > 3 cm in depth
IV Parenchymal disruption involving 25−75 % of lobe or one to
three segments
V Parenchymal disruption of > 75 % of lobe or more than three
segments
Juxtahepatic venous injury
VI Hepatic avulsion < 1 Near 100
15 25
7 45
3 > 80
Because clinical examination of the abdomen is unreliable in trauma patients with an altered
level or loss of consciousness, a Focused Assessment with Sonography for Trauma (FAST) should
be undertaken as an adjunct to the primary survey. In hemodynamically unstable patients with
free uid in FAST, a diagnostic laparotomy without further investigation is indicated. In stable
patients, CT scanning of the abdomen represents the gold standard with evaluation of hemoperitoneum and parenchymal fractures, as well as vascular mapping including a three-phase study
(arterial, portal, and venous) as a preparation for a possible arterial embolization. e decision
for operative or nonoperative management of blunt hepatic trauma aer the CT scan is made
according to the grade of liver injury and other abdominal injuries that are diagnosed or suspected, whereas for penetrating abdominal injuries, an operative exploration of the abdomen is
still standard.
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_57, © Springer-Verlag Berlin Heidelberg 2016
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Section III • Liver: Nontransplant Procedures
Indications for Nonoperative Management
Liver injuries of gradesI throughIII should be treated nonoperatively. In case of active bleeding
(diagnosed by CT scan), an angiographic embolization should be performed in patients with
injuries of gradesI throughIV. However, the following conditions should be fullled:
Patient without altered level or loss of consciousness
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Hemodynamic stability or rapid stabilization aer initial uid resuscitation
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Exclusion of hypothermia, acidosis, or severe coagulopathy
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No doubt about another abdominal lesion
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Intensive care unit available with continuous pulse and arterial blood pressure monitoring;
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repeated measurements of hemoglobin, hematocrit, and coagulation parameters; and careful follow-up clinical examination and sonography
Availability of a surgical team
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Availability of arteriography and an experienced radiologist
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Indications for Laparotomy
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Step1
Hemodynamic instability
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Peritonitis on physical examination
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Other abdominal injuries in diagnostic studies
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Failed nonoperative treatment
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Procedure
Incision and abdominal exploration
A midline incision is performed, as well as (depending on the type of injury) an extension into
the chest by median sternotomy or le or right thoracotomy. e initial step in a trauma laparotomy is to pack all four quadrants of the abdomen in order to control hemorrhage as quickly
a
s possible. e next step is to determine the site(s) of bleeding and injuries by exploration of
the whole abdomen, with special attention to the pancreas and the right retroperitoneal area.
Packs are removed from one quadrant at a time, starting in the noninjured area and ending
in the most seriously injured area. Injuries of the small or large bowel and of the biliary tree
are repaired.
In addition, a rapid transfusion device with warmed crystalloids and blood is essential. Aer
exclusion of hollow-organ injuries, blood should be collected in the peritoneal cavity for autotransfusion (cell saver). Dilutional coagulopathy may follow massive blood transfusions, prompting the
need for transfusion of platelets, fresh frozen plasma, and/or activated factorVII.
In general, three situations can be found aer laparotomy:
Diuse, severe active bleeding or cardiac arrest at the opening: e control of massive exsan-
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guinating hemorrhage requires clamping of the aorta and/or inferior vena cava (IVC). Aor-
tic control can be approached through a sternotomy or le thoracotomy allowing supradia-
phragmatic, intrathoracic aorta cross-clamping and open cardiac massage in situations with
cardiac arrest. is is predictable if an external cardiac massage on a “dying person with
a tense abdomen” is performed. Furthermore, the suprarenal abdominal aorta can be ap-
proached through the gastrohepatic ligament or aer medial rotation of the splenic exure
of the colon (Mattox maneuver). e infradiaphragmatic IVC can be controlled by direct
digital pressure or clamping aer an extended Kocher maneuver or right-side-to-medial
visceral rotation (Cattel Braasch maneuver).
No active bleeding from the liver: Simple hepatic injuries such as gradesI, II, or III without
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active bleeding do not require further operative investigation or treatment.
Active bleeding from the liver: Proceed with Step2.
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Chapter • Special Maneuvers in Liver Trauma
Step2
Manual compression of the liver
In case of active hemorrhage from the liver, the surgeon (or ideally, the assistant) performs initial
tamponade by manual compression for at least 10min (
found:
When the hemorrhage can be controlled by manual compression, a competent team is
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available for appropriate assessment, and the patient is hemodynamically stable without
hypothermia or acidosis, a one-step intervention leading to denitive surgical repair can be
decided (see Step3).
When the hemorrhage is not controllable and hemodynamic instability, hypothermia, aci-
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dosis, or coagulopathy occur, liver packing (see Step9) with or without vascular control (see
Step10) must be performed.
. Fig. 57.1). en, two situations can be
. Fig.57.1
Section III • Liver: Nontransplant Procedures
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Step3
Mobilization of the liver
e liver can be fully mobilized to facilitate the examination and exploration of the posterior
surface and the retrohepatic vena cava. Mobilization must be done carefully to avoid hepatic vein
damage. Aer dissection of the falciform ligament, the right triangular, the coronary, and the
le triangular ligaments are divided while the assistant is taking care of the fracture by manual
compression (
. Fig. 57.2).
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. Fig.57.2
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Chapter • Special Maneuvers in Liver Trauma
Step4
Risk of hepatic vein damage during liver mobilization
When liver packing is needed (Step9), hepatic mobilization is not recommended, as this maneuver
increases the risk of hepatic vein damage and aggravates the initial liver injury.
Major hepatic lesions are usually caused by a deceleration trauma leading to a liver fracture
at the level of the right triangular ligament along the right hepatic vein. is location is oen difcult to access. To stop the bleeding, the fracture should be closed by placing the assistant’s hand
beyond the fracture; traction should be avoided (
. Fig.57.3
. Fig. 57.3).
Step5
Vascular ligation
e wound may require enlargement to visualize the source of bleeding by utilizing nger-fracture
technique and retractors (hepatotomy). Bleeding vessels can be controlled using sutures, surgical
clips, and electrocautery. Deep stitches, which could lead to ischemic areas, should be avoided
(
. Fig. 57.4).
A Pringle maneuver may be required, but prolonged pedicle clamping must be avoided whenever possible, as it may aggravate ischemic injury caused by hypotension. If pedicle clamping
longer than 30min is needed, intermittent clamping is recommended (15min of clamping and
5min of reperfusion).
Hepatic defects can be lled by vascularized omentum (omentoplasty). is helps to eliminate
dead space, tamponades venous oozing, and may reduce the risk of a signicant bile leakage.
. Fig.57.4
Section III • Liver: Nontransplant Procedures
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Step6
Resectional débridement
Devitalized hepatic tissue must be removed because of the risk of abscess. e hepatic parenchyma
is divided along the line of fracture in the plane between devascularized liver and the remaining
parenchyma, using the back of the scalpel handle. When resistance is encountered, this indicates
the elastic tissue of vessels or biliary ducts, which are doubly clamped, divided, and suture ligated
(. Fig. 57.5). In most instances, a nonanatomical resection rather than a standard anatomical hepatectomy is preferred. A major hepatectomy is rarely indicated in the presence of extended injuries.
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Step7
. Fig.57.5
Ruptured subcapsular hematoma
In case of a ruptured subcapsular hematoma, hemostasis is performed using an argon beam coagulator, and the capsula is glued onto the bleeding parenchyma. e glue can be injected between
the parenchyma and the glissonian capsule (
sealer can be used.
. Fig.57.6
. Fig. 57.6
). Alternatively, a TissueLink dissecting
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