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Chapter • Special Maneuvers in Liver Trauma
Step8
Methylene blue test and cholangiography
Aer complete hemostasis, the integrity of the biliary tract is evaluated by a methylene blue test.
e test can be performed through a gallbladder puncture combined with a manual choledochal
compression. Biliary leaks are repaired by selective ligations (
e opening of the gallbladder wall must be closed carefully (cholecystorrhaphy). In case of
limited liver trauma, a cholecystectomy is preferred, allowing cholangiography through the cystic
duct to detect biliary leaks into the fracture line.
. Fig. 57.7).
. Fig.57.7
Section III • Liver: Nontransplant Procedures
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Step9
Packing
Packing is the mainstay of damage control. e principle is to perform a compression of the liver
against the diaphragm (upper and posterior direction), which works very well for venous bleeding. Gauze swabs are placed around the liver – not inside the lesion – in order to compress the
fracture and keep the compression against the diaphragm (
be placed between the liver and the diaphragm, to avoid compression of hepatic veins and vena
cava compromising venous return and resulting in decreased cardiac inow and a hepatic venous
thrombosis. However, the elevation of the diaphragm leads to a high peak airway pressure with
hypoventilation, which must be taken into account in the postoperative care.
e abdomen is closed under tension without drainage to maintain pressure on the packs.
e increased intra-abdominal pressure represents a major risk for an abdominal compartment
syndrome and therefore needs to be checked regularly.
If the hemorrhage is not controlled, manual compression is performed again and the liver is
packed one more time. If this step does not lead to control of the bleeding, partial or total vascular
exclusion of the liver needs to be performed (Step10).
. Fig. 57.8). However, no pack should
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Step10
. Fig.57.8
Vascular control
If packing fails to control hemorrhage in complex liver injuries, the Pringle maneuver allows control of hemorrhage from the hepatic artery and portal venous system. e technique also helps to
rule out other sources of bleeding such as retrohepatic veins and the vena cava. If this maneuver
does not lead to control of the bleeding (gradeVI lesions), total vascular exclusion of the liver is
performed by clamping the supradiaphragmatic IVC aer sternotomy and the infradiaphragmatic
IVC (see ▶
in Liver Surgery”). e appropriate and early use of vascular control allows for accurate identication of the injury and the control of hemorrhage.
Chap. 41
, “Techniques of Vascular Clamping, Vascular Exclusion, and Caval Resection
23
Chapter • Special Maneuvers in Liver Trauma
Step11
Step12
Hepatic venous exclusion
In case of a retrohepatic caval injury, an atrial-caval shunt to the superior vena cava or a hepatic
venovenous bypass should be used in addition to the Pringle maneuver early in the operation, to
preserve venous return during repair of the retrohepatic caval injury. An atrial-caval shunt can be
performed with a large chest tube through the right atrial appendage placed and advanced into
the IVC distal to the renal veins. Additional side holes are cut in the tube at the atrial level. Tourniquets are tightened around the vena cava at the level of the supradiaphragmatic and suprarenal
cava levels and the atrial appendage.
Intrahepatic balloon tamponade
Hemorrhage control for through-and-through penetrating liver injuries can be achieved by an intrahepatic balloon, avoiding an extensive hepatotomy (tractotomy) (
balloon is created from a Penrose drain, which acts as a balloon and hollow catheter. Ination of
the balloon causes a tamponade within the liver parenchyma. Alternatively, a simple Foley catheter
can be taken. e tamponade is maintained for 48h.
. Fig. 57.9
). e intrahepatic
. Fig.57.9
Postoperative Management
Postoperative care on the intensive care unit requires correction of hypovolemia and the
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“triad of death”: hypothermia, acidosis, and coagulopathy.
Intra-abdominal pressure should be measured frequently by means of a Foley catheter in
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the bladder aer primary closure of the abdomen, to detect the development of an abdominal compartment syndrome.
If packing is decided upon, a planned reintervention (second look) with removal of the
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packs, as well as repacking, denitive hemostasis, and denitive abdominal closure or abdominal vacuum-assisted closure, is necessary aer the resuscitation period. e time point
of the second look depends on rewarming and correction of acidosis and coagulopathy,
which usually takes 24 to 48hours.
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Section III • Liver: Nontransplant Procedures
Postoperative Complications
z Short-term:
Hemorrhage
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Abdominal compartment syndrome
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Bile leaks
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Liver failure
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Acidosis, coagulopathy, and hypothermia with multiple organ failure
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z Long-term:
Biloma
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Biliary stula
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Biliary stricture
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Abscess and hematoma infection
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Tricks of the Senior Surgeon
Do not hesitate to call for help from a hepato-pancreato-biliary (HPB) surgeon.
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Request experienced anesthesiologists.
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Ask regularly for temperature and quantity of transfusions.
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Do not mobilize the liver until volume replacement has been achieved.
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Alert the anesthesiologist prior to clamping of major vessels, as a sudden decrease in venous
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return is tolerated poorly by hypovolemic patients.
A decision to use packing is usually the best in a complex situation.
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Robotic Hepatectomy
Hari Nathan, Yuman Fong
Laparoscopic liver resection is now standard for resection of peripherally located lesions. Laparoscopic wedge resections, segmental resections, and le lateral sectionectomies are routinely
performed at many centers, and laparoscopic lobectomies are performed at specialty centers.
Recent development of new instrumentation for robotic surgery now allows routine robotic liver
and biliary surgery to be performed safely. Articulated instruments, sealers, and staplers allow
liver surgeons to take advantage of the binocular vision, ease of suturing, and decrease in tremor
aorded by robotic surgery. Data indicate that lobectomies are much more likely to be completed
through the robotic approach than through the usual laparoscopic approach.
In this chapter, we present the standard positioning and conduct of a robotic liver resection.
We use the le lobectomy as an example. is is clearly an evolving area, in which ever-changing
instrumentation and improving expertise will likely bring great changes in the next few years.
Indications
Contraindications
Indications and Contraindications
Primary malignancies of the liver
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Metastases malignancies of the liver
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Benign tumors of the liver
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Symptomatic cysts of the liver
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Abscesses of the liver
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Cardiopulmonary comorbidities
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Advanced tumors
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Patients older than 75years (relative)
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Preoperative Investigations/Preparation for the Procedure
Chest radiograph: In cases of malignancies, to check for
metastases
CT scan: To check resectability. To plan port place-
ment
MRI: In patients with hepatosteatosis, to check
presence and position of tumors
Risk analysis: Cardiac, lung, liver function
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_58, © Springer-Verlag Berlin Heidelberg 2016
Section III • Liver: Nontransplant Procedures
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Step1
Positioning and exposure
For most resections in the le or right liver, a supine position is best (. Fig. 58.1). e patientside cart (tower with the robotic arms) will be docked so that the cart, line of liver transaction,
and camera ports are roughly in line. us, the cart is generally on the patient’s le for le-sided
resections and on the right for right-sided resections. For bilateral resections, the tower should be
on the side of the dominant lesion or docked directly over the head of the patient.
e table is slightly rotated to the opposite side of the target lesion so that the liver to be
removed is suspended on the ipsilateral triangular ligament. In addition, unlike in an open operation, a reverse Trendelenburg position is generally used. is allows the intestines to fall away
from the liver to a dependent position. is also allows the liver to fall away from the diaphragm.
Gravity is used for retraction.
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. Fig.58.1
Chapter • Robotic Hepatectomy
Step1 (continued)
Port placement for standard right or le hepatectomy is shown in . Fig. 58.2. Generally, the camera port is placed in the umbilicus (black). A balloon port works well as the camera or accessory
ports (umbilical or more medial ports). e 8-mm robotic ports are generally used for instrument
ports. One other option is to use a 5- to 12-mm port in the right midclavicular line. A long 7-mm
“bariatric” robotic port can be placed within the standard 12-mm laparoscopic port for robotic
docking. is allows the exibility of placing the camera in the midclavicular line as well as using
the 12-mm port as an assistant port for smoke evacuation, suction, retraction, and stapling. For
minor resections, four total ports may be all that is necessary. For major resections an additional
assistant port may be placed (
. Fig.58.2
. Fig. 58.3).
Section III • Liver: Nontransplant Procedures
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Step1 (continued)
Positioning for Right Posterior Lesions
For lesions in the right posterior sector (segment6 or 7), patients should be placed in a le lateral
decubitus position (
between the costal margin and the iliac crest is at the break in the table. e table is then extended
similar to the positioning for a renal or retroperitoneal operation. e table should also be in a
reverse Trendelenburg position as explained earlier. e port sites are illustrated (
camera port (black), robotic ports (white outline), and assistant port (black outline). e most
posterior port in the space between the costal margin and the iliac crest is placed as posterior
as possible and as low as possible (
assistant port should be 12-mm ports, so that the camera can be used in either, and staplers can
be applied from either.
. Fig. 58.3). e patient should be positioned on the table such that the space
. Fig. 58.4) for
. Fig. 58.4b). Both the umbilical port and the midclavicular
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. Fig.58.3
7th intercostal space
Chapter • Robotic Hepatectomy
Step1 (continued)
. Fig.58.4
6th intercostal space
8th intercostal space
9th intercostal space
Section III • Liver: Nontransplant Procedures
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Step2
Assessment and planning
Aer docking the robot, entire peritoneal cavity is assessed for ascites, location of pathology, and
location of other organs. Resection planning is then performed. e direction of the camera is
placed as close to the line of liver transaction as possible. An instrument with monopolar coagulation attached is used to mark the line of liver transaction (.
verify locations of tumors and major vasculature (. Fig. 58.5b). For this purpose a drop-in probe
that can be manipulated with the robotic arms is best.
. Fig.58.5
Fig. 58.5a
). Ultrasound is then used to
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