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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Robotic Hepatectomy
Step3
Liver parenchymal transection
Supercial areas in the liver can be transacted with the scissors with monopolar coagulation attached (hot scissors). ere are a number of options for transaction of deeper areas. A bipolar
coagulation instrument such as a PK dissecting forceps can also be used (
renchyma is then transected with scissors aer sealing (
with a built-in knife can be used (
be used in conjunction with a blunt crushing instrument such as a Cadiere forceps. Clamp-clysis
is then followed by sealing with the vessel sealer if only vessels less than 5 mm are seen. Larger
vessels can be tied, clipped, or stapled. is method is akin to the Kelly clamp-clysis that is commonly used in open hepatectomy.
. Fig. 58.6c). Such a vessel sealer can be used alone, or it can
. Fig. 58.6b). Alternatively a vessel sealer
. Fig. 58.6a). e pa-
. Fig.58.6
Section III • Liver: Nontransplant Procedures
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Step4
Securing and ligating inflow vasculature
Individual components of the inow pedicle can be dissected and ligated separately.
If it is a resection for benign disease or if the tumor is more than 2 cm from the junction of the
le and right portal pedicles, however, the easiest way of securing the inow to the piece of liver
being resected is to leave the Glissonian sheath of the portal pedicle intact and staple it en masse.
. Figure 58.7
is encircled. e vessel sealer is an instrument suited for this dissection because of the smooth,
round, and atraumatic nature of this nger-like instrument. An umbilical tape is placed around
this pedicle. e umbilical tape is then used as countertraction for application of a stapler. It is
best to hold the umbilical tape with a very secure grasper such as the Pro-Grasp. An umbilical
tape is used and not a vessel loop because there is little give in the umbilical tape and it allows the
best traction to ensure that the vessels and biliary tree on the right cannot be accidentally ligated.
e stapler is then applied and red.
illustrates a le portal pedicle ligation for a le lobectomy. e le portal pedicle
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Step5
. Fig.58.7
Control and ligation of outflow vessels
Parenchymal transaction is continued until the junction of the middle and le hepatic veins is
encountered. e le vein is then dissected with care taken to protect the junction of the le
and middle vein (
is made, the hepatic vein(s) to be ligated are stapled or suture ligated (
. Fig. 58.8a). Once the decision whether to save or not to save the middle vein
. Fig. 58.8b).
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23
. Fig.58.8
Chapter • Robotic Hepatectomy
Step6
Division of triangular and falciform ligaments
In general, as much of the triangular and falciform ligaments as can be le intact are le for
division at the end of the resection (
countertraction during the surgery and allow the most atraumatic way of holding the liver for the
surgery.
At the conclusion of the resection, the ligaments are divided. e tumor is then placed into a
specimen retrieval bag and extracted.
. Fig. 58.9). is is because these ligaments can be used for
. Fig.58.9
Standard Postoperative Investigations
Complete blood count
-
Phosphorous level
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Coagulation panel
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Postoperative Complications
Bleeding
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Pulmonary insuciency from eusion or pneumothorax
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Liver failure
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Injury from positioning
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Tricks of the Senior Surgeon
Leave as many of the ligamentous attachments of the liver as possible until the end of the
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case.
Convert early in case of bleeding or loss of orientation.
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Have sutures and stapler ready in case of bleeding to attempt repair.
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Most cases do not require application of the Pringle maneuver, but a laparoscopic bulldog
-
clamp or a Rumel tourniquet can be used if necessary.
A gel port can be placed if a large specimen extraction port is anticipated to be needed.
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Two or more ports can be placed in the gel port for use as robotic or assistant ports.
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Transcutaneous sutures can be used to suspend the liver for exposure.
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Most small bleeding vessels can be sutured or sealed with the vessel sealer.
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Technique of Multi-Organ Procurement (Liver, Pancreas,
and Intestine)
Jan Lerut, Michel Mourad, Tom Darius
e growing success of liver transplantation led to the development of a exible procedure for multiple cadaveric organ procurement as introduced by Starzl in 1984. e subsequent development of
pancreas, multivisceral, and intestinal transplantation has required modication and improvement
of the initially described technique. Dierent procedures, varying from isolated procurement of
the dierent abdominal organs to total abdominal evisceration, were described during the 1990s.
Donation aer circulatory death (DCD) became reactualized during the beginning of the 21st
century as a means to increase the number of donor organs. (It should be noted that the term
“Non-Heart-Beating Donation [NHBD]” has been abandoned recently.) In these donors, the diagnosis of death is based on the cessation of the heartbeat and/or blood circulation. According to
the Maastricht classication, proposed in 1995 by Kootstra, four DCD categories exist: CategoryI
means dead on arrival in hospital; categoryII, cardiac arrest aer unsuccessful resuscitation; categoryIII, cardiac arrest aer withdrawal of organ support; and categoryIV, cardiac arrest occurring
in a brain-death donor. DCD donation is restricted mostly to Maastricht category3 and 4donors.
Because surgical approaches in donation aer cardiac death (DCD) dier somewhat from
approaches in donation aer brain death (DBD), both methods of organ procurement are described separately. e dierent clinical settings of uncontrolled DCD (Maastricht category1 and
2) and controlled DCD (Maastricht category3 and 4) also need some more specic procedural
information.
It is important to note that in DCD donors, the rst warm ischemia time, dened as the time
from “switch o” to the start of the cold perfusion, must be kept as short as possible (preferably
less than 30min), to minimize ischemia reperfusion injury of the procured organs.
e aim of every multiple-organ cadaveric procurement should be the maximal use of organs,
the minimal dissection of their cardinal structures, and an adequate repartition of their vascular axes. A technique combining minimal in situ dissection, rapidity, safe repartition of organs,
and easy acquisition of technical skills should become standard in today‘s organ transplantation
practice.
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_59, © Springer-Verlag Berlin Heidelberg 2016
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Step1
Section III • Liver: Transplant Procedures
Surgical Technique of Donation After Brain Death (DBD)
En bloc pancreas-liver procurement
Access to the abdominal vessels
A midline xyphopubic incision is performed. Aer exploration of the abdominal organs for previously undiagnosed pathologies, the white line of Toldt is incised, the right colon is mobilized to the
le, the duodenum and bowel are extensively kocherized, and the peritoneal root of the mesentery
is divided from the right iliac fossa to the ligament of Treitz (. Fig. 59.1).
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. Fig.59.1
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Chapter • Technique of Multi-Organ Procurement (Liver, Pancreas, and Intestine)
Step2
Preparation of the major abdominal vessels
e distal abdominal aorta and the inferior vena cava (IVC) are freed from their bifurcation to
the level of the le renal vein. Slight traction on the distal duodenum by the assistant allows the
procurement surgeon to identify the superior mesenteric artery, located just above the le renal
vein. e periarterial solar plexus is incised longitudinally on its le side in order to visualize the
rst 2 to 3 cm of the superior mesenteric artery. is maneuver allows aberrant liver vascularization to be individualized (e.g., a right hepatic artery originating from the superior mesenteric
artery) (. Fig. 59.2a).
Next, the hepatoduodenal and hepatogastric ligaments are inspected for anatomic variants
(e.g., a le hepatic artery originating from the le gastric artery). e supraceliac part of the aorta
is prepared for later occlusion by encircling it at the supradiaphragmatic or infradiaphragmatic
level by means of a vessel loop (
. Fig. 59.2b).
. Fig.59.2
Section III • Liver: Transplant Procedures
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Step3
Access to the pancreas
e stomach is gently separated from the transverse colon by dividing the gastrocolic ligament.
is allows the whole pancreas to be visualized. e splenic artery can be encircled and marked
close to its origin from the celiac trunk; this mark can be helpful during later ex-situ division of
the pancreas-liver bloc (
. Fig. 59.3).
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. Fig.59.3
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Chapter • Technique of Multi-Organ Procurement (Liver, Pancreas, and Intestine)
Step4
Preparation and perfusion of the abdominal organs
e gallbladder fundus is opened with the electric cautery, and the gallbladder and bile ducts are
ushed out with saline. Manual compression of the distal bile duct allows a better proximal duct
cleansing, which should be completed through a small catheter once the bile duct is transected
(
. Fig. 59.4a).
When the thoracic team is ready for procurement, heparin is given (500units/kg body weight)
and the aortic canula is inserted right above the aortic bifurcation. If the thoracic team prefers to
clamp the suprahepatic IVC during the procurement, the IVC can be cannulated at the same level
as the aorta in order to obtain better decompression and clean exsanguination. For both the aorta
and the IVC, chest drains can be used (.
in situ, but only during the back-table preparation.
e supraceliac aorta is clamped or ligated at the beginning of aortic perfusion with the preservation solution (e.g., 60mL/kg body weight of UW solution) and the intravascular cooling of
the abdominal organs is completed by abundant topical irrigation using cold saline.
e bile duct is transected just above the duodenal arch and needs to be rinsed once more
with saline through a small catheter.
Fig. 59.4b
). e portal vein does not need to be perfused
. Fig.59.4
Section III • Liver: Transplant Procedures
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Step5
Preparation and procurement of the arterial axis
Once the abdominal organs are discolored and the thoracic procurement is completed, the en
bloc liver-pancreas procurement can start. e dissection of the superior mesenteric artery trunk
is completed at the anterior side of the abdominal aorta. Retroperitoneal tissue and solar plexus
located between the IVC and aorta are transected from the le renal vein towards Winslow’s fora
men in order to fully expose the right side of the aorta and the superior mesenteric artery. Next,
the anterior side of the aorta is incised just distal to the origin of the superior mesenteric artery.
Aer visualization of the orices of the renal arteries, an arterial aortic Carrel patch encompassing
the origin of both the superior mesenteric artery and the celiac trunk is created. e simultaneous
excision of the vascular roots of the tissue bloc is an important step of the en bloc liver-pancreas
procurement.
Aerwards, the colon and intestine are repositioned in the abdomen. All branches of the le
gastric artery are transected closed to the stomach, allowing the preservation of a possible le
hepatic artery originating from the le gastric artery (. Fig. 59.5).
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. Fig.59.5
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Chapter • Technique of Multi-Organ Procurement (Liver, Pancreas, and Intestine)
Step6
Preparation of the duodenum and the pancreas
Aer instillation of a betadine solution through a gastric tube, the duodenum and the jejunum
are stapled distal to the pylorus and the ligament of Treitz, respectively. e mesenteric root is
transected distal to the pancreas using the GIA stapling device. e splenocolic ligament is taken
down and the spleen and the pancreas are freed retroperitoneally. Finally, the IVC is transected
at the level of the right adrenal gland, the liver is mobilized by transection of the falciform ligament, and the liver-pancreas bloc is removed, containing a large diaphragmatic patch (.
e ex vivo separation of liver and pancreas is done on the back table aer identication of
the vascular anatomy. (See back-table work.)
Fig. 59.6
).
. Fig.59.6
Modifications of en bloc liver-pancreas procurement
Pancreas removal for islet transplantation
For islet procurement, the pancreas is removed together with the liver, and the duodenum is
simply removed from the pancreatic head.
Procurement of intestine for transplantation
Aer initial preparation of the superior mesenteric artery and the celiac trunk, the intestine is
repositioned adequately in the abdominal cavity. e rst jejunal loop is transected about 10 cm
distal to the ligament of Treitz using a GIA stapler (.
pulled up by the assistant in order to better individualize the mesenteric root. A second assistant
maintains the intestine in place to avoid traction on the superior and inferior mesenteric veins,
as malpositioning causes reduced splanchnic perfusion.
Several small branches of the jejunal mesentery are transected close to the serosa (as is usually
done in a duodenopancreatectomy). e proximal part of the mesenteric vessels are freed for about
2 cm, so the small pancreatic veins joining the right part of the superior mesenteric vein (SMV)
are ligated, as well as those branches of the SMV draining the pancreatic isthmus. Once the SMV
is freed, the abdominal organ perfusion can be started.
As soon as the perfusion is completed, the liver-pancreas-small bowel bloc can be retrieved.
In case of an isolated intestinal transplant, it can be necessary to extend the superior mesenteric
vein and artery using free iliac venous and arterial gras.
Fig. 59.7
). e transected jejunal loop is