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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Right hepati
vein
ft hepatic vein
Middle hepati
vein
In
Cava
Right posterio
portal vein
Hepatic Procedures
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c
463
Le
c
Inferior vena cava
Fig. 2 Identication of the hepatic veins by placing the ultrasound probe at the hepatocaval
conuence
Right anterior
portal vein
Right hepatic
vein
S V/VIII
r
Middle hepatic
vein tributaries
S VI/ VII
feriorVena
Fig. 3 Identication of the right portal vein branches and the right liver segments
(d) Position 4: once the left portal vein is identied, cephalad rotation should be
done to identify the left portal vein branches, namely segment II, III, and IV
portal vein branches. This would allow us to detect the left liver segments and
relevant tumor locations (Fig.5).
(e) Scanning:
The liver is scanned to conrm the presence of tumors detected on preoperative imaging and to look for occult metastases not detected on preoperative
imaging. Furthermore, scanning allows us to conrm the absence of tumors in
the future liver remnant.
464
In
cava
Seg
portal vein
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Right portal
vein
ferior vena
Fig. 4 Identication of the main and left portal veins
A. Haddad and T. E. Newhook
Left portal
vein
ment IV
S III
SegmentIII
S IV
portal vein
S II
Left portal
vein
Fig. 5 Identication of the left portal vein branches and the left liver segments
S I
SegmentII
portal vein
4 Right Hepatectomy
4.1 Mobilization oftheLiver
The retroperitoneal attachments of the right liver are cleared at rst permitting the
mobilization and retraction of the liver and exposure of the porta hepatis.
Mobilization of the left liver may be required to better rotate or “medialize” the
right liver for exposure of the right retroperitoneum and inferior vena cava. This can
be achieved by division of the left triangular and coronary ligament from the left
hemidiaphragm to the hepatocaval conuence.
The rst step in mobilization of the right liver is by dissecting the falciform liga-
ment from the anterior abdominal wall and the ligamentum teres hepatis. The
Stapled an
divided Makuuchi
ligament
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465
falciform ligament is ligated and divided at the umbilical ssure. The division of the
falciform ligament from the anterior abdominal wall continues to the hepatocaval
conuence, which is dissected meticulously to expose the middle and right hepatic
veins. We advocate for a “pinch and burn” cautery technique here to allow precise
dissection of diaphragmatic bers from the hepatocaval conuence and complete
exposure of the notch between the right and left hepatic veins.
We then mobilize the right liver from its diaphragmatic and right retroperitoneal
attachments by dividing the right triangular and coronary ligament and proceeding
towards the right hepatic vein, which is constantly visualized from previous dissection. The peritoneum over the right retroperitoneum is then incised 1–2mm from
the liver and the liver is mobilized from the inferior vena cava from medial-tolateral, thus allowing for protection of the right adrenal gland and division of short
hepatic veins. Adequate mobilization of the right liver from the inferior vena cava is
critical for complete rotation of the right liver and operative safety.
4.2 Dissection oftheRight Hepatic Vein
Attention is turned to identify the inferior vena cava (IVC) and right hepatic vein
(RHV). The dissection of the IVC is accomplished by dissecting around and posterior to the liver. Makuuchi’s IVC ligament is divided using a vascular load of a
surgical stapler (Fig.6).
Dissection of the IVC is performed afterwards to identify the RHV.The origin of
the right inferior phrenic vein is an important landmark to locate the right hepatic
vein; the insertion of the extrahepatic portion of the RHV in the IVC runs just
Right liver
Inferior vena
cava
Fig. 6 Inferior vena cava with stapled Makuuchi ligament
d
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Right inferior
phrenic vein
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Right hepatic
vein encircled
using a tie
Inferior vena
cava
Short hepatic
vein divided
Fig. 7 Isolation of the right hepatic vein using a tie
A. Haddad and T. E. Newhook
caudal to the insertion of the right inferior phrenic vein into the IVC [6]. Small
draining veins into the IVC are ligated and divided as well (Fig.7).
The right hepatic vein is then transected using a vascular load of the stapler in a
similar fashion to the left hepatic vein during left hepatectomy (Fig.19).
4.3 Dissection oftheRight Porta Hepatis
We proceed next by dissecting the right aspect of the porta hepatis. The right portal
vein is isolated rst by gently elevating the right bile duct with a vein retractor to
allow dissection and visualization of the bifurcation of the portal vein. The right
portal vein is encircled with a vessel loop. The right hepatic artery is then dissected
from the posterior aspect of the bile duct, provided that is the anatomy reviewed on
imaging preoperatively (Fig.8).
The RHA is then ligated and divided (Fig.9).
The right portal vein (RPV) is then divided using a vascular load of the surgical
stapler, taking care not to narrow the PV bifurcation (Fig.10).
4.4 Hanging Maneuver andDemarcation ofTransection Line
After the inow and outow of the liver are controlled, the hanging maneuver may
be performed to facilitate the transection of the liver in an anterior to posterior
approach. The hanging maneuver, rst described by Belghiti and colleagues,
Right hepati
arte
n
Distal
end of RH
Distal
end of right
hepatic arte
e
Hepatic Procedures
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c
ry
Fig. 8 Identication of the right hepatic artery and portal vein in the porta hepatis
467
Portal vei
ligated
A
Right portal
vein
Fig. 9 Division of right hepatic artery and identication of portal vein branches
ligated
ry
Stapler over
right portal
vein
Fig. 10 Stapler over the right portal vein
Proximal
ligated end of
RHA
Portal Vein
Proximal ligated
end of right
hepatic artery
Portal vein
Vessel loop
protecting the
bifurcation of th
portal vein
468
Is
demarcation
of the liver
https://t.me/med1917
A. Haddad and T. E. Newhook
consists of anterior tension exerted by tape introduced anterior to the surface of the
IVC between the right hepatic and middle hepatic veins [7]. This maneuver is helpful to elevate the hepatic transection plane along the middle hepatic vein. It is
important to note that this maneuver is not required but is helpful (Fig.11).
The division of the blood supply of the liver results in demarcation of the liver.
The line of transection is then dened along the ischemic demarcation line using
electrocautery. Stay sutures using 4-0 polypropylene are also placed along both
sides of the suture line to allow for elevation and lateral distraction of the liver
throughout transection (Figs.12, 13, and 14).
Fig. 11 Modied hanging
maneuver modication to
elevate hepatic transection
plane
Non-ischemic
liver
Transection
line
chemic
Fig. 12 Ischemic demarcation of the liver and transection line
Saline linked
Ultrasonic
aspirato
polypropylene
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cautery
r
Fig. 13 Transection of the liver parenchyma using the saline linked cautery and ultrasonic
aspirator
4-0
469
stay sutures
Fig. 14 Transected liver parenchyma with stay sutures
4.5 Liver Transection andPringle Maneuver
The liver parenchyma is then transected with the saline-linked cautery commonly
known as TissueLink (Salient Surgical Technologies, Portsmouth, NH) and ultrasonic aspirator commonly known as Cavitron Ultrasonic Suction Aspirator
(CUSA)® (Integra LifeSciences, Princeton, NJ, USA) as part of the “Two-Surgeon
Technique” [8] (Fig.13). The saline-linked cautery is used for hemostasis and sealing whereas the ultrasonic aspirator is used for parenchymal dissection. Vessels
smaller than 3mm were coagulated with saline-linked cautery. Larger structures are
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Right hepati
bile duct
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c
Fig. 15 Right hepatic bile duct isolated in transection plane
A. Haddad and T. E. Newhook
taken with ties or clips as needed (Fig.28). It is important to note on preoperative
imaging the transection path along the MHV and what tributaries will be encountered, such as segment 5 venous tributaries to the MHV and segment 8 hepatic
veins. The transection line should leave the “right” side of the MHV exposed on the
remnant liver. The Pringle maneuver is applied for inow control in intervals of
15min on Pringle maneuver with 5min off Pringle. During the time off Pringle
maneuver, the transected liver surfaces are approximated as to decrease bleeding
along with hemostatic agent (Fig.34).
Transection continues to the right Glissonian pedicle, containing the right hepatic
duct. The right hepatic duct is then stapled, taking care to not encroach upon the
hepatic ductal conuence (Fig.15).
5 Left Hepatectomy
5.1 Mobilization oftheLiver
The falciform ligament is dissected from the anterior abdominal wall and the ligamentum teres hepatis is ligated and divided at the umbilical ssure. The division of
the falciform ligament from the anterior abdominal wall continues to the hepatocaval conuence, which is dissected meticulously to expose the right and left hepatic
veins. We advocate for a “pinch and burn” technique here to allow precise dissection
of diaphragmatic bers from the hepatocaval conuence and complete exposure of
the notch between the right and left hepatic veins.
Hepatic Procedures
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471
We then mobilize the left liver from its diaphragmatic attachments by dividing
the left triangular and coronary ligament and proceeding towards the left
hepatic vein.
5.2 Dissection oftheLeft Hepatic Vein
Attention is turned to identify the ligamentum venosum and isolate the left hepatic
vein. The ligamentum venosum is identied after dissecting the ssure of the ligamentum venosum just posterior to the left hepatic vein and superior to the caudate
lobe (Fig.16).
Dissection is done carefully to isolate the ligamentum venosum (Fig.17).
Fig. 16 Identication of
the left hepatic vein
Fig. 17 Ligamentum
venosum encircled using
a tie
472
ft hepatic vein
Le
pedicle encircled
y
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A. Haddad and T. E. Newhook
The ligamentum venosum is ligated and divided along with a suture ligature on
the cephalad aspect of the ligamentum venosum in case of patency. The left hepatic
vein can be clearly visualized at this stage (Fig.18). The left hepatic vein is left for
division following inow dissection.
5.3 Dissection oftheLeft Porta Hepatis
Dissection of the left portal pedicle shows the left hepatic artery which is further
dissected and divided (Fig.19).
Further dissection of the left portal pedicle is performed to identify the left portal
vein (Fig.20). The left portal vein is divided using a vascular load of the surgical stapler.
Fig. 18 Left hepatic vein identied with vessel loop
ft portal
Le
Divided
ligamentum
venosum
Left hepatic arter
ligated prior to
division
Fig. 19 Dissection of the left portal pedicle to reveal the left hepatic artery. This is an example of
a replaced left hepatic artery from the left gastric artery
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