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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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Hepatic Procedures
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Fig. 20 Identication of the left portal vein
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Left portal vein
Divided left
hepatic artery
Divided left
hepatic vein
Fig. 21 Divided left hepatic vein after division of the left portal vein and left hepatic artery
The previously isolated and identied left hepatic vein is divided using a vascular load stapler after isolation and division of the left portal vein and left hepatic
artery (Fig.21).
Divided left
hepatic arte
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n
Transection
line
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A. Haddad and T. E. Newhook
Stay
sutures
Fig. 22 Ischemic demarcation, transection line, stay sutures and Rummel Tourniquet
Ischemic
demarcatio
Rummel
Tourniquet
5.4 Demarcation andStay Sutures
Ischemic demarcation of the left liver ensues. The liver is scored with electrocautery
along this demarcation to draw transection line with stay sutures placed on either
side. A Rummel tourniquet is placed around the hepatoduodenal ligament for
Pringle inow control (Fig.22)
5.5 Parenchymal Transection andPringle Maneuver
The liver is transected using the ultrasonic aspirator and saline linked cautery as part
of the “Two-Surgeon Technique” [8] (Fig. 23). The stay sutures are used for traction, and the Pringle maneuver is applied in intervals of 15min on pringle maneuver
with 5-min breaks for reperfusion. During time off pringle, the liver is approximated
to decrease bleeding. Vessels smaller than 3mm are coagulated with saline-linked
cautery. Larger structures are taken with ties or clips as needed.
Transection continues to the left Glissonian pedicle, containing the left hepatic
duct. The left hepatic duct is then stapled, taking care to not encroach upon the
hepatic ductal conuence. The resected left liver and the liver remnant are shown in
Figs.24 and 25, respectively.
Ultrasonic aspirator
Seg
II
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Fig. 23 Dissection of liver parenchyma using the Two-Surgeon Technique
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ment IV
Fig. 24 Resected left liver
Segments II/I
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Fig. 25 Liver remnant
with exposed MHV
A. Haddad and T. E. Newhook
6 Parenchymal Sparing Hepatectomy
The use of parenchymal sparing hepatectomy is increasing, especially for patients
with colorectal liver metastases because of its association with improved salvageability and survival [9].
6.1 Demarcation oftheTransection Area
After incision and exposure of the abdomen as described above, intra-operative
ultrasound is used to conrm the extent of lesion for resection. Then, the liver surface is scored with electrocautery at the proposed transection margins (Fig.26).
Proposed margins may be conrmed using IOUS.
6.2 Parenchymal Transection
Stay sutures are placed in corners of the specimen and used for elevation and distraction of the liver transection margins. The liver parenchyma is then transected via
the Two-Surgeon Technique [8] (Fig.27).
Vessels smaller than 3 mm are coagulated with saline-linked cautery. Larger
structures are taken with ties or clips as needed (Fig.28).
Mass in the right
liver
Saline linked
cauter
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Transection
margin
Fig. 26 Transection margin for parenchymal sparing resection
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Ultrasonic
dissector
y
Fig. 27 Two-Surgeon Technique in parenchymal sparing hepatectomy
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Fig. 28 Clip applier used
to divide intermediate
sized blood vessels and
bile ducts
A. Haddad and T. E. Newhook
7 Left Lateral Sectionectomy (Bisegmentectomy II/III)
7.1 Liver Mobilization
After incision and placement of the retractor, the falciform ligament is dissected
from the anterior abdominal wall and ligamentum teres hepatis ligated and divided
at the level of the umbilical ssure. The falciform ligament is dissected along the
liver to the hepatocaval conuence, which is dissected to expose the middle and left
hepatic veins as described above. The left triangular and coronary ligament is
divided to dissect the left lateral liver from the left diaphragmatic attachments.
7.2 Dissection oftheLeft Hepatic Vein
The left hepatic vein is exposed at the hepatocaval conuence. The ligamentum
venosum is dissected from its ssure, ligated, and divided as it enters the left hepatic
vein posteriorly. The left hepatic vein is then encircled with a vessel loop for later
division (Fig.29).
7.3 Isolation andDivision ofSegments II andIII Pedicles
The left aspect of the umbilical ssure is then dissected by rst incising the peritoneum over the segment II and III pedicles. The pedicles may be encircled and
divided en masse using suture ligatures or stapled, or, the hepatic arteries, portal
Divided ligamentum
Li
teres hepati
ft lateral section
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Left hepatic vein
venosum
Fig. 29 Identication of the left hepatic vein after ligation and division of the ligamentum venosum
Le
with colorectal
liver metastasis
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gamentum
Fig. 30 Isolation of segment III pedicle
s
Segment III
pedicle
veins to segments II and III may be individually dissected, ligated, and divided
(Figs.30 and 31). Demarcation of segments II and III ensues along the sectional
plane. Following inow dissection, we then ligate and divide the LHV using a vascular load of the surgical stapler. The liver then is scored with electrocautery to draw
a transection line at the ischemic demarcation liver segments II and III (Fig.32).
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e
Li
hepatis
Transection line
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gamentum teres
Fig. 31 Isolation of segment II pedicle
A. Haddad and T. E. Newhook
Segment II pedicl
Segments II and III
ischemic demarcation
Fig. 32 Ischemic demarcation and transection line for segments II and III
7.4 Placement ofStay Sutures andRummel tourniquet
Stay sutures are placed on either side of the transection line for elevation and traction throughout hepatic transection. Also, a Rummel tourniquet is placed around the
hepatoduodenal ligament to employ Pringle maneuver for inow control during
transection (Fig.33).
t
n
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Fig. 33 Rummel tourniquet and stay sutures
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Rummel tournique
Lap sponges placed
underneath the liver to
support its approximatio
and elevation while off
pringle maneuver
Fig. 34 Positioning of the liver while off pringle maneuver
7.5 Transection andPringle Maneuver
Transection is performed while applying the Two-Surgeon Technique as described
previously (Figs.13, 23, and 27) and using the Pringle maneuver in intervals of
15min on pringle maneuver with 5min off Pringle maneuver. During time of reperfusion, the liver transection is approximated to decrease bleeding, as shown below
(Fig.34).
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A. Haddad and T. E. Newhook
8 Cyst Fenestration
Cysts are usually asymptomatic and do not require intervention. However, in cases
of large and symptomatic cysts (Fig.35), fenestration of cysts may be considered
for symptom relief. Frequently, this operation may be done using a minimally invasive approach.
8.1 Unroong theCyst
The cyst is rst localized and mobilized as needed (Fig.36).
8.2 Aspiration ofCyst Contents
Aspiration of cyst content can be done using suction (Figs.37 and 38).
Left live
Fig. 35 Computed tomography scan showing multiple liver cysts, the most prominent one located
in the anterior left liver
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