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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. 36 Anterior Abdominal wall cyst arising from the left liver€
Fig. 37 Aspiration of the
cyst contents
483
Falcifo
ligament
Left liver
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Fig. 38 Decompressed cyst after aspiration of contents
8.3 Resection ofCyst Roof
A. Haddad and T. E. Newhook
Left liver
The cyst roof may then be removed using cautery and sent for pathology. Care
should be taken to inspect the cyst oor for an evidence of bile leak in which case
this can be repaired.
References
1. Dimick JB, Wainess RM, Cowan JA, Upchurch GR Jr, Knol JA, Colletti LM.National trends in
the use and outcomes of hepatic resection. J Am Coll Surg. 2004;199(1):31–8.
2. Lendoire M, Maki H, Haddad A, Jain AJ, Vauthey JN. Liver Anatomy 2.0 Quiz: Test
Your Knowledge. J Gastrointest Surg. 2023;27(12):3045–68. https://doi.org/10.1007/
s11605-023-05778-7.
3. Lendoire M, Maki H, Haddad A, Jain AJ, Vauthey JN. Biliary Anatomy 2.0 Quiz: Test
Your Knowledge. J Gastrointest Surg. 2023;27(7):1510–29. https://doi.org/10.1007/
s11605-023-05634-8.
4. Geller DA, Tohme S. Liver Anatomy Quiz: Test Your Knowledge. J Gastrointest Surg.
2021;25(4):1093–104. https://doi.org/10.1007/s11605-020-04582-x.
5. Chang SB, Palavecino M, Wray CJ, Kishi Y, Pisters PW, Vauthey JN.Modied Makuuchi inci-
sion for foregut procedures. Arch Surg. 2010;145(3):281–4.
6. Torzilli G, Montorsi M, Palmisano A, et al. Right inferior phrenic vein indicating the right
hepatic vein conuence into the inferior vena cava. Am J Surg. 2006;192(5):690–4.
Hepatic Procedures
https://t.me/med1917
7. Belghiti J, Guevara OA, Noun R, Saldinger PF, Kianmanesh R.Liver hanging maneuver: a safe
approach to right hepatectomy without liver mobilization. J Am Coll Surg. 2001;193(1):109–11.
8. Aloia TA, Zorzi D, Abdalla EK, Vauthey JN.Two-surgeon technique for hepatic parenchymal
transection of the noncirrhotic liver using saline-linked cautery and ultrasonic dissection. Ann
Surg. 2005;242(2):172–7.
9. Mise Y, Aloia TA, Brudvik KW, Schwarz L, Vauthey JN, Conrad C. Parenchymal-sparing
hepatectomy in colorectal liver metastasis improves salvageability and survival. Ann Surg.
2016;263(1):146–52.
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Perihilar Cholangiocarcinoma
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JoséDonizetide MeiraJúnior andIsmaelDominguezRosado
1 Introduction
Cholangiocarcinoma accounts for approximately 3% of gastrointestinal tumors and
nearly 20% of deaths from hepatobiliary cancer [1]. According to its location, it is
classied as intra-hepatic, perihilar, or distal, representing three distinct entities in
biology, treatment options, and prognosis [2]. Perihilar cholangiocarcinoma
(h-CCA) accounts for two-thirds of the cases. It is dened anatomically as tumors
located in the extrahepatic biliary tree proximal to the origin of the cystic duct [3].
The most frequent presentation of h-CCA is obstructive jaundice, associated
with pruritus or weight loss, with up to 10% of patients presenting with cholangitis
[4]. In addition, non-specic symptoms may occur, such as abdominal pain or discomfort. Patients with suspected h-CCA should preferably be managed in a specialized center before any invasive procedure is performed because these could impair
further imaging workup and staging [5].
Although most patients with hilar strictures and jaundice have cholangiocarcinoma, alternative diagnoses are possible in 10% to 15% of patients. The most common are gallbladder carcinoma, Mirizzi syndrome, autoimmune cholangitis, and
primary sclerosing cholangitis. In most cases, tissue diagnosis is not mandatory to
proceed with resection [6].
J. D. de MeiraJúnior
Hospital das Clínicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
I. D. Rosado (*)
Instituto Nacional de Ciências Medicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_40
487© The Author(s), under exclusive license to Springer Nature
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J. D. de MeiraJúnior and I. D. Rosado
2 Preoperative Preparation
An imaging workup (contrast-enhanced CT scan or MRI) should be done before
biliary drainage. The latter may impair adequate visualization of the tumor location,
its extension through the biliary tree, and any vascular involvement at the hepatic
hilum [5]. After a complete understanding of the patient’s anatomy and its relation
to the tumor, adequate drainage of the remaining liver should be granted if needed.
Nodal (outside the hepatoduodenal ligament) or distant metastasis should preclude
resection as well as signicant baseline comorbidities such as portal hypertension,
cirrhosis, and poor performance status [6]. It is essential to mention that adenopathy
in imaging studies may be reactive in the setting of biliary instrumentation, therefore, should not necessarily preclude surgical exploration [7].
Biliary drainage is still controversial. However, it is mandatory in patients presenting with cholangitis, and it is recommended when an extensive resection is
planned, as obstructive jaundice hampers regeneration capability. Patients with less
than 30 to 40% of future liver remnant (FLR) should undergo biliary drainage [7, 8].
Some authors consider drainage in patients with FLR lower than 50%, as it has been
pointed out as a risk factor for mortality [9]. Percutaneous transhepatic biliary
drainage is associated with less conversion and lower rates of pancreatitis and cholangitis than endoscopic biliary stenting, but the former has the risk of seeding
metastasis. In Eastern countries, endoscopic nasobiliary stents are widely used, with
good results [7, 8].
Patients with less than 40% of future liver remnant should undergo portal vein
embolization (PVE) [8]. A post-PVE kinetic growth rate of the FLR exceeding 2%
per week correlated with reduced hepatic insufciency rates [10].
3 Indications
The Bismuth-Corlette classication (Fig. 1) aids in planning the resection, as it
indicates the proximal extent of biliary involvement and is used along with the
detailed study of vascular compromise [11].
The Bismuth-Corlette type I tumor is rare, and some authors suggest that most
tumors considered as a Bismuth I cholangiocarcinoma are gallbladder tumors with
common bile duct inltration. Therefore, bile duct resection alone may be considered for this type of tumor [11].
Bismuth-Corlette type II tumors can theoretically be treated with bile duct resection and caudate lobe resection. However, associating this procedure with a hepatectomy (generally right or extended right) increases the radicality of the procedure [11].
Except for Bismuth type I cholangiocarcinoma, all other types require concomitant liver resection as it improves the R0 rates and 5-year survival. Type III tumors
require right or left hepatectomy, according to the side of the biliary extension. In
Perihilar Cholangiocarcinoma
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489
Fig. 1 Bismuth-Corlette classication of perihilar cholangiocarcinoma. (Reprinted from Atlas of
Advanced Operative Surgery, 1st edition, Cherqui D, Bismuth, Resection Hilar Cholangiocarcinoma
with en Bloc Hepatectomy, 324–333, Copyright (2013), with permission from Elsevier) [11]
both cases, segment I should be included in the resection. Type IV tumor is theoretically a contraindication to surgery. However, extended hepatectomies can occasionally be applied to highly selected cases [11].
Because of specic biliary drainage and anatomical location (Fig.2), caudate
lobe resection should be included in all cases, as it improves the likelihood of R0
resection and survival. Additionally, it may decrease the risk of postoperative biliary
stula, as leaving the caudate in place could mean to leave an orphaned caudate
duct, which could contribute to bile leak [12].
Invasion of vascular branches ipsilateral to the biliary extension of the tumor is
not a contraindication to resection. Vascular invasion of the central portal vein, common hepatic artery, or branches contralateral to the biliary extension is a contraindication to resection. Invasion of the portal or arterial bifurcation is generally a
contraindication to surgery, although vascular resection and reconstruction could be
considered in selected cases [11].
Frozen sections are recommended to assess biliary or vascular surgical margins.
However, these should only be done if additional resection is feasible [13].
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J. D. de MeiraJúnior and I. D. Rosado
Fig. 2 Biliary drainage and anatomic location of caudate lobe. (Reprinted from Atlas of Advanced
Operative Surgery, 1st edition, Cherqui D, Bismuth, Resection Hilar Cholangiocarcinoma with en
Bloc Hepatectomy, 324–333, Copyright (2013), with permission from Elsevier) [11]
4 Surgical Technique
The principle of surgical treatment is to obtain R0 margins with hepatic pedicle
lymphadenectomy and en bloc extrahepatic bile duct and liver resection, as it is the
only potentially curative treatment for patients with resectable disease [8, 11].
Initially, the abdominal cavity must be inspected for carcinomatosis, nodal
metastasis, intrahepatic metastasis, and ductal invasion at the pancreas level.
Intraoperative ultrasound is paramount to evaluating ductal extension and vascular
invasion [7].
Exploration and dissection of the hepatoduodenal ligament is the next step
(Fig.3). Irreversible divisions should not be performed before the possibility of
resection is conrmed [11].
Perihilar Cholangiocarcinoma
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491
Fig. 3 Exploration and dissection of the hepatoduodenal ligament. (Reprinted from Atlas of
Advanced Operative Surgery, 1st edition, Cherqui D, Bismuth, Resection Hilar Cholangiocarcinoma
with en Bloc Hepatectomy, 324–333, Copyright (2013), with permission from Elsevier) [11]
The right gastric artery and minor supra duodenal vessels are divided. Next, the
lymphatic tissue around the gastroduodenal artery, common hepatic artery, proper
hepatic artery, and portal vein is dissected, completely exposing these vessels.
Dissection is continued to expose the portal vein and hepatic artery bifurcations,
and vascular invasion is assessed [11].
After dening that the tumor is resectable, the common bile duct is divided above
the duodenum, and a frozen section can be performed if additional resection (including pancreatoduodenectomy) is feasible [13]. Bile samples are sent for culture if
previously stented Bile duct resection is continued cranially, allowing a better exposure of vascular structures (Fig.4).
Until now, the steps are the same for right and left hepatectomies. However, from
now on, the following steps depend on the side of the resection.
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Fig. 4 Exposure of vascular structures and lymphadenectomy of the hepatoduodenal ligament.
(Reprinted from Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, 2nd ed.,
Cherqui D, Bismuth, Shimizu H, Miyazaki M, Left-sided Hepatectomy (Left Hemihepatectomy or
Left Trisectionectomy) Extending to the Caudate Lobe with Bile Duct Resection for Perihilar
Cholangiocarcinoma. 649–661, Copyright (2016), with permission from Springer) [15]
J. D. de MeiraJúnior and I. D. Rosado
5 Right Hepatectomy
With the hepatic pedicle exposed and all the hepatoduodenal ligament’s lymphatic
tissue resected, the right hepatic artery is now ligated and divided. The right portal
vein is now divided with a vascular stapler or after clamp placement with 5-0 nonabsorbable running suture (Fig.5). Next, the left portal pedicle is detached from the
hilar plate.
The falciform ligament, the right coronary ligament, and the right triangular ligament are divided to expose the right hepatic vein and free the right liver. Next, the
vena cava ligament is divided between clamps, and the proximal stump is sutured,
as it may contain venous branches. Short hepatic veins draining the caudate lobe to
the vena cava are then ligated and divided, freeing the caudate lobe from the vena
cava. Finally, the right hepatic vein is stapled or divided between clamps and sutured
(Fig.6) [14].
At this point, an ischemic demarcation should be visualized in the liver surface
in the Cantlie line, between the right and left livers. The liver transection is then
started with the technique chosen by the surgeon. After the transection, the specimen should be hanging by the hilar plate at the left bile duct level (Fig.7) [14].
Next, the left hepatic duct is transected, and the specimen is removed. If additional
resection is feasible, frozen section evaluation should be performed in the intrahepatic biliary margin [13].
Perihilar Cholangiocarcinoma
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Fig. 5 Control of the right
hepatic pedicle in right
hepatectomy. Exposure of
vascular structures and
lymphadenectomy of the
hepatoduodenal ligament.
(Reprinted from Atlas of
Upper Gastrointestinal and
Hepato-Pancreato-Biliary
Surgery, 2nd ed., Ebata T,
Nagino M, Right
Hepatectomy (Resection of
Segments 5, 6, 7, 8, and 1)
with Bile Duct Resection.
637–647, Copyright
(2016), with permission
from Springer) [14]
Fig. 6 Mobilization of the
right liver, ligation of short
hepatic veins and control
of the right hepatic vein.
(Reprinted from Atlas of
Upper Gastrointestinal and
Hepato-Pancreato-Biliary
Surgery, 2nd ed., Ebata T,
Nagino M, Right
Hepatectomy (Resection of
Segments 5, 6, 7, 8, and 1)
with Bile Duct Resection.
637–647, Copyright
(2016), with permission
from Springer) [14]
493
6 Left Hepatectomy
Once the hepatoduodenal lymphadenectomy is completed and the hepatic pedicle is
fully exposed, the left hepatic artery and the artery to segment IV (or middle hepatic
artery) are ligated and divided in their origin. Next, the left portal vein is ligated and
divided, or stapled with a vascular cartridge. If there is not enough length for ligation and division, the portal vein is divided after clamping the portal trunk and right
portal vein and is transversely sutured to prevent stenosis [15].
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