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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1260_Библиотеки_им_академика_М_И_Перельмана
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PART II
Video Atlas
The procedures carried out in the videos are designed to be viewed in
conjunction with the text, images, and anatomic schemes shown in this
section.
Video and Figure Abbreviations
BD bile duct
HA hepatic artery
IRHV inferior right hepatic vein
IVC inferior vena cava
LHA left hepatic artery
LHV left hepatic vein
LPP left portal pedicle
LPV left portal vein
MHV middle hepatic vein
P portal branch
PP portal pedicle
PV portal vein
RAHA right anterior hepatic artery
RAPP right anterior portal pedicle
RHA right hepatic artery
RHV right hepatic vein
RIHV right inferior hepatic vein
RPHA right posterior hepatic artery
RPHV right posterior hepatic vein
RPP right portal pedicle
RPPP right posterior portal pedicle
V venous branch
SECTION 1 Liver
Laparoscopic minor liver resection and segmentectomy
VIDEO 1
Intraoperative ultrasonography for safe
laparoscopic livery surgery
Video duration 9 minutes 42 seconds
In this video, we will show you intraoperative ultrasonography for safe laparoscopic liver surgery.
Left lateral sectionectomy
The first section will show you the key structures that
should be identified for left lateral sectionectomy. The
first two structures that should be identified are the
drainage of the left and the middle hepatic veins; in
particular, the drainage of the middle hepatic vein into
the IVC is important to identify. Identifying the left
hepatic vein a little bit more lateral will allow for safe
staple division at the end of the case. Moving the probe
inferiorly, we identify the portal branches of segments II
and III. Identifying the portal branches of segment II and
its relationship to the left hepatic vein can be helpful in
identifying the left hepatic vein inside the parenchyma.
Here, we open up the parenchyma which will facilitate
staple division of the portal branch of segment III. Now,
we will staple divide the portal branch of segment II.
We know from the ultrasound that the left hepatic
vein will be quite close to it. The transmitted respiratory
variation into the left hepatic vein seen on the parenchymal transection margin gives you a hint where the left
hepatic vein will be found. Because we know from the
ultrasound the relationship between the middle hepatic
vein and the left hepatic vein, we can progress with the
parenchymal transection and finally staple divide the left
hepatic vein. At the end of the case, we have divided the
portal branches to segments II and III, as well as the left
hepatic vein.
Right hepatectomy
In this section, we will discuss which landmark structure
should be identified on intraoperative ultrasound for a
right hepatectomy. The landmark structure that will
guide the parenchymal transection is the middle hepatic
vein. At the end of the case, the right hepatic vein will be
divided. It is crucial to identify the drainage anatomy on
intraoperative ultrasound. In every laparoscopic right
hepatectomy, the hepatic venous drainage of segment
VIII must be checked on preoperative imaging. Not knowing where the drainage of segment VIII is and injuring it
can lead to significant bleeding at the end of the case.
In this patient, the segment VIII branch drains into the
middle of the hepatic vein but it can also drain directly
into the IVC. Other important branches are V4 and V5.
They can be identified by positioning the probe along the
axis of the middle hepatic vein. We try to identify the
middle hepatic vein very early after opening up the
parenchyma. The first branch of the middle hepatic
vein we will encounter is also identified on ultrasound
as the V5 branch. This branch is clipped and divided.
As mentioned, the middle hepatic vein guides our parenchymal transection. We recommend identifying the
hepatic venous drainage of segment VIII for each right
hepatectomy because when we know from
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
351
352 Video 1
intraoperative ultrasound where this branch is, we can
safely identify and transect it. The final image shows you
the anatomy at the end of the case.
Segmentectomy of segment VIII
Next, we will show you the critical structures to be identified on ultrasound for an anatomical segmentectomy of
segment VIII. The critical structures here are the V8 drainage vein and the middle hepatic vein with its relationship
to the tumor. Placing the probe horizontally, we identify
the relationship between the tumor and the portal branch
to segment VIII. The right hepatic vein will determine the
lateral resection margin. We recommend using the ultrasound and the energy device at the same time to mark the
resection margin on the liver surface. The next section will
show you how to identify the portal pedicle to segment
VIII that is involved with the tumor. The use of Doppler
flow imaging can be helpful at this step. A hemostatic
agent made of oxidized regenerated cellulose can be used
as a fixed point which can be identified on intraoperative
ultrasound.Here, we see the portal branch of segment VIII
in the resection margin. The right posterior portal pedicle
should be identified and injury to it avoided.The clamp on
the P8 branch can be identified on the ultrasound and can
be useful for orientation. The resection line itself can also
be identified on the ultrasound. Next, we place a clip on
the P8 branch. Intact vascularization of the future liver
remnant should be confirmed with ultrasound. Here, we
confirm drainage of segment IVa. Next, we confirm drainage of segment IVb.
Posterior superior sectionectomy
The next section will cover identification of the drainage of
the right hepatic vein for posterior superior segmentectomy.
For this case, we place cuff ports transthoracically. While
performing inferior traction on the liver, we identify the
drainage of the right hepatic vein with intraoperative ultrasound. Again, the drainage of V8 should be identified. Here,
we open up the parenchyma to control the right hepatic
vein. We know from the ultrasound that the drainage vein
of segment VIII will be close. It is clipped and divided with
scissors. Now the drainage of the right hepatic vein is
completely exposed. On this image, the important structures that we identified on intraoperative ultrasound (the
right hepatic vein, middle hepatic vein, and P8 branch) can
be seen. The clip marks the drainage vein of segment VIII.
Anatomy figures
Figure v1.1 Relevant anatomy for laparoscopic left lateral sectionectomy. The operation begins by opening the umbilical fissure. The
key is to avoid injury to the main LPP or the P4b pedicle. The MHV can be surprisingly close to the falciform ligament. Undercutting
the falciform ligament should be avoided. Care must be taken during the dissection of the drainage of the LHV into the IVC. An
MHV injury at a common drainage with the MHV can lead to significant injury.
Intraoperative ultrasonography for safe laparoscopic livery surgery 353
Figure v1.2 Critical anatomy for a right hepatectomy. The RPP as well as the RHA are exposed. The key is to avoid injury to the LPP.
This patient has a common RPP but also a trifurcation and staged division is frequently seen.
Figure v1.3 Critical anatomy for a resection of segment VIII. The typical portal branching of segment VIII is a dominant P8 ventral
and P8 dorsal PP coming off the RAPP.
354 Video 1
Figure v1.4 Critical anatomy for a posterior sectionectomy. During the dissection, the RAPP is preserved while P6 and P7 are taken.
In this case, the patient has a trifurcation and therefore P6 and P7 should be taken individually.
VIDEO 2
Left lateral sectionectomy
Video duration 7 minutes 17 seconds
In this video, we will show a left lateral sectionectomy.
A left lateral sectionectomy is a good starting case for a
laparoscopic liver surgery experience. Nevertheless, the
approach needs to be very structured.
OUTLINE
The video has the following outline:
• Port positioning
• Division of segment III portal branch
• Division of segment II portal branch
• Division of the left hepatic vein and specimen
mobilization
• Important points.
This scheme demonstrates the port positioning
(Figure v2.1). Make sure to place the ports far enough
to the left that the round ligament does not obstruct your
view (but far enough medial to have a view along the
parenchymal transection line).
With ultrasound, we identify the drainage of the left
hepatic vein (Figure v2.2). At this step, check the common
drainage with the middle hepatic vein as this can be injured
during the staple division of the left hepatic vein. Next, we
check for the segment II portal branch as well as the segment
III portal pedicle (Figure v2.3 and Figure v2.4).
Next, we will dissect out and divide the segment III
portal branch. The segment III portal branch runs in the
umbilical fissure. In order to facilitate staple division, we
open the parenchyma above and below the segment III
portal branch.
Here, the Glissonian sheath to the segment III portal
branch comes into view. Now the segment III portal
Figure v2.1 Port positioning for a left lateral sectionectomy. Place the ports far enough to the left so that the round ligament does not
obstruct your view. The ports should nevertheless be far enough medial to have a view along the parenchymal transection plane.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
355
356 Video 2
Figure v2.2 With intraoperative ultrasound determine the drainage of the LHV into the IVC.
Figure v2.3 Use intraoperative ultrasound to determine the location of the P2.
Left lateral sectionectomy 357
Figure v2.4 Shortly after P2 is controlled P3 is divided.
branch can be easily divided with a stapler. As we carry on
with the parenchymal transection, we encounter the
segment II portal branch. Here, the segment II portal
branch has been dissected out and can be divided with
a stapler. The last step is the division of the left hepatic vein
and specimen mobilization.
Undercutting the falciform ligament can lead to injury
of the middle hepatic vein. Using ultrasound, identify its
location as well as its drainage either in the left hepatic
vein or in the IVC. Also watch out for a prominent
umbilical fissure vein.
In order toavoid injury to the extraparenchymalportion
of the left hepatic vein, we carry on the dissection using
scissors. Here, you can see how we open up the parenchyma above the left hepatic vein with an energy device.
Now we have identified the precise location of the left
hepatic vein. We completely isolate the left hepatic vein
before the staple division. As we staple, we divide the left
hepatic vein. We always have a vascular clamp ready in
case of stapler misfiring. The final step is specimen mobilization, for which we divide the left triangular ligament.
Finally, we confirm hemostasis at the parenchymal transection margin. The specimen is placed into an endoscopic
retriever bag and removed from the abdomen.
IMPORTANT POINTS
• Ports are placed more medially for inline working.
• Use ultrasound to identify the portal branch to segments
II and III as well as the middle hepatic vein.
• Control the portal branch to segment III early.
• Leave the falciform ligament attached: it can guide
the transection plane and can also be used for retraction.
• Do not undercut the falciform ligament as this can lead to
middle hepatic vein injury. Use ultrasound to understand the anatomy of the middle hepatic vein.
358 Video 2
Anatomy figures
Figure v2.5 Relevant anatomy for laparoscopic left lateral sectionectomy. The operation begins with opening the umbilical fissure.
The key is to avoid injury to the main LPP or the P4b pedicle. The MHV can be surprisingly close to the falciform ligament.
Undercutting the falciform ligament should be avoided. Care must be taken during dissection of the drainage of the LHV into the
IVC. An MHV injury at a common drainage with the MHV can lead to significant injury.
Figure v2.6 Initial view for laparoscopic left lateral sectionectomy. After opening the umbilical fissure, the PP to segment III and,
shortly thereafter, the pedicle to segment III are controlled. Notice the closeness of these two pedicles (P3 and P2).
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