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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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Segmentectomy IVa 379
Anatomy figures
Figure v6.7 Critical anatomy for a resection of segment IVa. After opening the umbilical fissure, the first PP branch encountered is
usually P4b. This needs to be preserved. As the parenchymal transection deepens, P4a will be encountered and needs to be controlled.
Figure v6.8 Relationship of portal structures and LHV and MHV. The parenchymal transection follows LHV and MHV. V4a branches
need to be controlled.
380 Video 6
Figure v6.9 View from superior to inferior. The dorsal border of segment IVa is the IVC and the confluence of LHV and MHV.
The confluence is usually several centimeters below the liver capsule but can also be very close.
Segmentectomy IVa 381
Figure v6.10 View from superior to inferior. The confluence (if present) of the LHV and MHV forms the dorsal border of segment
IVb and is usually dissected last.
VIDEO 7
Segmentectomy IVb
Video duration 10 minutes 27 seconds
In this video, we demonstrate a IVb segmentectomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Opening the umbilical fissure
• Controlling the segment IVb pedicle
• Dissection along the main left portal pedicle
• Transection between segments IVb and V
• Transection between segments IVa and IVb
• Important points.
Figure v7.1 demonstrates the port positioning. The first
step is opening the umbilical fissure. Here you see the
large lesion in segment IVb. We place an umbilical tape
around the porta in case a Pringle maneuver becomes
necessary. While leaving the ligamentum teres and falciform ligament intact, we are opening the umbilical fissure. Injury to the portal structures in the left lateral sector
at this step needs to be avoided. The parenchymal bridge
between the left lateral and medial sectors is divided. This
helps with opening the umbilical fissure. We are now
further opening the umbilical fissure along the falciform
ligament. By deepening this parenchymal transection
line, we will approach the portal pedicles to segments
IVa and b (Figure v7.2).
Next, we will control the portal pedicle to segment IVb.
Here you can see the segment IVb portal pedicle above the
Figure v7.1 Port positioning for a segmentectomy IVb.
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.
382
Segmentectomy IVb 383
Figure v7.2 By deepening this parenchymal transection line,
we will approach the portal pedicles to segments IVa and b.
bipolar forceps (Figure v7.2). The IVb portal pedicle is
completely dissected out. In order to avoid a thermal
injury to the left portal pedicle, we are using scissors at
this step. Once the IVb portal pedicle is completely dissected out, it is clipped and divided. Here we are continuing to deepen the transection lie between segments III
and IVb.
Next, we perform the dissection along the left main
portal pedicle. The first step of this dissection is lowering
the hilar plate. You can see the gallbladder at the left side
Figure v7.4 The segmental drainage vein to IVb is completely
dissected out.
of the image. Here we are dissecting the left main portal
pedicle superiorly. This parenchymal transection line will
ultimately join the earlier parenchymal transection line
along the umbilical fissure (Figure v7.3). Next, we will
transect the liver between segments IVb and V. We can
see a good demarcation of segment IVb. We recommend
leaving the gallbladder attached as a handle. It is important to avoid injury to the middle hepatic vein at this step.
Here, the drainage vein of segment IVb comes into view
which drains into the middle hepatic vein; we will control
it later in the case.
The final step is transection between segments IVa and
IVb. The parenchymal transection line between IVa and
IVb will join the earlier transection line along the umbilical fissure. Here, we are dissecting out the drainage vein to
segment IVb. The segmental drainage vein to IVb is
completely dissected out (Figure v7.4). It is clipped and
divided. Here the two parenchymal transection lines are
joining. Now the specimen is completely detached from
the rest of the liver.
Figure v7.3 This parenchymal transection line will ultimately
join the earlier parenchymal transection line along the
umbilical fissure.
IMPORTANT POINTS
• Avoid bile leaks from IVb portal pedicle variants.
• Do not injure the portal pedicle to segment IVa.
• Leave the gallbladder and falciform ligament attached for
retraction.
• Avoid injury to the main left portal pedicle.
384 Video 7
Anatomy figures
Figure v7.5 Critical anatomy for a resection of segment IVa. After opening the umbilical fissure, the first PP branch encountered is
usually P4b. This needs to be preserved. As the parenchymal transection deepens, P4a will be encountered and needs to be controlled.
Figure v7.6 Relationship of portal structures and LHV and MHV. The parenchymal transection follows the LHV and MHV. V4a
branches need to be controlled.
Segmentectomy IVb 385
Figure v7.7 View from superior to inferior. It is difficult to define the precise border between segments IVb and IVa if there is no
good demarcation after taking P4b. Note also that the border usually does not follow a straight line.
VIDEO 8
Bisegmentectomy IVb and V
Video duration 9 minutes 0 seconds
In this video we demonstrate a bisegmentectomy of
segments IVb and V.
OUTLINE
The outline of this video is as follows:
• Port positioning
• Ultrasound
• Parenchymal transection
• Portal pedicle dissection
• Important points.
Figure v8.1 demonstrates the port positioning. Segments IVb and V are centrally located and a good understanding of the anatomy is important, which we will gain
from the intraoperative ultrasound.
First, we open up the liver between segments III and IVb.
This will be the landing zone of our dissection and will help
us orient during intraoperative ultrasound. In Figure v8.2,
we can see the relationship between the tumor, the ventral
branch of segment VIII, and the anterior portal pedicle. The
portal branch to segment V goes into the tumor. The border
between segments V and VI is defined by the right hepatic
vein which we identify here (Figure v8.3). This will be our
lateral border of transection. With ultrasound, we identify
the inferior border of our transection which is the anterior
portal pedicle (Figure v8.4. With ultrasound control, we
begin our parenchymal transection between the borders of
segment V and segment VI defined by the right hepatic vein.
Next, we would like to show you the parenchymal transection. We deepen our parenchymal transection which we
have begun using ultrasound control. We open up the liver
Figure v8.1 Port Positioning for a bisegmentectomy IVb/V.
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.
386
Bisegmentectomy IVb and V 387
Figure v8.2 This ultrasound image shows the relationship between the tumor, the ventral branch of segment VIII, segment V
pedicle, and the APP.
capsule to the inferior portion of our parenchymal transection defined by the anterior portal pedicle. Using ultrasound
again, we confirm the location of the portal branch of
segment V going into the tumor. From the air artifacts, we
can see that the transection line is close to the anterior portal
pedicle, the inferior border of our parenchymal transection
line (Figure v8.5). Dissection at the anterior portal pedicle is
donewith scissors. Wearenow dissecting theborder between
segments V and VIII. This dissection will join the earlier
transection line at the border between segments III and IVb.
Now that the parenchymal transection line has been
defined, we can deepen our dissection. Here we are dissecting at the border between segments IVb and IVa. The most
distal drainage of the middle hepatic vein is controlled using
bipolar forceps. Using ultrasound control, we dissect out the
portal branch to segment V going into the tumor. At this
step, the dissection of the portal branch of segment V has
been completed and we can proceed to the portal pedicle
dissection. The suction tip aids in the dissection of the portal
pedicle. At this step, we are dissecting the cystic duct and the
cystic artery for better exposure of the portal pedicle. Next,
we separate the hilar plate from the portal structures, using
laparoscopic scissors. With the Doppler flow mode on the
ultrasound, we confirm excellent flow to segment VIII.
After we have confirmed that the portal pedicle to
segment V is isolated and there is good flow to the rest
of the portal pedicle, we can proceed with transecting it.
We transect the portal branch to segment V using scissors.
At this step, the specimen is completely detached and we
are confirming excellent hemostasis.
By injecting air through the cystic duct we confirm that
(1) there is no bile leak, and (2) there is excellent biliary
drainage to the anterior sector. The white air artifacts
confirm the presence of excellent biliary drainage. Also,
the lack of air bubbles at the parenchymal transection
surface confirms the absence of a bile leak. The cystic duct
is controlled using an Endoloop; this is the final operative
site.
388 Video 8
Figure v8.3 The border between segments V and VI is defined by the RHV.
Figure v8.4 With ultrasound, we identify the inferior border of our transection which is the APP.
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