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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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Bisegmentectomy IVb and V 389
Figure v8.5 The air artifacts demonstrate that the transection line is close to the APP, the inferior border of our parenchymal
transection line.
IMPORTANT POINTS
• Have a good preoperative understanding of the portal
branching.
• Use ultrasound to anticipate anatomical landmarks.
• Spend time on the hemostasis during the parenchymal
transection for excellent working conditions.
• Confirm drainage to the remaining segments using
ultrasound.
390 Video 8
Anatomy figures
Figure v8.6 Critical anatomy for resection of segments IVb and V. After opening the umbilical fissure, the first PP branch encountered
is P4b which is controlled. P4a can be close behind P4b. Also, there can be (most commonly) more than one P4b branches. If an
intermediate branch of the HA is present, it should be taken. There are usually several PPs to segment V coming off the RAPP.
Figure v8.7 Relationship of portal structures and V4b and V5 drainage veins. The MHV bisects segments IVb and V. It gives off
drainage veins to segments IVb and V. Injury to the RAPP during dissection of the inferior border of segment V should be avoided.
Bisegmentectomy IVb and V 391
Figure v8.8 View from ventral to dorsal. Segment V is especially rich in portal pedicles and drainage veins that need to be controlled
during parenchymal transection.
Figure v8.9 View from superior to inferior. The RHV is the lateral border of the transection. RHV can give off prominent drainage
veins to segment V. V5 and V4b drainage veins from the MHV will be encountered when performing the superior aspect of the
parenchymal transection.
VIDEO 9
Segmentectomy VI
Video duration 9 minutes 44 seconds
In this video, we present an anatomical resection of
segment VI.
OUTLINE
The outline of this video is as follows:
• Port positioning
• Distinction between P6 and P7 on ultrasound
• Dissection of the hepatocaval ligament
• Dissection of Rouviere’s sulcus
• Parenchymal transection
• Important points.
The port portioning for resection of segment VI is more
variable than for other segmentectomies. In general, the
ports are placed more laterally (Figure v9.1). An effective
approach might be to place an umbilical port first and then
to place the rest of the ports depending upon the relative
location of the liver.
Next, we identify important structures for resection of
segment VI. One important landmark structure is the
right hepatic vein (Figure v9.2), which defines the medial
border of segment VI. Very important is the branching of
the right posterior portal pedicle (RPPP) into P6 and P7
you will learn more about this later in the video.
We will beginthe dissection at the hepatocavalligament;
the dissection of Rouviere’s sulcus will end up at the
hepatocaval ligament. Performing this dissection early in
the case gives us a safe landing zone. This is the view along
the IVC andsegmentVI canbe seen on the leftside with the
lesion. Short hepatic vein branches are controlled using
thermofusion. In addition, we transect the right triangular
Figure v9.1 The port portioning for resection of segment VI is more variable than for other segmentectomies. In general, the ports
are placed more laterally and placing the patient in left decubitus position can improve degree of freedom of the instruments.
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.
392
Segmentectomy VI 393
Figure v9.2 The RHV constitutes the medial border of segment
6 and should be identified at the beginning of the case.
ligament in order to mobilize the liver. We achieve control
of the portal branch to segment VI through opening up
Rouviere’s sulcus (Figure v9.3). Here, we can see the
dissection of the hepatoduodenal ligament which islocated
on the right side of the image. Please bear in mind that the
portal branches to the caudate lobe can be found at this
location and must be controlled early, prior to beginning
the parenchymal transection.
We will control the portal branch to segment VI
through opening up Rouviere’s sulcus (Figure v9.4).
Please be careful when you open up this capsule as the
portal structures can be found very close. Opening up
Rouviere’s sulcus will help in performing intraoperative
Figure v9.4 We achieve control of the portal branch to segment
VI through opening up Rouviere’s sulcus. Notice that the RPP
is very close to the surface of Rouviere’s sulcus.
ultrasound. The air artifacts can help identify the right
posterior portal pedicle. Pushing with forceps in the sulcus
on the right posterior portal pedicle ensures that we are
distal to the location where the segment VII portal pedicle
arises (Figure v9.5, Figure v9.6).
As mentioned earlier, our landmark structure is the
right hepatic vein which defines the medial border of
segment VI. It can be seen here in the middle of the image.
Here we are controlling a portal branch goinginto segment
VI. Here we are connecting the dissection of Rouviere’s
sulcus with the earlier dissection of the hepatocaval ligament. Indocyanine green counterstaining can be helpful
Figure v9.3 Opening up Rouviere’s sulcus will help in
performing intraoperative ultrasound. RPPP divides on the
ultrasound image into P6 and P7.
Figure v9.5 Pushing with forceps in the sulcus on the RPPP
ensures that we are distal to the take-off of the segment VII
portal pedicle.
394 Video 9
Figure v9.6 On this image P6 has been occluded while P7 is
preserved.
to define the border to neighboring segments. Here you
can see the border between segments V and VI. Here we
have connected the dissection of Rouviere’s sulcus to the
dissection of the hepatocaval ligament.
The final step is the dissection along the right hepatic
vein. Ultrasound is crucial in identifying the right hepatic
vein in its intraparenchymal location. After opening the
parenchyma along the right hepatic vein, we confirm that
we have a good flow to the portal branch of segment VII.
Finally, we control the drainage vein of segment VI into
the right hepatic vein. We detach the specimen and
remove it from the abdomen using an endoscopic
retriever bag.
IMPORTANT POINTS
• In general, the ports are placed more lateral than for a
right hepatectomy.
• Early dissection of the hepatocaval ligament allows for
safe opening of Rouviere’s sulcus to dissect out the
segment VI portal branch.
• Use ultrasound to identify the branching between segments VI and VII of the right posterior portal pedicle.
• The right hepatic vein defines the medial border of segment
VI and should guide your parenchymal transection.
Anatomy figures
Figure v9.7 Critical anatomy for resection of segment VI. This patient has a prominent PP to segment VI. V6 drainage veins come off
the RHV.
Segmentectomy VI 395
Figure v9.8 Relationship of portal structures and V6 drainage veins. Notice the relationship between the PP to segment VI and the
RIHV and the V6 drainage veins into the RHV.
Figure v9.9 View from superior to inferior. Notice the close relationship between the P6 and the two V6 drainage veins.
VIDEO 10
Segmentectomy VII
Video duration 8 minutes 23 seconds
In this video, we will demonstrate a resection of
segment VII.
OUTLINE
The outline of this video is as follows:
• Port positioning
• Ultrasound
• Caval dissection
• Right hepatic vein dissection
• Controlling the drainage vein of segment VII
• Controlling the portal pedicle to segment VII
• Important points.
The patient is positioned in a modified French position.
Thelegsareinstirrups,theleftsideisdownandtherightside
is up, and the right arm is positioned above the patient’s
head. The surgeon stands either on the right side or between
the legs of the patient. The ports are positioned as shown in
Figure v10.1. The 12 mm port for the camera has to be
positioned high enough to enable a good view of the
drainage of the right hepatic vein into the IVC.
In this patient, the left lateral sector has already been
removed. Here you can see placement of the two 12 mm
ports. A balloon port for the high 12 mm port ensures
opposition of the diaphragm. Next we perform an intraoperative ultrasound. A key structure to identify is the
Figure v10.1 The patient is positioned in a modified French position. The legs are in stirrups, the left side is down and the right side is up,
and the right arm is positioned above the patient’s head. The surgeon stands either on the right side or between the legs of the patient.
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.
396
right hepatic vein and its drainage into the IVC. The right
hepatic vein constitutes the medial border of segment VII.
Here we open the parenchyma right above the drainage
of the right hepatic vein into the IVC. It is important to
avoid the injury of the right hepatic vein at this step. Here
we continue to deepen the parenchymal transection
plane in order to expose the drainage of the right hepatic
vein into the IVC.
Next, we will show the dissection along the IVC. For
this part, we are using scissors. A small hole in the IVC or
the right hepatic vein made by scissors can be more easily
repaired than a hole made with an energy device. Blunt
dissection with the suction tip at this step can also be very
helpful.
Next, we show the exposure of the right hepatic
vein along the medial border of segment VII. Using the
blunt suction tip for dissection, we are exposing the
lateral wall of the right hepatic vein. The next step
would be controlling the venous branches draining
segment VII into the right hepatic vein. Here the
dominant drainage vein of segment VII comes into
view. Using ultrasound with Doppler flow and the
laparoscopic vascular clamp, we confirm that we
have indeed exposed the drainage vein of segment
VII. On this image, we can see two drainage veins of
segment VII (Figure v10.2). On this Doppler image,
the right hepa tic vein is demonstrated.
Segmentectomy VII 397
Figure v10.3 Finally the hepatocaval ligament is transected.
We can now proceed to clipping and dividing the
drainage vein of segment VII. The second drainage vein
to segment VII is exposed, clipped, and divided. We have
identified it previously using ultrasound with Doppler
flow. Next, we will dissect the border between segments
VI and VII and control the pedicle to segment VII. The liver
is elevated with the liver retractor and we are deepening
our parenchymal transection line between segments VI
and VII. Here, we have identified the portal pedicle to
segment VII which we will control using the bipolar
forceps.
The final steps are mobilizing the specimen off the IVC.
Some blunt dissection with the suction tip can be helpful
at this step. Finally we will transect the hepatocaval
ligament (Figure v10.3).
Figure v10.2 Using ultrasound with Doppler flow and the
laparoscopic vascular clamp, we confirm that we have indeed
exposed the drainage vein of segment VII. The two drainage
veins of segment VII can be seen.
IMPORTANT POINTS
• It is important to position the trocars high
transdiaphragmatically.
• The right hepatic vein serves as a landmark.
• Dissection at the IVC is carried out with scissors.
• The segment VII portal pedicle is best identified using
ultrasound.
• It is critical to avoid injury to the segment VI portal
pedicle.
398 Video 10
Anatomy figures
Figure v10.4 Critical anatomy for resection of segment VII. The patient has a trifuction of P6, P7, and RAPP. Several drainage veins
constitute the RHV.
Figure v10.5 Relationship of PP P7 and V7 drainage veins. P7 can come off a common RPPP or form a trifurcation, as is seen in this
patient. Usually P7 is superior and posterior to P6. When controlling P7, injury to P6 has to be avoided.
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