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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 VII 399
Figure v10.6 View from lateral to medial. An RPHV, in addition to several drainage veins off the RHV, drains segment VII in this
patient.
Figure v10.7 View from lateral to medial. Injury to the RHV, especially at its drainage into the IVC, needs to be avoided during the
parenchymal transection of the superior border.
VIDEO 11
Segmentectomy VIII (transthoracic access)
Video duration 6 minutes 41 seconds
In this video, we demonstrate a segmentectomy of segment VIII using a transthoracic access.
OUTLINE
The video is divided into the following parts:
• Transthoracic port placement
• Determining the borders of segment VIII
• Parenchymal transection and dissection
• Management of bleeding
• Important points.
Let’s start with port placement (Figure v11.1). The scheme
demonstrates the port positioning. Here we show port positioning under the costal margin, and in the 10th and 11th
intercostal space. For the intercostal trocars, we use cuffed
ports. This will help to keep the diaphragm out of the field.
The next step of the operation is determining the anatomical borders of segment VIII. The scar indicates the lesion
in segment VIII. Using ultrasound, we identify the portal
branch to segment VIII (Figure v11.2).Thetumorissuperior
to it and can be seen as well. We are now injecting indocyanine green to this branch to stain segment VIII. This is
done with ultrasound guidance. An ultrasound head that
facilitates the cannula greatly helps with this process.
Although the medial border stains nicely, the inferior and
lateral margins are not well demarcated. We therefore
revert to ultrasound guidance to stain the inferior and lateral
margins. Here we use the right hepatic vein as a landmark.
This determines the lateral border of segment VIII.
Figure v11.1 Ports are placed just under the costal margin and the 10th and 11th intercostal space.
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.
400
Segmentectomy VIII (transthoracic access) 401
Figure v11.2 Using ultrasound, we identify the portal branch to segment VIII. The tumor is superior to it and can also be seen.
The next step covers parenchymal transection and
dissection. Hemostasis is facilitated with the fenestrated
bipolar forceps. Here you can see the dissection of the
medial border of segment VIII (Figure v11.3). The dissection of the coronary ligament bearing the suprahepatic
part of the IVC is performed using scissors. Scissors allow
Figure v11.3 The suprahepatic IVC has been dissected out using scissors.
402 Video 11
more tactile feedback than the harmonic cutting device.
Also, an injury with the scissors can be more easily
repaired than one caused by a harmonic cutting device.
At this step, the superior border of segment VIII has
been entirely dissected out. We now continue the dissection at the inferior border of segment VIII, approaching
the portal branch feeding the segment. We now clip the
portal branch to segment VIII and divide it with scissors.
Now the posterior border of segment VIII is dissected off
the middle hepatic vein. In this last step, we encounter
some significant bleeding and we will show you some of
our techniques in managing this bleeding. At this step, we
encounter bleeding from the middle hepatic vein. We
apply bipolar coagulation directly to major hepatic veins
which can be very helpful. In order to determine the exact
location of the bleeding, we are improving exposure. This
unfortunately leads to more bleeding. The bleeding is
temporarily controlled with the bipolar forceps until a
vascular clamp can be applied. As there is still some
bleeding, we introduce gauze into the abdomen which
can be applied to the bleeding site with compression. In
addition, parenchymal compression can be applied which
can stop bleeding temporarily. As the hole in the middle
hepatic vein has been clearly identified, we suture close
the hole. Now that the bleeding has been controlled, we
continue the parenchymal transection along the superior
border of segment VIII.
Segment VIII is now almost completely mobile and
superior traction helps to detach the segment from the
rest of the liver. The exposed MHV, as well as the portal
branch, confirms the anatomical resection of segment
VIII. Before completing the case, we go back to inspect
the bleeding from the middle hepatic vein. As this is
continuing, we apply a patch soaked in human thrombin
and fibrinogen to the bleeding site. Wrapping the patch in
gauze helps with the laparoscopic application.
IMPORTANT POINTS
• Transthoracic access provides an excellent view of segment VIII.
• Laparoscopic ultrasound is essential for anatomical
resection of segment VIII.
• Using scissors for the dissection of critical structures adds
safety.
• The laparoscopic liver surgeon needs to be well versed
in the various techniques of controlling bleeding laparoscopically. This is especially true when attacking a
challenging case such as an anatomical resection of
segment VIII.
Anatomy figures
Figure v11.4 Critical anatomy for resection of segment VIII. The typical portal branching of segment VIII is a dominant P8 ventral
and P8 dorsal PP coming off the RAPP.
Segmentectomy VIII (transthoracic access) 403
Figure v11.5 Portal pedicle to segment VIII. At the distal end of the RAPP is P8v and P8d. The V8 drainage vein can be a dominant
branch close to the drainage of the RHV into the IVC (as in this patient). Injury to this branch during either a laparoscopic right
hepatectomy or a segmentectomy VIII can lead to significant bleeding. Therefore we recommend identifying this branch on
preoperative imaging and during the dissection.
Figure v11.6 View from superior to inferior. Segment VIII drains into the RHV and MHV. This patient has prominent V8 drainage
veins of the RHV. A prominent V8 drainage vein (not this patient) can come off the MHV which can be easily injured near the end
of the parenchymal transection for a right hepatectomy.
404 Video 11
Figure v11.7 View from lateral to medial. Notice the relationship of P8 ventral and P8 dorsal and the RHV and MHV.
Figure v11.8 Sub-segmentectomy segment VIII ventral. With the knowledge of portal branching into P8 ventral and dorsal,
anatomical resection of the sub-segments of segment VIII can be performed. Since segment VIII is a large segment, knowledge of this
branching allows for parenchyma-sparing surgery.
Laparoscopic major liver resection
VIDEO 12
Left hepatectomy
Video duration 13 minutes 24 seconds
In this video we will demonstrate a left hepatectomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Mobilization of the left liver
• Ultrasound
• Portal dissection
• Parenchymal transection
• Division of the left hepatic vein
• Important points.
First, we would like to show you the port positioning
(Figure v12.1). The port positioning of the right and left
hepatectomy is similar. However, for a left hepatectomy,
the line of transection is more towards the left and more in
a craniocaudal direction. This is the port positioningfor the
portal dissection. As the parenchymal transection progresses, we move to this port positioning (Figure v12.2).
Next, we will show you mobilization of the left liver. We
begin by taking down the falciform ligament. Now that the
coronary and triangular ligaments have been dissected, the
left lobe of the liver is mobile. A very important component
of this operation is the intraoperative ultrasound. Identification of the middle hepatic vein is crucial for the parenchymal
transection (Figure v12.3). Having an accurate understanding of the precise location of the middle hepatic vein will help
you to avoid getting lost with the two-dimensional view of
the laparoscopic camera. The other important structure is
drainage of the left hepatic vein into the IVC (Figure v12.4).
Identifying the presence of an umbilical fissure vein will
avoid its injury and significant bleeding.
The next step is the portal dissection, which begins with
transection of the cystic duct. The hilar plate is lowered and
we leave the gallbladder attached as a handle. We now focus
the dissection on the left portal pedicle. Here, the Glissonian
sheath of the left portal pedicle is opened. Then we open up
the hepatoduodenal ligament. We continue the dissection
along the ligament of Arantius. This gives us more mobility
of the liver and we can continue the dissection of the left
portal pedicle. For dissection of the left portal pedicle, we
open the hepatoduodenal ligament more widely. The first
structure that has been dissected out is the left hepatic
artery. The main left hepatic artery and the branch to
segment IV are dissected out individually. In the background, the left portal vein comes into view. The left hepatic
artery is clipped and divided. Back bleeding is controlled
with thermofusion. Now the anterior branch to segment IV
is divided using thermofusion. We continue to mobilize the
left portal vein off the Glissonian sheath. Once the left portal
vein is completely dissected out, it is clipped and divided.
The last step of portal dissection is dissecting out the left
bile duct. Using a right-angled dissector, we dissect the left
bile duct off the Glissonian sheath. We clip the distal part
and we will divide proximally. After division of the bile
duct, you can see the proximal lumen which we will
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.
405
406 Video 12
Figure v12.1 The port positioning is similar for the right and left hepatectomy. However, for a left hepatectomy, the line of
transection is more towards the left and more in a craniocaudal direction.
suture close. When the bile duct is divided close to its takeoff from the common bile duct, suture closing it will avoid
stricturing of the remaining right bile duct.
Next we will show you the parenchymal transection. The
landmarks for the parenchymal transection are the middle
hepatic vein identified earlier on ultrasound as well as the
demarcation line. As we can see here, leaving the gallbladder
attached after division of the cystic duct allows it to act as a
handle. Here we are getting right on the middle hepatic vein
and dividing the drainage vein of segment IVb.
The drainage vein to segment IVb is clipped and divided
using thermofusion. We continue to divide the liver
Figure v12.2 As the parenchymal transection progresses and we approach the hepatic venous confluencewemovetothisport
positioning.
Figure v12.3 Identification of the MHV is crucial for the
parenchymal transection.
Left hepatectomy 407
The last step is division of the left hepatic vein. Prior
to division, we always check whether we have a good
angle to place a vascular clamp in case of stapler misfiring. Now the left hepatic vein is staple divided.
Finally, we check for parenchymal bleeding at the
resection surface and stop it using the bipolar forceps.
Here we can see the exposed middle hepatic vein as
well as the drainage veins to segments V and VIII. We
go back and check the transected portal structures. We
notice some bile leakage from the left bile duct which
we control using suture closure.
The last step of the operation is removing the
gallbladder. Finally, we would like to give you an overview of our dissection.
capsule following the line of demarcation. Following the
middle hepatic vein ensures an optimal line of parenchymal transection. Here we are identifying the drainage vein
to segment IVa. The drainage vein is clipped and divided.
As we continue the parenchymal transection, we reach
the dome of the liver. Here we will find the drainage of the
left hepatic vein and middle hepatic vein into the IVC.
Here we can see the origin of the middle hepatic vein
being dissected out.
IMPORTANT POINTS
• Mobilize the left lobe early.
• Use ultrasound to identify the middle hepatic vein and
left hepatic vein origin.
• Leave the gallbladder attached as a handle.
• Do not get lost during the parenchymal transection; let
the middle hepatic vein guide you.
• Have a laparoscopic vascular clamp ready when staple
dividing the left hepatic vein.
Figure v12.4 Drainage of the LHV into the IVC. Identifying the presence of an umbilical fissure vein will avoid its injury and
significant bleeding.
408 Video 12
Anatomy figures
Figure v12.5 Critical view during the portal dissection for a left hepatectomy. Usually, the A4 artery (intermediate branch of the
LHA) is divided first. It is critical to identify the branching of the main portal vein into its left and right branch. This will avoid
narrowing of the right portal vein. Once the parenchymal transection is begun at the border between S4b and 5, the horizontal
crossing V4b drainage vein into the MHV will be identified.
Figure v12.6 View at the beginning of the parenchynmal transection. Once the portal structures have been controlled, the
parenchymal transection follows the MHV. Two branches draining S4b are identified. As the transection progresses, the V4a
drainage vein is identified. The MHV and LHV will often share a common drainage into the IVC.
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