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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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Left hepatectomy 409
Figure v12.7 The view the laparoscopic surgeon should obtain during parenchymal transection. By orienting the camera along the
axis of the MHV, the optimal view for the parenchymal transection is obtained. Small radicals of the P4a and b pedicle might reach
to the parenchymal transection plane.
VIDEO 13
Right hepatectomy
Video duration 16 minutes 31 seconds
In this video, we demonstrate a laparoscopic right
hepatectomy.
OUTLINE
The video is divided into the following parts:
• Portal dissection
• Parenchymal transection
• Division of right hepatic vein
• Specimen mobilization
• Important points.
Figure v13.1 demonstrates the port positioning. The
first 12 mm port is placed between the costal margin and
the umbilicus. With this port and two 5 mm working
ports, the portal dissection can be completed. Make sure
not to place this port too low.
The second 12 mm port is placed to the right at the
costal margin; this will allow completion of the parenchymal transection and dissection of the right hepatic
vein. Here we show the 12 mm port coming into the right
at the costal margin (Figure v13.2); notice the distance
between this port and the liver.
The next step will be intraoperative ultrasound and
identification of the middle hepatic vein. With the ultra-
sound,you are notonly ruling out lesions in the future liver
remnant – you are also identifying the middle hepatic vein
as a landmark for the lateral parenchymal transection.
In order to lower the hilar plate, we divide the cystic
duct and cystic artery. However, we recommend leaving
Figure v13.1 The first 12 mm port is placed between the costal margin and the umbilicus. With this port and two 5 mm working
ports, the portal dissection can be completed. Make sure not to place this port too low.
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.
410
Right hepatectomy 411
Figure v13.2 The second 12 mm port is placed to the right at the costal margin; this will allow completion of the parenchymal
transection and dissection of the RHV.
the gallbladder itself attached to the liver to act as a
handle. Here we can see the opening of the hilar plate
itself which usually leads to minor bleeding. This step is
necessary in order to be able to come easily around the
bile duct later during the portal dissection. We place a
hemostatic agent into the crevice after opening the hilar
plate in order to avoid blood in the portal structures, to
allow excellent visualization during the dissection later.
Here we open the hepatoduodenal ligament at its
lateral portion. This will allow us to dissect out the right
hepatic artery. Dividing the right hepatic artery at this step
will open up the space and will help in dissecting out the
right hepatic vein. The small right anterior and posterior
right hepatic arteries will be controlled using thermofusion and later with a clip (Figure v13.3). The right hepatic
artery is controlled using a locking clip.
The next step will be dissecting out the right portal vein
branch. This is the dissection at the bifurcationbetweenthe
rightand left portal vein. Notice also the closeness of theleft
hepatic artery at this point of dissection (Figure v13.4). As
we get closer to the portal vein, we switch to scissors for
dissection. This allows for more tactile feedback and an
injury with scissors can be much more easily controlled.
Using scissors, the portal vein is now separated from the
Glissonian sheath at the inferior portion. Using a 5 mm
dissector, now the portal vein is completely mobilized, we
place a suture around the right portalvein in order to have
traction which facilitates placing a locking clip. It is important to be careful with the branches of the right portal vein
running directly into the caudate lobe. Injury to these
branches can be difficult to control. Here we control these
branches with thermofusion.
The next step is dissection of the retrocaval ligament
and transection of the Spiegel lobe. This is the view along
the IVC. You will encounter direct branches into the IVC
which need to be controlled. In order to avoid any
surprises, check on preoperative imaging for the right
inferior hepatic vein. An additional short hepatic vein can
be controlled using thermofusion.
The next step is transection of the paracaval portion of
the caudate lobe, also known as Couinaud’s segment IX.
Because of the augmented view of the laparoscopic camera, this part may be performed more easily via a laparoscopic than an open procedure. Performing this step early
in the operation will facilitate control of the bile duct (BD)
(Figure v13.5). We are now placing a clamp behind the
bile duct in the direction of the later stapling. The right bile
duct is staple divided. It is important to make sure that you
leave sufficient distance to the left bile duct to prevent
postoperative stenosis.
At this point of the operation, all portal structures to the
right side have been controlled and we are now moving
412 Video 13
Figure v13.3 The small right anterior and posterior RHAs will be controlled using thermofusion and later with a clip.
Figure v13.4 This is the dissection at the bifurcation between the right and left portal vein. Notice also the closeness of the LHA at
this point of dissection.
Figure v13.5 The next step is transection of the paracaval
portion of the caudate lobe, also known as Couinaud’s segment
IX. Because of the augmented view of the laparoscopic camera,
this part may be performed more easily via a laparoscopic than
an open procedure. Performing this step early in the operation
will facilitate control of the bile duct (BD).
on to the parenchymal transection. Our technique for the
parenchymal transection is to activate the energy device
outside the parenchyma and keep it activated while
closing. At this location, we encounter the middle hepatic
vein branch to segment V. It is easy to get lost with the
transection plane in the two dimensions of the laparoscopic view. Having the IVC in view and keeping the
falciform ligament attached can help to guide the parenchymal transection plane. Now the crucial landmark is
Right hepatectomy 413
the middle hepatic vein that was identified using ultrasound at the beginning of the case (Figure v13.6). This is
very helpful if you are inside the parenchyma.
Because the paracaval portion of the caudate lobe was
transected earlier, we can now connect the plane between
the middle hepatic vein and the IVC. Once we get closer to
the origin of the middle hepatic vein, we should look out
for the segment VIII branch. We also strongly recommend
identifying this branch during preoperative imaging.
The flat IVC and the respiratory variations that can be
seen are indicative of the low CVP.
Dissecting out the hepatic vein origin is always done
using scissors. The last step of the operation is the staple
division of the right hepatic vein and mobilization of the
specimen. This is done with scissors because an injury
with scissors can be much more easily controlled than an
injury with an energy device. Now the right hepatic vein
is completely dissected out and we will divide using a
stapler. We recommend always having a vascular clamp
ready in case of stapler misfiring, as seen here. The
dissection of the hepatocaval ligament is now completed.
Short hepatic veins are controlled using thermofusion.
With the division of hepatic vein branch VIII ventral,
the specimen is now completely devascularized. The
specimen needs to be detached from the triangular ligament; medial traction of the specimen with the help of the
30° camera aids in this process. Using Doppler, we confirm
vascular inflow and outflow.
IMPORTANT POINTS
Figure v13.6 The crucial landmark is the middle hepatic vein that
was identified using ultrasound at the beginning of the case.
• Laparoscopic ultrasound is crucial during this operation. It is
used to identify lesions in the future liver remnant and identify
the MHV as a landmark for the parenchymal transection.
• After division of the cystic duct and cystic artery, we
recommend leaving the gallbladder attached to the liver
as it can be used for retraction.
• Complete the retrocaval ligament dissection as well as the
paracaval portion of the Spiegel lobe transection early. This
can help during division of the bile duct and during the
parenchymal transection.
• Umbilical tape around the porta can be used as an emergent Pringle.
• Do not become lost because of the 2D laparoscopic view; let
the MHV guide you.
• Have a vascular clamp ready when firing the stapler across
the right hepatic vein.
• Finally, be prepared that specimen mobilization at the end
may take time.
414 Video 13
Anatomy figures
Figure v13.7 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 is commonly seen.
Figure v13.8 Relationship of the portal structures and MHV. Notice the close relationship between the PP and the MHV drainage
veins to segment V (V5). During a cholecystectomy, the V5 branches can be close to the surface and cause significant bleeding. They
need to be controlled at the beginning of the parenchymal transection.
Right hepatectomy 415
Figure v13.9 View along the parenchymal transection plane. After the RPP has been controlled and the V5 branches divided, we
follow the MHV up to its drainage into the IVC. It is important to check preoperative imaging for a prominent V8 drainage vein (not
present in this patient). Injury to a V8 drainage vein can lead to significant bleeding at near-completion of the case.
VIDEO 14
Left trisegmentectomy with caudate lobectomy
Video duration 16 minutes 12 seconds
In this video, we will show you a left trisegmentectomy
with caudate lobectomy. The video is divided into the
following parts:
OUTLINE
• Port positioning
• Liver mobilization
• Left portal pedicle dissection
• Right anterior portal pedicle dissection
• Caudate lobectomy
• Parenchymal transection
• Left and middle hepatic vein division
• Important points.
The port positioning is similar to a left hepatectomy
(Figure v14.1). After liver mobilization, portal pedicle
dissection and the beginning of liver transection, we
then move to position 2 (Figure v14.2).
The first step is to complete mobilization of the left liver.
Here the falciform ligament is taken down and we are
dissecting along the ligament of Arantius. We proceed to
taking down the left triangular ligament. As full liver
mobilization is necessary, we are now dividing the coronary ligament.
The next step is the left portal pedicle dissection. Here
we are preparing for a potential Pringle maneuver should
that become necessary during the parenchymal transection. We are now beginning to dissect the left portal
Figure v14.1 The port positioning is similar to a left hepatectomy.
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.
416
Left trisegmentectomy with caudate lobectomy 417
Figure v14.2 After liver mobilization, PP dissection and the beginning of liver transection, we then move to position 2.
structures. Here we are opening the hepatoduodenal
ligament, and the left hepatic artery comes into view.
At this step, the left hepatic artery and the medial branch
of the segment IV artery, also known as the A4 branch, are
dissected out (Figure v14.3). The arteries are clipped and
divided. Here we are beginning to lower the hilar plate.
To facilitate this step, the cystic duct is divided.
The next step is dissecting out the portal vein. After
opening the Glissonian sheath, the portal vein comes
into view. The portal vein and right hepatic artery are
separated (Figure v14.4). Next, the left hepatic duct is
divided and then suture closed. We reopen the cystic duct
and inject air into the biliary system. We are doing this with
the right anterior portal pedicle clamped. The air artifacts in
the ultrasound will help us delineate the posterior sector.
Now, the left portal vein is dissected out and divided and
the left portal pedicle has been controlled, we dissect out and
control the right anterior portal pedicle. Here, the right
Figure v14.3 After liver mobilization, PP dissection, and
the beginning of liver transection, we then move to
position 2.
Figure v14.4 After opening the Glissonian sheath, the
portal vein comes into view. The PV and RHA are
separated.
418 Video 14
Figure v14.5 There is good demarcation between the RAPP and
the RPPP.
anterior sectoral artery comes into view. Here, the right
anterior sectoral vein is dissected out and it will also be
controlled and divided. Following the portal pedicle dissection, we will perform a caudate lobectomy. Here you can see
us opening up the hepatocaval ligament. The ligament of
Arantius is divided. Next, we will open up the hepatocaval
space. Caudate veins are controlled and divided. Passing a
suture behind those veins allows for some traction that
facilitates clipping. The hepatocaval space is further opened.
The next crucial step is the parenchymal transection.
Using ultrasound, we again confirm the location of the
right hepatic vein. We can also see a nice demarcation line
between the right anterior and right posterior sectors
(Figure v14.5). Here we are beginning the parenchymal
transection between segments V and VI. We are opening
up the liver capsule along the demarcation line. Here we
are making progress with the parenchymal transection
between segments V and VI. Here, the segment V drainage vein into the right hepatic vein is controlled. We are
encountering some minor bleeding of the right hepatic
vein. As we make progress with the parenchymal transection, we encounter the drainage vein to segment VIII,
also known as VIII ventral. We are continuing to follow
the right hepatic vein. Minor bleeding from the right
hepatic vein is controlled with the bipolar forceps. The
dorsal drainage vein of segment VIII is dissected out and
divided. We continue the dissection directly on the right
hepatic vein (Figure v14.6). The drainage vein of segment
VIII is dissected out, controlled, and divided. As we reach
the origin of the right hepatic vein, we switch to scissors
Figure v14.6 We continue the dissection directly on the RHV.
for the dissection. Here, the anterior fissure vein is clipped
and divided. Now, the right anterior and posterior sectors
are completely separated. In the middle of the image, the
IVC can be seen.
The last step of the operation is division of the left and
middle hepatic veins. With inferior traction on the specimen, the middle and left hepatic veins are staple divided.
Having a vascular clamp ready for stapler misfiring is
crucial for this step. The exposed right hepatic vein confirms a true anatomical dissection (Figure v14.7). At the
end of the case, we inspect the transection surface for any
bleeding or bile leaks.
Figure v14.7 The exposed RHV confirms a true anatomical
dissection.
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