Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1260_Библиотеки_им_академика_М_И_Перельмана
.pdf
Anatomy figures
Left trisegmentectomy with caudate lobectomy 419
IMPORTANT POINTS
• Start with the left portal pedicle and then proceed to the
right anterior portal pedicle dissection.
• Be certain that the right posterior pedicle is intact to avoid
damage to the future liver remnant.
• Use ultrasound to identify the right hepatic vein; it will
guide your parenchymal transection.
• Have a laparoscopic vascular clamp ready when stapling the middle or left hepatic vein in case of stapler
misfiring.
Figure v14.8 Relevant anatomy. Initially, the left liver inflow and outflow is controlled. The LPP is divided. Next, the RAPP is
controlled. In this schema, there is a trifurcation of RAPP, P6, and P7.
420 Video 14
Figure v14.9 Dissection of the RAPP. This is the caudal view at the beginning of the dissection. During dissection of the RAPP, injury
to the RPHA needs to be avoided. This patient has an IRHV which needs to be preserved or controlled.
Figure v14.10 Additional view of portal structures. Preserving the RPHA while controlling the RAHA is critical.
Left trisegmentectomy with caudate lobectomy 421
Figure v14.11 Lateral view to the posterior section. Once the portal structures are controlled, the parenchymal transection is carried
out along the RHV. V5 is taken first. P8 has a constant dorsal and ventral branch. The dorsal branch can reach into the parenchymal
transection plane. At the end of the parenchymal transection, the MHV/LHV are divided.
VIDEO 15
Right trisegmentectomy
Video duration 19 minutes 30 seconds
In this video, we would like to show you a right
trisegmentectomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Right portal pedicle dissection
• Left medial portal dissection
• Parenchymal transection
• Right and middle hepatic vein division
• Important points.
The port positionis similar to a left hepatectomy.We will
move from position 1 (Figure v15.1) to position 2 (Figure
v15.2) as we progress with the parenchymal transection.
The first step of the operation is controlling the right
portal pedicle. Here we are taking down the falciform
ligament and performing a complete liver ultrasound.
Here we are determining the anatomical relation between
the middle hepatic vein and the left portal pedicle
(Figure v15.3). Here the lesion at segment IVa at the
origin of the middle hepatic vein is seen, necessitating a
right trisegmentectomy. Here we are beginning the dissection of the hepatoduodenal ligament. Area 12p lymph
node station is dissected out and sent for frozen section
analysis. Next, the cystic duct is clipped and divided.
The next step is lowering of the hilar plate. The right
hepatic artery is dissected out, clipped, and divided. Here
lymph node station 12p is dissected out. Now we are ready
to clip and divide the right hepatic artery. Here the right
Figure v15.1 The port position 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.
422
Right trisegmentectomy 423
Figure v15.2 We will move to port position 2 once we progress with the parenchymal transection and to control the hepatic venous
confluence.
anterior hepatic artery is clipped and divided. Next, the
right posterior hepatic artery is controlled. We proceed to
dissecting out the right portal vein. Using a right-angled
dissector, we dissect the right portal vein off the Glissonian
sheath. Once it is completely mobile, we can clip and
divide it. The last structure of the right portal pedicle
Figure v15.3 Here we are determining the anatomical relation between the MHV and the LPP.
424 Video 15
Figure v15.4 As we proceed with the parenchymal transection,
the confluence between the MHV and LHV comes into view.
that needs to be controlled is the right bile duct. The right
bile duct is divided with scissors. At this step, we are also
beginning the division of the hepatocaval ligament.
The next step is controlling the portal pedicle to segments IVb and IVa. In order to control the portal pedicle to
segment IV, we have to open the umbilical fissure. Opening the parenchyma here facilitates location of the portal
pedicle to segment IVb. Using ultrasound, we are tracing
our later parenchymal transection line. Injury to the left
hepatic vein has to be avoided at all costs. Tracing out the
parenchymal transection line at this step facilitates opening up the umbilical fissure.
With the parenchyma opened along the umbilical
fissure, we are dissecting out the portal branch to segment
IVb. The portal branch to segment IVb is usually located
inside the parenchyma. Opening up the parenchyma
widely above and below the portal pedicle facilitates
controlling it. Using the gallbladder as a handle, we
connect the earlier parenchymal transection line with
the parenchymal transection line along the umbilical
fissure. A key maneuver is ensuring that the portal pedicles to left lateral sectors are preserved. Here we are
placing a vascular clamp on the portal pedicle to segment
IVb while ensuring preserved flow to the left lateral
sector. With this vascular clamp that fits through a
12 mm port, we confirm that we are all the way around
the portal pedicle to segment IVb. The IVb pedicle is
clipped and divided. Here the dissection is carried out
along the paracaval portion of the caudate lobe. By
opening up the paracaval portion of the caudate lobe,
the segment IVa branch is fully dissected out and clipped
and divided. At this step, all the portal pedicles for our
right trisegmentectomy have been taken and we can
proceed to complete our parenchymal transection.
As we progress with the parenchymal transection, it is
crucial to avoid injury to the left hepatic vein. We will
come back to this part. Here we encounter minor bleeding
from the left hepatic vein, which we stop using the bipolar
forceps. Here, the coronary ligament is taken down. As we
proceed with the parenchymal transection, the confluence between the middle hepatic vein and left hepatic
vein comes into view (Figure v15.4). As mentioned
before, it is crucial to avoid any injury to the left hepatic
vein. At this step, the confluence between the middle and
left hepatic veins is completely dissected out.
The last step is division of the right and middle hepatic
veins. For later division of the middle hepatic vein, we
have to ensure that its drainage into the IVC is completely
dissected out. We use the suction tip and the blunt grasper
below the middle hepatic vein to ensure that we can later
control it without difficulty.
We are now ready to clip and divide the middle hepatic
vein at its drainage into the IVC. Here the right trisegmentectomy specimen is completely dissected off the IVC.
Now we are dividing the middle hepatic vein. The last
structure that needs to be divided is the right hepatic vein
which we can see in the background. The drainage of the
right hepatic vein into the IVC is completely dissected out
and we can proceed now to staple divide it. The right
triangular ligament is divided in order to completely
mobilize the specimen. We inspect the transection margin
of the future liver remnant for any bleeding.
IMPORTANT POINTS
• Start by controlling the right portal pedicle and then
proceed to dissecting out the portal pedicle to segments
IVa and IVb.
• Dissecting out the segment IVa and IVb pedicle is greatly
facilitated by opening up the parenchyma widely along
the umbilical fissure.
• The left portal pedicle and left hepatic vein have to be
protected at all costs.
• Frequentuse of ultrasound during the parenchymal transection helps to identify and protect the left hepatic vein.
• Frequent use of ultrasound will also help to ensure that
you do not become lost during the parenchymal
transection.
Anatomy figures
Right trisegmentectomy 425
Figure v15.5 Critical anatomy for a right trisegmentectomy. After division of the RPP, including the RHA and the intermediate
branch of the HA, P4b and P4a are divided. This is performed by opening up the umbilical fissure. The LPP must be protected.
Figure v15.6 Relationship of portal structures and MHV. Notice the close relationship between the P4b and MHV.
426 Video 15
Figure v15.7 View along the parenchymal transection plane. After RPP, P4b and P4a have been controlled and the parenchymal
transection plane follows the LHV. At completion of the parenchyma transection, the MHV and RHV are divided. Often, the MHV
and LHV share a common drainage into the IVC. When dividing the MHV, the LHV drainage needs to be protected.
VIDEO 16
Posterior sectionectomy
Video duration 14 minutes 9 seconds
In this video, we will show you a posterior sectionectomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Ultrasound
• Dissection of the hepatocaval ligament
• Preparation of the Pringle maneuver in case it is needed
for control led staged conversion
• Dissection of the right posterior portal pedicle
• Parenchymal transection
• Important points.
This scheme demonstrates the port positioning
(Figure v16.1). In addition, we recommend tilting the
patient 45° to the left side.
A crucial step for this operation is intraoperative ultrasound. It is not only essential to rule out metastasis in the
future remnant liver but also to identify the branching
between right anterior and right posterior pedicles
(Figure v16.2 and Figure v16.3). We strongly recommend
identifying this image with the ultrasound in order to
avoid injury to the right anterior portal pedicle. On this
sequence, the hypoechoic lesion can be seen. Also, there
is a cyst in the left top corner of the image which we will
encounter during the parenchymal transection.
We perform the dissection of the hepatocaval ligament
early in the case. This allows for safe completion of the
parenchymal transection. For the dissection of the hepatocaval ligament, we displace the liver towards the left of
the patient. The most lateral trocar can be used for retraction of the liver. Here the IVC comes into view and this
Figure v16.1 This scheme demonstrates the port positioning. In addition, we recommend tilting the patient more than 45° to the left
side (so called modified French position).
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.
427
428 Video 16
Figure v16.2 It is critical to identify the branching between
RAPP and RPPP on ultrasound.
dissection is more safely done with scissors. Small short
hepatic branches can be controlled using the bipolar forceps. As more of the hepatocaval ligament is transected,
the liver becomes more mobile. This allows for safe transection of the superior and medial portion of the right
triangularligament. Laparoscopic posterior sectionectomy
has a not insignificant risk for bleeding. Therefore, it is
useful to be prepared to use the Pringle maneuver laparoscopically. This would allow for a safe and possibly
staged conversion; by staged, we mean that another
port or a hand port is placed to control the bleeding
laparoscopically. If this cannot be done with minimal
blood loss, immediate conversion is prudent. In order to
Figure v16.3 Here the branching of RAPP and RPPP is
identified. It is critical to preserve the RAPP while dividing the
RPPP.
have a good working condition in the porta, we retract the
liver with an endo-closure device superiorly.
The next step is opening the hepatoduodenal ligament
in order to expose the right posterior portal pedicle. Here
you can see a Glissonian approach in exposing the right
posterior portal pedicle. Gentle retraction on the nontightened umbilical tape aids in exposure. At this step, we
have dissected out the right posterior hepatic artery which
opens up the space to dissect out the right posterior portal
vein. We follow the right main portal pedicle until we find
the initial branching of the right posterior portal pedicle.
Here you can see the critical portion of the dissection
between the right anterior and right posterior portal
pedicle. You can see the right anterior portal pedicle
appearing in the background of the dissection. We will
pass a suture behind the right posterior portal pedicle with
a 5 mm dissector in order to traction it for clip placement.
Now the right posterior portal vein has been controlled.
The next step is to control the bile duct.
With all the inflow to the posterior sector controlled, we
can retract the liver more superiorly, which opens up the
hepatocaval space. Performing this dissection early will
allow for a safe landing zone of the parenchyma transection. Before beginning the parenchymal transection, we
divide the paracaval portion of the caudate lobe.
The last step of this operation is the parenchymal transection. The right hepatic vein defines the medial border of
the right posterior sectionectomy. We can also see the nice
demarcation line between right anterior and posterior
sectors. Using the gallbladder as a handle aids in the
parenchymal transection. The drainage vein of segment
VI is controlled using thermofusion. Here, we can safely
connect the parenchymal transection with the dissection
of the hepatocaval ligament. Using ultrasound as a guide,
we define the border between segments VII and VIII. At
this step, we identify a small simple cyst which we have
seen earlier on ultrasound. Here we continue the parenchymal transection plane along the line defined by the
right hepatic vein. Here, we expose the right hepatic vein
between segments V and VI and follow it superiorly. The
drainage vein to segment VI is controlledusing the bipolar
forceps as well as thermofusion. Once we reach the top
portion of our transection, we identify the drainage of the
right hepatic vein into the IVC using ultrasound. The
bipolar forceps is used for hemostasis along the transection
margin. Now the specimen is completely detached. At the
end, we perform a cholecystectomy and remove both the
specimen and the gallbladder using a retriever bag.
Соседние файлы в папке Библиотека им академика М.И. Перельмана