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Anatomy figures
Posterior sectionectomy 429
IMPORTANT POINTS
• It is important to have a good understanding of the
branching between the right anterior and right posterior
portal pedicles from preoperative imaging and intraoperative ultrasound.
• Perform the dissection of the hepatocaval ligament early.
• Umbilical tape around the porta can be used for a lapa-
roscopic Pringle maneuver.
• The parenchymal transection should be guided by the
right hepatic vein.
Figure v16.4 Critical anatomy for a posterior sectionectomy. During the dissection, the RAPP is preserved while P6 and P7 are taken.
In this case, the patient has a trifurcation and therefore P6 and P7 should be taken individually.
430 Video 16
Figure v16.5 Relationship of portal structures and RHV. After controlling P6 and P7, the parenchymal transection follows the RHV.
Notice its closeness to the RAPP, which should be preserved.
Figure v16.6 View along the right anterior fissure. V6 can be followed to the drainage into the RHV to find its intraparenchymal
location. While the RHV guides the parenchymal transection, injury to V7 at the completion of the parenchymal transection must be
avoided. An RIHV should be identified on preoperative imaging to avoid injury.
VIDEO 17
Hilar lymphadenectomy (with right
hepatectomy and caudate lobectomy for
Klatskin tumor)
Video duration 17 minutes 3 seconds
In this video, we demonstrate a hilar lymphadenectomy
with right hepatectomy and caudate lobectomy for Klatskin tumor.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Hilar lymph node dissection
• Right hepatectomy with resection of segment I
• Hepaticoduodenostomy
• Important points.
The port positioning is similar to right hepatectomy and
we choose position 1 for the portal dissection and position
2 later for the parenchymal transection phase (Figure
v17.1 and Figure v17.2).
Next, we would like to show you the hilar lymph node
dissection. This is an overview of the lower 12 mm port
site. We begin by dissecting out the left portal structures in
order to secure them to avoid injury. The first structure
we dissect out is the left hepatic artery which is located
close to lymph node station 12a. We secure the left
hepatic artery with a vessel loop. After the left hepatic
artery has been secured, we dissect out the left portal vein
Figure v17.1 The port positioning is similar to right hepatectomy and we choose position 1 for the portal dissection.
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.
431
432 Video 17
Figure v17.2 This port positioning is used later in the parenchymal transection and for controlling the hepatic venous confluence.
branch. After securing the left hepatic artery and vein, we
can begin the lymph node dissection.
As mentioned earlier, lymph node station 12a is located
close to the left hepatic artery (Figure v17.3). We are
following the hepatic artery proximally in order to dissect
lymph node station 12a. After opening up the hepatoduodenal ligament, we aim to dissect the common bile
duct. Using indocyanine green and an infrared camera
Figure v17.3 Lymph node station 12a is located close to the LHA.
Hilar lymphadenectomy (with right hepatectomy and caudate lobectomy for Klatskin tumor) 433
Figure v17.4 Using indocyanine green and an infrared camera helps us to identify the bile duct in the porta. You can see the bile
duct and lymph node station 12b, which is right lateral to the common bile duct.
helps us to identify the bile duct in the porta. You can see
the bile duct and lymph node station 12b which is right
lateral to the common bile duct (Figure v17.4).
Ventral to the common bile duct, between the border of
theduodenumandthecommonbileduct,islymphnode
station 5. In order to gain more mobility for our dissection,
we are kocherizing the first portion of the duodenum. As we
continue our kocherization, the IVC comes into view (Figure v17.5). Next we dissect lymph node stations 12b and 5.
The next step is dissecting the bile duct off the portal
vein. Now we are proceeding to transect the bile duct. As
we open up the common bile duct, the plastic stent comes
into view. Next we remove the plastic stent; at this step we
routinely perform cultures. The proximal bile duct is sent
for frozen section analysis. The proximal bile duct is closed
with a 4.0 PDS suture. Now we are mobilizing the common bile duct off the main portal vein. As we proceed
with the portal dissection, the right hepatic artery comes
into view which will be clipped and divided. We are
proceeding with our lymph node dissection and are
now dissecting lymph node station 12p (Figure v17.6).
Stripping all the lymph node tissue of the porta will
facilitate exposure of the bifurcation of the portal vein.
Now that all lymphatic tissue has been stripped off the
porta and the bifurcation of the portal vein has been
exposed, we can proceed to performing the right hepatectomy with caudate lobectomy.
Figure v17.5 As we continue our kocherization, the IVC comes
into view.
434 Video 17
Figure v17.6 We are proceeding with our lymph node
dissection and are now dissecting lymph node station 12p.
The first step will be lowering the hilar plate; this
usually leads to some minor bleeding. In order to maintain excellent working conditions in the porta, we will
stop this bleeding with bipolar forceps and a hemostatic
agent containing regenerated oxidized cellulose. This
hemostatic agent is placed into the crevice. Lowering
the hilar plate will help us to expose the left bile duct
which we can see here. At this step we are opening up the
left bile duct (Figure v17.7). We are exposing the left
portal vein a bit more. Here we are beginning the parenchymal transection of the caudate lobe (Figure v17.8).
Figure v17.8 Here we are beginning the parenchymal
transection of the caudate lobe.
Beginning the parenchymal transection of the caudate
lobe at this step will aid with mobility and transecting the
right portal structures.
Now that the right portal vein has been completely dissected out, it can be clipped and divided. At this step, the left
bile duct canbe transectedcompletely. The bile duct margin is
sent for frozen section analysis. Now we can deepen our
parenchymal transection along the middle hepatic vein. At
this step, we are exposing thedrainage vein to segment V and
we will later use the middle hepatic vein as a landmark for
our parenchymal transection (Figure v17.9).
Figure v17.7 Lowering the hilar plate will help us to expose the
left bile duct, which we can see here. At this step we are
opening up the left bile duct.
Figure v17.9 At this step, we are exposing the drainage vein to
segment V and we will later use the MHV as a landmark for
our parenchymal transection.
Hilar lymphadenectomy (with right hepatectomy and caudate lobectomy for Klatskin tumor) 435
We are now following the demarcation line between
segments IVb and V; the gallbladder helps with retraction.
Having connected the two parenchymal transection lines,
we can clip and divide the drainage vein to segment V and
continue to follow the middle hepatic vein. Here we have
followed the middle hepatic vein all the way towards its
drainage into the IVC. As the right hepatic vein is completely exposed, it can be staple divided. As always, we
have a vascular clamp ready in case of stapler misfiring.
The specimen is completely removed by detaching it from
the triangular ligament. It will be removed from the
abdomen using an endoscopic retrieval bag.
The last step of the operation is the bilioenteric anastomosis. We will be using a hepaticoduodenostomy. The
advantage of hepaticoduodenostomy is continued access
to the anastomosis via an endoscopic route. The first step is a
small enterotomy in the duodenum. After the enterotomy
has been made, we perform a continuously running anastomosis using a monofilament suture. If there is any
Anatomy figures
concern about the tension at the anastomosis at this step, the
kocherization maneuver should be widened. After initial
anchoring stiches, the back wall is constructed first. It is
important to avoid back walling the anastomosis, so good
visualization into the lumen of the small bile duct is crucial.
The magnified view of the laparoscopic camera aids in
constructing the small anastomosis. After constructing
the back wall, the anterior wall is constructed. After final
inspection of the operating site, we complete the case.
IMPORTANT POINTS
• Be sure you know the lymph node station to dissect.
• Early division of the bile duct facilitates exposure.
• Ensure that there is only minimal bleeding at the porta
for optimal dissection and visualization.
• Remove the caudate lobe for oncologi cal purposes and
optimize the trocar p osition for suturing the
hepaticoduodenostomy.
Figure v17.10 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.
436 Video 17
Figure v17.11 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.
Figure v17.12 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 nearcompletion of the case.
Hilar lymphadenectomy (with right hepatectomy and caudate lobectomy for Klatskin tumor) 437
Figure v17.13 Critical anatomy of the caudate lobe. The caudate lobe extends between the IVC and PP up to the hepatic venous
confluence. Venous drainage is from direct branches from IVC. Direct branches from left and RPP supply segment I.
Figure v17.14 Relationship of portal structures to segment I. The direct branches from the LPP and RPP can cause
significant bleeding. They are relevant not only when performing a caudate lobectomy but also when dissecting out the
main PP for other types of liver resection.
VIDEO 18
Mesohepatectomy
Video duration 5 minutes 48 seconds
In this video we will demonstrate a total laparoscopic
mesohepatectomy.
OUTLINE
The operative tactics are as follows:
• Dissection of the coronary ligament
• Parenchymal dissection along the falciform ligament
• Division of the right anterior sectoral pedicle
• Parenchymal dissection along the right portal fissure
• Division of the middle hepatic vein.
At completion of the case, the remaining liver segments
will be I, II, III, VI, and VII. At the end of the case, we will
have divided hepatic and portal venous branches to
segments IVb and IVa, including the medial segmental
branch of the left hepatic artery. We will have stapled off
the right anterior sectoral branch of the right portal
pedicle and we will divide portal and hepatic venous
branches to segments V and VIII, including the middle
hepatic vein at the end.
This scheme demonstrates the anatomy after a mesohepatectomy. The numbering indicates the operative
tactics.
Let’s start with dissection of the coronary ligament. The
falciform ligament leading up to the coronary ligament is
divided. As we approach the suprahepatic IVC, we will
switch to dissection with laparoscopic scissors. Next, we
demonstrate parenchymal dissection between the left
lateral and the left medial sector along the falciform
ligament. The dissection is begun to the right of the
ligamentum teres. As we go deeper into the parenchyma,
the first branches we encounter are the portal branches to
segment IVb. These branches will be controlled with
locking clips and divided. The parenchymal dissection
is continued along the left border of segment IVa. This
is continued until the anterior surface of the IVC is
reached. Again, as we are approaching the IVC, laparoscopic scissors will be used for the dissection.
So far, we have compl etely defined the left border of
our laparoscopic mesohepatectomy. We will move back
now to the porta and staple and divide the right anterior
sectoral pedicle. For the division of the right anterior
sectoral pedicle, we elevate the liver using the gallbladder
as a handle. This is the view of the porta along the
hepatoduodenum ligament. The next step will be a Glissonian approach through dissection of the anterior sectoral branch of the right porta pedicle. After completion of
the dissection, a vascular clamp is placed on the anterior
sectoral pedicle. The resulting ischemia helps to define the
border between segments V and VI. Using ultrasound, we
confirm that the posterior sectoral pedicle is intact. We
now staple and divide the anterior sectoral pedicle.
The next step of the operation is parenchymal dissection along the right portal fissure. Using systemically
administered indocyanine green and a laparoscopic
near infrared camera, we confirm the border between
V and VI and preservation of the posterior sectoral branch.
The parenchymal dissection is now continued along the
right portal fissure. We are now reaching the border
between segments VIII and VI and we are again using
ultrasound to define the right hepatic vein as a landmark.
With this information, the border between segments VII
and VIII can be safely divided.
The final step of the operation is division of the middle
hepatic vein. On this image, the central liver segments IV,
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.
438
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