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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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Mesohepatectomy 439
V, and VIII are almost completely mobile and the middle
hepatic vein has already been clipped. The middle hepatic
vein is now divided with scissors. Towards the end of the
dissection, a branch from the middle hepatic vein to
segment VIII is clipped and divided. The central liver is
now detached completely from the remaining liver. On
this view of the completed dissection, the respiratory
variations of the right hepatic vein indicate the exact
anatomical border to segment VI.
Open or laparoscopic, a total mesohepatectomy is technically a very challenging procedure. We have shown that
a total laparoscopic approach is technically feasible and
the dissection at the dome of the liver might be aided by a
laparoscopic view. Intraoperative ultrasound or
Anatomy figures
indocyanine green staining is helpful in defining the
anatomical landmarks of this operation. In order to complete this operation safely, advanced laparoscopic skills
and an excellent understanding of the hepatic anatomy
are essential.
Acknowledgments
Laparoscopic parenchymal-sparing liver resection of
lesions in the central segments: feasible, safe, and effective, Claudius Conrad. Surg Endosc. 2015 Aug;29(8):2410-7.
doi: 10.1007/s00464-014-3924-9. Epub 2014 Nov 13. Source:
Conrad 2014. Reproduced with permission of Springer.
Figure v18.1 Critical anatomy for a mesohepatectomy. During a central hepatectomy, liver segments IV, V, and VIII are removed.
The MHV is removed with the specimen. The lateral border is RHV and LPP. The medial border is LHV and LPP. A critical portal
structure is the RAAP, which is removed at the time of surgery. It is important to protect the RPPP or P6 and P7. This patient has a
trifurcation of RAPP, P6, and P7. On the left side, the intermediate branch of the left hepatic artery (A4) is taken as well as portal
branches to segment IV.
440 Video 18
Figure v18.2 Caudal view for a mesohepatectomy. A critical structure to identify during the surgery is the RPP and its division into
RAPP and RPPP. This patient has a trifurcation of RAPP, P6, and P7. The PP to segment IV usually consists of several branches that
need to be controlled.
Figure v18.3 Lateral view. The RHV constitutes the lateral margin. P6 and P7 need to be preserved.
Mesohepatectomy 441
Figure v18.4 View from cranial to caudal. The MHV will be divided and resected with the specimen.
Figure v18.5 Angled cranial to caudal view. Preservation of RHV and LHV is critical to preserve outflow to the future liver remnant.
Laparoscopic living donor liver transplantation
VIDEO 19
Living donor left lateral sectionectomy
Video duration 8 minutes 17 seconds
In this video, we demonstrate a living donor left lateral
sectionectomy. Living donor liver transplantation in
general is high-risk surgery. Laparoscopic graft harvest
adds a significant level of complexity to the case. Only
an expert transplant team with significant experience
in living donor liver transplantation, parenchymal
transection, and laparoscopic liver surgery should
attempt such a case in patients who have been very
well selected.
OUTLINE
The video has the following outline:
• Donor information
• Port positioning
• Liver mobilization
• Portal dissection
• Left bile duct division and parenchymal transection
• Graft extraction
• Important points.
The living donor is a 32-year-old man. He does not have
any vascular variations. However, segments II and III
drain independently from segment IV into the common
bile duct (Figure v19.1). This scheme demonstrates the
port positioning (Figure v19.2). It is advisable to mobilize
the liver early (Figure v19.3). This can limit the incision in
case of nonprogression and will minimize warm ischemia
time in case of urgent conversion.
The falciform, coronary, and left triangular ligaments
and ligament of Arantius are taken down and the hilar
fissure opened. The parenchymal bridge between segments II and IV is divided.
The next step is the portal dissection. The porta is
approached from the left side. First, the hepatic artery
Figure v19.1 It is critical to have an excellent understanding of
the vascular and biliary anatomy. Segments II and III drain
independently from segment IV into the common bile duct.
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.
442
Living donor left lateral sectionectomy 443
Figure v19.2 This scheme demonstrates the port positioning for a living donor left lateral sectionectomy graft harvest.
and then the portal vein are dissected out. Once the
hepatic artery has been encircled, the left portal vein is
dissected out. Here, the portal vein is being dissected out
(Figure v19.4). A caudate branch is dissected out and
controlled with a locking clip (Figure v19.5). The portal
vein is dissected out and encircled with umbilical tape.
The left branch of the portal vein is dissected out and
encircled with scissors.
Figure v19.3 It is advisable to mobilize the liver at an early
stage of the operation. In case of nonprogression or a
complication, graft harvest can be expedited.
The next step is division of the left bile duct and the
parenchymal transection. The liver capsule is opened
along the falciform ligament (Figure v19.6). Then the
transection is deepened and, in an open book approach,
the left bile duct is approached. Portal branches to segment IV are controlled with locking clips (Figure v19.7).
The V4 drainage vein is dissected out, clipped, and
divided. The left lateral bile duct is exposed with an
Figure v19.4 Once the HA has been encircled, the LPV is
dissected out.
444 Video 19
Figure v19.5 A caudate branch is dissected out and controlled
with a locking clip.
Figure v19.6 The liver capsule is opened along the falciform
ligament.
ultrasonic aspirator device (Figure v19.8). The bile duct is
divided with laparoscopic scissors. The staying side of the
bile duct is clipped (Figure v19.9).
We then proceed with the parenchymal transection.
Bile duct division facilitates the parenchymal division,
opening the transection plane further. As we approach
the IVC, the left hepatic vein is dissected out and will be
encircled with umbilical tape. This is the final step prior to
graft extraction (Figure v19.10). Before division of inflow
and outflow, we perform a Pfannenstiel incision through
Figure v19.7 Portal branches to segment IV are controlled with
locking clips.
Figure v19.8 The bile duct is divided with laparoscopic scissors.
Figure v19.9 The staying side of the bile duct is clipped.
Figure v19.10 This is the final step prior to graft extraction.
Before division of inflow and outflow, a Pfannenstiel incision is
performed through which we bring in an endoscopic retrieval bag.
Anatomy figures
Living donor left lateral sectionectomy 445
which we bring in an endoscopic retrieval bag. With
division of the left hepatic artery and portal vein, the
warm ischemia time begins. After stapling off the left
portal vein, it is divided with scissors. The left hepatic vein
is staple divided. The specimen is brought out through the
Pfannenstiel incision.
IMPORTANT POINTS
• Only experienced liver transplant surgeons and laparoscopists should perform this operation.
• Excellent understanding of donor portal and liver anatomy, especially biliary variations, is crucial.
• Mobilize the liver early.
• Protect remaining portal structures.
• Prepare for graft extraction early to minimize warm
ischemia time.
Figure v19.11 Relevant anatomy for laparoscopic living donor left lateral sectionectomy. For living donor liver transplantation, it is
crucial to have an excellent understanding of donor anatomy. In addition to vascular anomalies, variations of the biliary system
need to be identified preoperatively and anticipated during the operation to avoid injury.
446 Video 19
Figure v19.12 Initial view for laparoscopic living donor left lateral sectionectomy. It is key to avoid injury to the remaining structures
in the porta. In the video, the parenchymal transection is performed medial to the branching of P3 and P2.
Figure v19.13 Cranial to caudal view. The LHV needs to be protected until the end of the surgery. It is staple divided at the drainage
into the IVC.
SECTION 2 Pancreas
Laparoscopic splenic resection
VIDEO 20
Total splenectomy
Video duration 7 minutes 10 seconds
In this video, we will show you a total splenectomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Controlling the hilar vessels and short gastric vessels
• Splenic mobilization
• Specimen extraction
• Important points.
Figure v20.1 demonstrates the port positioning. The
positioning might have to be modified depending on the
size of the specimen. The first step, particularly when
removing a very large spleen, should be controlling the
hilar vessels.
We gently retract the spleen laterally, and open up
the splenorenal ligament. At this step, the tail of the
pancreas can be easily damaged. Once the splenic hilar
vessels have been completely uncovered, we clip the
individual branches using locking clips. Adhesions to
the spleen can cause capsular tears during mobiliza-
Figure v20.1 The patient is in the French position with slight left decubitus positioning. The port placement might have to be
modified depending on the size of the specimen.
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.
447
448 Video 20
tion; therefore, any adhesions should be divided early
with gentle traction on the specimen. The splenic
artery and venous branches of the middle portion of
the spleen ar e controlled here. The next step is to
control and divide the short gastric vessels. The left
lateral section of the liver is retracted superiorly. Here
you can see the division of adhesions between the
spleen and stomach. Next, we open up the gas trosplenic ligament and control and divide the short
gastric vessels.
After the initial step of the dissection of gastrosplenic
ligament, the superior pole vessels can be identified
and dissected out. Note the closeness of the pancreas to
the superior pole vessels on this image. Now all of the
hilar vessels have been controlled. With gentle traction
superiorly, adhesions t o the re troper itone um are
divided. The next step of the operation is splenic
mobilization. Especially during inferior mobilization
of the spleen, we need to be careful not to injure the
splenic fl exure of the colon.
The last step is specimen extraction. It is possible to
avoid using an additional port by placing an endoscopic
retrieval bag directly through the abdominal wall. We
need to be careful not to rupture the spleen when placing
it in the endoscopic retrieval bag
IMPORTANT POINTS
• Place the ports high enough in the left upper quadrant
and far enough to the left. However, the final port
position should be determined depending on the size
of the specimen.
• Avoid minor tears in the splenic parenchyma or capsule,
which can easily happen during retraction when the
spleen is fixed as a result of adhesions.
• Avoid a pancreatic tail injury when dissecting out the
hilar vessels .
• Gentle retraction avoids rupturing the spleen or bleeding
at the end of the case.
• Consider placing the retrieval bag directly through the
abdominal wall through a Pfannenstiel incision, for
example, in order to avoid an additional port.
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