clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

SECTION 3

Liver

Pierre-Alian Clavien

Introduction

Pierre-Alain Clavien

Liver surgery was considered until the early 1980s as a “heroic” field of medicine associated with much blood loss, and high patient morbidity and mortality. With such a reputation only life-threatening conditions were usually referred for liver surgery. As surgeons acquired a better understanding of surgical anatomy and physiology, a better understanding of periand intraoperative management, and importantly formal training periods in this field, hepatic surgery began to enjoy rapid expansion and high credibility among colleagues and patients. Today, liver surgery is one of the most complex and successful areas of medicine with the availability of a variety of highly sophisticated procedures for many indications including complex liver resection or transplantation of only one part of the liver from a living donor.

The first chapter presents a comprehensive approach to the terminology of liver anatomy and resection (Brisbane 2000 terminology), according to an international effort including leaders from all continents. The next three chapters present available techniques for vascular exclusion, parenchyma dissection and the “hanging” maneuver, which may enable better exposure for anatomic resections. The hepatic surgeon must be familiar with all these techniques, which may be of great help in many difficult situations. Then, the focus turns to formal anatomic and non-anatomic liver resections, including laparoscopic approaches, which are gaining increasing popularity. As liver resection is often not possible due to local difficult situations (poor liver reserve or location of a tumor) or poor general condition of the patient, alternative techniques

are presented including cryosurgery, radiofrequency ablation and selective intra-arterial chemotherapy. Benign and infectious cysts require particular strategies, which are well covered in two separate chapters. A chapter also comprehensively covers the available strategies for liver trauma in the modern area of “damage control injury.” The last

six chapters cover various aspects of liver transplantation from organ procurement, to partial living or cadaveric orthotopic liver transplantation, as well as auxiliary liver transplantation.

While there is no substitute for experience in performing complex surgical procedures, we hope that this section, prepared by worldwide experts, will clarify standards and limitations for surgeons in performing hepatic surgery.

Terminology of Liver Anatomy and Resections:

The Brisbane 2000 Terminology

Steven M. Strasberg

In 1998 at its meeting in Berne, Switzerland, the Scientific Committee of the International Hepato-Pancreato-Biliary Association (IHPBA) established a Terminology Committee to deal with the confusion in terminology of hepatic anatomy and liver resections (see below: members of the committee). The recommendations of the Terminology Committee were presented to the Scientific Committee at the biannual meeting of the IHPBA in Brisbane, Australia, in 2000. These recommendations, consisting of a new terminology termed The Brisbane 2000 Terminology of Liver Anatomy and Resections, were unanimously accepted by the Scientific Committee of the IHPBA and were presented to the membership as the official terminology of the IHPBA. The terminology was published in the official journal of the IHPBA in 2000.

The terminology shown below is based on the hepatic artery and bile duct (Figures 1–3). A terminology based on the division of the portal vein was added as an addendum.

The terminology is presented as a set of four figures. The liver is divided in the tables into successive orders. The following notes serve as a guide to the tables.

Note 1

Couinaud segments are indicated in short form as Sg1–9 (e.g., Sg6).

Comment: Sg is chosen rather than S to avoid confusion of segment with section or sector. Arabic numerals are chosen rather than Roman numerals because many nonWestern nations do not use Roman numerals.

Note 2

Anatomical and surgical terms are underlined. Explanatory terms and notes within the figures are in italics.

Note 3

Wherever the word “OR” (uppercase, bold) appears in the table it indicates equally acceptable terminology; e.g.,“right hemiliver” OR “right liver.” The choice is that of the user. Wherever the word “or” (lowercase, bold) appears in the table or these notes it indicates that the first choice is preferred but that the second is acceptable; e.g.,“right trisectionectomy” or “extended right hepatectomy.” The choice is up to the user but the first term is the preferred term. The reason in this case is as follows. As some use the adjective “extended” to indicate any degree of extension of a resection over the midplane, which in some cases is less than a whole section, the terms in the table containing the word “extended,” while acceptable, are less preferred.

314 SECTION 3 Liver

Note 4

When segment 1 is resected as part of a procedure, it should be stated as in the following example: “left hemihepatectomy with resection of segment 1” or “left hemihepatectomy extended to segment 1.”

Note 5

It is always correct to refer to any resection by its segments. For instance,“right hepatectomy” and “resection Sgs 5–8” are equally acceptable.“Left lateral sectionectomy” and “resection Sgs 2, 3” are equally acceptable.

Reference

Terminology Committee of the International Hepato-Pancreato-Biliary Association: SM Strasberg (USA), J Belghiti (France), P-A Clavien (Switzerland), E Gadzijev (Slovenia), JO Garden (UK), W-Y Lau (China), M Makuuchi (Japan), and RW Strong (Australia).

The Brisbane 2000 Terminology of Liver Anatomy and Resections. HPB 2:333–339, 2000

Border or watershed: The border or watershed of the first order division which separates the two hemilivers is a plane which intersects the gallbladder fossa and the fossa for the IVC and is called the “midplane of the liver”.

Fig 1. Nomenclature for first order division anatomy and resections

Extended Left Hepatectomy

or

Extended Left Hemihepatectomy

(stipulate +/-segment 1)

Border or watershed: The borders or watersheds of the sections are planes referred to as the right and left intersectional planes. The left intersectional plane passes through the umbilical fissure and the attachment of the falciform ligament. There is no surface marking of the right intersectional plane.

Fig 2. Nomenclature for second order division anatomy and resections, based on bile ducts and hepatic artery

For clarity Sg.1 and 9 are not shown. It is also acceptable to refer to ANY resection by its third-order segments, eg. right hemihepatectomy can also be called resection Sg 5–8.

Border or watershed: The borders or watersheds of the segments are planes referred to as intersegmental planes.

Fig 3. Nomenclature for third order division anatomy and resections

Techniques of Liver Parenchyma Dissection

Mickaël Lesurtel, Pierre-Alain Clavien

Parenchyma dissection of the liver may cause complications including blood loss, hematoma, infection, bile leakage and liver failure. Various surgical techniques have been developed for careful and safe dissection of the liver parenchyma to prevent intraoperative and postoperative complications.

The aim of this chapter is to give an overview of the techniques and devices frequently used to perform parenchyma dissection of the liver, including:

■Kelly clamp and bipolar forceps

■Water jet dissection

■Ultrasonic dissection

■Ultrasound cutting

■Dissecting sealer

Preparation of Parenchyma Dissection

The liver capsule is incised with diathermy on the resection line. For a better exposure, two stay sutures (2-0 silk) can be placed at the inferior margin of the liver, one on each side of the resection line. These stay sutures are used to lift up the liver and the resection line. Care should be taken not to pull and tear the liver parenchyma, leading to bleeding. To prevent unnecessary liver ischemia, the Pringle maneuver for continuous or intermittent inflow occlusion is applied individually depending on the intraoperative surgical

situation. Indeed, except for the Kelly clamp, the other techniques were developed to avoid use of the Pringle maneuver and to minimize risk of liver ischemia.

Water Jet Dissection (Helix Hydro-Jet, Erbe)

With this device the liver parenchyma is dissected by a jet of water (A-1). Saline is pressurized by high pressure pump and is conducted by a high pressure hose to the nozzle. Here the pressure is converted into kinetic energy. For liver parenchyma, pressures of 30–50bar should be used. The soft liver tissue is washed off the more resistant vessels and bile ducts (A-2). The applicator should be used in direct contact with the tissue and moved like a paintbrush. It can be used in combination with suction and with an electrosurgical unit. Vessels and bile ducts are isolated and can be secured using bipolar forceps, clips or ligatures as with the Kelly clamp. They can then be transected under controlled conditions.

A-1

A-2