clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Complications

These are the same as for right hemihepatectomy, the most common being:

Tricks of the Senior Surgeon

■In performing the hilar dissection, start on the right lateral aspect when identifying the right portal vein and hepatic artery. This avoids excessive dissection and skeletonization of the right hepatic duct and bile duct.

■Identification of the biliary anatomy by intraoperative cholangiography should be performed early in the operation. A radiopaque metal clip or small bulldog should be used to mark the area of the right hepatic duct during the cholangiogram. An atraumatic bulldog can be placed on the distal bile duct to avoid passage of contrast into the lower bile duct.

■Marking the pathway of the middle hepatic vein by intraoperative ultrasound helps decide the parenchymal transection line, which should be 1cm to the right of the middle hepatic vein.

■Central venous pressure should be maintained low by anesthesia as it helps to reduce blood loss.

■The hanging maneuver makes the parenchymal dissection easier, particularly in the last part.

The lateral segment is rotated to the right, and the ligamentum venosum is encircled, ligated and divided near the inferior vena cava (A). The connective tissue is detached from the superior aspect of the Spigelius lobe to expose the left side of the inferior vena cava as well as the posterior surface of the left hepatic vein (B).

The serous membrane on the ventral aspect of the hepatoduodenal ligament is detached at the level of the cystic duct and the hepatic arteries are identified. The left and middle hepatic arteries are dissected out at the hepatic hilum up to the bifurcation of the right and left hepatic artery (A). The middle hepatic artery can be cut off when it is clearly smaller than the left hepatic artery.

When the anterior aspect of the hepatoduodenal ligament is separated, the common bile duct can be identified. After the left hepatic duct is identified a small vascular clip is placed to the predetermined cut line on the bile duct. A 24-G puncture needle with

a trocar is inserted into the common bile duct and cholangiography is obtained (B). In some cases, the left hepatic duct may be located inside the hepatic parenchyma

and it is difficult to be identified. In such cases, it can be identified during the dissection of the parenchyma.

The cholangiography provides information of the biliary anatomy and allows to determine the dissection line of the left hepatic duct (C). After the cholangiography, the catheter is removed and the puncture site is closed by a 6-0 Prolene stitch. The left hepatic duct can now be encircled at the point of predetermined cut line (D).

A

starting from the right side of the middle hepatic vein to the liver bed of the gallbladder. The location of the middle hepatic vein is confirmed with ultrasonography before parenchymal dissection. The cutting line on the posterior side starts from the liver bed and reaches to the right side of the predetermined cutting point of the left hepatic duct.

The parenchymal dissection follows the sagittal plane from the top surface until the level of the middle hepatic vein (line 1). When the entire middle hepatic vein is included in the graft side, the direction of the dissection is changed in an oblique plane (line 2). To prevent injury of the middle hepatic vein and its small venous branches, some parenchymal tissue should be left on the middle hepatic vein. After dissection of the left hepatic duct, the direction is changed toward the space between the lateral segment and the caudate lobe (line 3). The curved DeBarkey forceps are useful as a guide as in left lateral segmentectomy.

After accomplishing the parenchymal dissection, the donor is systemically administered 1,000units of heparin. The left hepatic artery is clamped with two clips and divided. The anterior wall of the left portal vein is opened and the tip of the catheter for perfusion is inserted into the lumen. Subsequently the left portal vein is divided (A-1). The left hepatic veins is clamped with a spoon clamp and divided. Immediately after dividing the left hepatic vein (A-2), the graft is perfused with preservation solution [histidine-tryptophan-ketoglutarate (HTK) or University of Wisconsin [UW] solution] (A-3). The artery is not rinsed. The hepatic duct is washed with the solution.

The donor hepatic vein is closed with 5-0 Prolene, the donor portal vein with 6-0 Prolene and the donor hepatic artery is closed with 6-0 Prolene suture or 3-0 silk double ligation.

If the left hepatic vein has a septum close to the orifice, it is cut sharply with scissors and sutured to make a single orifice with enough length of the cuff (B).

to provide adequate length and enough options for arterial reconstruction. In children suffering from biliary atresia the hepatic artery frequently has a larger size than expected. In this particular situation, dissection of the hepatic artery inside the liver

of the recipient is required to adjust the size of hepatic artery between the graft and the recipient. Double ties on the proximal side of the hepatic arteries are recommended to prevent injury to the intima. The first ligation is done loosely just to occlude the lumen with 4-0 silk. The second tie is placed tightly just distal to the first.

The portal pedicle is elongated by dissecting the tissue around the portal vein up to the confluence of the superior mesenteric and splenic vein. Removal of the lymph nodes around the portal vein is helpful as it provides the desired smooth curve of the portal vein. The portal flow should be confirmed by unclamping the portal vein. The left gastric vein is divided routinely to increase portal flow.