clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

A right cadaveric graft is ideally split in situ. If performed ex situ the median hepatic vein should be preserved on the graft side in order to avoid congestion and bleeding of the graft cut surface at the time of revascularization. The graft includes (A):

■Segments 5–8

■The right branch of the hepatic artery

■The right branch of the portal vein

■The right hepatic duct(s) along with the confluence and the common hepatic duct

■The right and median hepatic vein both attached to the retrohepatic inferior vena cava. Since the left hepatic vein has been divided by retaining a narrow patch from the common trunk, the defect has to be closed by transverse suture

In a right living donor graft (see also chapter on living donor liver transplantation), the retrohepatic vena cava, median hepatic vein, and extrahepatic biliary tract must stay on the donor side. Consequently, the graft includes (B):

■Segments 5–8

■The right branch(es) of the hepatic artery

■The right branch(es) of the portal vein

■The right hepatic duct(s)

■The right hepatic vein

uous 4-0 Prolene suture is performed. While the posterior layer is stitched, the graft is flushed with Ringer’s or 4% albumin solution.

Note: Implantation of a Right Liver Graft from a Living Donor

The right liver graft from a living donor differs from the cadaveric graft implantation at step 1 only. Since the IVC has been left to the donor, the graft’s right hepatic vein is implanted in an end-to-side fashion to the recipient IVC

■Never start the recipient procedure before the split procedure has been shown to be anatomically feasible.

■Two teams need to work simultaneously, headed by two experienced liver surgeons.

■Never start before a biopsy of the recipient liver has been performed. Fibrosis or cirrhosis would lead to perform orthotopic rather than auxiliary liver transplantation.

SECTION 4

Biliary Tract and Gallbladder

Yuman Fong

Introduction

Yuman Fong

Diseases of the biliary tract represent some of the most challenging problems for the surgeon. Gallstone disease is a common ailment, for which surgical treatment has been recorded since ancient times. In the following chapters, authorities in the field will describe the often performed procedures of cholecystectomy and common bile duct exploration. Versions of these procedures performed as open surgery will

be presented as well as the laparoscopic versions, which are arguably one of the major advances in general surgery in the past two decades. Surgery to fix the most feared complication from treatment of gallstone disease, namely bile duct injury, will also be presented.

We will then proceed to discussions of treatments for diseases that are much rarer: congenital malformations of the biliary tree and malignancies of the proximal/mid bile duct and gallbladder. Resections of these conditions are extremely challenging from a technical perspective. The principles, operative conduct, and “tricks of the senior surgeon” are presented by accepted masters of this trade. Distal bile duct problems will be presented in the chapters on pancreatic resection.

Finally, palliative bypasses for obstructions of the biliary tree will be presented. These chapters will describe the general approach to performing a facile biliary-enteric anastamosis, as well as methods of specific bypass procedures such as a choledochoduodenostomy or a hepaticojejunostomy. Even though biliary stent placement by endoscopic or percutaneous routes is widely used for patients who have clearly unresectable malignancies, for patients with benign disease or with disease found unresectable at surgery, such bypasses offer durable palliation with little added morbidity over the surgical exploration.

Laparoscopic Cholecystectomy, Open Cholecystectomy

and Cholecystostomy

George A. Fielding

Laparoscopic Cholecystectomy

Mouret performed the first laparoscopic cholecystectomy in Lyon in 1988, and the first written report was by Dubois in 1989. Reddick popularized the procedure in the United States in 1990.

Indications and Contraindications

Preoperative Investigation and Preparation for the Procedure

Preoperative investigations include liver function tests and typically an ultrasound examination. If the laparoscopic cholecystectomy is being performed for acalculous cholecystitis, patients may have had nuclear studies to assess gallbladder function.

If there is the suspicion of gallbladder cancer or big polyps, a CT scan is required. There is no place for routine preoperative endoscopic retrograde cholangio-

pancreatography (ERCP) in laparoscopic cholecystectomy.

The patient should have prophylactic antibiotics on induction and appropriate anti-thromboembolic measures.

Typically there is no requirement for invasive anesthetic monitoring.

Patients are placed supine, legs together with a slight reverse Trendelenburg position. There is little to gain by using a steep reverse Trendelenburg position.

Safe access:

Open insertion of a Hasson cannula through a transumbilical incision. Eversion of the umbilicus creates access via the gap in the linea alba at the base of the umbilicus.

The Hasson cannula can be sat directly in the peritoneal cavity. There is no need for stay sutures nor to suture the port in place. A 30° telescope is used; insufflation pressures are set at 15mmHg. Placement of other access parts is as shown in the figure.