clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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Techniques of Vascular Exclusion and Caval Resection |
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Reconstruction of Vena Cava
This technique is an alternative to associated cava reconstruction. It restores liver perfusion while working on the vena cava.
STEP 1
Open hepatic outflow by releasing the clamp on the suprahepatic vena cava.
Clamp the vena cava again below the hepatic veins.
STEP 2
Open hepatic inflow by releasing the tourniquet on the hepatoduodenal ligament.
Now the retrohepatic cava is occluded while the liver is perfused.
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SECTION 3 |
Liver |
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STEP 3
The retrohepatic vena cava can now be resected. Reconstruction is accomplished with a Gore-tex interposition graft in an end-to-end fashion. Then release the cava clamp and the tourniquet on the lower cava.
Tricks of the Senior Surgeon
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Hanging Maneuver for Anatomic Hemihepatectomy |
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(Including Living-Donor Liver Transplantation) |
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Jacques Belghiti, Olivier Scatton |
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In addition to the conventional approach described for liver resection in the chapters on |
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conventional hepatectomies, the hanging maneuver has gained wide acceptance among |
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liver surgeons. Depending on the situation, it can be used for resective liver surgery or |
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for living related liver donation. |
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STEP 1 |
Suprahepatic preparation |
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After the hilar preparation, the anterior leaf of the coronary ligament and the anterior |
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part of the right triangular ligament are dissected to expose the left side of the right |
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hepatic vein. The space between the right and the median hepatic vein and the supra- |
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hepatic vena cava is freed by means of a vascular clamp. |
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SECTION 3 |
Liver |
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STEP 2 |
Infrahepatic preparation of the vena cava |
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Starting right above the origin of the right renal vein, the space between the vena cava and the liver is freed. In order to prepare the tunnel where the tape will be passed, one or two short veins to the caudate lobe need to be ligated. The tunnel is now prepared by carefully opening the avascular plane between the liver and the anterior surface of the vena cava with scissors. A tape is passed with an aortic clamp from the right side of the median hepatic vein along the retrohepatic IVC to the inferior part of segment 1 (A), which is divided to place the tape near the right portal pedicle (B).
Hanging Maneuver for Right Hemihepatectomy (Including Living-Donor Liver Transplantation) |
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STEP 3 |
Parenchymal transsection |
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Slight traction on the tape leads to a separation of the right and the left hemiliver and allows easy identification of the right plane of parenchymal transsection. Depending on the situation, transsection is done with or without inflow occlusion and with the appropriate technique as described in the chapter on parenchymal transsection. Vessels with a diameter of less than 3mm are coagulated while larger vessels are ligated using
sutures or clips. At the end of the transsection, the two hemilivers are completely divided just joining together by hilar vessels and hepatic veins. The procedure is now continued depending on the situation (i.e., living related liver transplantation or liver resection
for a tumor).
338 SECTION 3 Liver
Modified Hanging Maneuver
for Middle Hepatic Vein Harvesting
For the harvest of the middle hepatic vein in a living donor procedure or for an oncologic extended resection, the hanging maneuver is adapted in order to facilitate the transsection along the left side of the vein. First, the hepatotomy is started on the top, near the median hepatic trunk, which allows identification of the left hepatic vein and the median hepatic vein, respectively (A).
Once the median hepatic vein has been freed, the tape is switched to the left side of the middle hepatic vein (B) and the procedure is continued as described in Step 3.
Tricks of the Senior Surgeon
Liver Resections
Panco Georgiev, Pierre-Alain Clavien
Indications and Contraindications
Indications |
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Primary and secondary malignancy (e.g., hepatocellular carcinoma, intrahepatic |
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cholangiocarcinoma, colorectal metastases, neuroendocrine tumors) |
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Benign neoplasia (e.g., adenoma, giant hemangioma) |
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Echinococcus multilocularis (alveolaris) |
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Abscesses refractory to conservative management |
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Other benign diseases (e.g., Caroli syndrome) |
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Living donor liver transplantation (modified technique; see chapter “Living Donor |
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Liver Transplantation”) |
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Klatskin’s tumor (modified approach to the bile duct; see Section 4 |
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Traumatic liver lesions |
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Acute hepatitis (viral or alcoholic) |
Contraindications |
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Severe chronic hepatitis |
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Poor liver reserve (e.g., Child-Pugh C cirrhosis) |
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Severe portal hypertension (e.g., esophageal varices, ascites or hepatic venous |
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pressure gradient >10mmHg) |
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Severe coagulopathy despite vitamin K administration |
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Severe thrombopenia (platelet count <30,000/mm3) |
Preoperative Investigation and Preparation for the Procedure
History: |
Alcohol, hepatitis and hepatotoxic medication, blood transfusions, |
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tattoos, etc. |
Clinical evaluation: Encephalopathy, ascites, jaundice, nutritional status, signs of portal
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hypertension |
Laboratory tests: |
ALT, AST, bilirubin, alkaline phosphatase, albumin, coagulation |
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parameters (PT, platelets), tumor markers and serologies |
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(e.g., hepatitis, echinococcus) when indicated |
CT scan or MRI |
Assessment of liver volume (major resections) and resectability |
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of the lesion |
PET scan |
Searching for extrahepatic lesions (e.g., colorectal metastases) |
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SECTION 3 |
Liver |
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Postoperative Tests |
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Postoperative surveillance in an intensive or intermediate care unit |
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Coagulation parameters and hemoglobin for at least 48h |
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Check daily for clinical signs of liver failure such as jaundice and encephalopathy |
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Postoperative Complications
■Short term:
–Pleural effusion
–Ascites
–Liver failure
–Intra-abdominal bleeding
–Bile leak
–Subphrenic abscess
–Portal vein thrombosis
■Long term:
–Biloma
–Biliary stricture
–Bronchobiliary fistula
Right Hemihepatectomy |
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Right Hemihepatectomy |
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Panco Georgiev, Pierre-Alain Clavien |
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Procedure |
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STEP 1 |
Access, exposure and exploration |
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After a right subcostal incision, the round and falciform ligaments are divided, a |
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retractor (e.g., Thompson) is installed and the abdomen is explored (A-1). Tumor size, |
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number, and location in relation to vascular structures are evaluated by intraoperative |
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ultrasound and a definitive decision regarding resectability of the lesion is made (A-2). |
A-1
A-2
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SECTION 3 |
Liver |
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STEP 2 |
Mobilization of the right lobe |
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The right lobe is mobilized by dissection of the anterior leaf of the coronary ligament and the right triangular ligament. The assistant retracts the liver inferiorly and to the left using a gauze swab. The finger blade (Thompson) which is retracting the stomach and duodenum should be removed during this part of the procedure. Approaching the cava, the ligament can be exposed by means of a right angle or a Kelly clamp (A-1). Ligaments can be well presented by passing a finger between the diaphragm and the coronary ligament (A-2). Care must be taken to protect the phrenic vessels and secure hemostasis from phrenic collaterals.
Next, the Pringle maneuver is prepared as shown in the chapter “Techniques of Vascular Exclusion and Caval Resection.” The falciform, round, and right coronary ligaments are divided and the gallbladder is removed as described in Sect.4, chapter “Laparoscopic Cholecystectomy, Open Cholecystectomy and Cholecystostomy.”