clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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Right Hemihepatectomy |
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STEP 2 (continued) |
Mobilization of the right lobe |
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The suprahepatic vena cava and the right hepatic vein should be identified. FigureB |
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depicts the mobilized liver as well as the structures which need to be identified during |
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the next steps: hepatic artery, portal vein, and bile duct. An aberrant left hepatic artery |
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(single asterisk in B) is found in about 20–25% of cases. It should be isolated for later |
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possible inflow occlusion (B). An aberrant right hepatic artery (double asterisk in B) is |
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present in 10-15% of cases. |
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SECTION 3 |
Liver |
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STEP 3 |
Preparation of the hilar structures and transsection of the right hepatic artery |
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The hepatoduodenal ligament is divided from the cystic duct to the left in order to identify the common hepatic duct and the right branch of the hepatic artery. No attempt is made to visualize or even secure the right hepatic duct (A).
To test the patency of the arterial blood supply to the left hemiliver, a “bulldog” is placed on the right branch of the hepatic artery. The patency of the left branch of the hepatic artery can now easily be assessed by palpating it through the hepatoduodenal ligament (B). Search for an aberrant right hepatic artery (10–15%, posterior and right to the portal vein, indicated by double asterisk in STEP 2 Figure B) from the superior mesenteric artery should be routinely performed prior to identification of the right portal vein.
Once the arterial anatomy is clearly identified, the right branch of the hepatic artery is divided between ties (C). In the presence of an aberrant right hepatic artery, the same maneuver should be applied.
Right Hemihepatectomy |
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STEP 3 (continued) |
Preparation of the hilar structures and transsection of the right hepatic artery |
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SECTION 3 |
Liver |
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STEP 4 |
Transsection of the right portal vein |
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The bifurcation of the portal vein should be convincingly identified. A small branch to the caudate process is often present. By ligating it, about 2cm of length along the right portal vein is obtained to facilitate safe ligation of the right portal vein (A-1).
Once the right branch of the portal vein is freed from the adventitial tissue, a rightangle clamp is passed around the vein (A-2).
A vascular clamp (e.g., small Satinsky clamp) is placed distally and the right portal vein is ligated with 1-0 silk. The distance to the bifurcation should be about 5mm to avoid portal vein stenosis and subsequent thrombosis (A-3).
An alternative (e.g., in the case of a short right portal vein) is to use a small Satinsky clamp on the proximal right portal vein and a running Prolene 6-0 suture (A-4).
As another alternative, a vascular stapler can be used in this position, but usually the small window in the porta hepatis through which this dissection is being performed lends itself more to a suture ligation than to a stapling. The portal vein on the liver side is controlled through suture ligature as a single ligature could slip away and cause bleeding. Now the demarcation line between the left and right hemiliver can be observed.
Right Hemihepatectomy |
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STEP 5 |
Transsection of short hepatic veins |
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The short hepatic veins on the right side are divided between ties. Clips should be |
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avoided particularly on the caval side, as the clip can detach once the low CVP has been |
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corrected postoperatively. |
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SECTION 3 |
Liver |
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STEP 6 |
Transsection of the right hepatic vein |
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The right hepatic vein is prepared (separated from the mid and left hepatic vein) from the top and below on the cava by means of a Kelly clamp (A-1). A 1-0 silk or vessel loop is placed around the right hepatic vein. The transsection can be performed by means of a vascular stapler (A-2). An alternative technique is to occlude the right hepatic vein with a vascular spoon clamp and ligate the proximal hepatic side with a 1-0 silk ligature in combination with a large clip (A-3). Should bleeding occur despite the combined ligature and clip, it can easily be controlled by putting a finger on the transsected right hepatic vein. Just continue on the caval side, which is secured by a running 4-0 polypropylene suture. Once the caval side is secured, the bleeding on the transsected proximal hepatic vein can be controlled by a suture ligature.
Right Hemihepatectomy |
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STEP 7 |
Transsection of the liver parenchyma |
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Two stay sutures (2-0 silk) are placed at the inferior margin of the liver, one on each side |
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of the demarcation line. At this point, verify that CVP is low (below 3mmHg). If the CVP |
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is higher, ask the anesthesiologist to correct it and wait. The liver capsule is incised with |
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diathermy a few millimeters on the ischemic side (A). Sometimes the resection line has |
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to be extended to segment IV for oncological reasons. |
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The dissection of the parenchyma is started at the inferior margin between the stay |
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sutures. The possible techniques for parenchyma dissection are described in the chapter |
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“Techniques of Liver Parenchyma Dissection.” The Pringle maneuver for continuous or |
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intermittent inflow occlusion is used if needed. The dissection is continued posteriorly, |
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then inferiorly, preserving the mid hepatic vein. |
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SECTION 3 |
Liver |
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STEP 7 (continued) |
Transsection of the liver parenchyma |
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The technique of bipolar forceps and Kelly clamp is shown (B). A band can be placed between the cava and the liver, which allows lifting and better exposure (see also the chapter”Hanging Maneuver for Right Hepatectomy”). As an alternative, the left hand of the surgeon can be placed between the liver and the cava. Each identified bile duct or vessel (>3mm) is ligated on the left side and divided. In the hilum, the right bile duct is divided away from the main confluence above the caudate process.
Right Hemihepatectomy |
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STEP 7 (continued) |
Transsection of the liver parenchyma |
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A gauze swab is placed on the resection surface and a slight compression is maintained |
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for a few minutes or longer in case of diffuse bleeding. Each bleeding on the cut surface |
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should be suture-ligated. At the end of the procedure, the gauze swab is removed and |
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inspected carefully. Any bile leaks (yellow spots on the gauze swab) are oversewn by PDS |
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4-0 or 5-0. Some groups routinely inject methylene blue in the common bile duct to |
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identify bile leaks. In order to prevent rotation of the left hemiliver, the falciform liga- |
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ment needs to be reattached (C). The abdomen is closed without drainage. |
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SECTION 3 |
Liver |
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Tricks of the Senior Surgeon |
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■Ask the anesthesiologist early in the procedure for a low central venous pressure: this significantly reduces overall blood loss.
■If you use a ligature to secure the right hepatic vein on the liver side: add a large clip to the ligature – this prevents bleeding!
■If it bleeds despite the clip: do not panic! Compress the right hepatic vein with your finger and continue on the caval side.
■While you dissect the liver parenchyma, hold the right hemiliver with your left hand or a band for optimal exposure and protection of the cava.