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General Surgery
Liver Surgery
Built from Skandalakis' Surgical Anatomy: The Embryologic and Anatomic Basis of Modern Surgery
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11 sections · 139 slides
Overview
- Biopsy: open wedge or percutaneous needle Suture of lacerations after hepatic trauma Right hepatectomy (lobectomy), typical or extended Left hepatectomy (lobectomy), typical or extended; segmentectomy Removal or drainage of hepatic cysts Total or partial (split, living-related) transplantation
- Opening quotation on hepatic surgery
Exploration and operative assessment
- If a pathological diagnosis is needed first, biopsy the liver as soon as the abdomen is opened Early biopsy avoids artefact from instrument injury and from anaesthetic drugs Needle biopsy or wedge biopsy are both acceptable Take the specimen far from the gallbladder Especially so if gallbladder disease may involve adjacent liver tissue Ultrasonography can localise the area of pathology first
- Withdraw omentum, transverse colon and mesocolon; pack them at the upper incision Pass the hand to the pelvis: left colon, pelvic organs, bladder, great vessels, retroperitoneum Run the small bowel from the ligament of Treitz to the ileocaecal valve; retrograde is acceptable Examine the second, third and fourth parts of the duodenum Note the relation of the superior mesenteric artery to the third part of the duodenum Harvest abnormal nodes for histology while liver mobilisation begins
- Palpate the pancreas before leaving the infracolic compartment Inspect the abdominal wall for hernias, omphalomesenteric anomalies and urachal cysts Replace omentum, transverse colon and mesocolon From the right: right kidney, duodenum, head of pancreas, pylorus Feel the stomach up to and including the gastro-oesophageal junction Palpate the spleen with great care: short attachments, capsule tears easily
- Evaluate the entire liver and biliary tract methodically Inspect the inferior surface of the diaphragm before hepatic exploration Examine the area of suspected pathology last Intraoperative ultrasonography is the most accurate method and should be routine Ultrasonography confirms the internal vascular skeleton before any transection line is chosen
- Pass the hand left of the falciform ligament to the coronary and left triangular ligaments Pass it right of the falciform to the coronary and right triangular ligaments Palpate the falciform and splenorenal ligaments The base of the falciform is occasionally not fused with the abdominal wall That leaves a hiatus through which a loop of intestine may herniate
- The hilar plate system
- Right hepatic ducts fall into four types; the standard type in 53-72% of cases Left: the medial segmental duct joins near the hilar area in 35.5% Those cases are treated like the caudate lobe in hilar bile duct carcinoma Portal vein shows little main variation: 16-26% The hepatic artery varies far more: 31-33% Observe the plate system and its variations during hilar carcinoma surgery
- The dilemma: resect and cure if benign, palliate if malignant, or leave alone History and laboratory results guide the decision Nearly all common lesions are distinguishable on CT, spiral CT, MRI and arteriography Biopsy may confirm but is not always necessary Gross appearance overlaps: hepatocellular carcinoma versus cholangiocarcinoma Liver cell adenoma, focal nodular hyperplasia and haemangioma may look identical
- A small haemangioma will bleed copiously if sampled Aspiration of an Echinococcus cyst may produce a fatal anaphylactic reaction Both diagnoses are usually made on imaging, not on needle sampling Nuclear medicine helps separate haemangioma and focal nodular hyperplasia from adenoma That distinction decides whether an operation is appropriate at all
- This topic tabulates the gross appearance of hepatic and biliary pathology Presented with mixed feelings, because appearances genuinely overlap Use it to narrow the differential, never as a substitute for histology Abscess, cirrhosis, cyst and tumour are the four headings The gallbladder and duct table follows the same purpose
- Anatomic Differential Diagnosis of the Liver in the Operating Room
- Anatomic Differential Diagnosis of the Liver in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Liver in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Liver in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Liver in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Liver in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Liver in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Liver in the Operating Room (continued)
- The companion table covers gallbladder and duct findings at operation Acute calculous, acute acalculous, chronic and choledocholithiasis are separated Gallbladder cancer and other common duct pathology complete it Read it as a checklist of what to palpate before opening the duct
- Anatomic Differential Diagnosis of the Gallbladder and Ducts in the Operating Room
- Anatomic Differential Diagnosis of the Gallbladder and Ducts in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Gallbladder and Ducts in the Operating Room (continued)
- Anatomic Differential Diagnosis of the Gallbladder and Ducts in the Operating Room (continued)
Anatomy of the left lateral graft
- Czerniak dissected 60 cadaveric livers to test left lobe resection for grafting The left lobe here means segments II and III It formed 12% to 28% of liver mass, mean 19.4% An extrahepatic segment of left hepatic vein was isolable in 95% of specimens Arterial supply was a single artery in 92%, two arteries in 8%
- Type I: a single portal vein segment to the left lobe, 35% of livers Type II: branches from a common orifice on the left portal vein, 35% Type III: separate orifices from the left portal vein, 30% Types II and III need partial section of the left portal vein wall to prepare a portal segment Biliary drainage was extrahepatic in 56 of 60 livers Type I single duct 78%; type II two ducts 15%
- Graft quality of the left lateral segment
- Kazemier studied 39 corrosion casts and disagreed strikingly with the dissection data Casts gave a single artery in 59% and a type I duct in 56% Every cast showed type III separate portal orifices Czerniak attributed the gap to technique: dissection versus casting With the cast method, judging the plane relative to the umbilical fissure is only approximate Ducts and vessels emerging under the fissure blur the relationship in a cast
- Anatomy of Supplying and Draining Structures of Couinaud Segments II and III (Resection at Plane in Umbilical Fissure)
- Michels, dissecting 200 livers, found a single artery to the left lobe in 88.5% Couinaud reported a single portal branch to segment II in 96% and to segment III in 31% Couinaud found a single bile duct draining the left lobe in 77% of 100 livers These dissection figures are close to Czerniak's 92% and 78% Czerniak recommended the plane of resection lie within the umbilical fissure That plane allows accurate extrahepatic dissection and avoids damaging segment IV
- Extra-Hepatic Segmental Arteries to the Left Hepatic Lobe According to Origin. Multiple Branches to a Single Segment Are Underlined
- Extra-Hepatic Segmental Arteries to the Left Hepatic Lobe According to Origin. Multiple Branches to a Single Segment Are Underlined (continued)
- Morphologic patterns of the extra-hepatic left biliary tree
- Cutting planes for a left graft
- Average Number of Arterial, Portal, Biliary, and Total (= A + P + B) Anastomoses (±SD; Range) to Be Made at Three Different Cutting Planes in the Left Liver to Create a Viable (Left) Graft for SG and LRG Purposes
- Planes A and B create a small wound surface and leave segment IV with the right liver or donor Volume reduction at A and B is only two small segments, II and III But branches to segment IV are transected in 17% arterial and 20% biliary Plane B needs reconstruction of the left portal vein at Rex' sinus to perfuse segment IV Plane C creates the largest wound surface and removes segments II, III and IV At plane C the branches to II and III can be denuded by removing segment IV parenchyma
- Cutting plane C in the liver hilum was judged the best option for split or living-related grafting It gives the lowest average number of anastomoses, 3.1 It creates a relatively large wound surface on the remnant It reduces the living donor's functional liver mass by segments II, III and IV The plane has proved usable in clinical reports
Variant anatomy that decides a split
- Detected preoperatively by portography or ultrasonography Couinaud reported five occurrences, a frequency of 1.9 percent It presents as a huge portal ring; the large vein turns to the right After reaching the umbilical fissure it gives the usual branches and ends at the caudate lobe There is therefore no left portal vein When the bifurcation is missing, bipartition is usually impossible
- Total vascular bypass, skeletonisation of the portal vein, and resection Alternatively, deep interruption of the portal stem in the hilum Then division of the main portal fissure at the right margin of the middle hepatic vein And transection of the transverse portion of the portal ring Either route demands the anomaly be known before the incision
- Liver without portal bifurcation
- Portal ring pattern described by Agossou-Voyeme
- Portal ring pattern described by Hardy
- Modalities of bipartition for two grafts
- Devascularisation of segment IV in a lobe-lobe split
- Portal veins of segment IV
- Biliary canals of segment IV
- Segment IV artery arising from the right hepatic artery
- Left arterial and biliary distribution types
- Left hepatic artery from the left gastric artery
- Right hepatic artery from the superior mesenteric artery or celiac trunk
- Resection of segment IV as a splitting manoeuvre
- Using the common hepatic duct in a biliary duplication
- Using the common hepatic artery in an arterial duplication
- Tripartition of the liver
- Variable liver shape rarely causes difficulty; situs inversus is the exception Arterial variants may be the source of great difficulties Biliary variants of note: low junction of right and left hepatic ducts in the main portal pedicle Cystohepatic ducts, a right duct entering gallbladder or cystic duct, occur in 2% to 15% Right liver-left liver and right liver-left lobe bipartition are well controlled techniques Right lobe-left lobe bipartition should never be performed
- The left hepatic vein is attributed to the left transplant If the left vein is duplicated, the terminal middle vein goes to the left transplant Continuity of the middle vein with the inferior vena cava must then be reconstructed The middle hepatic vein is always attributed to the right transplant Missing portal bifurcation usually makes bipartition impossible When the right portal vein is duplicated, the portal stem goes to the right liver
- A thorough preoperative investigation is necessary in a living donor Back-table cholangiography and arteriography are essential for ex vivo bipartition Three manoeuvres are available: resect segment IV, allot the main duct, allot the main artery In vivo harvesting of a left transplant is possible in 86% of cases Ex vivo it is possible in 95.70% Tripartition of the liver is not yet a controlled technique
Hepatic resections
- The caudate lobe is its own segment, segment I, and lies posteriorly Clockwise from the top: segments II and III lie left of the falciform ligament That is the left lateral segment in the American system Segment IV lies between the falciform ligament and Cantlie's line or the middle hepatic vein Segment IV is the left medial segment; sometimes divided into IVa superior and IVb inferior Segments V, VI, VII and VIII continue the clockwise labelling
- The gallbladder fossa lies between segments IV and V The figure depicts the internal vascular skeleton, confirmed with intraoperative ultrasonography The diaphragmatic surface gives little indication of internal lobulation The only surface clue is the sulcus dividing lateral segments II and III from medial segment IV Segmental boundaries must therefore be defined by vessels, not by the capsule
- True lobulation and segmentation of the liver
- Subsegmentation of the liver
- Intrahepatic distribution of the hepatic veins
- The basic plan of intrahepatic vessels is subject to many variations Preoperative aortic, celiac or selective hepatic arteriography must be performed Study the films carefully before attempting any procedure The main arterial trunk to the medial segment arises from the right hepatic artery in about 25% Precede ligation of any arterial branch with manual occlusion Observe the limits of colour change in the tissue before dividing
- Interlobar and intersegmental spaces are occupied by the hepatic veins Therefore transect in a paralobular or parasegmental plane, not exactly on the boundary This matters most in the true interlobar, or umbilical, fissure There, vessels and bile ducts may lie in the fissure and return to the medial lobe more distally In left lateral segmental resection, incise 1 cm to the left of the umbilical fissure
- Planes of transection for lobectomy and segmentectomy
- Sequence of a right lobectomy
- Use a right subcostal incision for right or extended right lobectomy It may be continued upward into the thorax, paraxiphoid, or to the left if needed Incise the right triangular and coronary ligaments to retract the right lobe Divide all ligamentous attachments for complete mobilisation and visualisation In a true right or left lobectomy the gallbladder must be sacrificed
- Dissection begins at the hilum, using blunt dissection throughout Ligate the hepatic artery, portal vein and bile duct of the lobe to be removed Preserve the interlobar hepatic veins The interlobar fissure, line of Rex or median fissure, runs from gallbladder fossa to inferior vena cava The dissection must pass to the right of the middle hepatic vein to preserve segment IV drainage Ligate the right hepatic vein extrahepatically before transecting the liver
- Right hepatic lobectomy
- Ligate the left hepatic artery, portal vein and bile duct Section the triangular ligament to mobilise the left lobe Transect from the left side of the gallbladder fossa to the left side of the fossa for the vena cava Expose and ligate the left and middle hepatic veins within the liver or extrahepatically at the cava Confirm the precise anatomy by ultrasound before ligating In most cases the left and middle veins form a common trunk before leaving the liver
- It may be best to ligate the hepatic veins at the end of the dissection That ensures only veins draining the resected segments are divided A left resection may be lobar, segmental, or wedge-shaped for a superficial tumour Povoski found extended left hepatectomy a viable technique for large, strategically placed lesions Those include left-sided and central lesions extending rightward Such lesions involve the right anterior sectorial portal pedicular structures
- Left hepatectomy
- Consists of removal of segments II and III only These segments lie lateral to the falciform ligament Segment IV remains in situ Incise the liver 1 cm to the left of the umbilical fissure The umbilical portion of the portal vein lies within that fissure
- Left lateral segmentectomy
- Similar to a right lobectomy, but the liver is transected just to the right of the falciform ligament It takes the anterior and posterior segments of the right lobe and the medial segment of the left lobe The middle hepatic vein must be ligated, since the medial segment is removed Take extreme care to preserve the left hepatic vein The middle vein typically joins the left vein before its junction with the vena cava
- Extended right hepatectomy
- Right trisegmentectomy
- Mesohepatectomy is removal of segments IV, V and VIII Wu and colleagues reported it as time-consuming Its advantages nonetheless justify its use in selected patients The indication given is centrally located large hepatocellular carcinoma It preserves the lateral segments on both sides
Liver trauma
- The AAST developed the liver injury scale in 1989; the 1994 revision is in use Seventy to ninety percent of liver injuries are grade I or II Those may be managed non-operatively The utility of CT scanning in liver trauma cannot be overstated Subcapsular and intrahepatic haematomas are managed with observation and serial CT Pooling contrast within the parenchyma on CT indicates active bleeding
- Liver Injury Scale (1994 Revision)
- Liver Injury Scale (1994 Revision) (continued)
- Improved prehospital care means patients arrive in extremis but alive with enormous injuries This produced a resurgence of perihepatic packing for early management Formal hepatic resection for trauma carries a high mortality rate Cogbill reported a 0.89% rate of formal resection with 58% mortality Hollins and Littell: of 281 patients, 42 (14%) had resection, 83% of those resectional debridement Mortality for that entire group was 21%
- Hepatic resection is safe when performed electively; formal resection for trauma is not Resectional debridement is more common and approaches the site of a specific injury The finger fracture technique is useful in this approach Portal occlusion is safe in otherwise healthy trauma patients for up to an hour Selected isolated grade I and II gunshot injuries can be managed non-operatively Candidates for observation are infrequent and require resources for complications
Resection for malignant disease
- Survival after resection for hepatic malignancy
- The ratio of future liver remnant to preoperative liver volume relates to outcome Vauthey found the correlation useful for evaluating response to portal vein embolisation It also predicts outcome before extended liver resection Intraoperative ultrasonography is critical for safe hepatic resection Cryoablative therapy and microwave coagulation were under study as non-resectional options
- Bakalakos: unilobar and certain bilobar metastases achieve long-term survival The requirement is resection with tumour-free margins A preoperative carcinoembryonic antigen level of 30 ng/mL marked a more resectable group That group also had the longest survival Wigmore found no differential pattern of hepatic metastasis by site of the primary D'Angelica: patients disease-free 5 years after resection are likely to have been cured
- HCC is the most common solid organ tumour worldwide, causing over 1 million deaths annually Bilimoria: death from HCC is rare beyond 5 years after resection without fibrosis or cirrhosis Chronic liver disease acts as a field of cancerization contributing to new tumours Nakajima: repeat resection for recurrent HCC has a low disease-free survival rate Miyazaki advised limited resection of segments I and IV for hilar cholangiocarcinoma Roayaie advised tumour-free margins in intrahepatic cholangiocarcinoma
- Yamamoto isolates the caudate lobe by an anterior transhepatic approach The parenchyma is separated along the interlobar plane with identification of the caudate's right margin Azoulay: the anterior approach is useful for massive liver resection It minimises tumour rupture with spillage and haemorrhage from vascularised adhesions It avoids damage to the right hepatic vein or retrohepatic vena cava It removes the need to rotate the huge right liver, preventing warm ischaemia and pedicle torsion
- Yamamoto treated a tumour involving the hepatic venous confluence and cava by in situ pedicle resection That case was a left trisegmentectomy with right hepatic vein reconstruction Midorikawa: hepatectomy in the impaired liver is now as safe as in the normal liver, if guidelines are followed Bosscha used twelfth rib resection as a posterior approach for subphrenic abscess That was used when percutaneous drainage failed or was unsafe, or the abdomen was inaccessible Billingsley recommended segmental resection for metastases and hepatocellular carcinoma
- Open surgery is the treatment of choice for malignant primary tumours Also for lesions located posteriorly or close to major hepatic vasculature Laparoscopic resection of metastases is reasonable with a 1 cm safety margin That applies when the total number is fewer than four and there is no extrahepatic disease Ablative options: radiofrequency, microwave, laser, cryoablation, ethanol and chemoembolization These are acceptable for non-surgical patients
- Nearly all common lesions are distinguishable on CT, spiral CT, MRI and arteriography Delbeke used fluorine-18 fluorodeoxyglucose positron emission tomography to separate benign from malignant False-positive results occur in a minority of hepatic abscesses False-negative results occur in a minority of hepatocellular carcinomas Nuclear medicine separates haemangioma and focal nodular hyperplasia from adenoma
Operative management of portal hypertension
- Choice depends on underlying liver disease, comorbidity and local expertise Medical: beta-blockers for prophylaxis Vasopressin or somatostatin infusion for acute bleeding Endoscopic sclerotherapy or variceal banding for acute bleeding or to prevent rebleeding Liver transplantation is the most radical and definitive therapy in appropriate candidates
- Developed by Dean Warren and colleagues after the era of portacaval shunting It selectively decompresses oesophageal and gastric varices Antegrade portal perfusion of the liver is maintained Rebleeding rate at three to five years is approximately 6% Operative mortality in recent series ranges from 0% to 15% Encephalopathy occurs in only 15%, controlled by protein restriction and lactulose
- A reinforced 8 mm polytetrafluoroethylene graft between portal vein and vena cava It decompresses the portal vein less completely than a standard shunt It still decreases portal pressure and maintains antegrade flow to the liver Technically easier than the distal splenorenal shunt The rate of flow reversal in the portal vein is higher Perioperative complications are similar to those of DSRS
- A wire passes from the jugular vein through a hepatic vein into a portal vein branch The tract is dilated and stented with an expandable metal stent This forms a functional side-to-side portacaval shunt It decompresses the portal vein and therefore the oesophageal and gastric varices Success rate at least 90% in reducing the portal to hepatic vein gradient below 12 mmHg Early rebleeding roughly equals DSRS and is significantly lower than sclerotherapy
- Selective shunt compared with TIPS
- A randomised trial is needed to fix the exact role of TIPS Follow-up at 18 to 24 months shows 40% to 70% shunt stenosis or thrombosis TIPS is not recommended for definitive decompression in Child A cirrhosis with good function It is best suited to Child C patients awaiting transplantation It also suits those who bleed but are high risk for surgery Child B occupies an intermediate category; best long-term treatment unknown
- Child's Classification of Hepatic Reserve
Anatomic complications
- Wedge biopsy is taken at mini-laparotomy or during another procedure Bleeding is its only complication and is easily controlled In percutaneous biopsy the colon is the organ most frequently perforated Pancreatic and renal tissue occasionally appear in the specimen Pneumothorax occurs about once in 800 biopsies Haemorrhage and peritonitis are the most frequent complications
- Complications of Percutaneous (Needle) Biopsy
- Complications of Percutaneous (Needle) Biopsy (continued)
- Millward-Sadler and Whorwell reviewed mortality in several large series from the 1950s onward By 1992 they estimated about 0.01%, one death per 10,000 biopsies Some years earlier the same authors had found 0.1%, one death per 1,000 Schwartz in 1994 concluded the overall mortality was 0.8% Commonest complications were pain, pneumothorax, haemorrhage and bile peritonitis Needle fracture during biopsy is an uncommon complication
- When a hepatic vein occludes, resection of its territory might be expected Mays stated this is unnecessary in humans, because of anastomoses between left and right hepatic veins Two reports describe hepatic vein ligation with survival of most of the affected liver In one the left hepatic vein was ligated; in the other the middle and left veins Segmental hepatic vein ligation avoids the tedious construction of a vena caval shunt Intraoperative ultrasonography and anatomic knowledge prevent most venous occlusions
- Ligation of the left or right portal vein after injury has been successful in some patients Mortality from portal vein injuries remains about 50% Stone reported 15 survivors among 20 patients undergoing emergency portal vein ligation Pachter: ligation may be safer than immediate shunting, which risks encephalopathy Ligation still risks portal hypertension and intestinal infarction Resectional debridement may then be needed to remove devitalised tissue
- Severe hepatic trauma limited to one lobe is the main indication Ligate both the portal vein and hepatic artery supplying the injured lobe The artery should be ligated first If that fails to stop the haemorrhage, ligate the portal branch to that lobe The umbilical portion of the portal vein lies within the umbilical fissure
- Repair inadvertent ligation of a lobar hepatic artery if possible With good supportive care the patient usually survives even if flow is not restored Kim found 50 deaths among 322 hepatic artery occlusions Twenty-seven deaths followed accidental ligation during major operations Ligation was the direct cause of death in only 12 cases, a mortality under 4% Ligation of the left hepatic artery carries higher mortality than the right; no valid reason is known
- The degree of ischaemia depends on where the hepatic artery is ligated Ligation proximal to the gastroduodenal artery probably causes no liver ischaemia The same is true proximal to the origin of the right gastric artery If ligation is distal to the right gastric artery, an aberrant hepatic artery may be the sole supply In up to 25% the left medial segmental artery to segment IV arises from the right hepatic artery Sectioning the right hepatic artery for a right lobectomy could then ischaemise segment IV
- Accidental section of a segmental duct requires immediate repair The alternatives are proximal and distal ligation of the severed duct, or resection of the segment Ligation of a segmental duct produces jaundice, hypocholic stools and urine It also enlarges the lobe of the liver on the obstructed side Braasch reported atrophy of the obstructed segment; initial hypertrophy may be followed by atrophy Unilateral lobar obstruction produces jaundice, while unilateral lobectomy does not
- Lo recommended preresection cholangiography for left-sided hepatectomy And early surgical intervention for leakage of the common bile duct The tables that follow give incidence by type of resection and site of leak Biliary complications are commoner after left-sided than right-sided resections Most of the upper abdominal organs lie close enough to be injured during hepatic resection
- Types of Hepatic Resection and Incidence of Biliary Complications
- Types of Hepatic Resection and Incidence of Biliary Complications (continued)
- Site of Biliary Leakage According to Different Types of Hepatic Resection
Surgical anatomy of liver transplantation
- The described preparation is anatomic rather than technical It is based on the work of Starzl, Shaw, Gordon, Quinones-Baldrich and Ekberg The arterial supply is abnormal in almost half of patients encountered Hardy and Jones found hepatic artery anomalies in 38.5% of prospective donor livers Arterial anastomosis can still be carried out successfully from such livers Accept the dictum that all hepatic arteries are end arteries
- A left gastric branch to the left lobe lies in the gastrohepatic ligament beneath the left lobe Dissect it back to the left gastric artery, which is preserved to the celiac axis A right hepatic artery from the superior mesenteric artery is found by pulsation behind the portal vein and duct Its origin lies just beneath the splenic vein near the junction with the portal vein Dividing the splenic vein for the portal cannula improves exposure of that origin Dissect the superior mesenteric artery from the aorta to 1 cm beyond the aberrant origin
- The origin of the celiac axis is also dissected clean at the aorta After cold perfusion, remove a patch of anterior aortic wall The patch contains the origins of both the celiac axis and the superior mesenteric artery This preserves the entire hepatic arterial supply It is the first step in reconstructing a common channel As the patch is cut, avoid the closely placed aortic origins of the renal arteries
- In situ perfusion of the donor liver
- Aberrant donor arterial supply at transplantation
- Bismuth: the liver can be divided into two hemilivers along the main fissure The right hemiliver is segments V, VI, VII and VIII The left hemiliver is segments II, III and IV Resection of the caudate lobe, segment I, is advised Srinivasan transplanted segment III alone into six babies with liver failure That monosegment series had an 83.3% success rate
- Couinaud presented a simplified method for controlled left hepatectomy He emphasised variations in shape, arterial and biliary variants, and cystohepatic ducts A left transplant should include the left hepatic vein; a right transplant the middle hepatic vein Preoperative work-up must cover absent portal bifurcation and duplicated right portal vein Thompson considered the technique unsafe unless biliary variants are stringently excluded first The authors' comment: proceed with no acceptance of any assumption
- Egawa reconstructed the hepatic vein by wide end-to-side anastomosis to the recipient veins The cuff consists of the recipient middle and left hepatic veins, with an incision to the vena cava Marcos: right lobe variations are accommodated without donor complications or complex reconstruction Previous transplantation and TIPS do not significantly complicate right lobe transplantation Microvascular arterial anastomosis is not necessary; vascular complications should be infrequent Biliary complications can be minimised with stenting
- Pomfret stressed careful evaluation of potential living donors Significant donor morbidity is encountered even with careful selection Massive ascites after transplantation is uncommon but increases morbidity and mortality It is primarily related to difficulties of hepatic venous drainage Measure hepatic vein and atrial pressures to detect a significant gradient Postoperative portal vein stenosis may be treated by balloon dilatation through an iliac vein
- The major challenge is the shortage of donor organs Imaginative approaches include more effective use of marginal donor livers Splitting livers and developing living-related transplantation are the other routes Advances have been made in xenotransplantation Many hurdles remain before xenotransplantation can enter human practice
Summary
- Intraoperative ultrasonography defines the internal vascular skeleton; the surface does not Hepatic veins lie between segments, so transect in a paralobular or parasegmental plane Test every artery by occlusion and colour change before ligating it Treat all hepatic arteries as end arteries; preserve accessory and replacing vessels Assume nothing about the biliary tree: image it before dividing on the left Segment IV depends on the left portal pedicle and must never be orphaned
- Segments II and III are 12-28% of liver mass, mean 19.4% Single artery to the left lobe in 92% by dissection; 59% by corrosion cast Segment IV artery arises from the right hepatic artery in up to 25% 70-90% of liver injuries are grade I or II and may be managed non-operatively TIPS reduces the portal-hepatic gradient below 12 mmHg in at least 90% Shunt stenosis or thrombosis follows TIPS in 40-70% at 18-24 months
- Sources of the figures reproduced in this topic
- Sources of the figures reproduced in this topic (continued)
- Skandalakis' Surgical Anatomy: The Embryologic and Anatomic Basis of Modern Surgery
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