Close relation between the inferior vena cava ligament and the caudate lobe in the human liver

Surgical Anatomy of the Liver-Significance in Ovarian Cancer Surgery

INTRODUCTION

Ovarian cancer is the leading cause of death among all gynecological malignancies. Most patients present with an advanced stage of the disease. The routes of spread in ovarian cancer include peritoneal dissemination, direct invasion, and lymphatic or hematogenous spread, with peritoneal and lymphatic spread being the most common among them. The flow direction of the peritoneal fluid makes the right subphrenic space a target site for peritoneal metastases, and the most frequently affected anatomical area in advanced cases is the right upper quadrant. Complete cytoreduction with no macroscopically visible disease is the most important prognostic factor.

METHODS

We reviewed published clinical anatomy reports associated with surgery of the liver in cases of advanced ovarian cancer.

RESULTS

The disease could disseminate anatomical areas, where complex surgery is required-Morrison's pouch, the liver surface, or porta hepatis. The aim of the present article is to emphasize and delineate the gross anatomy of the liver and its surgical application for oncogynecologists. Moreover, the association between the gross and microscopic anatomy of the liver is discussed. Additionally, the vascular supply and variations of the liver are clearly described.

CONCLUSIONS

Oncogynecologists performing liver mobilization, diaphragmatic stripping, and porta hepatis dissection must have a thorough knowledge of liver anatomy, including morphology, variations, functional status, potential diagnostic imaging mistakes, and anatomical limits of dissection.

Isolated caudate lobectomy using a modified hanging maneuver

BACKGROUND

The caudate lobe is located deep in the dorsal portion of the liver. Complete resection is an extremely demanding surgery due to the limited surgical field, especially in cases with severe intra-abdominal complications. A major concern of isolated caudate lobectomy is the difficulty associated with securing the contralateral visual field during parenchymal transection. To overcome this issue, we present a new technique for isolated caudate lobectomy that uses a modified hanging maneuver.

METHODS

We performed an anatomical isolated caudate lobectomy via the high dorsal resection technique using our new modified hanging maneuver in two patients with HCC in November and December 2019.

RESULTS

Patient 1 was severely obese, so the upper abdominal cavity was occupied by a large amount of great omental fat, and fibrous adhesions were observed around the spleen. Patient 2 had undergone six preoperative treatments, and a high degree of adhesion was observed in the abdominal cavity around the liver. It was difficult to secure the surgical field due to severe abdominal complications in both cases. The total operation times in these two cases were 617 and 763 min, respectively, while the liver parenchymal dissection times of the caudate lobe were 96 and 108 min, respectively. The resection margin was negative in both patients (R0). Neither patient had any complications after surgery; both were discharged on postoperative day 14.

CONCLUSION

Our modified hanging maneuver is useful, particularly in cases with a narrow surgical field due to severe adhesions, bulky tumors, and/or hypertrophy of the Spiegel lobe.

Blood supply to the caudate lobe of the liver from the right inferior phrenic artery: observation by cone-beam computed tomography during arteriography

PURPOSE

To retrospectively evaluate blood supply to the caudate lobe of the liver from the right inferior phrenic artery (RIPA) using cone-beam computed tomography during arteriography (CBCTA-RIPA).

METHODS

CBCTA-RIPA examinations during transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) were collected from 2448 procedures in 787 patients. The exclusion criteria were (1) major artifacts, (2) TACE of hepatic arterial branches before performing CBCTA-RIPA, and (3) repeated CBCTA-RIPA studies in the same patient. Blood supply to three subsegments, the Spiegel lobe (SP), paracaval, and caudate process, was evaluated on CBCTA-RIPA images. The origins and routes of branches supplying the caudate lobe were also evaluated by three-dimensional vessel-tracking software.

RESULTS

Forty-seven CBCTA-RIPA examinations in 47 patients (38 with a history of TACE [repeated TACE group] and nine without it [initial TACE group]) were eligible, including five who had previously undergone hepatectomy. Seven had caudate lobe HCCs. Blood supply to the caudate lobe was demonstrated in 21 (44.7%) patients: in 50% (19/38) and 22.2% (2/9) of the repeated and initial TACE groups, respectively. The caudate arteries had previously been embolized in eight patients, the RIPA branch in three, and both in one. Forty-one proximal branches mainly supplied the dorsal part of the SP. All branches but five reached there through the inferior vena cava (IVC) ligament. The RIPA supplied eight of nine caudate lobe HCCs, totally (n = 7) or partially (n = 1).

CONCLUSION

The proximal RIPA branches mainly supply the dorsal SP through the IVC ligament, especially in the repeated TACE group.

Vena cava encirclement predicts difficult native hepatectomy

Recipient hepatectomy is a challenging liver transplantation (LT) procedure that has life-threatening complications. The current predictive mortality clinic-biological scores (Child/Model for End-Stage Liver Disease [MELD]) do not take into consideration the recipient's liver anatomy. The aim of this study was to evaluate the impact of the dorsal sector anatomy of a cirrhotic liver on the morbidity/mortality rates of hepatectomy. A multicenter retrospective study (clinic-biological and morphologic) was performed from 2013 to 2014. The degree of encirclement of the inferior vena cava (IVC) by the dorsal sector of the liver was measured. The study population included 320 patients. Seventy-four (23%) patients had complete IVC encirclement. A correlation (P = 0.01) has been reported between the existence of a circular dorsal sector and the number of transfusions during LT (4 packed red blood cell [PRBC] transfusions in the group without IVC versus 7 PRBC transfusions in the other group). The existence of such anatomy increases the relative risk of early reoperation for IVC bleeding by 31% (P = 0.05). There is a correlation between alcoholic cirrhosis and dorsal-sector hypertrophy (126 cc versus 147.5 cc; P = 0.05). Concerning surgical time, we found no significant between-group differences. Compared to the severity of cirrhosis, an inverse correlation was observed between the MELD and Child scores and the dorsal sector hypertrophy (P < 0.001). No significant difference in terms of transfusion was found between the temporary portocaval shunt group (n = 168) and the other group (n = 152). The presence of a circular sector is associated with an increased risk of hemorrhage during hepatectomy, as well as an immediate postoperative risk of reoperation. Liver Transplantation 22 906-913 2016 AASLD.

[Vascular management in anatomical liver resection]

The vascular management in anatomical liver resection plays a pivotal role in maintaining an adequately functional residual liver volume. In this respect it is essential to guarantee an adequate portal and arterial inflow as well venous outflow for the whole residual liver (lobe or segments). To achieve this, the liver surgeon should have excellent perioperative imaging, surgical expertise based on knowledge of vascular anatomy, physiology and hemodynamics of the liver and a well-designed and cautious operative strategy. The use of intraoperative ultrasonography (with or without contrast enhancement) and modern parenchymal dissectors (e.g. ultrasound or water jet dissectors) are strongly recommended.

Ectopic intracaval liver

Congenital abnormalities of the liver are rare with prior descriptions of lobar or segmental agenesis, Reidel's lobe, and ectopic hepatic lobes. Intrathoracic ectopic hepatic lobes have been reported in many instances; however, there is only one documented case of abnormally positioned liver tissue within the inferior vena cava (J Chapman-Fredricks, R Birusingh, M Ricci, M Rodriguez, Intracaval liver with cardiac extension. A new developmental anomaly? Fetal and Pediatric Pathology. 2010; 29:401-406). We report a second case of an ectopic intracaval liver defined as a mass in an adult who presented for abdominal pain and review the radiological findings.

Right-sided retrocaval approach using guidance via the lesser sac for Spieghel lobe resection

BACKGROUND

Few reports describe technical problems encountered in resections of the Spieghel lobe of the liver.

METHODS

The relationship of the caudate lobe with the inferior vena cava (IVC) was analyzed using computed tomography in 51 patients without hepatobiliary diseases. Using reconstructed 1 mm axial images, the angles of the most dorsal part of the Spieghel lobe (angle A) and the right hepatic lobe (angle B) around the IVC were measured clockwise from the ventral midpoint of the IVC.

RESULTS

In 11 (22%) patients, angle A was 180 ° or more, thus the retrocaval part of the Spieghel lobe projected rightward beyond the dorsal midline, but in 1 patient (2%) the right dorsal part of the liver extended leftward beyond the dorsal midline. In 20 (39%) patients, angle A was less than 135 degrees. The Spieghel lobe surrounded the IVC most dorsally at 22% of the distance from the top of the retrohepatic IVC. In 9 patients (18%), the retrocaval process of the Spieghel lobe appeared to be connected to the dorsal part of the right lobe.

CONCLUSION

The Spieghel lobe sometimes extends to the right, dorsal aspect of the IVC, such that a right-sided approach facilitates securing the retrohepatic IVC through the lesser sac and allows a safe dissection of the protruding portion of this lobe.

Liver anatomy

Understanding the complexities of the liver has been a long-standing challenge to physicians and anatomists. Significant strides in the understanding of hepatic anatomy have facilitated major progress in liver-directed therapies--surgical interventions, such as transplantation, hepatic resection, hepatic artery infusion pumps, and hepatic ablation, and interventional radiologic procedures, such as transarterial chemoembolization, selective internal radiation therapy, and portal vein embolization. Without understanding hepatic anatomy, such progressive interventions would not be feasible. This article reviews the history, general anatomy, and the classification schemes of liver anatomy and their relevance to liver-directed therapies.

Intracaval liver with cardiac extension. A new developmental anomaly?

Inferior vena cava (IVC) obstruction is uncommon in children. We report a patient with liver within a IVC extending to the right atrium who underwent successful surgical resection. A 12-year-old boy with an Arnold Chiari malformation was admitted for seizures. Premature ventricular contractions prompted an echocardiogram. This revealed a pedunculated mass in the right atrium and an IVC producing turbulent flow. He underwent a mass excision that was continuous with the liver. Histology demonstrated normal liver parenchyma. Based on the embryologic intimacy between the caudate lobe and the IVC, we postulate that the ectopic hepatic nodule was due to aberrant migration of hepatocytes into the IVC during embryogenesis.