Beneficial use of the round ligament as a patch graft for vena cava reconstruction

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy

BACKGROUND AND PURPOSE

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy.

METHODS

Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed.

RESULTS

The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy.

CONCLUSIONS

Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

The New Interest of Bariatric Surgeons in the Old Ligamentum Teres Hepatis

The search for an operation that effectively prevents and treats intrathoracic gastric migration (ITGM) after bariatric surgery has revived a long-forgotten technique: ligamentum teres cardiopexy (LTC) by which a vascularized flap of the teres ligament is wrapped around the distal esophagus. The systematic search of publications in the English language revealed 4 studies (total number of patients 53) in the non-bariatric literature with an unsatisfactory resolution of GERD. There were 5 reports from the bariatric literature with small patient numbers (total 64) and a short follow-up (6-36 months). There were no objective signs of gastric remigration in 93% of investigated patients. Acknowledging the limitations of these preliminary reports, bariatric surgeons are encouraged to further investigate the potentials of LTC in their patients.

A comparison between the mechanical properties of the hepatic round ligament and the portal vein: a clinical implication on surgical reconstruction of the portal and superior mesenteric veins

Abdominal malignant tumors originated from cancers, such as vater ampulla carcinoma (VAC) and pancreatic cancer (PC), often invades the portal vein (PV) and the superior mesenteric vein (SMV) upon metastasis. Surgical removal of these tumors leads to sacrifice of parts of these vessels that need to be reconstructed with autograft tissues. Current options for the replacement tissue all have their limitations in certain aspects. Therefore, improved interstitial material for the reconstruction with better tissue compatibility is urgently needed. In the present study, we explored the potential of hepatic round ligament (HRL) as a candidate tissue for the task from the biomechanical point of view. We reveal that HRL and PV share similar geometrical parameters in terms of vascular cavity diameter and wall thickness. In addition, they also have similar elastic properties and tissue flexibility and intensity upon increased cavity pressure. Our study strongly supports HRL as potential replacement tissue for PV reconstruction in term of mechanical properties and encourages further biological studies to be performed on these two tissues for further verification.

Laparoscopic repair of a perforated duodenal ulcer: another use of a round ligament flap

Management of a perforated duodenal ulcer is most commonly performed by laparoscopy and consists of suture of the perforation after performing lavage of the peritoneal cavity. In most cases, a flap is created, and an omental flap is usually the preferred choice because of its simplicity and its proximity to the site of duodenal perforation. However, in some cases, the greater omentum cannot be used due to the severity of peritonitis or due to previous surgical removal. We report a laparoscopic technique for surgical repair of a perforated duodenal ulcer using a round ligament flap. The present manuscript and the associated video highlight some important technical aspects to easily perform this procedure.

Autologous falciform ligament graft as A substitute for mesentericoportal vein reconstruction in pancreaticoduodenectomy

OBJECTIVE

To evaluate the falciform ligament as an autologous substitute for mesentericoportal vein reconstruction during pancreaticoduodenectomy.

BACKGROUND

Mesentericoportal vein reconstruction was needed in some certain cases during pancreaticoduodenectomy, and a rapidly available substitute was required.

METHODS

The falciform ligament was used as an autologous substitute during pancreaticoduodenectomy in 6 patients between June 2016 and May 2017. Anticoagulation was not performed at any stage and venous patency was estimated by Color-Doppler ultrasonography and contrast-enhanced computed tomography.

RESULTS

6 patients underwent vascular resection during pancreaticoduodenectomy for malignant tumors. The falciform ligament graft, with a mean length of 26 mm (10-40), was immediately harvested and used as a lateral patch for reconstruction of the mesentericoportal vein (n = 6). Severe morbidity included Clavien grade-III complications occurred in 1(16.7%) patients but there was no graft-related complications. Histological vascular invasion was present in all the patients (n = 6, 100%), and all had an R0 resection (100%). All venous reconstructions were patent (100%) after a mean follow-up of 12 (6-16) months.

CONCLUSIONS

An autologous falciform ligament graft can be safely used as a lateral substitute for mesentericoportal vein reconstruction during pancreaticoduodenectomy; this could help improve the radical resection rate of malignant tumors when oncologically required.

Immunohistochemical evaluation for outflow reconstruction using opened round ligament in living donor right posterior sector graft liver transplantation: A case report

Utilizing the opened round ligament as venous grafts during liver transplantation is useful but controversial, and there are no pathological analyses of this procedure. Herein, we describe the first reported case of a pathological analysis of an opened round ligament used as a venous patch graft in a living donor liver transplantation (LDLT). A 13-year-old female patient with biliary atresia underwent LDLT using a posterior segment graft from her mother. The graft had two hepatic veins (HVs), which included the right HV (RHV; 15 mm) and the inferior RHV (IRHV; 20 mm). The graft RHV and IRHV were formed into a single orifice using the donor’s opened round ligament (60 mm × 20 mm) as a patch graft during bench surgery; it was then anastomosed end-to-side with the recipient inferior vena cava. The recipient had no post-transplant complications involving the HVs, but she died of septic shock with persistent cholangitis and jaundice 86 d after LDLT. The HV anastomotic site had no stenosis or thrombus on autopsy. On pathology, there was adequate patency and continuity between the recipient’s HV and the donor’s opened round ligament. In addition, the stains for CD31 and CD34 on the inner membrane of the opened round ligament were positive. Hepatic venous reconstruction using the opened round ligament as a venous patch graft is effective in LDLT, as observed on pathology.

Parietal Peritoneum as an Autologous Substitute for Venous Reconstruction in Hepatopancreatobiliary Surgery

OBJECTIVE

To evaluate the parietal peritoneum (PP) as an autologous substitute for venous reconstruction during hepatopancreatobiliary (HPB) surgery.

BACKGROUND

Venous resection during liver or pancreatic resection may require a rapidly available substitute especially when the need for venous resection is unforeseen.

METHODS

The PP was used as an autologous substitute during complex liver and pancreatic resections. Postoperative anticoagulation was standard and venous patency was assessed by routine computed tomographic scans.

RESULTS

Thirty patients underwent vascular resection during pancreatic (n = 18) or liver (n = 12) resection, mainly for malignant tumors (n = 29). Venous resection was an emergency procedure in 4 patients due to prolonged vascular occlusion. The PP, with a mean length of 22 mm (15-70), was quickly harvested and used as a lateral (n = 28) or a tubular (n = 2) substitute for reconstruction of the mesentericoportal vein (n = 24), vena cava (n = 3), or hepatic vein (n = 3). Severe morbidity included Clavien grade-III complications in 4 (13%) patients but there was no PP-related or hemorrhagic complications. Histological vascular invasion was present in 18 (62%) patients, and all had an R0 resection (100%). After a mean follow-up of 14 (7-33) months, all venous reconstructions were patent except for 1 tubular graft (97%).

CONCLUSIONS

A PP can be safely used as a lateral patch for venous reconstruction during HPB surgery; this could help reduce reluctance to perform vascular resection when oncologically required. Clinical trials identification: NCT02121886.

Use of an autologous liver round ligament flap zeros postoperative bile leak after curative resection of hilar cholangiocarcinoma

BACKGROUND

Postoperative bile leak is a major surgical morbidity after curative resection with hepaticojejunostomy for hilar cholangiocarcinoma, especially in Bismuth-Corlette types III and IV. This retrospective study assessed the effectiveness and safety of an autologous hepatic round ligament flap (AHRLF) for reducing bile leak after hilar hepaticojejunostomy.

METHODS

Nine type III and IV hilar cholangiocarcinoma patients were consecutively hospitalized for elective perihilar partial hepatectomy with hilar hepaticojejunostomy using an AHRLF between October 2009 and September 2013. The AHRLF was harvested to reinforce the perihilar hepaticojejunostomy. Main outcome measures included operative time, blood loss, postoperative recovery times, morbidity, bile leak, R0 resection rate, and overall survival.

RESULTS

All patients underwent uneventful R0 resection with hilar hepaticojejunostomy. No patient experienced postoperative bile leak.

CONCLUSIONS

The AHRLF was associated with lack of bile leak after curative perihilar hepatectomy with hepaticojejunostomy for hilar cholangiocarcinoma, without compromising oncologic safety, and is recommended in selected patients.

One-step venous reconstruction using the donor's round ligament in right-lobe living-donor liver transplantation

We herein report the use of an opened round ligament as a venous patch graft for inferior right hepatic vein (IRHV) reconstruction and anastomosis to the inferior vena cava (IVC) in living-donor liver transplantation (LDLT) using a right-lobe (RL) graft. After laparotomy, the donor's round ligament was harvested and opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed on the back table for use as a patch graft. The right hepatic vein of the graft was anastomosed to the harvested patch, and the IRHV was anastomosed to an independent hole made in the wall on the other side of the patch, to form a bridged vascular patch for anastomosis to the IVC. The interposition graft filled promptly and provided a good outflow from the posterior segment. This is the first report of venous reconstruction using a donor's round ligament graft in RL-LDLT.

Pathological analysis of opened round ligaments as venous patch grafts in living donor liver transplantation

Although the round ligament, including the umbilical vein, could be used as a venous graft in living donor liver transplantation (LDLT), no studies have determined its appropriate use on the basis of pathological findings. We prospectively examined 19 LDLT cases in which the donor's round ligament was procured and used as a venous graft. The round ligaments were categorized into 3 types based on the CD31 immunohistochemistry of tissue cross-sections: (I) canalized umbilical veins (n = 7 or 36.8%), (II) capillary umbilical vessels (n = 4 or 21.1%), and (III) occluded umbilical veins (n = 8 or 42.1%). After dilatation and incision, the round ligaments provided patch grafts that were 5.8 ± 0.4 cm long and 1.8 ± 1.2 cm wide. However, histological studies showed the absence of fine intimal layers on the dilated round ligaments after mechanical maneuvers. The ligaments were used to cuff the venous orifices in 15 patients (left lobe, n = 8; right lobe, n = 7) and were used as venous bridges in 4 patients (left lobe, n = 2; right lobe, n = 2). We detected no thrombosis at the implant sites after LDLT. Our pathological findings indicate that opened round ligaments can be used safely as venous patch grafts in LDLT.

Segment 4 architecture and proposed parenchyma-wise technique for Ex vivo graft procurement and implantation

A parenchyma-wise technique for the ex vivo procurement of segment 4 (S4) grafts, based on the detailed architecture of the segment, is proposed. Eighteen normal, fresh livers from adult cadavers were injected differentially with colored latex; dissection casts were prepared; and the intricate architecture of S4 was studied. The portal vein elements of the sheath forming most of the inferior part of S4 (S4b) and the superficial major fraction of its superior part (S4a) arose constantly from the medial aspect of the umbilical part of the left portal vein branch. The arterial elements arose constantly from a branch, whose diameter ranged from 2.00 to 3.35 mm (mean = 2.61 ± 0.54 mm) and whose length ranged from 15.15 to 45.65 mm (mean = 27.98 ± 12.13 mm). The biliary elements coalesced as a single duct at the corner, which was formed from the umbilical and transverse parts of the left portal vein branch; the duct's diameter ranged from 2.90 to 6.85 mm (mean = 3.90 ± 1.34 mm). Theoretically, this parenchymal mass-S4b and the superficial fraction of S4a-could be procured for implantation in an infant, and the rest of the liver could be split for an adult and a child. The portal vein branches of the graft would be procured with a patch from the medial aspect of the donor's umbilical portion of the left portal vein branch. This umbilical portion would be reconstructed with a patch from the donor's round ligament. The recipient's portal vein would be reconstructed through the fashioning of a conduit anastomosed with the graft's venous patch.

[Latest indications for hanging manoeuvre in liver surgery]

By definition the liver hanging manoeuvre (LHM) means that a slip is passed between the liver parenchyma and the inferior vena cava. It was first published by Belghiti in 200l, and several changes in the indication as well as in the method have been published since then. In parallel, the anatomical and histological basis has been clarified for LHM, too. According to general consensus LHM increases safety and radicality of liver surgery. Initially LHM was applied for removal of huge tumours infiltrating the diaphragm. Authors worked out two modifications for LHM. Tumours / primary or secondary / in segment IVA are sometimes located in close proximity to the median hepatic vein and inferior vena cava , and the resectability of these tumors can determined by the hanging manoeuvre. Tumors in segment VII can be removed by partial resection of vena cava facilitated by LHM. Four patients with LHM are discussed, and based on this limited experience as well as the latest observations from relevant literature the authors claim that LHM increases the safety of resections from segment IVA and VII. Vascular infiltration of the vena cava is always a technical challenge, which can be suspected on preoperative imaging modalities, but in borderline cases only the intraoperative ultrasound and surgical judgment together with LHM would lead to the exact diagnosis and makes the resection possible.

Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: results of a retrospective cohort study

BACKGROUND

The significance of surgery in the treatment of hepatocellular carcinoma (HCC) extending into the inferior vena cava (IVC)/right atrium (RA) is currently unclear. We sought to clarify whether surgical treatment can improve survival in such patients.

METHODS

A retrospective review was undertaken of patients with HCC and IVC/RA tumor thrombus who were potential candidates for surgery but who were finally treated surgically and nonsurgically between September 2000 and October 2010. The patients were subdivided according to therapeutic modalities, and the results for each group were compared.

RESULTS

A total of 56 patients were included in this study. They were divided into three groups. Twenty-five patients underwent hepatectomy plus thrombectomy (surgical group), with minor morbidity and no mortality; the patients in this group had 1-, 3-, and 5-year survival rates of 68.0, 22.5, and 13.5%, respectively, with a median survival of 19 months. Twenty patients were treated with transcatheter arterial chemoembolization, with 1- and 3-year survival rates of 15.0 and 5.0%, respectively (median survival 4.5 months). Eleven patients received symptomatic treatment only, and no one in this group survived longer than 1 year (median survival 5 months). The patients in surgical group survived significantly longer than the patients in the other two groups (p < 0.001).

CONCLUSIONS

Although technically challenging, surgery for HCC with IVC/RA tumor thrombus can be safely performed and should be considered in patients with resectable primary tumor and sufficient hepatic reservoir because compared with transcatheter arterial chemoembolization or symptomatic treatment, it significantly improved patient survival.