Intrahepatic Glissonian approach for pedicle control during anatomic mesohepatectomy

Impact of anatomical liver resection for hepatocellular carcinoma in preventing early-phase local recurrence after surgery

BACKGROUND

The superiority of anatomical liver resection (AR) for localized hepatocellular carcinoma (HCC) over nonanatomical liver resection (NR) remains controversial. This study aimed to investigate the impact of AR in preventing local and early HCC recurrence.

METHODS

A total of 280 patients who underwent initial liver resection for solitary HCC ≤5 cm in diameter were categorized into the AR and NR groups and compared using propensity score matching analysis.

RESULTS

Between the matched pairs (n = 87 in each group), the incidence rates of local and early (recurrence within 2 years after surgery) recurrences in the AR group were significantly lower than those in the NR group (13.8% vs. 28.7%, p = .025; 20.7% vs. 35.6%, p = .028, respectively). The overall survival in the AR group was better than that in the NR group (median: 13.4 vs. 7.6 years, p = .003). NR was among independent risk factors for early recurrence (odds ratio: 1.98, 95% CI: 1.1-3.6, p = .023) and prognostic factors for local recurrence (hazard ratio: 2.44, 95% CI: 1.4-4.4, p = .003).

CONCLUSION

AR is superior in controlling local and early recurrence postoperatively for solitary HCC ≤5 cm in diameter compared with NR.

Role of Mesohepatectomy for Pediatric Centrally Located Liver Tumors

Background

Mesohepatectomy (MH) or central hepatectomy (CH) is a recognized surgical technique for centrally located pediatric liver tumors. This technique of liver resection avoids extended liver resections and thereby helps in the preservation of liver parenchyma. In this article, we aim to analyze our experience and outcome with this technique of liver resection.

Methods

A retrospective analysis of patients who underwent MH from January 2015 to June 2023 at our institute was performed. The variables analyzed include demographics, preoperative treatment, perioperative management, and postoperative outcome.

Results

A total of five patients underwent CH. Four patients had hepatoblastoma, and one patient had mesenchymal hamartoma. All four patients with hepatoblastoma received neoadjuvant chemotherapy. All five patients had negative surgical margins, and one of the five developed disease recurrences necessitating resurgery and ultimately died of metastasis. one patient sustained intraoperative major bile duct injuries, and one patient had postoperative Abnormal, well-circumscribed, extra-biliary collection of bile.

Conclusion

MH with clear margins is feasible in the selected subset of pediatric liver tumors involving segments IV, V, and VIII with outcomes equivalent to extended hepatic resections.

A Combined "Hanging Liver Maneuver" and "Intrahepatic Extra-Glissonian Approach" for Anatomical Right Hepatectomy: Technique Standardization, Results, and Correlation With Portal Pedicle Anatomy

Background: The hanging liver maneuver and intrahepatic extra-Glissonian approach are distinct modalities to facilitate safe anatomical liver resections. This study reports a standardized combination of these techniques focusing on safety, results and correlation with portal pedicle anatomy in oncological patients.

Method: Combined hanging liver maneuver and intrahepatic extra-Glissonian approach for anatomic right hepatectomy was described stepwise. Portal pedicle anatomy was correlated with the Glissonian approach failure and complications. Clinical characteristics of patients, perioperative outcomes, short and long-term survival rates were analyzed.

Results: Thirty colorectal liver metastases patients submitted to the combined approach were evaluated. Anatomical variations of the right portal pedicle were present in 26.6%. Hanging liver maneuver was feasible in 100%, and Glissonian approach in 96.7% despite portal pedicle variations. Mean operative time was 326 min. Mean blood loss was 507 ml. Mean hospital stay was 8 days. There was no 90-day operative mortality and no significant morbidity. Oncological surgical margins were free. Overall and disease-free 5-year survival were 59 and 37%.

Conclusion: Regardless of frequent anatomical variations of the right portal pedicle, the hanging liver maneuver, and intrahepatic extra-Glissonian approach can be combined, being useful for anatomical right hepatectomies in a safe and reproducible way in most patients.

"Liver parenchyma dissecting-first" method facilitates the Glissonean pedicle approach in anatomical laparoscopic hepatolobectomy

Background

Anatomical laparoscopic hepatolobectomy (ALH) is a difficult and challenging operation, and avoiding massive hemorrhage during parenchyma transection remains one of its major concern. Glissonean pedicle approach (GPA) has achieved great success in open liver surgery due to its simplicity and reproducibility, but it is difficult to apply in ALH for the limited vision and motion. We thus aimed to introduce a modified method to facilitate the GPA in ALH.

Methods

In this retrospective study, in 15 patients who underwent ALH (at least 2 couinaud segments), the liver parenchyma was dissected at first (LPDF) adequately under intermittent total inflow control to reveal the Glissonean pedicle (GP) sufficiently for safe and precise transection. The technical details of LPDF for different types of hepatolobectomy and a modified laparoscopic Pringle maneuver are described, and the surgical outcomes are reviewed.

Results

LPDF was applied in all patients, and intraoperative blood transfusion was not needed. LPDF facilitated GPA in ALH without any severe morbidity or mortality.

Conclusions

LPDF is a safe and effective technique, it reduces the difficulties in inflow occlusion in GPA and can promote the application of ALH. Further clinical control trails are needed to validate the superiority of LPDF compared with GPA in ALH.

The outcomes of central hepatectomy versus extended hepatectomy: a systematic review and meta-analysis

BACKGROUND

Central hepatectomy (CH) is a relatively uncommon liver resection technique. It is generally perceived as a more complex operation than extended hepatectomies (EH), with potentially higher associated morbidity. The outcomes of CH compared with EH is not well defined and there is a need to reassess.

METHODS

A systematic literature search was conducted in PubMed, MEDLINE, EMBASE and Web of Science according to PRISMA guidelines for studies on the treatment of liver tumours with CH published from 1972 until February 2017. Outcomes of patients undergoing CH were assessed and compared to those undergoing EH.

RESULTS

18 publications including 1380 CH were included for analysis. Mortality rates after CH ranged from 0 to 9%. There were 20 (1.4%) deaths after CH and the most common cause of death was post-hepatectomy liver failure (PHLF). Morbidity rates varied between 12 and 61% and 316 (23%) post-operative events were reported. Analysis of five comparative studies showed similar mortality between CH and EH groups (OR: 0.64, 95% CI = 0.24-1.70, p = 0.37). There were significantly fewer overall post-operative complications in the CH group (OR: 0.38, 95% CI = 0.28-0.51, p < 0.001) and reduced PHLF was found in the CH group compared to EH (OR: 0.53, 95% CI = 0.29-0.98, p = 0.04). The rates of post-hepatectomy biliary complications were similar between groups (OR: 0.98, 95% CI = 0.51-1.88, p = 0.96). Mean length of stay (days) was shorter in the CH group (MD: -2.67, 95% CI = -4.93 to -0.41, p = 0.02).

CONCLUSION

CH appears to have similar post-operative mortality rates compared to EH but is associated with fewer post-operative complications, including PHLF and shorter overall length of stay.

Updates and Critical Insights on Glissonian Approach in Liver Surgery

Recent advances in surgical techniques have broadened the indications of surgical management of liver malignancies. Intraoperative bleeding is one of the known predictors of postoperative outcomes following liver surgery, signifying the importance of vascular control during liver resection. Furthermore, preservation of future liver remnant plays a critical role in prevention of post-hepatectomy liver failure as one of the main causes of postoperative morbidity and mortality. Glissonian approach liver resection offers an effective method for vascular inflow control while protecting future liver remnant from ischemia-reperfusion injury. Several studies have demonstrated the feasibility of Glisson's pedicle resection technique in modern liver surgery with an acceptable safety profile. Moreover, with increasing popularity of minimally invasive surgery, laparoscopic liver resection via Glissonian approach has been shown to be superior to standard laparoscopic hepatectomy. Herein, we systematically review the role of Glissonian approach hepatectomy in current practice of liver surgery, highlighting its advantages and disadvantaged over other methods of vascular control.

Left hepatectomy after right paramedian sectoriectomy

Repeat hepatectomy is beneficial for selected patients with recurrence of liver malignancies. However, the operative procedure becomes technically demanding when the previous hepatectomy was complex, with hepatic veins and stump of portal pedicles exposed on the liver transection surface. We performed left hepatectomy after right paramedian sectoriectomy (RPMS) for three patients. Here, we describe our surgical technique and the postoperative outcomes achieved. This procedure allowed for safe adhesiolysis between the middle and right hepatic veins by following a fibrous plane. The mean operative time was 8.7 h, including 4.9 h of adhesiolysis. The mean remnant liver volume (right lateral sector and the caudate lobe) was calculated as 704 ml, being 62% of total liver volume. There was no postoperative liver failure or mortality. In conclusion, left hepatectomy after RPMS is a feasible procedure for patients with sufficient remnant liver volume, even though the middle and right hepatic veins run side by side after liver regeneration.

Preventive Measures for Postoperative Bile Leakage After Central Hepatectomy: A Multicenter, Prospective, Observational Study of 101 Patients

BACKGROUND

There are no conclusive measures for preventing postoperative bile leakage (POBL).

METHODS

First, 310 patients who underwent hepatectomy were analyzed retrospectively to clarify risk factors for POBL. Then, focusing on operations at high risk of POBL, patients who underwent central hepatectomy were recruited prospectively among 18 institutions, to evaluate various preventive measures for avoiding POBL. The primary endpoint was the frequency of POBL.

RESULTS

The retrospective analysis revealed central hepatectomy and repeated hepatectomy to be independent risk factors for POBL. One hundred and one patients undergoing central hepatectomy were enrolled in the prospective study. POBL developed in 13 patients (12.9 %). Intraoperative bile leakage was recognized in 42 of the 101 patients (41.6 %), and 10 of the 42 patients developed POBL (23.8 %). Primary closure of the site of bile leakage and/or biliary drainage tube placement was preferable for preventing POBL in the patients with intraoperative bile leakage. Although 59 patients (58.4 %) did not show intraoperative bile leakage, three patients (5.1 %) developed POBL. In the group without intraoperative bile leakage, treatment with fibrin glue with a polyglycolic acid (PGA) sheet or collagen sheet coated with a fibrinogen and thrombin layer (CSFT) had good results.

CONCLUSIONS

Primary closure of the site of bile leakage and/or placement of biliary drainage tubes may be recommended in cases involving intraoperative bile leakage. Treatment with fibrin glue with a PGA sheet and/or CSFT might have preventive effects in patients without intraoperative bile leakage.

A Technique for Simultaneous Cholecystectomy During Bariatric Surgery

Background and Objectives:

Cholecystectomy performed during bariatric surgery is technically demanding. Herein is described a technique we term the Glissonian approach along with an evaluation of its effectiveness and safety.

Methods:

From April 1, 2009, through February 28, 2014, laparoscopic cholecystectomy was performed during laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in 38 patients with proven cholecystopathy on diagnostic imaging. Perioperative outcomes were compared between the patients operated on with the Glissonian approach and those who underwent conventional laparoscopic cholecystectomy.

Results:

The Glissonian approach was adopted in 13 patients—11 during LRYGB and 2 during LSG—and the conventional operation was performed on 16 patients during LRYGB and 9 during LSG. Mean body mass indexes were 40.1 kg/m² in the Glissonian-approach group and 37.6 kg/m² in the conventional group. Laparoscopic cholecystectomy by the Glissonian approach saved a mean operative time of 7 minutes compared with the operative time of the conventional operation. No surgical complications related to cholecystectomy were noted in either group.

Conclusion:

This simple technique can be performed safely in morbidly obese patients, with low resultant morbidity and acceptable operation times.

Impact of three-dimensional reconstruction technique in the operation planning of centrally located hepatocellular carcinoma

BACKGROUND

The aim of this retrospective study was to compare the outcomes of operations based on 3-dimensional (3D) operation planning with non 3D-assisted operations in the treatment of centrally located hepatocellular carcinoma.

STUDY DESIGN

From April 2008 to March 2014, 116 patients with centrally located hepatocellular carcinoma received surgical treatment in our department. Among these cases, a total of 60 patients received resection with operation planning based on 3D reconstructions (group A); the remaining 56 received treatment with the aid of traditional imaging (group B). Three-dimensional surgical planning, including the classification system for centrally located hepatocellular carcinoma, was elaborated in the study.

RESULTS

Compared with group B, group A was linked to shorter operation time (294.5 ± 61.9 minutes vs 324.3 ± 83.1 minutes; p = 0.028) and lower rate of hepatic inflow occlusion (51.7% vs 71.4%; p = 0.029). No differences were found in surgical methods, intraoperative blood transfusion, and intraoperative blood loss. The groups were similar in their rates of complications, except that group B was more liable to have Clavien Grade III to V complications (3.3% vs 14.3%; p = 0.048). In addition, a significant difference in ascites was found across the 2 cohorts (2 in group A and 8 in group B; p = 0.048), and the 2 groups also differed significantly in total bilirubin (23.2 ± 16.1 g/L vs 31.1 ± 24.1 g/L; p = 0.032) and albumin (29.3 ± 5.2 g/L vs 27.8 ± 7.9 g/L; p = 0.033).

CONCLUSIONS

Compared with non 3D-assisted operations, the operation planning based on 3D reconstruction is a more effective and reasonable method in the treatment of centrally located hepatocellular carcinoma. In addition, the classification system may facilitate the 3D operation planning.

Central hepatectomy for centrally located malignant liver tumors: A systematic review

AIM: To study whether central hepatectomy (CH) can achieve similar overall patient survival and disease-free survival rates as conventional major hepatectomies or not.

METHODS: A systematic literature search was performed in MEDLINE for articles published from January 1983 to June 2013 to evaluate the evidence for and against CH in the management of central hepatic malignancies and to compare the perioperative variables and outcomes of CH to lobar/extended hemihepatectomy.

RESULTS: A total of 895 patients were included from 21 relevant studies. Most of these patients who underwent CH were a sub-cohort of larger liver resection studies. Only 4 studies directly compared Central vs hemi-/extended hepatectomies. The range of operative time for CH was reported to be 115 to 627 min and Pringle’s maneuver was used for vascular control in the majority of studies. The mean intraoperative blood loss during CH ranged from 380 to 2450 mL. The reported morbidity rates ranged from 5.1% to 61.1%, the most common surgical complication was bile leakage and the most common cause of mortality was liver failure. Mortality ranged from 0.0% to 7.1% with an overall mortality of 2.3% following CH. The 1-year overall survival (OS) for patients underwent CH for hepatocellular carcinoma ranged from 67% to 94%; with the 3-year and 5-year OS having a reported range of 44% to 66.8%, and 31.7% to 66.8% respectively.

CONCLUSION: Based on current literature, CH is a promising option for anatomical parenchymal-preserving procedure in patients with centrally located liver malignancies; it appears to be safe and comparable in both perioperative, early and long term outcomes when compared to patients undergoing hemi-/extended hepatectomy. More prospective studies are awaited to further define its role.

Intrahepatic Glissonian approach and outflow vascular occlusion during partial hepatectomy

Under ultrasound guidance, a blunt suture needle was inserted around the Glissonian pedicle and then sutured. This technique significantly reduced the blood loss and facilitated the procedure of partial hepatectomy. We applied this technique in 182 patients who needed partial hepatectomy. We concluded that this method is simple and easy to occlude the vascular inflow and outflow, and allows an accurate delineation of the anatomic zone and therefore, simplifies the procedure of partial hepatectomy.

Anatomy and surgical relevance of Rouviere's sulcus

Rouviere's sulcus (RS) (i.e., incisura hepatis dextra, Gans incisura) represents an important anatomical landmark. The aim of the study was to determine the frequency of the RS, its description, its location, its relations to the right portal pedicle and to the plane of the common bile duct, and the evaluation of the surgical relevance of the obtained data. Forty macroscopically healthy and undamaged livers were removed during autopsies from cadavers of both sexes. The RS was present in 82% of the cases and in these the open RS was identified in 70% of the livers. The fused type was observed in 12% of the cases; 18% of the livers had no sulcus. The mean length of the open type RS was 28 ± 2 mm (range 24-32 mm) and its mean depth was 6 ± 2 mm (range 4-8 mm). The right posterior sectional pedicle was found in the RS in 70% of the cases. In 5% of the livers, we also dissected a branch of the anterior sectional pedicle. Inside 25% of the RS, we found the vein of segment 6. The RS identification may avoid bile duct injury during laparoscopic cholecystectomy and enables elective vascular control during the right liver resection.

Mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma

BACKGROUND

Mesohepatectomy with total resection of the caudate lobe and extrahepatic bile duct is sometimes performed for hilar cholangiocarcinoma or gallbladder carcinoma; however, only a few reports on mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma are available.

METHODS

A 71-year-old woman was preoperatively diagnosed with hepatocellular carcinoma in the central bisections (Couinaud's segments 4, 5, and 8) and the paracaval portion of the caudate lobe. Mesohepatectomy with total caudate lobectomy of the liver permitted the removal of tumors to provide a cancer-free raw surface of the liver. Mobilization of the caudate lobe is an important procedure in this surgery. Before the liver parenchyma was dissected, all short hepatic veins were ligated and divided from the left to the right side as the left lateral section was retracted to the right, and the caudate lobe branches of the portal vein and hepatic artery were ligated and divided. After the liver parenchymal dissection, both between the left lateral and medial sections and between the right anterior and posterior sections, the Glissonean branches of the caudate lobe were ligated and divided as the central bisections were anteriorly retracted. Finally, liver parenchymal dissection was performed between the caudate lobe and the right posterior section, which was along the right side of the inferior vena cava.

RESULTS

The surgery time was 538 minutes and blood loss was 1,207 mL. No blood transfusions were required during or after surgery. The postoperative course was uncomplicated. The patient is still alive 25 months after hepatectomy.

CONCLUSION

Although mesohepatectomy with total caudate lobectomy of the liver is technically more difficult than mesohepatectomy of the liver because the caudate lobe must be completely detached from the inferior vena cava and the hilar plate, it is a safe and effective treatment method in selected patients with hepatocellular carcinoma located at both the central bisections and the paracaval portion of the caudate lobe.

Resection of segment VIII for hepatocellular carcinoma

Background

Anatomical resection of segment VIII (SVIII) is technically demanding. Only two small studies have published short-term outcomes. The aim of the present study was to evaluate short- and long-term outcomes after anatomical resection involving SVIII for hepatocellular carcinoma (HCC), and to compare long-term outcomes with those after non-anatomical resection of SVIII.

Methods

Outcomes after anatomical resection of SVIII or its subsegments for HCC were compared with those in patients who underwent primary non-anatomical resection of SVIII during the same period.

Results

A total of 154 patients underwent anatomical resection involving SVIII and 122 had non-anatomical resection. In patients undergoing anatomical resection, the preoperative indocyanine green retention rate at 15 min ranged from 2·9 to 32·2 (median 13·6) per cent, and was 10 per cent or more in 109 patients (70·8 per cent). Median duration of operation and blood loss were 378 min and 705 ml respectively. There were no postoperative deaths, but major adverse events occurred in ten patients (6·5 per cent). The cumulative 5-year recurrence-free and overall survival rates were 28·5 and 79·6 per cent, which were significantly better than rates of 19·4 and 64·8 per cent respectively after non-anatomical resection (P = 0·036 and P &lt; 0·001).

Conclusion

Complete resection of SVIII or its subsegments can be performed safely and the long-term outcomes seem acceptable. This can be a curative procedure for HCC, especially in patients with limited liver function reserve, in whom right hepatectomy or right paramedian sectorectomy might otherwise be needed.

Alternative management of anatomical right hemihepatectomy using ligation of inflow and outflow vessels without hilus dissection

BACKGROUND AND AIM

The conventional method of anatomical right hemihepatectomy (ARHH) requires hilus dissection. We report a method without hilus dissection to minimize intraoperative bleeding.

METHODS

We retrospectively evaluated data of 107 patients who received ARHH involving ligation of corresponding inflow and outflow vessels (LCIOV) without hilus dissection between January 2000 and October 2008. Results were compared to those of patients who underwent non-anatomical right hemihepatectomies (NARHH).

RESULTS

The two groups had similar gender and age (both, P>0.05). The LCIOV group had a higher percentage of patients without intrahepatic metastases (94.6% vs 80.3%, P=0.003). Hepatocellular carcinoma (HCC) lesion size (9.3 vs 10.2, P=0.023), durations of inferior vena cava occlusion (4 vs 4.7, P<0.001) and portal triad occlusion (7 vs 11, P<0.001), blood loss (430 vs 580 mL, P=0.001), transfusion volume (300 vs 520 mL, P<0.001), and measures of postoperative liver function (e.g. maximum aspartate aminotransferase [AST]) of the LCIOV group were also significantly less than the NARHH group. Larger hepatic cavernous hemangiomas (HCH) lesion size (16.2 vs 13.0, P<0.001), longer operative time (168 vs 154 min, P=0.017), and a lower percentage of patients with inferior vena cava occlusion (17.8% vs 35.2%, P=0.001), pleural effusions (19.3% vs 30.9%, P=0.042), and blood transfusions (10.3% vs 75.0%, P<0.001) were found in the LCIOV group.

CONCLUSION

The reported method is a safe and bloodless technique for right hemihepatectomy in select patients.

Glissonian approach for laparoscopic mesohepatectomy

BACKGROUND

Experience with advanced techniques has increased the indications for laparoscopic liver resection. This video demonstrates technical aspects of a pure laparoscopic mesohepatectomy using intrahepatic Glissonian technique. To the best of our knowledge, this is the first case of anatomic laparoscopic mesohepatectomy using the Glissonian approach published in the English literature.

METHODS

A 62-year-old man with colorectal liver metastasis occupying central liver segments was referred for surgical treatment. The first step is the control of segment 4 pedicle. Using the round ligament as a guide, one incision is performed on its right margin and another is made at the bottom of segment 4. A vascular clamp is introduced through those incisions to occlude segment 4 Glissonian sheath. The next step is to control the right anterior pedicle. The first incision is made in front of the hilum and another is performed on the right edge of gallbladder bed. Laparoscopic clamp is introduced through these incisions and closed producing ischemic discoloration of segments 5 and 8. Vascular clamp is replaced by an endoscopic vascular stapling device and stapler is fired. Line of liver transection is marked along the liver surface following ischemic area. Liver transection is accomplished with bipolar vessel sealing device and endoscopic stapling device as appropriate. Specimen was extracted through a suprapubic incision. Liver raw surfaces were reviewed for bleeding and bile leaks.

RESULTS

Operative time was 200 min with minimum blood loss and no need for blood transfusion. Recovery was uneventful, and the patient was discharged on the fifth postoperative day. Histological examination revealed clear surgical margins.

CONCLUSIONS

Mesohepatectomy can be safely performed laparoscopically in selected patients and by surgeons with expertise in both liver surgery and laparoscopic techniques. The use of the intrahepatic Glissonian approach may help to identify the exact limits of the mesohepatectomy to avoid ischemic injury of the remnant liver.

Extra-Glissonian approach in liver resection

BACKGROUND

In this study we analyzed our most recent experience in the use of the extraglissonian approach to the hilar structures in two circumstances: pedicle transection during major liver resections, and selective clamping in minor hepatectomies.

METHODS

The major liver resections study group consisted of 89 cases. Extraglissonian approach and stapler transection of hilar structures was used in 61 (69%). The study group of minor liver resections consisted of 103 cases. Extraglissonian approach and selective clamping was used in 27 cases (26%).

RESULTS

In major hepatectomies pedicle stapling and hilar dissection demonstrated a similar operative time (240 vs. 260 min; P = 0.230); no differences were observed in the amount of haemorrhage (800 ml vs. 730 ml; P = 0.699), number of patients transfused (16 vs. 6; P = 0.418) and volume of blood transfused (4 PRC vs. 4 PRC; P = 0.521). Duration of vascular pedicle occlusion was 35 vs. 30 min respectively (P = 0.293). Major complications (grade >or=3a) occurred in 18 (20%) patients and mortality rates (4.9% vs. 3.5%; P = 0.882) were similar for both group. In minor liver resections there were no differences between Pringle and selective clamping in operative time (240 vs. 240 min; P = 0.321), haemorrhage (435 ml vs. 310 ml; P = 0.575), number of patients transfused (18 vs. 7; P = 0.505) and volume blood transfused (4 PRC vs. 3 PRC; P = 0.423). Major complications (grade >or=3a) occurred in 14 (14%) patients, and mortality (2.6% vs. 3.7%; P = 0.719) were similar for both groups. However, the duration of pedicle clamping was significantly longer in the selective clamping group (26 +/- 21 minutes vs. 44 +/- 18 minutes) (P = 0.001).

CONCLUSIONS

The extraglissonian approach can be extremely useful in liver surgery. Selective clamping with extraglissonian approach avoids ischemia to the other hemiliver. Selective clamping it is also important from the homodynamic point of view because there is no splanchnic stasis and low fluid replacement.

Anatomic resection of segment VIII of liver for hepatocellular carcinoma in cirrhotic patients based on an intrahepatic Glissonian approach

BACKGROUND

Isolated segmentectomy VIII is a technically demanding operative procedure and is reported only rarely. To our knowledge, no reports on anatomic segmentectomy based on an intrahepatic approach have been described. For cirrhotic patients with hepatocellular carcinoma (HCC) limited to segment VIII, this is a parenchyma-preserving hepatectomy that can be tolerated.

METHODS

Eighteen patients with HCC underwent anatomic segment VIII segmentectomy from January 2005 to January 2008 in our institution. The operative techniques, postoperative, and oncologic outcomes were reviewed.

RESULTS

Anatomic segmentectomy VIII was feasible with the technology described herein in all patients. The perioperative and oncologic outcomes were comparable with those of other similar hepatic resections. The median follow-up time was 28 months. The 3-year survival rate was 65%.

CONCLUSION

Although complex and technically demanding, an intrahepatic Glissonian approach for anatomic segmentectomy of segment VIII is an oncologically radical but parenchyma-sparing hepatic resection. In terms of preserving greater functioning liver parenchyma, it may be a safe and effective alternative to extensive hepatectomy.

Mesohepatectomy as an option for the treatment of central liver tumors

BACKGROUND

Despite substantial improvements in intra- and postoperative management of extended hemihepatectomy as the curative option for treatment of central liver tumors, the high morbidity and mortality rates accompanying the procedure still represent major obstacles. Mesohepatectomy preserves up to 35% more functional liver tissue than extended hepatectomy, but it has not been widely applied, perhaps because of its complexity as a resection method.

STUDY DESIGN

Forty-eight consecutive patients (29 men and 19 women) with centrally located liver tumors underwent mesohepatectomy. Peri- and postoperative morbidity and mortality rates were prospectively evaluated and analyzed. Mean age of the patients was 60.7 years. Indications for mesohepatectomy were liver metastasis (n = 29), hepatocellular carcinoma (n = 5), gallbladder carcinoma (n = 4), cholangiocellular carcinoma (n = 4), hemangioma (n = 2), and other benign diseases (n = 4).

RESULTS

Mean operative time was 238 minutes (range 65 to 480 minutes) and mean intraoperative blood loss was 1,120 mL (range 100 to 5,000 mL). Mean amount of intraoperative red blood cells and fresh frozen plasma transfusion was 3.6 U (range 1 to 12 U) and 3.8 U (range 2 to 14 U), respectively. Mean postoperative hospitalization was 15.8 days (range 6 to 104 days). Postoperative surgical complications were seen in 18.8% of patients (n = 9) and included liver failure (n = 1), intraabdominal abscess (n = 1), bilioma or bile leakage (n = 4), hemorrhage and hematoma (n = 2), peritonitis because of intestinal perforation (n = 1), and wound infection (n = 1). One patient (2%) died in the early postoperative phase from portal vein bleeding and disseminated intravascular coagulation, followed by liver failure.

CONCLUSIONS

Compared with extended liver resection, mesohepatectomy clearly leads to less parenchymal loss. Although it is a technically difficult operation and requires special attention to prevent surgical complications, it is justified in selected patients with centrally located tumors and is a feasible and safe alternative to extended liver resection.

Porcine liver: experimental model for the intra-hepatic glissonian approach

PURPOSE: The aim of the study is to evaluate the porcine liver as a teaching and training model for the glissonian approach. METHODS: Ten livers were removed from domestic adult white pigs weighting 35 to 45kg. Based on anatomical landmarks, the glissonian pedicles of each liver segments were dissected and biopsies were taken for histological examination, to analyze the presence of the glissonian sheath. RESULTS: During microscopic examination, a sheath of conjunctive tissue was observed wrapping each segmental pedicle in porcine liver. This could be clearly seen when histological preparation for connective tissue was obtained (Masson technique). CONCLUSION: The morphological arrangement of glissonian pedicles in porcine liver makes this model a useful tool for training the intra-hepatic glissonian approach.

Extraparenchymal control of hepatic veins during mesohepatectomy

BACKGROUND

Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding.

STUDY DESIGN

We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver.

RESULTS

Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins).

CONCLUSIONS

Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.