A 15-year experience of two hundred and twenty five consecutive right hepatectomies

BACKGROUND

In case of liver tumor, surgical resection is the therapeutic gold standard to increase patient survival. Among liver resections, right hepatectomy (RH) is defined as a major hepatectomy. The first aim of this study was to analyze the overall morbidity and mortality of patients undergoing RH, the second aim was to assess changes in both patients characteristic and surgical parameters and mortality rates in a single center institution.

MATERIALS

From 2001 to December 2015, 225 RH were performed in our center. We analyzed two time period: 2001-2007 and 2008-2015.

RESULTS

Ninety days post operative mortality was observed in 9 cases (4%) for the overall cohort. We observed a difference between the two groups in the use of Pringle Maneuver (p<0,001). This result is consistent in each major surgical indication: HCC (p=0,001), CLM (p=0,015) and BT (p=0,015). The estimated blood losses improved (p=0,028), particularly for the HCC cases (p=0,024). No difference was observed in terms of number of transfusions received between the two groups. Reduced length of stay was observed in the second group (p<0,001), more markedly for CLM cases (p=0,001).

CONCLUSION

To further improve the outcomes of RH, it is important to performed this major hepatectomy in hepatobiliary centers with an overall liver resection experience of at least few hundred cases.

Two-stage hepatectomy, a 10 years experience

Colorectal tumor represents in Europe the second most common cause of cancer death. Surgical resection in case of colorectal liver metastasis remain for patients the only cure. In 2003, Jaeck et al. described a one or two-stage hepatectomy combined with PVE for initially non-resectable colorectal liver metastases. The aim of our study was to retrospectively review all patients who underwent to a two-stage hepatectomy for CLM and evaluate the safety and feasibility of the procedure. We review all patient who underwent two-stage hepatectomy for CLM in our center. From 2004 to March 2014, 57 patients were candidate for a two-stage hepatectomy for CLM. Thirty-two patients (55.9 %) were men and twenty-five women (44.1 %). Median age was 60.9 years old. In forty-six cases, the two-stage hepatectomy was completed. Of these 46 patients, 38 patients completed the procedure with a PVL and 8 underwent a secondary PVE. Seven patients were planned but did not performed PVL after intraoperative evaluation and neither PVE after secondary evaluation due to disease progression. Five cases were treated with a laparoscopic approach for the first step procedure. We had no death in this series. Ten patients developed complications after the first-stage operation and 18 patients had complications after the second stage. The median interval between the two stages was 66 days. Long-term overall survival was 52 months from the first liver surgery. This study demonstrated the feasibility of two-stage hepatectomy without postoperative mortality. In our last experience in selected patient, a laparoscopic first step should be performed. Patients selection is extremely important to propose the best therapeutic option for each one.

Surgical anatomy of the posterior liver surface: the retrohepatic lamina as the basis for mobilisation of the right liver

BACKGROUND

During right hepatectomies, dissection of the bare area is performed to obtain mobilisation of the liver. Fifty computed tomography scans of the upper abdomen of patients were examined. Specimens of supramesocolic compartment were sampled from 10 un-embalmed cadavers. Macrosections were cut for histotopographic study. In four cadavers, in situ dissection of the posterior liver surface was performed.

RESULTS

The hepatophrenic tissue showed a stratigraphic organisation resulting from the juxtaposition of thin layer of dense connective tissue corresponding to the inferior diaphragmatic fascia (mean thickness is 30 ± 4 μm); variable amount of fibroadipose tissue corresponding to retroperitoneal fibroadipose tissue (mean thickness is 34 ± 8 μm); two connective layers with nets of flat cells forming a fusion fascia, the retrohepatic lamina (mean thickness 24 ± 6 μm); and layer of connective tissue corresponding to the hepatic capsule. The juxta-caval portion of the retrohepatic lamina, connecting the right and left sides of the caval groove, forms the inferior vena cava ligament. During dissection, fluid injection developed a preferential plane between the two layers of the retrohepatic lamina, close to the hepatic surface, and no major or minor vessels were ever found along this plane.

CONCLUSION

During right hepatectomy, to reduce the risk of dissemination of tumour cells, the dissection plane should be performed between the two layers of the retrohepatic lamina.

Anatomy of the retrohepatic segment of the inferior vena cava and the ostia venae hepaticae with its clinical significance

PURPOSE

The present study was undertaken to provide morphological data regarding the retrohepatic segment of the inferior vena cava (RHIVC) and ostia venae hepaticae with an emphasis on the clinical significance of the observations made.

METHODS

This was an observational study conducted on 160 apparently healthy, randomly selected, cadaveric adult human livers fixed in 10% formalin. The distribution of the hepatic venous openings was studied by dividing the interior of the RHIVC into 16 quadrants. These openings were classified as large, medium, small and very small openings based on their diameter and were also classified as single/double/triple/quadruple according to the number of veins opening into them.

RESULTS

The median length of RHIVC was 7.3 cm (6.2-8.4) and was directed obliquely with respect to the vertical axis of the liver in 92.5% of cases. A total of 1,376 ostia venae hepaticae were observed, and the median number of openings per liver was 7 (5-9). The right hepatic vein had a single opening in 156 (97.5%) and the left and middle hepatic veins had a common opening in 144 (90%) cases. A longitudinal area on the anterior wall of the RHIVC, to the right side of the midline, was relatively avascular with 10.1% of the venous openings, of which 70% were single openings of the right dorsal vein having a small diameter (0.1-0.5 cm).

CONCLUSION

During liver hanging maneuver, rightward direction of the dissecting forceps would avoid injury to the caudate vein and allow access to the safe avascular space in the RHIVC.

Resection of large hepatocellular carcinoma using the combination of liver hanging maneuver and anterior approach

BACKGROUND

Resection of a large hepatocellular carcinoma (HCC) is difficult and is associated with a poor outcome. Herein we describe our experience with the use of a liver hanging maneuver (LHM) in conjunction with the anterior approach (AA) in patients with large HCC (>10 cm) and compare the perioperative outcome with the conventional method (CM) for hepatic resection.

METHODS

Patients who underwent major hepatic resections for large HCC (>10 cm) were categorized as group 1 (n = 14), treated with LHM and AA, versus group 2 (n = 11), treated with CM. Variables including patient age, tumor size, operative time and transection time, blood loss, blood transfusion requirements, and postoperative ICU and hospital stay were used to compare the two groups.

RESULTS

There were 14 and 11 patients in groups 1 and 2, respectively. The variables in group 1 and 2 of median tumor size, median operative time, median transection time, median ICU stay, and median hospital stay were comparable. In contrast, the intraoperative blood loss and the blood transfusion requirements were significantly higher in group 2. Patients under LHM and AA and CM had a median blood loss of 375 ml (237.5-850) and 1,000 ml (500-1,200), requirement of blood transfusion of 3 (21.42%) and 8 (72.7%), respectively. Postoperative complications were comparable in the two groups. There were no deaths in the series.

CONCLUSIONS

The liver hanging maneuver in conjunction with AA is a safe and highly feasible procedure, particularly in patients with sizable (>10 cm) tumors and tumors found to be adherent to the diaphragm and retroperitoneum. The use of the procedure eventuated in lower blood loss as well as fewer blood transfusion requirements when compared to the conventional method.

Right hepatectomy by the anterior method with liver hanging versus conventional approach for large hepatocellular carcinomas

BACKGROUND

The aim was to compare short-term results of right hepatectomy using the anterior approach (AA) and liver hanging manoeuvre with the conventional approach (CA) for large hepatocellular carcinoma (HCC).

METHODS

This was a retrospective review of 71 consecutive patients with HCC at least 5 cm in diameter who underwent curative right hepatectomy using either the AA with the liver hanging manoeuvre (33) or the CA (38) between January 2004 and December 2008. Clinical data, operative results and survival outcomes were analysed.

RESULTS

The groups had similar clinical, laboratory and pathological parameters. The AA group had larger tumours than the CA group (P = 0.039), but comparable grade and stage distribution. The operative results were similar except for an increased blood transfusion requirement with the conventional procedure (P = 0.001). The AA group had a lower recurrence rate (P = 0.003) and better disease-free survival (DFS) (P = 0.001) than the CA group, but overall survival rates were not significantly different (P = 0.091). Presence of tumour encapsulation, absence of tumour microvascular invasion and AA were predictive of DFS, whereas tumour stage was the only independent predictor of overall survival.

CONCLUSION

The AA right hepatectomy with liver hanging manoeuvre for large HCC is associated with reduced blood transfusion requirement and lower recurrence rates in the short term.

The liver hanging manoeuvre

The liver hanging manoeuvre (LHM) facilitates the anterior approach (AA), which is one of the most important innovations in the field of major hepatic resections. The AA confers some definite advantages over the classical approach, in that it provides for: less haemorrhage; less tumoral manipulation and rupture; better haemodynamic stability by avoiding any twisting of the inferior vena cava; reduced ischaemic damage of the liver remnant, and better survival for patients with hepatocellular carcinoma (HCC). The LHM makes the AA easier because it serves as a guide to the correct anatomical transection plane and elevates the deep parenchymal plane. The LHM is a safe technique, in which minor complications have been reported in < or = 7% of patients and >90% feasibility has been demonstrated in experienced centres. Over the years, different variants of the LHM have been developed to facilitate almost all anatomical liver resections. In view of its advantages, feasibility and safety, the LHM should be considered for most anatomical hepatectomies.

Direct intrahepatic portocaval shunt through transhepatic puncture via retrohepatic inferior vena cava: applied anatomical study

BACKGROUND

DIPS is to create a portosystemic shunt directly between the portal vein and the retrohepatic inferior vena cava (RIVC) without passing through the hepatic vein. It has been recommended that the DIPS could be applied when routine TIPS is unsuccessful or the patient has anatomical variations of the hepatic vein. The aim of this study was to identify the safe area of the RIVC where the DIPS can be safely established.

MATERIALS AND METHODS

The lengths of the safe and unsafe areas of the RIVC were measured. The tributaries of the RIVC were examined. The diameter of these tributaries was measured and their incidence and relation to the safe area of the RIVC were observed. The puncture distances of DIPS and TIPS were measured and compared.

RESULTS

The liver together with the RIVC was collected from 31 adult cadavers (age 32-65 years; M/F 25/6). 1. The safe and unsafe areas of the RIVC: the total length of the RIVC was 70.1 +/- 13.0 mm (33.1-92.0 mm), whereas the length of the safe area of the RIVC was 54.3 +/- 12.3 mm (20.2-71.1 mm), which was about over 70% of the total length. The length of the unsafe area at the upper end was 5.9 +/- 1.8 mm (3.0-10.2 mm), and at the lower end was 8.9 +/- 2.9 mm (3.1-20.0 mm). 2. The tributaries of the RIVC: In about 90% of the cadavers (90.3%; 28 out of 31), the LHV and MHV had the common trunk. The other three cadavers (9.7%; 3 out of 31) had independent RHV, MHV and LHV. There were 217 of small hepatic veins draining into the lower segment of the RIVC. Over 70% of the small hepatic veins were smaller than 5 mm in diameter and distributed on the anterior and left wall of the lower RIVC. 3. Puncture distances of the DIPS and TIPS: The distances from the bifurcation of the portal vein to the RIVC, to the right and to middle hepatic veins were 31.2 +/- 7.9 mm (15.0-47.2 mm), 38.6 +/- 8.1 mm (17.2-59.0 mm), and 46.6 +/- 8.2 mm (34.0-68.1 mm), respectively. Thus, the puncture distances via the RIVC, RHV and LHV were significantly different (P < 0.001). The puncture distance of the DIPS was shortest.

CONCLUSION

Anatomically, DIPS is a feasible interventional procedure to make a intrahepatic shunt between IVC and portal vein directly, and has its anatomical advantages compared to TIPS.

Histological basis of the liver hanging maneuver

BACKGROUND

Liver hanging maneuver (LHM) consists in passing a tape between the retrohepatic inferior vena cava (RHIVC) and the liver to perform various kinds of hepatectomies. LHM is a well-known procedure but its histological basis remains poorly documented.

METHODS

Ten anatomical specimens comprising RHIVC, and surrounding hepatic parenchyma were studied after conventional staining and immunohistochemistry with specific antibody for alpha smooth muscle actin.

RESULTS

RHIVC wall structure consists of a thick muscular layer of longitudinal smooth muscle fibers and a peripheral loose connective tissue without smooth muscle fibers adherent to the liver parenchyma. This loose connective tissue between the liver and the RHIVC is the avascular plane for the passage of the clamp during LHM.

CONCLUSION

The histological structure of the RHIVC does not seem to have any special hemostatic property. The low bleeding rate during LHM can be only explained by the very low density of RHIVC afferent veins.