Laparoscopic unroofing of simple liver cyst

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Functional liver anatomy

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    In terms of surface relations, on the superior parietal surface the insertion of the ligamentum teres and the falciform ligament, and the sagittal fissure on the inferior aspect divide the liver into a large right and small left lobe (about 80:20 by volume), this gross anatomical division does not correspond with the functional anatomy of the liver. The functional structure of the liver is governed by the branches of the structures in the porta hepatis: Portal vein, hepatic artery and hepatic duct. Not only do these three anatomical structures branch, mostly in matching fashion, in the porta hepatis but also in the hepatic parenchyma. Because the blood supply and bile drainage of each hepatic segment are completely independent of all other segments, each segment may be resected without compromising the function of the remaining liver.

    Therefore, the concept of “functional anatomy” refers to the hepatic substructure based on circumscribed, hemodynamically independent areas of parenchyma, the knowledge of which is essential for surgical strategy in liver resections.

  • Portal vein and hepatic veins

    The functional structure of the liver rests on the portal vein ramifying into individual, completely independent subunits, the liver segments.

    In the porta hepatis, the portal vein usually bifurcates into a left and right lobar branch. The outer margin of these areas is defined by Cantlie’s line, i.e., the vertical plane extending from the inferior vena cava posteriorly to the middle of the gallbladder fossa anteriorly. The right lobar branch divides into an anteromedial and posterolateral branch supplying the liver segments V/VIII and VI/VII respectively. The left lobar branch of the portal vein courses transversely to the left, continuing anteriorly as umbilical branch and terminating at the insertion of the ligamentum teres in the recessus of Rex. The left lobar branch of the portal vein gives off branches to both left lateral segments II and III, and also to the median segments IVa and IVb. The small caudate lobe is special because it may receive sizable tributaries from the left and also right lobar branch of the portal vein.

    Couinaud identified eight portovenous liver segments which are numbered clockwise starting with the caudate lobe:

    Segment I………………………..caudate lobe

    Segments I/II/III………………….left lateral hepatic lobe

    Segment IV………………………left paramedian sector (quadrate lobe)

    Segments I/II/III/IV………………left lobe of liver

    Segments V/VIII…………………right paramedian sector

    Segments VI/VII…………………right lateral sector

    Segments V/VI/VII/VIII………….right lobe of liver

    Three major venous trunks traverse the liver caudocephalad; these are the right, median and left hepatic veins which divide the liver into a total of four hepatic sectors. The left hepatic vein almost exclusively drains the left lateral hepatic lobe, and just before its junction with the inferior vena cava it usually merges with the middle hepatic vein which courses along the cava-gallbladder line. The right hepatic vein travels between the posterolateral and anteromedial segments. The caudate lobe has its own venous drainage, the Spieghelian veins, comprising multiple small posterior veins draining directly into the inferior vena cava.

    In reality, the regularity of the venous branching described by Couinaud is seen only in few cases, and there are numerous branch variants supplying areas of varying size.

    The portal hila of liver segments II, III and IV are extrahepatic and can be easily exposed in the anterior section of the left umbilical fissure. The portal hila of the right liver segments are intrahepatic; while there are exceptions at times, these mostly pertain to segment VI. The anatomy of the hepatic veins is even more variable than that of the portal vein.

  • Hepatic artery

    While normally the common hepatic artery arises from the celiac axis, in rare cases its origin is directly with the aorta or superior mesenteric artery. After giving off the gastroduodenal artery, the proper hepatic artery bifurcates in the porta hepatis into the left and right hepatic arteries. Quite often, there are even more extrahepatic branches, such as the artery for liver segment IV, which usually arises from the left hepatic artery just before the umbilical fissure. Variants of this normal anatomy of the hepatic arteries have been described in about 30% of cases.

  • Bile ducts

    The extrahepatic section of the left hepatic duct is about 3 cm to 5 cm long and arises in the umbilical fissure from the junction of the two bile ducts draining segments II and III. In most cases the bile duct from segment IV will join proximal to this junction. With about 25%, the most common anatomical variant is a common junction of the bile duct from segment IV with those bile ducts draining segments II and III. This variant has clinical ramifications in left hemihepatectomy, split liver and living-donor liver transplants because it may easily impair the bile drainage from segment IV.

    Barely 1 cm long, the right hepatic duct is rather short and drains bile from segments V, VI, VII and VIII via an anterior and posterior branch. Sometimes the right hepatic duct may be missing altogether. The variant junctions of the posterior branch are clinically relevant because this branch may empty directly into the cystic duct, common hepatic duct or common bile duct.

  • Regional lymph nodes

    The liver has two lymphatic systems:

    1. Most of the liver lymph (90%) drains into the lymph nodes at the porta hepatis and from there via the celiac lymph nodes into the intestinal trunk.

    2. The second system, a subserous network of lymphatics (10%), drains the superficial aspects of the phrenic surface and the area nuda. The lymph passes through the diaphragm into the superior phrenic lymph nodes and from there via mediastinal lymphatics into the right venous angle.

  • Filderklinik Filderstadt-Bonlanden

    PD Dr. Marty Zdichavsky

  • Universität Klinik Tübingen

    Prof. Dr. med. Alfred Königsrainer

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 27.04.2009
  • Filderklinik Filderstadt-Bonlanden

    PD Dr. Marty Zdichavsky

  • Universität Klinik Tübingen

    Prof. Dr. med. Alfred Königsrainer

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  • Minilaparotomy

    44-4

    After skin prepping and draping of the surgical field perform an infra-umbilical minilaparotomy. Insert Verres needle and establish pneumoperitoneum.

  • Trocar positioning

    44-5

    Insert one 11 mm trocar for the laparoscope and the other 11 mm trocars left laterally (working trocar for, e.g., the scissors) and in the epigastrium (working trocar for, e.g., a grasper): Insert one 5 mm trocar in right upper quadrant (working trocar, e.g. for suction).

  • Exploration

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    Expose the cyst and open it with the electrocautery scissors. Suction the cyst contents.

    Tips: Depending on the thickness and quality of the cyst wall, resect it with the mono-/bipolar scissors or even the harmonic scalpel!

    Perform careful hemostasis!

    Deeper cysts (e.g., in polycystic liver disease) may display a blueish tinge and must be differentiated from veins: In these cases, laparoscopic ultrasound with vascular Doppler capability can be quite helpful!

  • Inspecting the cyst for neoplasia

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    Carefully inspect the cyst wall for any neoplastic changes.

  • Circular resection of cyst wall

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    Unroof the cyst by circular resection along the cyst margin with the monopolar scissors.

  • Inspecting the cyst bed

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    Inspect the cyst bed for bleeding and biliary leaks; carefully coagulate bleeders and clip or suture any biliary leaks.

  • Removing the trocars

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    Remove the trocars under vision and perform hemostasis, if needed.

    Tip: When ascites is present, close the fascia at all trocar sites to prevent any ascites channel formation!

  • Suturing the trocar site fascia

    External fascia sutures at the trocar sites, subcutaneous sutures and subcuticular absorbable suture, sterile dressing

  • Filderklinik Filderstadt-Bonlanden

    PD Dr. Marty Zdichavsky

  • Universität Klinik Tübingen

    Prof. Dr. med. Alfred Königsrainer

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  • Intraoperative complications

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  • Postoperative complications

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  • Filderklinik Filderstadt-Bonlanden

    PD Dr. Marty Zdichavsky

  • Universität Klinik Tübingen

    Prof. Dr. med. Alfred Königsrainer

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com