Left lateral liver resection, open - general and visceral surgery
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Laparotomy and exploration of the abdominal cavity
For the laparotomy the median incision is extended into the right flank just above the umbilicus Transect the right rectus muscle with bipolar scissors and incise the peritoneum. The incision may be kept to the left of the xyphoid: This yields good distance which facilitates the view, particularly regarding the hepatic veins.
Now transect the falciform ligament close to the abdominal wall. After lining the wound edges with towels insert the retractor for the abdominal wall and inspect the field: In primary cancer of the liver rule out extrahepatic metastasis and noticeably large lymph node in the hilum; in the example demonstrated here there is cirrhosis of the liver
Smaller procedures on the left hepatic globe, up to and including left lateral resection, may also be performed via median laparotomy, and wedge excisions of the inferior segments IVb, V and VI via a subcostal incision.
Freeing the liver
Start freeing the liver by transecting the left triangular ligament (bipolar scissors). Now free the liver from any adhesions with the diaphragm and expose the suprahepatic segment of the vena cava.
1. Careful exploration includes bimanual palpation of the liver which therefore must be fully freed.
2. Completely freeing the liver also helps to control possible bleeding complications.
3. Tumor invasion of the diaphragm does not contraindicate resection. The involved part of the diaphragm is resected en blocwith the tumor. In almost all cases the defect can be closed directly.
4. Since the left lobe of the liver is easily accessible, transection of the left triangular ligament is not mandatory.
Resecting the gallbladder
Started the resection by incising the serosa covering the anterior aspect of the hepatoduodenal ligament. Follow this by taking down the gallbladder in antegrade fashion from its hepatic bed to the hepatoduodenal ligament. Transect and ligate the cystic artery between Overholt dissecting forceps. This step in the dissection ends with exposure of the cystic duct.
Dissecting the hepatoduodenal ligament and lymph nodes
Start the hilar dissection by exposing and looping the left hepatic artery Follow this by freeing the common bile duct and portal vein. Dissect the lymph nodes.
1. When dissecting the hepatic artery ensure that any branches to the contralateral side (in the video on right) are spared.
2. Whenever lymph load dissection is not required, dissection in the hepatic hilum should be limited to the bare minimum; this prevents vascular injury and denuding of the bile duct.
3. In left liver resections portal vein branching is dissected from the left and in right hepatic resections from the right.
4. The retrohepatic vena cava need only be exposed if the resection includes the caudate lobe.
Continue the anatomical hilar dissection by exposing the right hepatic artery, which crosses posterior to the common bile duct, and looping the artery with a vessel loop. Now dissect the hilum to the left and loop the left branch of the portal vein.
Be careful when dissecting the common bile duct and common hepatic duct because complete skeletization of the duct may result in local necrosis and subsequent stenosis.
Local findings: Intraoperative ultrasonography (IOUS)
Once the liver is freed and the hilum dissected perform IOUS which has become standard in all liver resections. IOUS allows detection of additional tumor findings as well as assessment of the intrahepatic course of vessels. This permits inferences regarding resectability and assessment of the possible safety margin around the hepatic mass and therefore helps significantly in determining the resection margins. In the example demonstrated in the video, preoperative planning was for a left hemihepatectomy, but after IOUS ONLY segments II and III had to be resected.
Dissecting the segmental hila, ligating the segmental artery II/III
Resection of both left lateral liver segments requires that the liver be transected along the falciform ligament or somewhat to its left. Preliminary management of the left hepatic vein is not needed. The segmental hila are managed in the umbilical fissure. To do so, a large parenchymal bridge anterior the falciform ligament must be transected Now dissect the left hepatic artery and transect it laterally, thereby leaving a good blood supply for segments IVa and IVb.
Transecting the portal vein supply
Parenchymal dissection and bile duct transection
Successively transect the hepatic parenchyma paramedian to the falciform ligament with the water jet dissector (ERBEJET® 2) along the line of demarcation of segment II/III, managing smaller vessels by bipolar coagulation and larger ones either by clips or suture ligations. And finally, take down and suture ligate (Monosyn®) the bile duct draining segments 2/3.
Dividing the left hepatic vein
After complete transection of the parenchyma the left hepatic vein is the last major vessel remaining. Transect it between Overholt dissecting forceps and close the proximal stump by suture ligation.
In resection of segments II/III with rather peripheral location of the tumor the inferior vena cava may not necessarily need to be exposed. Where it is joined by the hepatic veins, the IVC only needs to be exposed far enough for control of the left hepatic vein. The IVC does not have to be looped since often this is somewhat difficult and risky; any vessel looping of the IVC should therefore be left to the end of the operation.
Specimen retrieval and hemostasis
Checking for bile leakage, resecting the gallbladder
Covering the resection area with the falciform ligament
Closing the abdominal wall
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