Left lateral liver resection, open

  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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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 to the median segments IVa and IVb as well. The small caudate lobeis special because it may receive sizable tributaries from the left and 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/I …………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 veinswhich 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 real life, 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 ductis 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, theright hepatic ductis 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.

  • Klinikum Bogenhausen

    Dr. med. Ehrl

  • Helios Amper-Klinikum Dachau

    Prof. Dr. med. Horst-Günter Rau

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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: 10.07.2012
  • Klinikum Bogenhausen

    Dr. med. Ehrl

  • Helios Amper-Klinikum Dachau

    Prof. Dr. med. Horst-Günter Rau

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  • Laparotomy and exploration of the abdominal cavity

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    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

    Note:

    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

    123-5

    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.

    Note:

    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

    123-6

    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

    123-7

    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.

    Note:

    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.

  • Hilar dissection

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    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.

    Note:

    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)

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    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

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    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

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    Dissect along the main left trunk of the portal vein and expose the segmental branch terminating in segment II/III. Transect this branch between clips. Any other branches of the portal vein are either sealed with the BiClamp® or transected between suture ligations.

  • Parenchymal dissection and bile duct transection

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    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

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    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.

    Note:

    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

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  • Checking for bile leakage, resecting the gallbladder

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  • Covering the resection area with the falciform ligament

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  • Closing the abdominal wall

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  • Klinikum Bogenhausen

    Dr. med. Ehrl

  • Helios Amper-Klinikum Dachau

    Prof. Dr. med. Horst-Günter Rau

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  • Prevention and management of intraoperative complications

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  • Prevention and management of postoperative complications

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  • Helios Amper-Klinikum Dachau

    Prof. Dr. med. Horst-Günter Rau

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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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