Liver resection for recurrent liver metastasis

Excision of the old upper abdominal right-angle laparotomy following previous atypical metastasis resection in the area of the posterior right liver segments. Preparation down to the peritoneum and opening of the abdomen.

Significant adhesions are encountered in the upper abdomen, making exploration of the abdomen to exclude an extrahepatic tumor and peritoneal carcinomatosis initially only partially possible. Both the right colonic flexure and small bowel loops are adherent to the liver and must be sharply dissected step by step. Then, reposition the wound edges and insert the retractor.

Next, the hepatoduodenal ligament is dissected out of the scar tissue and looped with a Mersilene band. This allows for temporary hilum occlusion (Pringle maneuver) in case of intraoperative bleeding complications.

A lymph node dissection is not performed, as it was already done during the primary procedure, and no enlarged lymph nodes are observed upon inspection and palpation.

Note:

In principle, lymph node dissection of the liver hilum is recommended for colorectal liver metastases, as the incidence, depending on the number and location of the metastases, is reported to be 3-28%.

To achieve adequate exposure of the posterior segments, the liver must be completely freed from the retroperitoneum, which is significantly complicated by extensive scarring from previous surgeries. Step by step, the liver is dissected from the adhesions, with the right adrenal gland being dissected and the diaphragm in the area of the tumor needing to be partially resected. Here, a partially organized subcapsular hematoma from a previous surgery is found.

Step by step, the V. cava is now pre-prepared. By initially exposing the V. cava from cranial (venous star) and caudal, it is possible to completely mobilize the right liver lobe.