Anatomy of the hepatic hilar area: the plate system

To surgically manage hilar bile duct carcinoma successfully, it is important to be familiar with the principal anatomical variations of the biliary and vascular components of the plate system in the hepatic hilar area, because all the variations in the bile ducts and vessels occur in the plate system. The plate system consists of bile ducts and blood vessels surrounded by a sheath. There are three plates in the hilar area: the hilar plate, the cystic plate, and the umbilical plate. The bile duct and blood vessel branches penetrate the plate system and form Glisson's capsule in all segments of the liver, except for the medial segment. The right hepatic duct is usually (in 53%–72% of individuals) formed by the union of the anterior segmental duct and the posterior segmental duct in the hilar area. However, three other variations have been found in which these segmental ducts do not form the right hepatic duct. Few anatomical variations have been identified in the left hepatic duct, but confusion arises because of the variations in the medial segment ducts (B4) which join the left hepatic duct at different sites. In 35.5% of individuals they join the hepatic duct in the vicinity of the hilar confluence (type I B4 anatomy), and in 64.5% of individuals they join the left hepatic duct some distance away from the confluence (type II B4 anatomy). Because B4 is very close to the hilar confluence in type I, hilar bile duct carcinoma can easily invade B4 and, for that reason, for curative resection of hilar bile duct carcinoma, resection of S4a (the inferior part of the medial segment) should be considered along with the resection of extrahepatic bile duct and caudate lobe. Variations in the portal vein and hepatic artery are found in 16%–26% and 31%–33% of individuals, respectively. Because a considerable number of anatomical variations in the bile ducts and vessels persist in the hilar area, and the reported proportions of the different variations vary, it is necessary to have a good knowledge of the plate system and the variations in the bile ducts and blood vessels in the hilar area to perform safe and curative surgery for hilar bile duct carcinoma. Received: June 3, 2000 / Accepted: July 20, 2000     

Extended liver resection for hilar cholangiocarcinoma

Liver resection for hilar cholangiocarcinoma should be designed for individual patients, based on both precise diagnosis of cancer extent and accurate evaluation of hepatic functional reserve. Therefore we have developed various types of hepatic segmentectomy. Combined caudate lobectomy is essential in every patient with separated hepatic confluence. So-called extensive hepatectomy, resection of 50% or more of the hepatic mass, includes right lobectomy and right or left trisegmentectomy. Right lobectomy with caudate lobectomy is indicated when the progression of cancer is predominant in the right anterior and posterior segmental bile ducts. The plane of liver transection is along the Cantlie line, and the left hepatic duct is divided just at the right side of the umbilical portion of the left portal vein. Right trisegmentectomy with caudate lobectomy is performed in carcinoma which involves the right hepatic ducts in continuity with the left medial segmental bile duct. The umbilical portion of the left portal vein is freed from the umbilical plate by dividing the small portal branches arising from the cranial side of the umbilical portion. Then the left lateral segmental bile ducts are exposed and divided at the left side of the umbilical portion of the left portal vein. Left trisegmentectomy with caudate lobectomy is suitable for carcinoma which involves the left intrahepatic bile duct in continuity with the right anterior segmental bile duct. Liver transection is advanced along the right portal fissure. The right posterior segmental bile duct is usually divided distal to the confluence of the inferior and superior branches.     

Anomalous intrahepatic portal system in a patient with hilar bile duct cancer

We report a case of anomaly of the intrahepatic portal system in a 65-year-old man with hilar bile duct cancer. Preoperatively, percutaneous transhepatic portography demonstrated that there was a right posterior portal vein arising from the main portal vein. In addition, a large portal branch originated from the left portal vein and coursed toward the right hepatic lobe. Following portal embolization of the right posterior branch, the patient underwent an extended right hepatectomy with a caudate lobectomy. Intraoperatively, to the left at the porta hepatis and then it first gave off the right anterior portal vein originated from the left portal vein and coursed toward the right hepatic lobe horizontally behind the gallbladder and then separated into superior and inferior segmental branches to supply the right anterior segment of the liver. The ramification of some major branches without malposition of the gallbladder or round ligament was the important clinical feature of this anomaly.     

Hilar cholangiocarcinoma—surgical anatomy and curative resection

We have studied the surgical anatomy of the intrahepatic bile duct, hepatic hilus, and caudate lobe based on intraoperative findings and selective cholangiography of surgical patients and resected specimens, and have established the cholangiographic anatomy of the intrahepatic subsegmental bile duct. Thorough knowledge of the three-dimensional anatomy of the subsegmental bile duct, hepatic hilus, and caudate lobe is indispensable for curative surgery of hilar cholangiocarcinoma. We designed and actually performed 15 kinds of hepatic segmentectomies with caudate lobectomy and extrahepatic bile buct resection in 100 consecutive patients, with curative resection being possible in 82 patients. Postoperative survival after curative resection of hilar cholangiocarcinoma was better than expected, and the 5-year survival rates for all 82 patients with curative resection and for 55 patients with curative surgery without portal vein resection were 31% and 43%, respectively. Hepatic segmentectomy with caudate lobectomy and extrahepatic bile duct resection should be designed not only in accordance with the preoperative diagnosis of tumor extension into the intrahepatic bile ducts but also so that curative surgery for advanced hilar cholangiocarcinoma can be performed.     

肝内胆管手术入路的解剖及临床应用

目的 探讨显露肝内叶、段胆管的手术入路。方法 研究30例成人肝脏标本的肝内叶、段胆管与血管的毗邻关系。结果 左右肝管均位于肝脏脏面门静脉门静脉左右干的前上缘,左内叶、右前叶胆管位于相应门静脉的前内侧。右后叶胆管位于门静脉右面支或右前叶下段支脏面深侧者占73％（22／30）;位于门静脉右后支脏面深侧或后上缘者占80％（24／30）。左外叶胆管位于门静脉矢状部脏面深侧者占93％（28／30）。选择经肝的脏面显露肝门、左右肝管,经肝的膈面显露肝内叶、段胆管相结合的手术入路,治疗复杂性肝内胆管结石并狭窄患者38例,均获成功。结论 经肝的脏面与膈面相结合的手术入路,比较容易显露和切开肝内胆管及其狭窄段、便于取出结石。     

Successful Duct-to-duct Biliary Reconstruction after Right Hemihepatectomy. Operative Planning Using Virtual 3D Reconstructed Images

Accurate knowledge of partial anatomy is essential in hepatic surgery but is difficult to acquire. We describe the potential impact of a new technique for constructing three-dimensional virtual images of the portal vein, hepatic artery, and bile ducts and present a representative case. An 80-year-old man was suspected of having papillary cholangiocarcinoma arising in S8 of the liver and extending to the hepatic hilum intraluminaly. Right hemihepatectomy with bile duct resection was planned. However, it was uncertain whether duct-to-duct biliary reconstruction would be possible based on the appearance of the confluence of the right and left hepatic ducts on cholangiogram and conventional computed tomograph. Virtual three-dimensional images of the liver were constructed and revealed vascular and biliary anatomy. They showed that the upper margin of bile duct excision would be 19 mm from the umbilical point of the left portal vein, and that the site of the left branch of the caudate lobe bile duct could be preserved. Based on this information, we performed a sphincter-preserving biliary operation safely without complications. Planning complex biliary surgery may be improved by the use of virtual three-dimensional images of the liver. This approach is especially useful in candidates for postoperative regional chemotherapy.     

Preliminary study of the anatomy of the venous drainage of the intrahepatic and extrahepatic bile ducts and its relevance to the practice of hepatobiliary surgery

Background : Although there have been many studies of the arterial supply of the biliary system, attempts to study the corresponding venous drainage have been few and all have been incomplete. The purpose of the present investigation is to describe the anatomy of the venous drainage of both the intrahepatic and extrahepatic bile ducts and to determine its relevance to hepatobiliary surgery. Methods : The intrahepatic and extrahepatic venous drainage of the bile ducts was investigated in seven specimens by injecting a solution of 10% gelatin coloured with Alcian blue into the portal vein or the superior mesenteric vein to outline the venous drainage. The specimens were dissected under loop magnification and representative drawings were obtained. Results : The surface of the intrahepatic and extrahepatic bile ducts was covered by a fine venous plexus. On the surface of the supraduodenal common hepatic duct and common bile duct the venous plexus drained laterally into marginal veins, usually two in number and known as the 3 o’clock and 9 o’clock marginal veins. Inferiorly the marginal veins and the venous plexus communicated with the pancreaticoduodenal venous plexus, which in its turn drained into the posterosuperior pancreaticoduodenal vein, a branch of the superior mesenteric vein. Superiorly the marginal veins divided into a number of branches. Some branches followed the left and right hepatic ducts into the liver, communicating with the venous plexus and the adjacent branches of the portal vein. Other branches of variable size entered either segment IV or the caudate lobe or process via the hilar venous plexus. A most important finding was that even after dividing the bile duct and all communicating veins at the upper border of the duodenum, the venous plexus and the marginal veins filled normally to the level of transection. This occurred almost certainly by retrograde filling from above. Conclusion : The satisfactory results of end‐to‐end anastomosis in whole liver transplantation depends partly on the presence of adequate venous drainage. This has been amply demonstrated by the injection studies. This would indicate that the poor results of end‐to‐end repair of the bile duct after surgical trauma results from other factors such as poor technique, devascularization of the cut ends due to trauma, and carrying out the anastomosis under tension. After resection of the hilum for cholangiocarcinoma the venous drainage of the left and right hepatic ducts and their branches depends mainly on the communications between the venous plexus on the ducts and the adjacent branches of the portal vein, even at a lobular or sinusoidal level. The satisfactory results obtained after anastomosis of the left and right hepatic ducts or their branches to a Roux loop of jejunum attest to this. This applies also to the transplantation of segments II and III in paediatric patients from related adult donors and in patients receiving split liver transplants. Finally, the venous drainage at the bifurcation of the common hepatic duct has been shown to enter the caudate lobe and segment IV directly. This suggests that a hilar cholangiocarcinoma may metastasize to these segments, and perhaps partly explain the significantly better long‐term results when the caudate lobe and segment IV are resected en bloc with the cholangiocarcinoma as part of modern radical surgery for this condition.     

Surgical Anatomy of Hepatic Hilum with Special Reference of the Plate System and Extrahepatic Duct

Background When resecting hilar cholangiocarcinoma, the surgeon cannot visualize the hilar vessels through thick connective tissue known as the plate system. Little has been reported regarding the anatomical relationship between the plate system and the extrahepatic bile duct. Methods Twenty-five formalin-fixed cadaveric livers were dissected carefully and 7 were sectioned sagittally. The extent, composition, and distribution of the extrahepatic bile ducts within the system were investigated. The length between the confluence of the hepatic duct and the branch point of the segmental duct (level I) and the length between the branch point of the segmental duct and the segmental Glisson’s pedicle (level II) were measured. Results The plate system—composed of the hilar, cystic, Arantian, and umbilical regions—was easily separated from the hepatic parenchyma. Histologically, dense connective tissue with abundant capillaries, lymphatic vessels, and neural fibers were noted. Level I of B1pcp and B4a measured 13.0 and 14.7 mm, respectively. Level II measured 8.6 and 17.3 mm, respectively. Conclusions The bile ducts in the plate system correspond to the extrahepatic bile ducts and their lengths are variable for every segment. Knowing the lengths of the resectable extrahepatic bile ducts is useful for deciding which segment should be resected according to the cancerous invasion.     

S4a + S5 With caudate lobe (SI) resection using the Taj Mahal liver parenchymal resection for carcinoma of the biliary tract

Recently we have been performing S4a + S5 with total resection of the caudate lobe (SI) by using a dome-like dissection along the root of the middle hepatic vein at the pinnacle, which we refer to as the Taj Mahal liver parenchymal resection, for carcinoma of the biliary tract. This procedure offers the following advantages: (1) It allows total resection of the caudate lobe, including the paracaval portion (S9), and (2) because the cut surface of the liver is large, it allows intrahepatic jejunostomy to be performed more easily with a good field of view. The indications for this procedure include hilar bile duct carcinoma, gallbladder carcinoma, and choledochal cyst (type IVA). Because of the high rate of hilar liver parenchyma and caudate lobe invasion associated with hilar bile duct carcinoma, the liver must be resected. The Taj Mahal procedure is indicated in cases where extended liver resection is impossible. The dissection limits of this procedure are, on the left side, the B2 + 3 bifurcation at the right margin of the umbilical portion of the portal vein and, on the right side, the B8 of the anterior branch and the B6+7 bifurcation of the right posterior branch. This procedure could also be described as a reduced form of extended right hepatectomy and extended left hepatectomy. For gallbladder carcinoma, this procedure is indicated to ensure an adequate surgical margin and eradicate transvenous liver metastasis, particularly in cases of pT2 lesions. Hilar and caudate lobe invasion also occurs in liver bed-type gallbladder carcinoma, and bile duct resection and caudate lobe resection are required for the surgery to be curative. We performed this procedure in four cases of hilar bile duct carcinoma, five cases of gallbladder carcinoma, and one case each of choledochal cyst (type IVA) with carcinoma of the bile duct and gallbladder adenomyomatosis. Curative resection was possible in all except the patient with adenomyomatosis, and all of the patients are alive and recurrence free 10 to 37 months postoperatively. This procedure, in addition to preserving liver function, provides a wide field of view and facilitates reconstruction of multiple intrahepatic bile ducts. Thus it can be said to be a curative operation not only in patients considered high risk but also in those whose hilar bile duct carcinoma is limited to the bifurcation area (Bismuth type IIIa and IIIb) and in gallbladder carcinoma up to pT2 with slight extension on the hepatic side. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998 (poster presentation).     

Ⅲ型肝门部胆管癌的外科治疗（附35例分析）

目的总结Ⅲ型肝门部胆管癌的手术经验。方法回顾性分析我院1999年1月至2006年12月，行手术切除的35例Ⅲ型肝门部胆管癌的临床资料。Ⅲa型16例，行肝门部胆管切除8例，行联合右半肝＋右侧尾状叶切除7例，行联合右半肝＋尾状叶切除、门静脉分叉部切除主干左支吻合1例。Ⅲb型19例，行肝门部胆管切除8例，行联合左半肝＋左侧尾状叶切除9例，行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合1例．行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合、肝固有动脉分叉部切除主干右支吻合1例。结果本组32例获得随访，随访时间18～113个月。肝门部胆管切除病例术后病理根治性切除率为37．5％，联合肝叶切除病例术后病理根治性切除率73．7％，3例联合肝叶切除＋血管切除病例均获术后病理根治性切除。肝门部胆管切除术后并发症发生率为31．3％，联合肝叶切除组术后并发症发生率为31．6％。3例联合肝叶切除＋血管切除病例术后均无胆肠吻合口漏、肝断面坏死、胆漏等严重并发症。结论联合肝叶切除，必要时行受累分叉部血管切除重建，有益于提高Ⅲ型肝门部胆管癌的根治性切除率，且不增加术后并发症的发生率。     

The surgical anatomy of the porta hepatis

The anatomy of the porta hepatis, with particular emphasis on the hilar relationships of the bile ducts to the portal vein, has been investigated in 30 fresh cadaver specimens. Meticulous dissertion delineated three major types of anatomic variations. Type A, the most common, revealed a left hepatic duct which, when it branched, sent its largest and major tributary beneath the portal vein to the lateral segment of the left lobe. Type B was characterized by the major division of the left hepatic duct running parallel to the portal vein into the hepatic sulcus. In Type C the divisions were of equal caliber. These observations should assist the surgeon in dissections of the hepatic ducts above their confluence.     

肝尾状叶手术的应用解剖研究

目的：为肝尾状叶手术提供形态学理论基础。方法：选取42具成人离体尸肝标本，采用雕琢法观测肝尾状叶形态、毗邻及管道。制作6具肝静脉铸型标本，观测尾状叶静脉系统属支及走行。制作1具肝尾状叶生物塑化薄层连续断面标本，并行计算机三维重建，显示尾状叶空间关系。利用3具整尸行单独全尾状叶切除。结果：大体解剖发现尾状叶门脉三管来源分散，行程短，不集中；铸型标本发现尾状叶门静脉有集中分布的优势；成功重建尾状叶及毗邻主要管道空间关系；在整尸上，顺利完成单独全尾状叶切除。结论：肝尾状叶位置特殊，毗邻关系复杂。肝尾状叶切除手术方式应依据病变部位及大小、性质、肝功状况而定，经后下入路游离尾状叶是值得尝试的途径。     

Highly anatomically systematized hepatic resection with Glissonean sheath code transection at the hepatic hilus

We have developed a new method of hepatic resection, in which the cancer-bearing Glissonean code (G-code) branches are served using a hilar approach for an anatomically systematized resection. Since the hepatic artery, portal vein and bile duct are surrounded by connective tissue, the portal triad can be treated as a fibroid code both outside and inside the liver. Compared to the ramification pattern of the hepatic artery, portal vein and bile duct, that of the G-code is simpler. In all our surgical procedures of hepatic resections, the cancer bearing G-code branch is selectively cut using a hilar approach before the dissection of the parenchyma of the liver. We have experienced 168 cases of several types of hepatic resection for hepatocellular carcinoma. Only in three cases was it impossible to accomplish the transection of some third branches using a hilar approach.     

Anatomicopathological Study of Vascular and Biliary Systems Using Cast Samples of Fasciola‐infected Bovine Livers

In 117 livers with fascioliasis, this study was focused on the number of Fasciola, the number and intrahepatic localization of affected hepatic ducts and bile ducts, and the degree of fibrosis in the hepatic segments and bile ducts. The degree of pathological changes in bile ducts caused by fascioliasis was classified into five levels. The site of Fasciola habitation was most often the hepatic ducts of the porta hepatis: it was the left hepatic duct in 101 livers and the right hepatic duct in 88 livers. Casts were prepared by infusing synthetic resin into the hepatic arterial, portal, hepatic venous and biliary systems of 15 bovine livers with fascioliasis and then examined. In the left lobe, quadrate lobe, and caudate process where atrophic fibrosis was noted, the bile ducts became rod‐shaped by losing branches, and the samples resembled dead branches of liver. Portal branches were thinned or completely terminated with marked fibrosis. Fine and irregular newly formed bile ducts not parallel with portal branches were observed in livers with markedly chronic fascioliasis. Distal portal branches in the right lobe, caudate lobe, and papillary process showed hypertrophic proliferative changes. The arterial system was generally well developed in thickened walls of bile ducts and formed vascular beds, and surrounded the bile ducts as tubes. In livers with severe fibrosis, capillaries were markedly developed and resembled glass cotton.     

Indications for combined resection and reconstruction of the hepatic artery in biliary tract carcinoma]

More than 10 years have passed since hepatic artery resection was first performed for the treatment of biliary tract cancer. The safety of this procedure has been established with the introduction of the microsurgery technique. However, the benefits of and indications for this treatment have not yet been clarified. Twenty-three patients underwent vascular resection (portal vein in 7, portal vein + hepatic artery in 9, hepatic artery in 7) among 114 resected patients with biliary tract cancer in our institution. The right hepatic artery was reconstructed by end-to-end anastomosis in most cases. The curative resection rate was 88.9% in hilar bile duct cancer. However, it was less than 50% in other carcinomas. Cumulative 5-year survival rates of vascular resection patients with hilar bile duct cancer, lower bile duct cancer, gallbladder cancer, and cholangiocarcinoma were 14.8%, 25%, 0%, and 0%, respectively. On the other hand, the rates were 38.9%, 0%, 0%, and 0%, in the stage III + IV patients who did not undergo vascular resection. The longest survival period among patients with hilar bile duct cancer and lower bile duct cancer was 85 months and 65 months, respectively, whereas it was 15 months in gallbladder cancer and 20 months in cholangiocarcinoma patients. No hilar bile duct cancer patient who survived for more than 3 years had lymph node metastasis. The longest surviving cholangiocarcinoma patient has received adjuvant chemotherapy consisting of 5-fluorouracil and cisplatin. It is concluded that patients with hilar bile duct cancer are good candidates for vascular resection. Adjuvant chemotherapy should be administered to gallbladder cancer and cholangiocarcinoma patients, because vascular resection alone does not result in prolongation of life in these patients.     

The feasibility of in vivo resection of the left lobe of the liver and its use for transplantation

The anatomical possibility of resecting the left lobe of the liver (segments II and III) in living subjects and using it for transplantation was evaluated. A group of 60 cadaveric livers were dissected at autopsy. The vascular and biliary elements of the left lobe were isolated and the lobe was resected and evaluated for possible grafting. The left lobe was 12-28% (mean 19.4%) of the liver mass. An extrahepatic segment of the left hepatic vein was isolated in 95% of specimens. Arterial blood supply to the left lobe consisted of a single artery (92%) or two arteries (8%). A single portal vein segment to the left lobe (type I) was found in 35% livers. Portal vein branches originated from a common orifice (type II, 35%) or separately (type III, 30%) from the left portal vein, and in these instances, preparation of a portal segment necessitated partial section of the left portal vein wall. Biliary drainage was extrahepatic in 56 livers and consisted of a single duct (type I, 78%), or two ducts (type II, 15%). The resected left lobe was evaluated as satisfactory (single hepatic vein and artery, types I or II portal vein, type I bile duct) in 48% of cases, while a less-satisfactory lobe (type III portal vein or type II bile duct) was obtained in 33%. It was found anatomically difficult or impossible to resect the left lobe for possible transplantation in 11 (19%) liver specimens.     

A left hepatectomy and caudate lobectomy combined resection of the ventral segment of the right anterior sector for hilar cholangiocarcinoma — the efficacy of PVE (portal vein embolization) in identifying the hepatic subsegment: Report of a case

This report presents a case of a left hepatectomy and a caudate lobectomy combined resection of the ventral segment of the right anterior sector for hilar cholangiocarcinoma using percutaneous transhepatic portal vein embolization (PVE). The patient was a 44-year-old man admitted to a local hospital with obstructive jaundice. He was diagnosed to have hilar cholangiocarcinoma and was referred to the hospital for further treatment. Cholangiography revealed stenosis of the left hepatic duct and the hilar bile ducts. The dorsal branch of the right anterior sector joined the right posterior branch and the tumor did not invade to the confluence of these branches. Arteriography and portography reconstructed by multidetector-raw computed tomography revealed the ventral branches of the right anterior sector, which separately diverged from the other right anterior branches. It was therefore necessary to perform a left hepatectomy and caudate lobectomy combined resection of the ventral segment of the right anterior sector to completely remove the tumor. Portal vein embolization was thus performed on the left portal vein and the ventral branches of the right anterior sector. Intraoperatively, when the hepatic artery was temporally clamped, the demarcation between the ventral segment and the dorsal segment of the right anterior sector could be clearly visualized. The planned surgery was performed safely. This case demonstrates that the utilization of PVE is useful for a difficult and intricate hepatectomy, which requires an accurate identification of a hepatic subsegment.     

门静脉尾状叶支解剖及在肝门部胆管癌外科治疗中应用进展

近年来，门静脉尾状叶支是肝门部胆管癌手术的研究热点之一，术中处理尾状叶支的安全性与有效性尚未明确。门静脉尾状叶支分布、走行于解剖结构复杂的H型横沟区域，涉及肝脏、胆囊、区域淋巴结等组织器官和门静脉、肝动脉、胆管及下腔静脉等脉管系统，是肝胆外科手术的难点区域，合理的手术入路至关重要。肝门部胆管癌根治术中预处理门静脉尾状叶支可以减少术中出血和术后并发症的发生，契合加速康复外科理念。因此，在实施肝门部胆管癌根治术时应强调门静脉尾状叶支预处理的地位。     

Infraportal bile duct of the caudate lobe: a troublesome anatomic variation in right-sided hepatectomy for perihilar cholangiocarcinoma

OBJECTIVE: We present our experiences with infraportal bile duct of the caudate lobe (B1) and discuss surgical implications of this rare variation. SUMMARY BACKGROUND DATA: Although various authors have investigated biliary anatomy at the hepatic hilum, an infraportal B1 (joining the hepatic duct caudally to the transverse portion of the left portal vein) has not been reported. METHODS: Between January 1981 and December 2005, 334 patients underwent hepatectomy combined with caudate lobectomy for perihilar cholangiocarcinoma. Four of them (1.2%) had infraportal B1 and were investigated clinicoanatomically. RESULTS: All infraportal B1 were B1l, draining Spiegel's lobe; no infraportal B1r (draining the paracaval portion) or B1c ducts (draining the caudate process) were found. The infraportal B1l joined the common hepatic duct or the left hepatic duct. Three patients underwent right trisectionectomy with caudate lobectomy; for one, in whom preoperative diagnosis was possible, combined portal vein resection and reconstruction were performed before caudate lobectomy to resect the caudate lobe en bloc without division of infraportal B1. For the other 2 patients, the infraportal B1 was divided to preserve the portal vein, and then the caudate lobe was resected en bloc. The fourth patient underwent right hepatectomy with right caudate lobectomy; the cut end of the infraportal B1 showed no cancer by frozen section, so the bile duct was ligated and divided to preserve the left caudate lobe. CONCLUSION: Infraportal B1 can cause difficulties in performing right-sided hepatectomy with caudate lobectomy or harvesting the left side of the liver with the left caudate lobe for transplantation. Hepatobiliary and transplant surgeons should carefully evaluate biliary anatomy at the hepatic hilum, keeping this variation in mind.     

肝门部胆管癌切除术中的血管切除重建

目的 探讨血管切除重建在肝门部胆管癌切除术中的价值.方法 2000年1月至2009年9月收治的肝门部胆管癌手术切除患者中,17例合并血管切除或重建,其中男性10例,女性7例,年龄30～72岁,平均53岁.病程4～30 d,平均(21±8)d.门静脉部分切除端端吻合6例,门静脉壁楔形切除、缝合修补3例,肝动脉结扎切除1例,肝动脉切除端端吻合2例,门静脉动脉化1例,1例同时行门静脉壁楔形切除+肝动脉结扎切除,2例同时行门静脉部分切除端端吻合+肝动脉部分切除端端吻合,1例同时行门静脉部分切除端端吻合+肝右动脉、胃十二指肠动脉端端吻合.对患者的临床资料进行分析.结果 住院死亡4例,病死率4/17,3例为术后出现肾功能不全后继发多器官功能衰竭,1例死于感染性休克.未死亡的13例患者中,6例恢复过程顺利,无并发症;7例发生并发症:3例胆瘘,1例呼吸衰竭,1例因U管阻塞发生胆管炎,1例腹腔内感染、门静脉血栓形成,1例远期门静脉狭窄、肝脓肿.中位生存期18个月,4例至今尚存活.结论 肝门部胆管癌切除联合血管切除重建有利于提高切除率但术后风险仍高,术后应警惕并发症的发生;肝动脉切除重建可能有利于降低术后风险.

Abstract：

Objective To investigate the value of vascular resection and reconstruction in resection of hilar cholangiocarcinoma.Methods The clinical data of 17 patients with hilar cholangiocarcinoma received resection in combination with vascular resection and reconstruction from January 2000 to September 2009 was retrospectively analyzed.Among the 17 patients,6 underwent portal vein segmental resection and end-to-end anastomosis,3 underwent portal vein wedge resection,1 underwent hepatic artery ligature,2 underwent hepatic artery segmental resection and end-to-end anastomosis,1 underwent portal vein arterialization,1 underwent portal vein wedge resection and hepatic artery ligature simultaneously,2 underwent portal vein segmental resection and heapatic artery segmental resection and end-to-end anastomosis simultaneously,1 underwent portal vein segmental resection and right heapatic artery and gastroduodenal artery end-to-end anastomosis simultaneously.Results Four patients died and the mortality was 4/17.Three patients died of renal dysfunction followed with multiple organ dysfunction and 1 patient died of sepsis shock.Among the 13 survive patients,6 had a smooth postoperative recover and 7 developed complications:3 had bile leakage,1 had respiratory failure,1 had cholangitis due to obstruction of U tube,1 had abdominal infection and thrombosis in portal vein system and 1 had portal vein stenosis and liver abscess.Follow-up investigation showed that the median survival time was 18 months and four patients still alive.Conclusions Combination of vascular resection and reconstruction in the resection of hilar cholangiocarcinoma may help to improve the resection rate but still have a high postoperative risk.The complications of renal dysfunction should be alert during the postoperative observation.The procedure of hepatic arterial reconstruction may help to reduce postoperative morbidity.