Extended right hepatic lobectomy with resection of inferior vena cava and portal vein for intrahepatic cholangiocarcinoma

We report a case of intrahepatic cholangiocarcinoma treated by extended right lobectomy and resection of the inferior vena cava (IVC) and portal vein. A 53-year-old man was referred with elevated serum alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (γ-GTP) levels on April 23, 1999. He was not jaundiced and did not have any symptoms. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregular strictures in both the anterior and posterior segmental ducts. Contrast-enhanced computed tomography (CT) scan demonstrated a low-density tumor with an unclear margin in the right lobe of the liver. The patient underwent extended right hepatic lobectomy and total caudate lobectomy. Partial resection of the IVC (6 cm) was performed under total hepatic vascular exclusion. The main portal trunk and left portal vein were resected and reconstructed with an end-to-end anastomosis. Macroscopically, a 5.0 × 5.0 × 4.5-cm periductal infiltrating-type tumor occupied the right hepatic parenchyma along the posterior and anterior segmental ducts. Histological examination revealed moderately differentiated tubular adenocarcinoma with marked perineural invasion. Lymph node metastasis was observed in the hepatoduodenal ligament and posterior surface of the pancreatic head. The resected margins of the common bile duct and left hepatic duct were free of tumor. The patient's postoperative course was uneventful, and he was discharged from hospital on the 28th postoperative day. Nine months after the operation, he suddenly developed obstructive jaundice, and died with recurrent disease. This is the first reported case of intrahepatic cholangiocarcinoma treated with major hepatectomy and resection of the IVC and portal vein except ex situ procedure. This aggressive surgical approach may offer hope for patients with intrahepatic cholangiocarcinoma involving the IVC. Received: March 27, 2000 / Accepted: August 8, 2000     

Anatomic variations in right liver living donors

BACKGROUND: Anatomic knowledge is crucial in right liver living donor transplantation. STUDY DESIGN: We reviewed radiologic and surgical findings in right liver donors. Arterial and portal anatomy was assessed in 96 donors, biliary anatomy in 77, and hepatic venous anatomy in 65. RESULTS: Portal vein (PV): 86.4% had classic anatomy; 6.3% had a trifurcated PV; 7.3% had a right anterior PV taken off the left PV. Hepatic artery (HA): 70.8% had classic anatomy; 12.5% had a left HA arising from the left gastric artery; 13.5% had a right HA arising from the superior mesenteric artery; 2.1% had a double replaced left HA and right HA; and in 1.0% the common HA arose from the superior mesenteric artery. Biliary tree: 55.8% had normal anatomy; 14.3% had a trifurcated biliary anatomy; in 5.2% the right anterior bile duct and in 15.6% the right posterior bile duct opened into the left bile duct; in 2.6% the right anterior and in 6.5% the right posterior ducts opened into the common bile duct. Hepatic veins: S5 and S8 accessory hepatic veins had incidences of 43% and 49%, respectively. The incidence of S6 or S7 short hepatic vein was 38%. CONCLUSIONS: Anatomic variations are common but do not contraindicate donation; surgeons should be prepared to recognize and manage them.     

Rare Portal Venous Anomaly in a Living Liver Donor: A Case Report

Knowledge of the anatomy of the portal system is essential for safe liver resection. We report a very rare anatomic anomaly of the portal system in a living liver donor. A 24-year-old female living liver donor was found to have anomalies of the portal system on preoperative contrast-enhanced computed tomography. The ventral branch of the right anterior segment arose from the transverse portion of the left portal vein. The gallbladder and round ligament were positioned normally. Intraoperative cholangiography for evaluation of biliary anatomy revealed very low confluence of the right and left hepatic ducts. All the bile ducts from the right lobe merged into the right hepatic duct. A right lobe graft was performed, including the ventral area of the right anterior segment. The portal branch of the ventral area of the right anterior segment could be transected extrahepatically. In the recipient operation, each of the right main portal branches, including the right posterior segment branch and the dorsal branch of the right anterior segment, and the ventral branch of the right anterior segment, were anastomosed to the right and left branches of the portal vein, respectively, of the recipient. The transected right hepatic duct of the graft was anastomosed with the recipient's common hepatic duct. Sixteen years after the liver transplant, the recipient continues to do well and has good portal flow.     

Liver resection under total vascular isolation. Variations on a theme.

Total vascular isolation (TVI) of the liver was employed during parenchymal transection in 16 patients undergoing hepatic resection for large tumors (mean diameter, 10.7 cm) located near hilar structures, hepatic veins, or the inferior vena cava (IVC). In 14 cases, TVI was achieved by clamping the suprahepatic and infrahepatic IVC and the porta hepatis, with or without aortic occlusion; in two, selective hepatic vein clamping was possible, obviating IVC occlusion. Procedures included standard and extended right and left lobectomies and caudate lobe resections. Concomitant resection and reconstruction of the portal vein (one case), IVC (one case), and bile duct (three cases) was required. Postoperative hepatic and renal failure did not occur. Mean intensive care unit and hospital stays were 2.8 +/- 1.9 and 12.5 +/- 5.2 days, respectively. There were two perioperative deaths. Total vascular isolation permits safe resection of large, critically located tumors that would otherwise present prohibitive operative risks.     

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.     

Left trisegmentectomy and combined resection of the inferior vena cava, without reconstruction, for giant cystadenocarcinoma of the liver

A 54-year-old woman with giant liver cystadenocarcinoma underwent left trisegmentectomy with combined resection of the inferior vena cava (IVC) and the right hepatic vein. As a result, only the right inferior hepatic vein was preserved as a drainage vein. Because the perivertebral plexus and the azygos vein were both well developed, neither veno-venous bypass nor IVC reconstruction was performed. The developed collateral veins acted as the venous drainage pathway to maintain a stable systemic circulation. On the seventh postoperative day, portal vein flow dramatically decreased and the patient tended to liver failure. Prostaglandin E₁ (PGE₁) was administrated via the superior mesenteric artery. The portal flow then gradually increased and liver failure was avoided. Six months after the operation, she was re-admitted due to obstructive jaundice and presented with complete stenosis of the common bile duct (CBD). The jaundice persisted and liver dysfunction progressed. The patient died seven months after the operation. The confluence of the right inferior vein and the IVC could have been deformed, causing outflow blockade. The intrinsic shunt was not good enough to act as the drainage pathway, and IVC reconstruction may have been needed.     

肝门区域血管阻断下肝段切除术的要点、扩展和评估

目的 总结1987-2008年344例通过肝门H沟中阻断肝叶、肝段或肝亚段入肝血管分支施行肝切除的经验.方法 (1)根据病变部位和大小分别实行大型肝切除(66例)、间隔性多个肝亚段切除(15例)、邻接多个肝亚段切除(216例)和单个肝亚段切除(47例),其中含肝尾叶切除29例.(2)肝左外段切除时在肝门左纵沟外侧游离、切断从门静脉左干矢状部外侧发出的左外上、下分支和肝左动脉.肝左内段切除时游离、切断从门静脉左干矢状部内侧发出的左内上、下分支和肝中动脉.肝右前段切除时游离、阻断肝右纵沟前支中的门静脉右前支和肝总管后的肝右动脉.肝右后段切除时阻断右纵沟后支中的门静脉右后支和肝右动脉.(3)断肝时尽量保护相应的肝静脉主干.结果 (1)术后病死10例(2.9%),其中死于肝衰8例,出血2例;(2)肝细胞癌病人(n=200)术后生存11～20年10例,7年4例,5年19例,5年生存率18.3%(33/180).肝内胆管癌(n=13)术后生存1/2～3年.肝门胆管癌(n=14)生存13、6、4年各1例.胆囊癌(n=12)生存1/2～1年.良性肝病(n=92)切肝后皆痊愈.7例肝内胆管结石尚需处理他处残留结石.结论 (1)间隔性多个肝段切除是一次手术治愈多支肝内胆管簇集性结石的有效方法.(2)该手术免去了阻断全入肝血流,缩小了术中肝缺血范围,减少了术中失血,提高了大肝癌切除率,减轻了术后肝功能损害,可以满足各种肝病肝切除要求,是一种合理、有效的切肝手术方法.     

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.     

Anatomy of the liver

This article highlights the clinically and surgically relevant aspects of the anatomy of the liver. The liver is the largest organ in the human body. It can be divided functionally into eight hepatic segments, each with their own blood supply and bile outflow. Anatomically, however, it is divided into the right, left, caudate, and quadrate lobes. The porta hepatis, effectively the hilum of the liver, receives the hepatic artery, hepatic portal vein, right and left hepatic ducts, as well as lymphatic and autonomic nerves.     

腹腔镜下中下段胆管癌根治术中联合肝动脉切除重建的疗效与安全性：附3例报告（附视频）

背景与目的：中下段胆管癌临床上主要以下段胆管癌多见,下段胆管癌一般采用胰十二指肠切除术,中段胆管癌可以采用胰十二指肠切除术或胆管癌根治、胆肠吻合术。中下段胆管癌因胆管紧邻肝动脉和门静脉,因此更容易发生门静脉侵犯,因肝动脉有动脉外鞘,因此肝动脉受侵犯相对较少,但一旦侵犯,因为涉及肝动脉切除吻合重建,具有较高技术难度,常需联合肝动脉切除重建才能实现R0切除。目前肝动脉切除重建在临床逐渐成熟,但腹腔镜下完成肝动脉切除重建经验缺乏,需要进一步积累。因此,本研究对3例完成腹腔镜下联合肝动脉切除重建的胆管癌患者的临床资料进行回顾性分析并评估短期结果,以期为临床实践提供初步经验。方法：回顾性分析2021年11月—2022年11月中国人民解放军陆军军医大学第二附属医院肝胆外科的3例行联合肝动脉切除重建的中下段胆管癌根治术患者的临床资料。结果：3例患者中女性1例,男性2例,年龄分别为61、65、69岁;病例1为胆管中段癌,因肿瘤侵犯右肝动脉和门静脉,且胆管下端切缘阴性,行联合右肝动脉切除重建、门静脉切除重建、胆管癌切除、胆肠吻合术、肝门部胆管整形术、淋巴结清扫术;病例2为胆管下段癌,因肿瘤侵犯替代右肝动...     

Left hepatic trisectionectomy for hepatolithiasis with occluded left and right anterior branches of the portal vein: report of a case

A 64-year-old male was admitted to a local hospital with epigastric pain. Diagnostic imaging revealed hepatolithiasis in the atrophic left lobe. However, endoscopic intervention was impossible because of the presence of many large stones. He was referred to our hospital for surgical treatment. Enhanced multidetector-row computed tomography revealed that the right posterior portal vein (PV) was branched from the portal trunk as a first-order branch, and the bile duct of segment 3 ran caudally to the umbilical portion of the left PV. Furthermore, the umbilical portion of the left PV, which was located between the dilated bile ducts of segment 2 and segment 3, and also the right anterior PV, was occluded with thrombus. Based on these findings, he underwent left hepatic trisectionectomy. Although the indications for left hepatic trisectionectomy for hepatolithiasis are limited, it is therefore extremely important to determine the most appropriate surgical procedure based on the anatomy and findings of hepatic hilus in individual cases.     

成人间活体肝移植供肝的后台准备

目的 探讨成人活体肝移植供肝的灌注和管道重建的技术。方法 回顾性分析41例成人活体肝移植供肝的后台处理临床资料。结果 41个供肝,均为不包括肝中静脉的右半肝,供者男9例,女32例,年龄19～65岁。供肝切取后经门静脉灌注HTK液2～3L（平均2.45L）。只有一支门静脉右支者35例,右前支＋右后支门静脉6例。右肝管29例,右前叶肝管＋右后叶肝管10例,右后叶肝管＋右前上段支＋右前下段支2例。肝静脉：右肝下静脉＋V_5/V_814例,只有一支右肝静脉15例,2支肝中静脉分支8例,4例有3支肝中静脉分支。肝中静脉分支直径〉0.5cm者均重建,重建V_5/V_8和右肝下静脉28例次（70.0%）,右前叶肝管和右后叶肝管整形6例（14.6%）,右后叶肝管和右前叶下段肝管整形3例（7.3%）,门静脉整形2例（4.8%）,门静脉搭桥4例（9.7%）。结论 成人活体肝移植的供肝后台处理与尸体肝移植有明显的不同,其断面的管道处理直接影响移植肝的存活和预后。     

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.     

Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe,simple, and reproducible

Background Hemorrhage from portal and hepatic veins is a major concern with laparoscopic right hepatectomy (LRH). The standard hilar approach is dissection of the portal pedicle outside the liver parenchyma with separate transection of the right hepatic artery, portal vein, and bile duct [1–5, 7, 9]. Variations in anatomy can hamper vascular and biliary control. The intrahepatic Glissonian access avoids these risks by en masse ligation of the portal structures without dissection for each separately [6, 8]. This technique was performed laparoscopically for the last 2 among 10 LRHs, and the results are presented. Methods Total LRH was performed under ultrasound assistance for two patients with malignancy. After lymph node sampling at the hepatoduodenal ligament, dissection was started with the incision of liver parenchyma posterior and anterior to the hilum, then continued outside the portal pedicle bifurcation toward the right and left sheaths. An endoscopic vascular stapling device was placed to transect the right portal pedicle en masse under direct laparoscopic vision and cholangiography guidance. Parenchymal transection and vascular control of the right hepatic vein was accomplished with harmonic scalpel, cavitron ultrasonic aspirator, bipolar diathermy, clips, and endoscopic stapling device, as appropriate. No Pringle’s maneuver was used. The specimen was extracted through a suprapubic incision using an endobag. Results The operative times for the two patients were, respectively, 180 and 240 min. No blood loss occurred during the intrahepatic Glissonian dissection. Intraoperative blood loss (from the right hepatic vein) of 700 and 800 ml, respectively, was controlled laparoscopically. The postoperative periods were uneventful, with discharge, respectively, on days 6 and 7. The surgical resection margins were free of tumor. Conclusions The laparoscopic intrahepatic Glissonian approach used for right hepatectomy is safe, simple, and reproducible. It facilitates the hepatic hilar dissection with minimal operative risk. Further implementation of this technique is encouraged to improve the outcome for patients undergoing laparoscopic liver resection. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users     

Superior approach for the exclusion of hepatic veins in major liver resection: A safe and easy technique

We describe a technique for isolating and excluding the hepatic veins during liver resection. First, the bare area near the right and left wall of the suprahepatic inferior vena cava (IVC) is dissected, exposing the right, left, and superior walls of the right hepatic vein (RHV) and the left-middle hepatic vein (LMHV). Two Satinsky clamps are used to clamp the roots of the right and common trunk of the LMHV, parallel to the IVC. It is not necessary to dissect the posterior wall of the hepatic veins. We used this method during major liver resection in 65 patients. The mean dissecting time of each hepatic vein was 7.31 ± 3.6 min. No hepatic vein was lacerated during dissection and exclusion. The postoperative complication rate was 31.2%. Thus, the superior approach is a safe and easy maneuver when the posterior wall of the hepatic vein is difficult to dissect due to tumor invasion. Li Aijun and Pan Zeya contributed equally to this work.     

下腔静脉与肝静脉的外科应用解剖

在３２例成人尸体上进行腔静脉与肝静脉的应用解剖学的研究，观测了右肾上腺静脉、左膈下静脉、主肝静脉的长度、横径、注入角度和部位及主肝静脉的汇合类型和下腔静脉各段长度。结果表明，术中阻断肝上膈下下腔静脉，有８４．４％的人可经腹部切口完成，另１５．６％者可能需开胸在心包内阻断下腔静脉，下腔静脉下阻断，有８７．５％可在网膜孔后分离阻断，１２．５％需行下腔静脉肝后段分离阻断。在游离肝右叶时，需注意可能出现的     

多层螺旋CT术前评价右叶活体肝移植供肝血管系统

目的探讨MSCT在右叶活体肝移植（LDLT）术前供体筛选中的应用价值。方法对40名拟行肝右叶捐献的志愿者于LDLT术前行MSCT腹部平扫及三期增强扫描,由2名医师观察肝脏血管系统的显影情况（采用4分法进行评价）、解剖结构及变异,并对最终作为供体接受肝右叶切除术者的CT表现及术中所见进行对照分析。结果 2名医师对肝动脉（HA）、门静脉（PV）、肝静脉（HV）分支及副肝静脉（AHV）显影情况的评分均为3～4分,观察者间一致性好（Kappa值分别为0.84、1.00、1.00和1.00）。40名志愿者中,HA正常19名,变异21名;PV正常28名,变异12名。10名志愿者因HA变异影响肝右叶捐献而被排除,包括7名肝右动脉（RHA）纤细和3名S4段肝动脉（S4A）变异;7名志愿者因PV变异被排除,包括2名PV右前支起自门静脉左支（LPV）、3名三叉型PV和2名门静脉右支（RPV）短干。最终包括2名RPV短干、1名PV右后支起自PV主干及2名三叉型PV在内的共15名志愿者作为供体接受肝右叶切除术。LDLT术中所见15名供体的肝脏血管系统解剖结构均与术前MSCT检查结果相符。结论MSCT是LDLT术前评价供肝血管系统的有效方法。     

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.     

Anatomy of the right liver lobe: a surgical analysis in 124 consecutive living donors

Bageacu S, Abdelaal A, Ficarelli S, ElMeteini M, Boillot O. Anatomy of the right liver lobe: a surgical analysis in 124 consecutive living donors.
Clin Transplant 2011: 25: E447–E454. © 2011 John Wiley & Sons A/S. Abstract: Background: Understanding anatomic variations of the right lobe is fundamental in adult to adult living donor liver transplantation. Methods: We analysed anatomy in 124 right liver (RL) donors. Results: Portal vein: normal anatomy was found in 85.5% donors. In 14.5% the main right portal vein (PV) was absent. Hepatic artery: single arterial inflow of the RL was identified in 96% of donors. In 4% two arterial stumps were found. Bile duct: classic anatomy was identified in 50.8% of donors; 9.7% had a trifurcation of the common bile duct; in 7.2% the right anterior and in 15.3% the right posterior bile duct opened into the left bile duct; one segmental bile duct opened directly into the common bile duct in 12.1% and two segmental bile ducts in 4.8%. Hepatic veins (HV): in 74.3% the right HV was the single outflow; in 24.2% significant accessory HV (>5 mm) were preserved, in 2.4% the middle HV was harvested. We found that patients with PV variations had high incidence of multiple bile ducts (88.9%) while patients with single right PV had lower incidence (42.4%) (p = 0.00026). Conclusion: While anatomic variations in the RL donor were common, no contraindication to RL harvesting was noted in this study.