The paracaval segments of the liver

Two segments constitute thedorsal sector: I to the left and in front of the inferior vena cava, and IX in front and to the right of the cava; they are united inferiorly by the caudate process. Segment I includes the caudate lobe, and segment IX is incorporated in the posterior surface of the right liver. Small dorsal pedicles, which are quite numerous, arise from the posterior margin of the main portal elements, and ascend upward. Segment I receives twigs from the left or right livers, many from the right lateral pedicle (67 biliary branches enter the right lateral duct, the unique duct in three cases). Segment IX consists of three subsegments. IXb lies under the interval between the middle and right superior hepatic veins, in 40% of the cases examined the veins come from the left portal vein or the bifurcation, in 6 cases the ducts enter the left hepatic duct, in 40 cases the branches extend higher than the plane of the main hepatic veins, in 18 cases reaching the upper surface of the liver. IXc is under the right hepatic vein, and IXd is to the right of a vertical plane passing by the right superior vein. Hepatic veins, enter the cava directly, sometimes the middle or the left hepatic veins.     

Versatility and viability of hepatic venoplasty in live donor liver transplantation using the right lobe with the middle hepatic vein

Including the middle hepatic vein in the right lobe liver graft has the advantage of providing direct venous drainage of the right anterior segment. To allow unimpeded passage of blood flow, we previously designed venoplasty of the middle and right hepatic veins. We found that venoplasty is also feasible when the inferior right hepatic vein is near to the right hepatic vein, or when multiple segment 8 hepatic vein orifices are exposed adjacent to the middle hepatic vein at the graft transection surface. By joining the hepatic vein orifices into a single opening, the anastomosis into the inferior vena cava is much facilitated. The technique is simple, yet versatile, and able to cope with variation of the configurations of the hepatic vein.     

Wedged hepatic venous pressure in congential heart disease.

Seventy cases of congential heart disease including the most frequent types were studied, and wedge hepatic venous pressure (WHVP) was measured in each. The mean pressure was determined in the "jammed position" and in the free hepatic veins, inferior vena cava, and low right atrium. The average mean WHVP was 7.0 mm Hg, 5.0 in inferior vena cava, and 3.4 in the right atrium. A direct relationship was found between wedge hepatic venous pressure of the inferior vena cava and the low right atrium, but not other parameters. Ten patients had a mean pressure above 10 mm Hg. We believe that in many circumstances in patients with congenital heart disease, liver function may be abnormal and high values of wedge hepatic venous pressure may also be found.     

Liver transplantation using a right lateral sector graft from a living donor to her granddaughter

One of the major concerns regarding living-related liver transplantation is graft-size disparity. The left liver graft is too small while the right is too large in some recipients. To overcome this problem, the right lateral sector (Segments VI and VII) was transplanted from a living donor (55 kg) to her granddaughter (17 kg). The common hepatic trunk had to be anastomosed end-to-end to the graft hepatic vein without being compressed by the graft overriding the vena cava and without unfavorable tension of the anastomosis. The anterior wall of the hepatic vein of the donor was resected as much as possible. The superficial left, left, middle and right hepatic veins of the recipient were made confluent by incision of the intervening venous walls, and the nicks were sutured to form a wide and long common venous trunk. The recipient received a graft corresponding to 75% of her standard liver volume. She was complicated with gastric dilation and acute rejection, but recovered with no signs of anastomotic stricture. Right lateral sector graft obtained by this innovative procedure may be useful for overcoming borderline graft-recipient size and shape differences.     

Surgical anatomy of retrohepatic inferior vena cava and hepatic veins: a quantitative assessment.

BACKGROUND: Accurate knowledge of the surgical anatomy of the retrohepatic inferior vena cava (IVC) and hepatic veins is necessary for hepatic surgery. METHODS: Lengths of different segments of retrohepatic IVC and their diameters, and prevalence of various types of ramification and lengths of different hepatic veins, were noted in 100 disease-free human livers during autopsy. RESULTS: The mean lengths of the IVC from entry into atrium to diaphragmatic hiatus, from the hiatus to the upper margin of right hepatic vein, between the upper margins of the right hepatic vein and the right suprarenal vein, from right suprarenal vein to the lowermost dorsal hepatic vein, and from the lower-most dorsal hepatic vein to the right renal vein were 29.1 mm, 8.6 mm, 40.6 mm, 28.6 mm and 33.7 mm, respectively. The mean diameter of IVC at the diaphragmatic level was 30.1 mm. The commonest ramification pattern of the hepatic veins was type I (82%) for the right hepatic vein, type II (63%) for the middle and left hepatic veins, and type II (55%) for the caudate veins. In 96% of cases the middle and left hepatic veins formed a common trunk. In a majority of cases, the diameters of the right and left hepatic veins were between 7 mm and 12 mm. No gender differences were found. CONCLUSION: This study provides an anatomical perspective for various hepatic surgical techniques.     

Phrenic vein dissection in partial liver graft harvesting

BACKGROUND/AIMS: Despite the impressive results of living donor liver transplantation, hepatic venous reconstruction remains a controversial component. METHODOLOGY: A total of 211 consecutive donor hepatectomies were performed. The proximal route of the hepatic vein was exposed by dissection of the connective tissue around the hepatic vein and by dividing and ligating all of the inferior phrenic veins that open into the hepatic vein, into the confluence of the hepatic vein and inferior vena cava, or directly into the inferior vena cava. RESULTS: In the 114 left-side hepatectomy procedures, the number of divided left inferior phrenic veins ranged from 1 to 4 and the diameters of the left and middle hepatic veins ranged from 7 to 33mm. For the 97 right-side procedures, the number of divided right inferior phrenic veins ranged from 1 to 4 and the diameters of right hepatic veins ranged from 9 to 34mm. This maneuver safely allowed for the safe exposure of all trunks and routes of the hepatic veins and the suprahepatic portion of the inferior vena cava. CONCLUSIONS: Our technique is useful for obtaining a wide ostium and a sufficient length of the hepatic vein for grafts obtained from living donors.     

Patterns of anomalous pulmonary venous drainage

All of our cases of abnormal pulmonary venous connections collected to the middle of 1965 and verified at surgery or autopsy have been reviewed by means of diagrams and tabulations, using a specially devised code to facilitate the survey. The material consisted of 52 autopsy cases (half of them obtained after surgery) and the cases of 72 patients who survived operation. The postmortem group was much younger than the surgical group and differed also from the latter by showing male preponderance as well as relatively many instances of total abnormal pulmonary venous connection and frequently associated cardiac anomalies. Partial anomalous connection of right pulmonary veins was 10 times more frequent than that of the left pulmonary veins. This was caused by (1) the frequent drainage of some of the right pulmonary veins into the junctional area between right atrium and superior vena cava in the presence of normal left pulmonary veins, and (2) the complete absence of isolated left pulmonary venous connection to the right atrium. Abnormal connection of solitary pulmonary veins was always effected to the most proximal venous structure among the four possible ones which are derived from the main embryonic channels (superior vena cava and inferior vena cava on the right side, and left superior vena cava and coronary sinus on the left side). Common pulmonary veins from one lung also drained in accordance with this proximity rule, if this may be taken to apply also to the drainage of right pulmonary veins into the right atrium. The one exception in our material was the drainage of all right pulmonary veins into the portal venous system. Total abnormal pulmonary venous connection may be found with all structures mentioned, but most frequently with the left superior vena cava, or coronary sinus, or both, usually by way of a common pulmonary vein. In a few cases however, drainage into different sites, all of them abnormal, did occur. Then again the proximity rule seemed to apply. A tentative embryological explanation is given for the patterns described.     

Caudate lobectomy (segmentectomy 1) (with video)

Background

The caudate lobe of the liver is located behind both major lobes and is surrounded by the inferior vena cava, three main hepatic veins, and the hepatic hilum. Despite a hard-to-approach anatomic location, isolated complete removal of the caudate lobe is recommended to improve curability in hepatocellular carcinoma (HCC). This is because most patients with HCC cannot undergo caudate lobectomy (segmentectomy 1) with resection of adjacent liver regions due to their poor liver function.

Methods

We performed an anatomic isolated caudate lobectomy using a high dorsal resection technique in patients with HCC involving the paracaval portion of the liver. In this procedure, the caudate lobe is dissected, the boundary of the caudate lobe is identified using counterstaining and tattooing techniques, and the liver is transected along landmarks. The caudate lobe can be removed completely, without loss of the parenchyma of the major lobes, thereby preserving liver function.

Conclusions

Given that most patients with HCC concurrently have chronic liver disease, those with HCC in the caudate lobe are good candidates for high dorsal resection of the liver, which is safe, potentially curative procedure.     

Analysis of Hepatic Vein Waveform by Doppler Ultrasonography in 100 Patients with Portal Hypertension

Objectives : We classified the Doppler waveform seen in patients with portal hypertension and examined the associations of the waveform type with the diagnosis of Budd-Chiari syndrome and severity of the liver cirrho-sis. Methods : The Doppler pattern of right and left hepatic veins in 100 consecutive Japanese patients with portal hypertension and esophagogastric varices was classified into six types: 1, triphasic waveform; IF, bi-phasic waveform without reversed flow; III, decreased amplitude of phasic oscillations; IV, flat waveform with fluttering; V, completely flat waveform with fluttering; VI, no waveform. All patients underwent computed tomography and magnetic resonance imaging. Patients in whom hepatic vein waveform showed type IV, type V, or type VI, positively underwent hepatic venography and inferior vena cavography. Resuits: Type I was seen in 31 of 100 patients, type II in 35, type III in 17, type IV in eight, type V in four, and type VI in five. Types I-IV waveform indicated no lesion in hepatic veins and inferior vena cava, type V indicated stenosis of hepatic veins or occlusion of inferior vena cava, and type VI, occlusion of hepatic veins. For one patient with type V hepatic veins, halloon angioplasty was done, and the waveform changed from type V to type II. Examining the relationship between hepatic vein waveform and the Child-Pugh score, liver function of type IV cases was worse than tbat of type I cases in 66 cirrhotie patients witbout bepatocellular carcinoma(p < 0.05). Tbere was no clear relutionship between bepatic vein waveform and portal venous perfusion, as based on Nordlinger's grade. Conclusions: Our classiflcation of hepatic vein waveform in Doppler ultrasonography is useful in di-agnosing Budd-Cbiari syndrome, in judging the effi-ciency of treatment for bepatic vein lesions, and in assessing severe liver function in cirrbotic patients.     

Two dimensional echocardiographic diagnosis of situs.

At present there is no reliable method of recognising atrial isomerism by two dimensional echocardiography. We therefore used two dimensional echocardiography to examine 158 patients including 25 with atrial isomerism and four with situs inversus. Particular attention was paid to the short and long axis subcostal scans of the abdomen. Using the position of the inferior vena cava and the aorta with respect to the spine it was possible to separate those with situs solitus from the others. Two false positives for abnormal situs had exomphalos. In situs solitus the aorta lay to the left of the spine and the inferior vena cava lay to the right. One patient with situs solitus and azygos continuation of the inferior vena cava also had inferior vena cava to right atrial connection. In the four patients with situs inversus the mirror image of the normal pattern was present. In nine patients with right isomerism the inferior vena cava and aorta ran together on one or other side of the spine. The inferior vena cava, anterior to the aorta at the level of the diaphragm, received at least the right hepatic veins (normal or partial anomalous hepatic venous connection). Of the 16 patients with left isomerism, 14 had azygos continuation of the inferior vena cava which was visualised posterior to the aorta in all but two. All patients with left isomerism had total anomalous hepatic venous connection to one or both atria via one or two separate veins. Two dimensional echocardiography therefore provides the means of detecting abnormal atrial situs and of diagnosing right or left isomerism in the great majority of patients, if not all.     

Panhepatography: Simultaneous radiographic visualization of all hepatic veins

Summary Panhepatography, a new method of hepatic phlebography by means of a single injection of contrast medium into the inferior vena cava, is described. Simultaneous arrest of caval flow during injection of contrast medium into the vena cava near the outlet of the hepatic veins enables opacification of all the hepatic veins and their branches. Because of the block at the level of the caval vein, the contrast medium follows a retrograde flow into the hepatic veins.The method was developed in 76 experiments on 36 dogs and applied clinically in 1 patient. In the animal experiments good visualization of all the hepatic veins and their branches was obtained. In one clinical trial on a patient suffering from portal hypertension and hypersplenism, the main right hepatic vein and the large accessory hepatic vein were clearly outlined, as well as their small branches.I believe that it is feasible to opacify all of the hepatic veins in man.The work described in this paper was carried out in collaboration with the Departments of Operative Technique and Experimental Surgery and of Radiology Faculty of Medicine, University of Minas Gerais, Belo Horizonte, Brazil.     

Hepatic resection through an anterior approach employing a modified liver hanging maneuver in patients with a massive liver tumor severely oppressing the inferior vena cava

For a large hepatic neoplasm existing in the right hepatic lobe, hepatic resection using an anterior approach is required. We have reported an operative procedure for hepatic transection using absorbable polyglycolic acid tape. In patients with suspected tumor invasion of the inferior vena cava, on the other hand, considering the range of the residual tumor while sparing the inferior vena cava as much as possible, combined resection and reconstruction of the inferior vena cava is conducted only if operative curativity is expected. We conducted hepatic transection while maintaining the blood flow of the residual liver by applying the liver hanging maneuver method of Belghiti et al. and polyglycolic acid tape in patients with giant liver tumors of the right hepatic lobe compressing the hepatic inferior vena cava. Strong angled dissecting forceps were inserted into the ventral side of the inferior vena cava from the caudal side, and the tip was induced between hepatic veins. Two strips of polyglycolic acid tape were pinched with forceps and strongly ligated on the right and left sides of the cutoff line. Subsequently, hepatic transection was conducted using electrocautery spray coagulation and CUSA without blocking the inflow blood of the residual liver, and the right hepatic lobe was extirpated. This procedure has already been performed in 5 patients suspected of inferior vena cava invasion, and the inferior vena cava was able to be preserved in all the patients.     

Transjugular intrahepatic portosystemic shunt in combination with oral anticoagulant for Budd-Chiari syndrome.

The antiphospholipid antibody syndrome is characterized by arterial and venous thrombosis including hepatic veins. Although transjugular intrahepatic portosystemic shunt or liver transplantation have been considered for Budd-Chiari syndrome, treatment options for patients with complete obstruction of three hepatic veins including the junction with the inferior vena cava are limited. We describe a 27-year-old female, who suffered thrombotic obliteration of hepatic veins including the portion confluent with the inferior vena cava (Budd-Chiari syndrome) associated with marked ascites and liver dysfunction. Transjugular intrahepatic portosystemic shunt using a Wall-stent (10 mm in diameter) between inferior vena cava and intrahepatic portal vein was performed. Intrastent coagulation and recurrence of thrombosis were prevented by combination therapy with warfarin potassium and ticlopidine hydrochloride. These treatments induced loss of ascites and improvement of liver function, and she has been able to resume daily life. The portosystemic shunt described above in addition to combination therapy with warfarin potassium and ticlopidine hydrochloride appeared to be one of the options for treating Budd-Chiari syndrome associated with antiphospholipid antibody syndrome.     

Anterior transhepatic approach for hepatocellular carcinoma located in deep positions of segment VIII

Liver resection for liver tumors located in deep positions in segment VIII remains a technical challenge. We successfully resected a hepatocellular carcinoma located in deep position in segment VIII and extended into the paracaval portion of the right caudate lobe, using an anterior transhepatic approach. The patient was a 73-year-old man with chronic hepatitis C. Preoperative ultrasonography and dynamic computed tomography revealed that the tumor was about 3.0 cm in diameter and close to the roots of the middle and right hepatic veins and the paramedian Glissonian pedicle. The right anterior artery was supplying the tumor. The liver was opened along the right side of the middle hepatic vein. The dorsal Glissonian pedicle of segment VIII was easily exposed, ligated, and divided. The dorsal part of segment VIII was removed, along with the paracaval portion of the right caudate lobe. The postoperative course was uneventful. The patient was disease-free 17 months after surgery. This anterior transhepatic approach provides a wide operating field and easy hemostasis, and could preserve the liver parenchyma as much as possible in a patient with liver dysfunction.     

Budd-Chiari syndrome： A case with a combination of hepatic vein and superior vena cava occlusion

We here report a recent, rare case of Budd-Chiari syndrome, associated with a combination of hepatic vein and superior vena cava occlusion. A young female, who had been in good health, was admitted to our hospital because of massive ascites. The patient had used no oral contraceptives. Tests for coagulation disorders, hematological disorders, and antiphospholipid syndrome were all negative. Budd-Chiari syndrome was diagnosed by radiographic examination. The patient was suffering from a combination of hepatic vein and superior vena cava occlusion. In particular, the venous flow returned from the liver mainly through a right accessory hepatic vein, and stenosis was recognized at the orifice of this collateral vein into the vena cava. Subsequently, the patient underwent percutaneous balloon dilatation therapy for this stenosis. After this treatment, the massive ascites was gradually reduced, and she was discharged from our hospital. It has now been one year since discharge, and the patient has been doing well. If deteriorating liver function or intractable ascites occur again, a liver transplantation may be anticipated. This is the first case report of Budd-Chiari syndrome associated with a superior vena cava occlusion.     

Inferior Vena Caval and Right Atrial Thrombosis Complicating an Amebic Hepatic Abscess

We describe a 50-yr-old black laborer who presented with right lower chest pain, weight loss, and pedal edema. Ultrasonography and computed tomograms showed a large abscess cavity in the right lobe of the liver which extended very close to the inferior vena cava. The lumen of the adjacent inferior vena cava was partially occluded by thrombus, which could be traced up into the cavity of the right atrium. The hepatic veins were normally patent. Sterile blood-stained pus was aspirated from the abscess. Antibodies against Entamoeba histolytica were present in high titer in the patient's serum. Although propagation of hepatocellular carcinoma into the inferior vena cava and even up into the right atrium is well recognized, inferior vena caval thrombosis extending up into the right atrium has not hitherto been reported as a complication of amebic hepatic abscess.     

Liver hanging maneuver for right hemiliver in situ donation--anatomical considerations

Background. An anatomical study was carried out to evaluate the safety of the liver hanging maneuver for the right hemiliver in living donor and in situ splitting transplantation. During this procedure a 4–6 cm blind dissection is performed between the inferior vena cava and the liver. Short subhepatic veins entering the inferior vena cava from segments 1 and 9 could be torn with consequent hemorrhage. Materials and methods. One hundred corrosive casts of livers were evaluated to establish the position and diameter of short subhepatic veins and the inferior right hepatic vein. Results. The average distance from the right border of the inferior vena cava to the opening of segment 1 veins was 16.7±3.4 mm and to the entrance of segment 9 veins was 5.0±0.5 mm. The width of the narrowest point on the route of blind dissection was determined, with the average value being 8.7±2.3 mm (range 2–15 mm). Discussion. The results show that the liver hanging maneuver is a safe procedure. A proposed route of dissection minimizes the risk of disrupting short subhepatic veins (7%).     

Surgical anatomy of the inferior vena cava ligament

BACKGROUND/AIMS: The inferior vena cava ligament is a fibrous membrane located around the inferior vena cava. Few reports exist on the ligament's location, attachment to the liver, or the inferior vena cava. METHODOLOGY: We obtained 16 specimens of human liver and inferior vena cava from cadavers. The inferior vena cava ligament was photographed and then dissected for histological examination. Relationships among the ligament, inferior vena cava, and liver were examined microscopically. The numbers and diameters of veins, arteries, and lymph vessels at least 1 mm in diameter were recorded. RESULTS: The cranial margin of the inferior vena cava ligament was ended in a blind loop. The cranial portion above the mid-portion of the Spiegel lobe was thicker than the caudal portion. The ligament was attached to the right and left hepatic veins. The mean length of the right side of the inferior vena cava ligament was 37.0 mm and the mean width 15.6 mm. The inferior vena cava ligament had a mean thickness of 0.8 mm (thin end) and 2.5 mm (thick end). Although the inferior vena cava ligament was usually tightly continuous with the liver capsule, microscopically the attachment between the ligament and the inferior vena cava was loose. The mean number and diameter of veins in the inferior vena cava ligament was 1.0 and 1.4 mm, respectively. The mean number and diameter of arteries was 0.2 and 2.4 mm, respectively. The mean number and diameter of lymphatic vessels was 2.8 and 1.7 mm, respectively. CONCLUSIONS: After dissection of the inferior vena cava ligament, major hepatic veins can be dissected extrahepatically. Because the ligament is wider caudally, the forceps should be inserted caudocranially during separation. Since both the number and diameters of lymphatic vessels in the ligament are large, the ligament should be ligated and cut.     

Update on the classification, assessment of prognosis and therapy of Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) occurs as a result of obstruction of hepatic venous outflow at any level from the small hepatic veins to the junction of the inferior vena cava with the right atrium. Diagnosis can be difficult because of the wide spectrum of presentation of the disease and the varying severity of liver damage. The traditional classification of BCS--as fulminant, acute or chronic--is not prognostically useful. This makes assessing the benefit of therapy difficult, especially as there is no evidence from randomized studies. This article highlights advances in the prognosis and therapy of BCS. Identification of the site of venous obstruction has a major effect on prognosis. Portal-vein thrombosis occurs in 20-30% of cases, and acute presentation of BCS reflects an acute or chronic syndrome in 60% of BCS cases. BCS can be diagnosed and treated on a single occasion in the setting of the radiology department, with hepatic venography, transjugular liver biopsy, retrograde CO2 portography and inferior vena cava pressure measurements performed simultaneously with therapies such as dilation or stenting of webs in the inferior vena cava or hepatic veins, and placement of transjugular intrahepatic portosystemic shunts. Disruption of a portal vein thrombus can also be done during the same session. Surgical shunts have been superseded by the use of transjugular intrahepatic portosystemic shunts. Liver transplantation is reserved for fulminant and progressive chronic forms of BCS. Anticoagulation therapy must be used routinely, before and after specific therapy, regardless of whether a thrombophilic disorder is diagnosed.     

Atrial tachycardia originating from the hepatic segment of inferior vena cava in interruption of inferior vena cava with azygos continuation

Interruption of inferior vena cava (IVC) with azygos continuation is a rare venous anomaly, and arrhythmogenic IVC is also rarely reported. Arrhythmogenicity of the hepatic segment of IVC in interruption of IVC has never been reported. We describe the case of a 37-year-old female with interrupted left IVC with azygos continuation to right superior vena cava and atrial tachycardia originating from the hepatic segment of IVC.