A suitable animal model for laparoscopic hepatic resection training

Background There is a growing interest in using laparoscopy for hepatic resection. However, structured training is lacking in part because of the lack of an ideal animal training model. We sought to identify an animal model whose liver anatomy significantly resembled that of the human liver and to assess the feasibility of learning laparoscopic hepatic inflow and outflow dissection and parenchyma transection on this model. Methods The inflow and outflow structures of the sheep liver were demonstrated via surgical dissection and contrast studies. Laparoscopic left major hepatic resections were performed. Results The portal hepatis of all 12 sheep (8 for anatomic study and 4 for laparoscopic hepatic resection) resembled that of human livers. The portal vein (PV) was located posteriorly; the common hepatic artery (CHA) and the common bile duct (CBD) were located anterior medially and anterior laterally with respect to the portal hepatis. The main PV bifurcated into a short right and a long left PV. The extrahepatic right PV then bifurcated into right posterior and anterior sectoral PV. The CBD and CHA bifurcated into left and right systems. The cystic duct originated from the right hepatic duct. The cystic artery originated from the right HA in 11/12 animals. The left hepatic vein drained directly into the inferior vena cava (IVC). The middle and the right hepatic veins formed a short common channel before entering the IVC. Multiple venous tributaries drained directly into IVC. Familiarity with sheep liver anatomy allowed laparoscopic left hepatic lobe (left medial and lateral segments) resection to be performed with accuracy and preservation of the middle hepatic vein. Conclusions The surgical anatomy of sheep liver resembled that of human liver. Laparoscopic major hepatic resection can be performed with accuracy using this information. Sheep is therefore an ideal animal model for advanced surgical training in laparoscopic hepatic resection.     

Hepatectomy with total vascular exclusion. Anatomical principles based on 64 dissections

Intra-operative hemorrhage is the main surgical risk during liver resections. Nowadays hepatectomies for large or posterior liver tumors close to the hepatocaval junction can benefit from total hepatic vascular exclusion (HVE) involving portal triad exclusion and clamping of the inferior vena cava (IVC) below and above the liver. Anatomical aspects of HVE have been studied in 64 subjects by segmental occlusive phlebographies of the IVC, injection of corrosive substances into the hepatocaval network, biometry of the retrohepatic IVC and serial sections of injected livers. A total HVE should exclude the right suprarenal and phrenic veins. Clamping of the suprahepatic IVC depends on the termination of the left inferior phrenic vein. Clamping of the subhepatic IVC must be retrohepatic: the right lobe of the liver has to be mobilized to free the right border of the retrohepatic IVC into which flows the right suprarenal vein 40 +/- 20 mm above the right renal vein and under the superior right hepatic vein. Both suprahepatic and retrohepatic clamps excluding the retrohepatic portion of the IVC (46.6 +/- 13 mm) and the hepatocaval junction should come in contact behind the IVC without overlapping.     

New Left Lobe Transplantation Procedure with Caval Reconstruction Using an Inverted Composite Graft for Chronic Budd-Chiari Syndrome in Living-Donor Liver Transplantation—A Case Report

When the Budd-Chiari syndrome (BCS) lesion extends to the inferior vena cava (IVC) or the orifices of the hepatic vein, the thickened IVC and/or hepatic vein wall must be removed and IVC reconstruction is required in living-donor liver transplantation (LDLT). In various reports about IVC resection in LDLT for BCS, there are none about left lobe liver transplantation with reconstruction of the retrohepatic IVC (rhIVC). To overcome removal and reconstruction of the rhIVC in LDLT for BCS, we introduced a composite IVC graft that is applicable to both right and left lobe partial liver grafts for LDLT for BCS. Pathogenic IVC was removed together with the native liver between the lower edge of the right atrium and 5 cm above the renal vein junction with the use of venovenous bypass. The e-polytetrafluoroethylene graft was anastomosed to the suprarenal intact IVC. Then the native part was detached at the level of just above the renal junction. The composite graft was inverted and a half rim of the native part of the graft was anastomosed to the posterior wall of the right atrium. Next, the common venous orifice of the left lobe graft was anastomosed to the wall defect which was composed of the anterior wall of the right atrium and the distal end of the native part of the composite graft. In conclusion, our inverted composite graft technique will overcome the weak points of LDLT for BCS, such as incomplete removal of the pathogenic caval wall and reconstruction of the rhIVC.     

In situ graft-trimming method using polyester vascular prosthesis for inferior vena cava reconstruction after hepatectomy

Hepatectomy for secondary liver cancer that has invaded the inferior vena cava (IVC) can be the only way to achieve long-term survival. We describe a method for hepatectomy combined with partial IVC resection without venous bypass circulation and an in situ graft-trimming method to avoid graft size mismatch after reconstruction. We carried out left hepatectomy extended to segment 1 with partial IVC resection first. During resection and reconstruction of the IVC, it was clamped below the right hepatic vein and above the inferior right hepatic vein to maintain systemic circulation. The graft was trimmed in situ, after a half running suture of the graft was finished to ensure the correct size. Preservation of both inferior right hepatic vein and right hepatic vein helps to maintain systemic circulation during reconstruction of the IVC. The in situ graft-trimming method is an easy and safe method to ensure the correct graft size after IVC reconstruction.     

Budd-Chiari syndrome treated by Senning's procedure

Two patients with Budd-Chiari syndrome who underwent a new surgical procedure developed by Senning are reported. A 33-year-old man was diagnosed as having Budd-Chiari syndrome with a membranous obstruction of the inferior vena cava (IVC) and right hepatic vein and short segmental obstruction of the left hepatic vein. Removal of the obstruction by dorsocranial resection of the liver and reconstruction of the veins by hepatoatrial anastomosis was carried out. In a 53-year-old female, the same procedure was carried out for a short segmental obstruction of the IVC and left hepatic vein. In both patients, postoperative examination revealed good patency of the IVC and the hepatic veins and increased portal venous flow as measured by Doppler-echography. This procedure is considered the method of choice for Budd-Chiari syndrome with membranous and/or short segmental obstruction of the IVC and hepatic veins.     

Liver resection with repair of major hepatic veins

BACKGROUND: Liver resections for tumors adjacent to major hepatic veins often require reconstruction of venous wall defects. We describe a new operative approach that facilitates repair of major hepatic veins during hepatectomies. METHODS: In 3 cases of liver tumors, the resection line had to include partially the wall of the right hepatic vein, middle hepatic vein and left hepatic vein of the preserved liver. The procedure was carried out by employing portal triad clamping combined with extrahepatic occlusion of the hepatic veins. Venous grafts for vascular repair were harvested from the inferior mesenteric vein. RESULTS: In all 3 patients, histology showed tumor-free resection margins. Follow-up of 32 to 42 months revealed no recurrence and excellent liver function. CONCLUSIONS: Combination of selective hepatic vascular exclusion with venous repair techniques, facilitates extensive liver resections in patients with tumors adjacent to the major hepatic veins and maximizes preservation of healthy liver tissue.     

Extended Left Hepatectomy by Severing All Major Hepatic Veins with Reconstruction of the Right Hepatic Vein

Curative liver resection is technically challenging when multiple liver metastases from colon cancer involve the confluence of the three major hepatic veins. We report two cases of successful extended left hemihepatectomy achieved by severing all of the major hepatic veins together with the wall of the inferior vena cava, to resect liver metastases from colon cancer. Reconstruction of the right hepatic vein was done after unroofing the right anterior area of the liver with a direct anastomosis of the right hepatic vein. We did not need to perform total vascular exclusion or portovenous shunting during the liver transection. This simple and safe method can increase the surgical indications for previously unresectable tumors.     

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.     

主肝静脉和肝短静脉的解剖学研究及其临床意义

目的:探讨主肝静脉和肝短静脉（SHVs）的数量、位置、分型、口径等参数。方法:取60具成人尸体标本, 测量肝左、中、右静脉的肝外长度、注入下腔静脉（IVC）管径;按其SHVs汇入下腔静脉左侧壁、前壁和右侧壁分为左、中、右3排，测量SHVs的数量、位置、口径及其与主肝静脉的关系。结果:肝左、中、右静脉开口于IVC肝后段上l/4段，其中肝左、中静脉共干者73.3%（44例），肝左、中、右静脉共开口者1.7%（1例），3支分别汇入者25.0%（15例），SHVs直径为1.5～17.8（5.4±1.4）mm,3～35支SHV从不同方向和节段注入下腔静脉。肝右静脉直径与SHVs直径呈负相关（r=-0.34，P＜0.05);肝左静脉直径与SHVs数目呈负相关（r=0.24， P＜0.05)。肝右后下静脉（IRHV）出现率为83.3%，平均直径为2.6～8.0（4.3±1.2）mm。结论:SHVs变异较大，管径粗者数量少。SHVs的口径、数目与主肝静脉口径、数目呈相互消长。肝右静脉直径愈大，SHVs直径愈小;反之SHVs直径愈大。肝左静脉直径愈大，SHVs数量愈少;反之SHVs数量愈多。     

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.     

The hepaticocaval intersection: current anatomosurgical aspects. Apropos of 32 dissections

Segmental occlusive phlebography of IVC coupled with a slit in its posterior wall, injection of corrosive substances into portal and hepaticocaval network, biometry of the retrohepatic IVC and serial sections of injected livers from 32 fresh subjects has allowed definition of the hepaticocaval intersection which constitutes one of the rare current stumbling-blocks to hepatic surgery. Emergency surgery for hepaticocaval injuries exposes patients to the risk of gas embolus and massive haemorrhage. Using a median sternolaparotomy approach they require previous temporary hemostasis by quadruple clamping or intracaval shunt: in more than half of cases the length of the subhepatic, suprarenal IVC of less than 1 cm does not permit application of a clamp and necessitates introduction of an intracaval shunt by the atrial route. Cold surgery for certain hepatic tumors close to the intersection can benefit from vascular exclusion of liver but the right middle capsular and inferior phrenic veins must be clamped: clamping of the suprahepatic IVC is dependent on the site of the intersection in relation to diaphragm. The principal right hepatic vein, lacking collateral over 1 cm external to liver in 1 of 2 cases, can be controlled extraparenchymatously after mobilization of right liver, but caution is needed because of the predominance of "accessory" hepatic veins in 25% of cases. Control of hepatic veins external to liver on left side is dangerous since a common trunk is frequent (87.5%), collateral branches numerous and often vulnerable. Relations between intersection, diaphragm and right atrium also define modalities of treatment of hepatic lesions in membranes of terminal IVC and in Budd Chiari's syndrome.     

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.     

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     

An anatomical study of short hepatic veins,with special reference to delineation of the caudate lobe for hanging maneuver of the liver without the usual mobilization

Abstract. Background/Purpose: The present study was designed to anatomically assess a very recently reported hanging maneuver of the liver without mobilization, in which forceps are inserted blindly between the inferior vena cava (IVC) and liver parenchyma. Methods: We dissected 56 formalin-fixed livers (1) to determine whether preservation of the caudate vein (the largest vein draining Spiegel's lobe) and inferior right hepatic vein (IRHV) was possible and (2) to identify the territories drained by other, non-preserved short hepatic veins. Results: A potential space for insertion of the forceps was found between the openings of the caudate vein and IRHV; however, if preservation of both veins is absolutely necessary, we recommended protecting the IRHV, such as by taping and retracting it. We classified the other short hepatic veins into two categories, i.e., those draining the left portal vein territory and those draining the right territory. The distributions of the openings of the veins in these territories overlapped. Conclusions: Clear delineation of the left caudate lobe according to the drainage veins appeared to be difficult when the liver was divided along a straight line in front of the IVC. Received: March 22, 2001 / Accepted: August 21, 2001     

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     

Course and anastomoses of the large hepatic veins to main structures on the liver surface

The upper liver veins of fifty adult people were dissected from their orifices up to their second ramifications. The courses of the hepatic veins to the main portal fissure and umbilical fissure were determined. Three large upper hepatic veins can be expected in 74%, an accessory one occurs in 26%. The three or four upper hepatic veins join V. cava inferior by two (66%) or three (34%) common terminal branches (length 0.9 cm). Mean diameters of right hepatic vein 1.5 cm, middle hepatic and left hepatic veins 1 cm, accessory upper hepatic vein 0.6 cm. The course of the middle hepatic vein to "cava-gallbladder-line" was determined. The most common vein of the umbilical fissure joins the left, occasionally the middle hepatic vein. The intrahepatic distribution of the liver veins was projected to the surface of the liver considering the typical resection lines. We recommend the following anatomical way of proceeding: right extended and left lateral lobectomy remain right to lig. falciforme hepatis; right lobectomy 1 cm right, left lobectomy 1 cm left to "cava-gallbladder-line".     

肝后隧道手术高危区的解剖特点及临床应用研究

目的:探讨肝后隧道及手术高危区的解剖特点及临床应用价值。方法:解剖20具成人尸体肝脏标本,收集经前入路绕肝提拉法右半肝切除术27例患者的临床资料,分别统计汇入肝后下腔静脉和肝后隧道路径上肝短静脉总数。结果:解剖研究中发现,肝短静脉主要从左右两侧汇入肝后下腔静脉,且较多集中于中、下1/3段;在肝后隧道路径上,汇入肝后下腔静脉的肝短静脉主要集中在下1/3段前方,平均(2.90±1.07)支,上1/3段仅有1例出现1支肝短静脉,中1/3段20例中仅4例出现1支肝短静脉;肝右后下静脉多出现在肝后下腔静脉的中、下1/3段,出现率达85.0%(17/20)。临床手术中发现,在肝后隧道路径上,汇入肝后下腔静脉肝短静脉主要集中在下1/3段,平均(3.21±1.67)支,多数病例此区域上下距离约3～4 cm,同时此区域中肝右后下静脉出现率达85.2%(23/27);27例中仅1例有1支肝短静脉汇入中段肝后下腔静脉前方。结论:肝后隧道手术高危区位于肝后下腔静脉下段前方3～4 cm区域,有较多肝短静脉伴随肝右后下静脉汇入。准确把握此区域的解剖特点并进行解剖分离是成功建立肝后隧道的关键。     

Left Extended Hemihepatectomy With Preservation of Large Inferior Right Hepatic Vein: A Case Report

For hepatic function to be preserved after an extended hemihepatectomy adequate venous drainage of the remaining liver is required. Most metastases close to the confluence of the superior hepatic veins are considered unresectable because hepatic venous outflow after resection would be compromised. In 10–25% of people, the inferior right hepatic vein is of large calibre. Thus the superior hepatic veins may be sacrificed and hepatic function preserved if a large inferior right hepatic vein is present.A patient with involvement of segments 2, 4 and 8 by metastatic colorectal cancer is presented. This patient had a large inferior right hepatic vein, and so was able to undergo an extended left hemihepatectomy with ligation of all superior hepatic veins. Subsequent quality of life was maintained.This case illustrates that an ‘unresectable’ hepatic lesion can be actually resectable if an alternative venous drainage is present. A pre-operative search for a prominent inferior right hepatic vein by ultrasound, computerised tomography, or even magnetic resonance imaging should be considered in these cases.     

Novel two-step resection for lesions between the middle hepatic vein and vena cava which allows the middle hepatic vein to be preserved

Patients with bilobar colorectal cancer metastases to the liver present a unique problem in terms of resection. They sometimes require a staged approach to resection that takes advantage of the liver’s ability to regenerate, as well as the newer chemotherapeutic agents (e.g., oxaloplatin, irinotecan (CPT-11), and bevacizumab) that have become available. In cases of multiple bilobar metastases, if segment IV is clear of tumor, a left lateral segmentectomy (LLS) can be performed, followed several months later by a formal right hepatectomy. The remnant liver composed of the hypertrophied segment IV is drained by the middle hepatic vein (MHV). In this context, patients with lesions between the origin of the MHV and the inferior vena cava (IVC) present a particularly difficult problem. Conventional excision would require an extended hepatectomy and division of the MHV along with either the right or left hepatic veins (RHV, LHV). This would make it impossible to continue with a formal resection of the remaining lesions in the contralateral liver without sacrificing the sole remaining hepatic vein. We present a novel two-step hepatectomy for lesions between the MHV and the IVC that allows the MHV to be preserved and all lesions to be resected. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005 (poster presentation).     

Right hepatic lobectomy and removal of inferior vena caval tumor embolus in a patient with hepatocellular carcinoma, using veno-venous bypass while preserving perfusion in the remnant liver: A case report

We describe a successful hepatectomy and the removal of a tumor embolus in a 43-year-old woman with hepatocellular carcinoma occupying the right lobe extending to the right branch of the portal vein and the inferior vena cava (IVC). Intraoperative echography revealed the tumor embolus in the IVC to originate from the main tumor via the right inferior hepatic vein, which extended cephalad from the confluence of the right hepatic vein to the IVC. Right hepatc lobectomy was performed via the anterior approach. Using femoro-axillary veno-venous bypass, we opened the IVC at the root of the inferior right hepatic vein to remove the tumor embolus after oblique clamping of the IVC between the right and middle hepatic veins was carried out to preserve perfusion in the remnant liver. Preserving perfusion in the remmant liver in radical hepatectomy for hepatocellular carcinoma with tumor embolism in the IVC appears to be a safe and advantageous technique in patients with poor liver reserve.