An anatomical laparoscopic approach for en bloc liver resection of segments 7 and 8.

Extended left trisegmentectomy combined with the three main hepatic veins ligation and inferior vena cava (IVC) resection for intrahepatic cholangiocarcinoma (ICC)

Initial experience with right lobe living donor liver transplantation

Domino transplantation (DT) with livers from recipients with metabolic diseases is a well recognized tool for expanding organ availability. The best technique for caval anastomosis in DT recipients is not well defined. We devised a new technique for outflow reconstruction that was adopted in 3 cases of DT, in which all donors had familial amyloidotic polyneuropathy. All DT donors received a whole liver graft from a deceased donor. DT donor hepatectomy was performed with preservation of the inferior vena cava. Short veins draining the caudate lobe were sutured. In two cases, the classic piggyback technique1 was used with an end-to-end anastomosis between the stump of the three major hepatic veins (right, middle, and left) and the donor suprahepatic inferior vena cava. In order to keep the hepatic vein cuff long enough to perform a piggyback reconstruction, no attempt was made to obtain a long caval stump in the native liver. In 1 case, the 3 major hepatic veins lying on different transversal planes were sutured and an end-to-side cavo-caval anastomosis was performed. In all cases, the orifices of major hepatic veins of the amyloidotic livers did not have sufficient tissue to perform a direct anastomosis with the caval cuff of the DT recipients, in whom a piggyback reconstruction had been planned (Fig. 1). Amyloidotic liver graft with the orifices of the caudate lobe hepatic vein (CLHV), left hepatic vein (LHV), middle hepatic vein (MHV), right hepatic vein (RHV), and superficial right hepatic vein (SRHV). DT, domino transplantation. At the back table, a vascular graft including the lower portion of the inferior vena cava in continuity with the left or right common iliac vein harvested from the deceased donor was used. The conduit was opened longitudinally and placed upon the above-mentioned venous stumps with its inferior wall, which was opened circularly in correspondence with each venous orifice and anastomosed with an everting 6/0 polypropylene suture. A venoplasty between the stumps of the amyloidotic graft was performed whenever possible. In the first case, a venoplasty was performed between 1 vein draining segment IV and the middle hepatic vein, and between a right superficial vein and the main trunk of the right hepatic vein, whereas 1 vein draining the caudate lobe was anastomosed separately. In the second case, 1 vein from the caudate lobe was anastomosed separately and a venoplasty was performed between the middle and left hepatic veins. In the third case, a venoplasty was performed between a common stump including the left hepatic vein and 1 vein from the caudate lobe, and the middle hepatic vein, while a common cuff including the main and the superficial right hepatic veins was anastomosed directly (Fig. 2). Venous patch anastomosed to the orifices formed by the caudate lobe hepatic vein (CLHV), left hepatic vein (LHV), and middle hepatic vein (MHV), and by the right hepatic vein (RHV) and superficial right hepatic vein (SRHV). The external edge of the vascular graft was trimmed in order to obtain a circular stump, which was anastomosed end-to-end with the recipient cuff formed by the right, middle, and left hepatic veins using an everting 5/0 polypropylene suture. Back-table preparation required less than 45 minutes in all cases. DT recipient procedures were carried out with standard techniques, without caval clamping. Ischemia time was 525, 290, and 212 minutes, respectively. Operation time was 345, 405, and 255 minutes, respectively. Packed red blood cell transfusion was 650, 1,000, and 0 mL, respectively. Postoperatively, Doppler ultrasound showed normal triphasic flow into all major hepatic veins of the amyloidotic liver in all cases. All DT recipients showed normal liver function and excellent clinical conditions within 2 weeks of transplantation. The technique described above allowed liver transplantation procedures to be safely performed with preservation of the inferior vena cava and without veno-venous bypass. The use of venous grafts, including inferior vena cava and iliac bifurcation, and portal vein bifurcation have been described in other studies.2, 3 However, a conduit with 2 terminal stumps may not be anastomosed to multiple venous cuffs and could have limited possibilities of orientation, determining outflow problems because of torsion.4 In our technique, 2 advantages can be recognized: the possibility of anastomosing several venous orifices to a single patch and of preventing outflow obstruction by creating a wide and adaptable cuff.5

The impact of hepatic venous anatomic variations on hepatic resection and transplantation is the least understood aspect of liver surgery. A prospective three-dimensional computed tomography study was undertaken on 200 consecutive subjects with normal livers to determine the prevalence of surgically significant hepatic venous anatomic variations. The prevailing pattern of the three hepatic veins in these subjects was a right hepatic vein (RHV) and a common trunk for the middle (MHV) and left (LHV) hepatic veins (122/200, 61%). The remaining patients had the RHV, MHV, and LHV draining independently into the inferior vena cava (IVC). In 39% of patients, the RHV was small and was compensated by a large right inferior hepatic vein (21.0%), an accessory RHV (8.5%) or a well-developed MHV (6.5%). A segment 4 vein was seen in 51.5% of patients. This segment 4 vein joined the LHV (26%), the MHV (17.5%), or the IVC (8%). An umbilical vein and a segment 4 vein were seen in 3.5% of patients. These two veins joined either the LHV (2.0%) or the MHV (1.5%). Knowing the variations of hepatic veins before surgery is useful during both partial hepatectomy and donor operations for living related liver transplantation.

Combined resection of the hepatic venous confluence following preoperative embolization of the right hepatic vein for liver tumor invading three hepatic veins

Objective To provide anatomic basis for the clinical application, the data were obtained by utilizing anatomic study of normal hepatic venous (HV) outflow tract and its adjacent structure in Chinese. Methods The data were observed and measured in 57 normal adult cadaver from March 2014 to March 2015. The following parameters were obtained: the opening form of left hepatic vein (LHV), middle hepatic vein (MHV) and right hepatic vein (RHV) drained into the inferior vena cava (IVC). The relationship of horizontal position among the openings of LHV, MHV and RHV. The position relations between openings of HV and diaphragm hiatus. The opening diameters of LHV, MHV and RHV, and the distances from the upper margin of HV to diaphragm hiatus were compared. The morphology of the diaphragm hiatus and the structure in the space between IVC and the wall of the hiatus were observed. The long diameter and short diameter of the diaphragm hiatus were compared. Quantitative data difference between two samples was analyzed by independent-sample t test, and the difference among more samples was analyzed by one-way ANOVA. LSD-t test was used in the comparison between any two means. Results There were four opening forms of HV in 57 cases. The probability of HV with two openings(LHV+ MHV, RHV) joining into IVC was 73.68%(42/57), with three openings (LHV, MHV, RHV) joining into IVC was 17.54%(10/57), with the right superior vein which joins into IVC directly at the side of the RHV was 5.26%(3/57), with cable structure in the opening of RHV was 3.51% (2/57). The opening diameters of LHV, MHV and RHV were (9.25±1.84)mm, (8.94±1.52)mm, and (14.29±2.84)mm, respectively. The diameter of RHV was larger than that in LHV and MHV(all P values<0.01). The probability of the upper margin of LHV or main trunk (LHV+ MHV) which was higher than the upper margin of RHV was 85.96% (49/57). The probability of the openings of them in the same horizontal plane was 14.04% (8/57). Openings of RHV in 39 cases and openings (LHV+ MHV) in 37 cases were below the diaphragm hiatus. Besides, the upper margin of common opening (LHV+ MHV) was located above the diaphragm hiatus in 2 cases. The distances between the upper margin of LHV and diaphragm hiatus, the upper margin of MHV and diaphragm hiatus, the upper margin of RHV and diaphragm hiatus were (3.19±0.74) mm, (3.62±0.81) mm, and (9.03±3.02) mm, respectively. The distance between the upper margin of RHV and diaphragm hiatus was larger than that in LHV and MHV(P<0.01). The long diameter of diaphragm hiatus was (26.94±3.47) mm and the short diameter was (19.62±2.80) mm. The difference between them was considered as statistically significant (t=10.242, P<0.01). Hematoxylin-eosin staining showed that large amount of fibrous connective tissues were distributed in the space between IVC and the wall of the tissue. Conclusions In normal adults, main trunk (LHV+ MHV) is the most frequent in the opening form of HV drained into the IVC. Mostly, the upper margin of main trunk (LHV+ MHV) is higher than the upper margin of RHV. A small number of openings of RHV have the cable structure. Compared to RHV, the openings of LHV and MHV are much closer to the diaphragm hiatus. The upper margin of LHV or common opening (LHV+ MHV) is located above the diaphragm hiatus in a small number of cases. Large amount of fibrous connective tissues distribute in the gap between IVC and the wall of diaphragm hiatus. The central key from diaphragm is not attached directly to IVC at diaphragm hiatus. This information is very important for the clinical research and the choice of the treatment of disease which is related to HV outflow tract. Key words: Hepatic veins; Outflow tract; Vena cava, inferior; Diaphragm; Anatomy

The aim of this paper is to report the authors' experience in performing adult-to-adult living donor liver transplantation (LDLT) by using a modified technique in using grafts of the right lobe of the liver. From January 2002 to September 2006, 56 adult patients underwent LDLT using right lobe grafts at the West China Hospital, Sichuan University Medical School, China. All patients underwent a modified operation designed to improve the reconstruction of the right hepatic vein (RHV) and the tributariers of the middle hepatic vein (MHV) by interposing a vessel graft, and by anastomosing the hepatic arteries and bile ducts. There were no severe complications or deaths in all donors. Fifty-two (92.8%) recipients survived the operations. Among the 56 recipients, complications were seen in 15 recipients (26.8%), including hepatic vein stricture (one case), small-for-size syndrome (one case), hepatic artery thrombosis (two cases), intestinal bleeding (one case), bile leakage (two cases), left subphrenic abscess (one case), renal failure (two cases) and pulmonary infection (five cases). Within three months after transplantation, four recipients (7.14%) died due to small-for-size syndrome (one case), renal failure (one case) and multiple organ failure (two cases). All patients underwent direct anastomoses of the RHV and the inferior vena cava (IVC), and in 23 cases, reconstruction of the right inferior hepatic vein was also done. In 24 patients, the reconstruction of the tributaries of the MHV was also done by interposing a vessel graft to provide sufficient venous outflow. Trifurcation of the portal vein was seen in nine cases. Thus, veno-plasty or separate anastomoses were performed. The graft and recipient body weight ratios (GRWR) were between 0.72% and 1.43%, and in three cases it was <0.8%. The graft weight to recipient standard liver volume ratios (GV/SLV) were between 31.86% and 71.68%, among which four cases had <40%. No "small-for-size syndrome" occurred. With modification of the surgical technique, especially in the reconstruction of the hepatic vein to provide sufficient venous outflow, living donor liver grafts in adults using the right lobe of the liver can become a relatively safe procedure and prevent the "small-for-size syndrome".

BackgroundWhen the inferior right hepatic vein (IRHV) is present, left hepatic trisectionectomy with resection of the right hepatic vein (RHV) is theoretically possible without reconstruction of the RHV. We here report a successful case of this extended hepatectomy after RHV embolization for advanced intrahepatic cholangiocarcinoma.Case presentationA 71-year-old man was admitted to our clinic with abdominal pain. Computed tomography showed a cholangiocarcinoma located at the caudate lobe that involved the inferior vena cava (IVC) and the roots of the three major hepatic veins. Portal vein embolization of the left and right anterior portal veins was performed. As the IRHV was present but thin, RHV was also embolized. Left hepatic trisectionectomy with resection of the involved IVC and RHV, preserving the IRHV, was done. The IVC was reconstructed with artificial graft. The patient was discharged on postoperative day 36.ConclusionRHV embolization is useful in extended left trisectionectomy with resection of the RHV when the IRHV is present but thin.

BackgroundThis study evaluates one-year clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) placement using a middle hepatic vein (MHV) versus right hepatic vein (RHV) access. Primary end points were shunt patency and one-year survival. Secondary outcomes included incidence of de novo hepatic encephalopathy (HE) and recurrence of portal hypertension related complications such as ascites, hepatic hydrothorax, and gastrointestinal bleeding. While prior studies have examined portal vein target selection, the clinical relevance of hepatic vein choice remains understudied.MethodsA retrospective chart review of adult patients who underwent TIPS using a Viatorr stent graft between January 2014 and December 2022 was conducted. Patients were included if the procedure used either RHV or the MHV. Intracardiac echocardiography (ICE) was employed to select a direct path from hepatic to portal vein. Shunts were dilated to 8 or 10 mm to achieve a post-procedural portosystemic gradient (PSG) ≤ 12 mmHg or a 50% reduction from baseline. Clinical and imaging data was analyzed to assess outcomes, stratified by hepatic vein of access.ResultsOne-year survival (84% MHV vs 75% RHV, p = 0.2) and overall one-year patency rates (96% MHV vs 87% RHV, p = 0.5) were similar between the groups. However, MHV access significantly reduced de novo hepatic encephalopathy (30% MHV vs 62% RHV, p = 0.008) and moderate to severe cases (16% MHV vs 42% RHV, p = 0.017). Despite more frequent use of smaller diameter shunts (8 mm: 72% MHV vs 47% of RHV, p < 0.001), MHV access achieved similar post-TIPS portosystemic gradient reductions (Average Pre-TIPS gradient: 17 mmHg MHV & 17 mmHg RHV, p = 0.8; Average Post-TIPS gradient: 8 mmHg MHV & 7.5 mmHg RHV, p = 0.12). Hepatic vein choice did not affect outcomes for ascites, hydrothorax, or gastrointestinal bleeding.ConclusionMHV and RHV access routes provided similar patency, survival, and TIPS indication outcomes, but MHV access had decreased incidence of hepatic encephalopathy and achieved similar portosystemic gradient reduction while using a smaller diameter shunt. MHV may be a preferred option for patients at higher risk of developing hepatic encephalopathy.

Certain variations in liver anatomy can aid in parenchymal-preserving hepatectomy.1,2 Inferior right hepatic vein (IRHV) is an accessory vein in the right side of liver draining segment 6.2 We present a case of 67-year-old man with HBV cirrhosis. One HCC in segment 7 abutting the right hepatic vein (RHV) and another large HCC in segment 8/4a were found. After two sessions of TACE, liver resection was scheduled. Resection of RHV was inevitable to get free margin. Fortunately, a significant IRHV was present, so we could preserve segment 6. Central bisectionectomy with segment 7 resection using the Glissonean pedicle approach, and hepatic vein guided transection was planned.3 METHODS: After placement of trocars, pneumoperitoneum was created. The main surgical steps were: (1) Right anterior Glissonean pedicle control; (2) Parenchymal transection along the umbilical fissure; (3) Transection of the right anterior portal pedicle, middle, and right hepatic vein; (4) Parenchymal transection between segments 5 and 6; and (5) Identification of IRHV and resection of segment 7. The operative time was 330min, and estimated blood loss was 80mL. The total intermittent inflow occlusion time was 90min. The histopathologic diagnosis was well-differentiated HCC. The tumors size of segments 8 and 7 was 4cm and 2.9cm, respectively. The resection margin was negative. The patient was discharged uneventfully on postoperative day 5. The preserved liver parenchyma after hepatectomy demands good vascular inflow and outflow. A large IRHV could be adequate outflow of segment 6, allowing more distinct operations.

Laparoscopic donor right hepatectomy with reconstruction of segment V and VIII tributaries of the middle hepatic vein using a cadaveric iliac artery allograft

Due to technical challenges and reduced pool of candidates, laparoscopic major hepatectomies remain relatively limited: In particular, right hepatectomy is technically more challenging than left since it requires liver mobilization, dissection of inferior vena cava (IVC) and hepatocaval confluence (HepCC), and section of right hepatic vein (RHV). Among 53 laparoscopic right hepatectomies (San Raffaele Hospital; 2013-2015), the approach to HepCC was standardized by three techniques: (1) primary approach to IVC and RHV with complete mobilization of right hemiliver; (2) anterior approach with hanging maneuver without liver mobilization (partial anterior approach-PAA); and (3) anterior approach without hanging maneuver without liver mobilization of right hemiliver (total anterior approach-TAA). The technique was defined preoperatively based on tumor size/position, IVC/RHV compression, and HepCC dislodgement. Type of parenchyma and risk of lesion rupture were also evaluated. Primary approach to IVC and RHV Before liver transection and after liver mobilization, IVC dissection is performed, and RHV is isolated and suspended on a vessel loop. RHV is sectioned after parenchymal transection. no compression by tumor of IVC/RHV, no HepCC dislodgement, soft parenchyma, no risk of lesion rupture. PAA IVC and HepCC are dissected free before transection, without previous liver mobilization; a tape is positioned in front of the anterior aspect of IVC, to perform the hanging maneuver. RHV section is performed after parenchymal transection. huge masses without compression of IVC/RHV, no HepCC dislodgement, liver stiffness, risk of lesion/parenchyma rupture. TAA Both IVC and RHV dissections are performed at the end of parenchymal transection, without previous mobilization of right lobe. huge masses with compression of IVC/RHV, HepCC dislodgement. Different approaches are available for HepCC dissection during laparoscopic right hepatectomy: Liver parenchyma characteristics, tumor size, and relationship with HepCC should be considered in surgical planning, to achieve satisfactory outcomes.

Objective To investigate the clinical significance of CT angiography (CTA) in preoperative evaluation of the distribution and variation of donor hepatic veins before right lobe living donor liver transplantation. Methods Clinical data of 40 donors undergoing right lobe living donor liver transplantation in the Third Affiliated Hospital of Sun Yat-sen University between May 2007 and April 2016 were retrospectively analyzed. Among them, 37 donors were male and 3 were female, aged 18-57 years with a median age of 46 years. The informed consents of all donors were obtained and the local ethical committee approval was received. Before operation, the middle hepatic veins (MHV) and right hepatic veins (RHV) and branches of donors were evaluated by multiplanar reformation (MPR), 3D maximum intensity projection (MIP) and volume rendering (VR) techniques. According to the Neumann classification, MHV were divided into type 1, 2 and 3. The diameter and quantity of major drainage branch of liver segment Ⅴ and Ⅷ were measured. Based upon the Nakamura classification, RHV were divided into type A, B and C. The quantity of accessory hepatic veins with diameter >5 mm was measured. Results All 40 donors underwent CTA successfully. Both MHV and RHV were clearly displayed. The percentage of Neumann type 1 MHV was 68% (27/40), type 2 was 12% (5/40) and type 3 was 20% (8/40). The percentage of Nakamura type A RHV was 78% (31/40), type B was 12% (5/40) and type C was 10% (4/40). There were 17 donors with the diameter of accessory hepatic veins of right lobe >5 mm, including 9 cases of type A, 4 of type B and 4 of type C. Twenty-one donors underwent right lobe living donor liver transplantation, including 14 cases of liver transplantation with MHV, 7 cases of liver transplantation without MHV. Preoperative CTA evaluation of MHV and RHV classification, quantity of major accessory hepatic veins of right lobe was found 100% consistent with the intraoperative findings. Conclusions CTA can clearly display the MHV, RHV, anatomy, variation and classification of accessory hepatic veins of right lobe, which can provide detailed imaging and anatomical data for treating MHV during right lobe living donor liver transplantation. Key words: Liver transplantation; Living donors; Hepatic veins; Angiography

A 51-year-old woman underwent right liver donation for her husband, who had a history of hepatitis C, liver cirrhosis, and hepatocellular carcinoma. Her preoperative dynamic computed tomography (CT) revealed that segment VIII was predominantly drained by a tributary of the right hepatic vein (RHV) and segment V by three tributaries (V5) of the middle hepatic vein (MHV). Three-dimensional graphic images created from the CT (Liver Segmentation Simulator, Hitachi Medico Inc., Chiba, Japan) revealed two anastomoses between V5 and the RHV tributaries (Fig. 1). Based on volumetric estimation, the right liver graft corresponded to 52% of the standard liver volume of the recipient. Right oblique view of the middle hepatic vein (blue) and right hepatic vein (red). This 3D graphic was rendered by Liver Segmentation Simulator, using 3 mm-thick CT images. Note the two anastomoses between V5 and right hepatic vein (arrowheads). RHV, right hepatic vein; MHV, middle hepatic vein; V5, tributary of middle hepatic vein in segment V. CT, computed tomography; RHV, right hepatic vein; MHV, middle hepatic vein. As predicted preoperatively, after transection of the liver parenchyma, congestion of the right paramedian sector was not observed by temporary clamping of the right hepatic artery. Intraoperative Doppler ultrasonography demonstrated regurgitation of venous flow in V5, which drained into the RHV tributary through the anastomosis (Fig. 2). A right liver graft was harvested with the distal portion of the MHV including V5, which communicated with the RHV. No reconstruction of MHV tributraies was performed in the recipient. Hepatic venous anastomosis (arrow) demonstrated by intraoperative Doppler ultrasonography after liver transection. Note V5 flow, which pours into the RHV tributaries. The postoperative course of the donor and the recipient was uneventful. Doppler ultrasonography consistently revealed hepatopetal portal flow of P5 in the recipient. The V5 was patent on CT 1 and 3 months after transplantation. Kaneko and colleagues1 reported postoperative formation of hepatic venous anastomosis. Sano et al.2 reported that intraoperative Doppler ultrasonography revealed anastomosis of hepatic veins in 24% of living donors. The indication for MHV reconstruction in a right liver graft depends on the anatomy of the MHV tributaries.3 If it is preoperatively known that the MHV tributaries are anastomosed with the RHV, vascular conduits for reconstruction of the MHV tributaries do not need to be prepared.4 Preoperative information regarding communication between the RHV and MHV is important for planning right liver transplantation, and it was provided by thin-sliced liver CT and 3-dimensional graphic images of hepatic vein anatomy in this particular case. We would like to thank Drs. Norio Nakao and Koui Miura (Department of Radiology, Hyogo College of Medicine, Hyogo, Japan), as well as Mr. Tomohiro Nagao (Hitachi Medico Inc., Chiba, Japan) for use of the Liver Segmentation Simulator.

Living-donor liver transplantation (LDLT) is now widely accepted as a therapeutic option for adult patients with acute and chronic end-stage liver disease. In the early period, the left lobe was the major liver graft used in adult LDLT to ensure donor safety, especially in Eastern countries. However, the frequent extremes of graft-size insufficiency in left-lobe LDLT represented a greater risk of small-for-size graft syndrome in the recipient, which has focused attention on transplantation of the right lobe from a living donor. The major concern of right-lobe LDLT has focused on its safety for the donor and the necessity for including the middle hepatic vein (MHV) in the graft to avoid congestion of the right anterior segment. The MHV carries out important venous drainage for the right anterior segment and is essential for perfect graft function. The decision of whether to take the MHV with the liver graft (extended right lobe graft) or whether to retain it in the donor, with reconstruction of the MHV tributaries in the liver graft (modified right lobe graft) has been extensively discussed in numerous studies. However, adequate right hepatic vein and major short hepatic vein (middle and inferior right hepatic vein [RHV]) drainage of the liver graft is perhaps equally important as MHV outflow drainage for the integrity of right-lobe graft function. Herein, the author describes various techniques of venoplasty of the right hepatic vein (RHV) and the major short hepatic veins to obviate venous outflow obstruction in these veins.