CHAPTER 103 - Adjuncts to hepatic resection: From ultrasound guidance to new oncologic and technical horizons

Abstract

Liver surgery often deals with advanced disease both for primary and metastatic tumors. Adequate oncologic margins and enough future liver remnant with proper inflow and outflow are the pillars for any strategy aiming to succeed. A distinctive role has been assumed by R1vascular surgery, which may be oncologically suitable for many liver tumors. This policy has been able to expand the suitability of parenchyma-sparing surgery also in the event of high tumor load and complex organ involvement. In this sense, intraoperative ultrasound (IOUS) addressing the suitability of a tumor-vessel detachment occupies a central role. On the other hand, IOUS is also the tool that has provided additional solutions in the event a hepatic vein has to be amputated. Indeed, IOUS discloses and traces the existence of communicating veins between the infiltrated vessel and the adjacent one able to allow parenchyma-sparing approach despite vessel amputation. Therefore IOUS has opened surgery based on two pillars: R1vasc and communicating veins, which have expanded the technical solutions for approaching complex tumor involvement of the liver by looking at major intrahepatic vessel exposure as something safe and helpful rather than dangerous, as representing a relevant novelty, and, above all, as representing a challenging vessel exposure as drivers for more complex but safe resection, foreseeing a parenchyma-sparing major hepatectomy not as a paradox but as an option. All these issues are detailed in this chapter.