Resection of caudate lobe hepatocellular carcinoma with enbloc IVC resection and replacement

Abstract

Presenter: Iswanto Sucandy MD | AdventHealth Tampa Background: This video describes how we undertook the resection of the caudate lobe for hepatocellular carcinoma with enbloc IVC resection and replacement. Methods: The patient is a 74-year-old man who present with a 6 cm caudate lobe mass. Patient has a history of Hepatitis C with liver cirrhosis (Child A). Workup included an MRI which showed the caudate lobe mass circumferentially invading the IVC. A percutaneous biopsy confirmed hepatocellular carcinoma. Results: The operation began with a complete mobilization of the left hemiliver. The falciform ligament was taken down to the hepatocaval confluence. The gastrohepatic ligament was then opened in a stellate fashion along the Arantius ligament, which was dissected all the way up to the origin of the left hepatic vein. Dissection along the caudal border of the tumor was undertaken by following the common hepatic artery, which was displaced by the tumor mass. The common hepatic artery lymph nodes were removed. The pancreas was then exposed and retracted caudally. The left gastric artery was involved by the tumor; therefore, it was isolated and transected with a laparoscopic vascular load stapler. The minor curvature of the stomach was dissected all the way up to the crus. The pars flaccida was open to show the anatomical landmarks of this operation. The gallbladder was then removed. Next, the Arantius ligament was ligated and divided. The hepatic artery and portal vein branches to the caudate lobe were isolated and divided. The duodenum was widely kocherized to access the retroduodenal IVC just above the left renal vein. The right gonadal vein was preserved. The entire retrohepatic IVC was removed after applying cross-clamping on the IVC (proximal vascular clamp was placed immediately caudal to the root of the hepatic veins and the distal vascular clamp was placed through the retroduodenal space behind the head of the pancreas). A 16mm woven Dacron vascular conduit was used for the IVC replacement. Once the graft-IVC anastomosis was completed, the IVC was unclamped. A vascular Doppler was utilized to check the flow within the vena cava conduit. Conclusion: Patient tolerated the procedure well and had an uneventful recovery. Pathology confirmed a 10 cm enbloc mass containing caudate lobe hepatocellular carcinoma and retrohepatic IVC. There was an absence of lymphatic invasion. Patient was discharged on post-operative day 4 after ambulating and tolerating oral diet.