Technical essentials, development, and evaluation of hepatic segmentectomy under regional vascular occlusion at hepatic hilum

Abstract

Objective To summarize the experience of performing a variety of hepatectomies by occluding the branches of the hepatic artery (HA) and portal vein (PV) to the liver lobe, segment or subsegments in hilar H fissure for 344 patients in this hospital from 1987 to 2008. Methods (1) According to the size and location of the liver focus, major hepatectomy (66 cases), resection of separated hepatic subsegments (15 cases HS), resection of adjacent HS (216 cases) and resection of single HS (46 cases) were performed. (2) For left lateral HS, the left lateral inferior PV and left lateral superior PV originating from the lateral aspect of the left PV (LPV) were dissected, isolated and severed in umbilical fissure after the LHA was occluded. (3) For left medial HS, the left medial inferior PV and left medial superior PV originating from the medial aspect of the left PV were dissected、isolated and severed in umbilical fissure after the middle HA was occluded. (4) For right anterior HS, the right anterior PV was isolated and occluded in the anteior sulcus of the right longitudinal fissure (RLF) after the RHA behind the main hepatic duct was occluded. (5) For right posterior HS, the right posterior PV was isolated and occluded in the posterior sulcus of RLF after RHA was occluded.(6)The corresponding hepatic venous stem was protected as much as possible during the operation.Results (1) The operative mortality was 2.9% (10/344). Of these 10 patients, 8 died of liver failure and 2 bleeding. (2) Ten HCC patients (n=200) survived for 11～20 years, 4 for 7years, 19 for 5years and the 5-year survival rate was 18. 3% (33/180). For patients with hilar cholangiocarcinoma (n= 14), only 3 survived for 13, 6, 4 years, respectively. The patients with intrahepatic cholangiocarcinoma (n=13) survived for 1/2～3 years. Those with carcinoma of the gallbladder (n=12) survived for 1/2～1 year. All the patients with benign liver diseases (n=92) were cured. In 7 patients with intrahepatic lithiasis, the stones in other locations needed to be managed. Conclusion (1) Separated multiple hepatic subsegmentectctomy is an effective procedure to cure the compacted stones in 2～6 subsegmental hepatic ducts in both right and left lobes. (2) This procedure is reasonable, effective and of low cost for hepatectomy, worthy of being used because of the decrease in the ischemic liver mass and blood loss in operation, increase in the resectability of bulk liver cancer, alleviation of postoperative liver dysfunction and meeting the technical needs of a variety of hepatectomies for various liver diseases fulfilled by regional vascular occlusion at hepatic hilum instead of total hepatic afferent blood flow occlusion. Key words: Hepatectomy; Liver neoplasm; Hepatic hilum; Regional vascular occlusion