Branch Of Hepatic Artery Research Articles

Endovascular Management of Hematomas in Pediatric Transplant Patients.

Transcatheter arterial embolization is used to control active hemorrhage at different anatomic locations. Because hematomas can suddenly deteriorate and become life threatening for transplant patients, they require prompt diagnosis and intervention rather than conservative management. Here, we evaluated computed tomography in treatment planning and transcatheter embolization effectiveness for hematoma management in pediatric liver transplant patients. Between June 2012 and December 2021, 10 pediatric liver transplant patients were referred to our interventional radiology unit. Computed tomography and angiograms were reviewed for hematoma location and presence of extravasation. We analyzed correlations between computed tomography and angiography findings and technical and clinical success of the endovascular interventions. Active leak of contrast material during arterial phase was detected on 9/10 CT scans. Although there was no active bleeding on CT in 1 patient, active arterial bleeding was detected on angiography. On the contrary, in 2 patients, although active bleeding was observed on computed tomography, it was not detected on angiography. Source of bleeding was superior mesenteric artery branches in 4, hepatic artery branch in 2, superior epigastric artery in 1, and phrenic artery in 1 patient. Six of 8 patients with active bleeding were treated with endovascular procedures. The remaining 2 patients received surgery: 1 had bleeding from liver cut surface originating from a hepatic artery branch and received open surgery because the bleeding branch was too thin for catheterization, and 1 was hemodynamically unstable and selective catheterization of the internal thoracic artery would take time. Two patients received embolization procedures with N-butyl 2-cyanoacrylate (glue) diluted with iodized oil, and 1 patient had coil and glue with iodized oil. Embolization with coils was performed in 3 patients. Rate of success with transcatheter arterial embolization was 75%. No complications related to patient comorbidities or embolization procedures were shown. No deaths occurred due to progression of the hematoma. Transcatheter arterial embolization is effective and safe for treatment of pediatric liver transplant patients with hematomas. Computed tomography has value in identifying the bleeding source and its anatomic relationships and may enhance our intervention abilities to become quicker, more effective, and more secured.

What Makes Cirrhosis Irreversible?-Consideration on Structural Changes.

Several studies have shown that liver fibrosis, and even cirrhosis can be reversed, disproving the old “dogma” that cirrhosis is irreversible. In addition to scaring, vascular alterations appear to be critically important in the progression of chronic liver diseases. To overcome the “tipping-point” of cirrhosis, we need to understand in depth what might make it irreversible in some cases. Morphologically, the initial, as well as the advanced stages of cirrhosis are characterized by specific structural changes. The hallmark of the initial stage is the division of the original liver parenchyma by centro-central or porto-portal septa. No significant vascular changes are observed in this stage. The advanced stage is characterized by several morphological alterations: (i) The main feature is the parenchymal extinction, with intact portal vein branches, hepatic artery branches, and biliary ductules; (ii) In the extinct areas we observed numerous loops in the ductular network, indicating the disruption of the hepato-biliary junctions; (iii) Although the ductular progenitor cells are able to generate hepatocytes via the budding process, the newly formed hepatocyte nodules cannot re-establish the original lobular architecture due to their disorganized growth. In conclusion, this regenerative process characteristic for the advanced stage, contributes to circulatory disorders, perpetuates parenchymal injury and may lead to the irreversibility of cirrhosis.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report

BackgroundIatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy.Case presentationWe report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later.ConclusionsEven with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.

Origin and Prevalence of the Retroportal Course of Hepatic Artery- A Retrospective Study

Introduction: Anatomical variations of celiac and hepatic arteries are relatively common and impact operative time and technique. Intraoperative identification of the entire course of these vessels can be a challenge due to limited surgical field and increases the chance of iatrogenic injury. Aim: To evaluate and describe the origin and prevalence of retroportal course of hepatic arteries seen in Computed Tomography (CT) angiography in a large series of patients. Materials and Methods: The present retrospective study was conducted in the Department of Radiology, affiliated to a tertiary cancer centre in Southern India. CT angiogram done between January 2020 to June 2021 were included. Total of 326 abdominal CT angiograms were studied for celiac axis variations, variations in the origin and branching pattern of hepatic arteries, trajectory of the hepatic artery and its relation to portal vein. The branching pattern of celiac axis was analysed with adherence to the modified definition of Common Hepatic Artery (CHA) and it was classified as normal/variant/ambiguous. Based on the origin and branching pattern, hepatic arteries were divided into standard/replaced/accessory and classic/variant divisions, respectively. Variant divisions include trifurcation, duplicate or double hepatic artery and late origin of Gastro Duodenal Artery (GDA). Retroportal hepatic arteries under each variation was identified separately and their prevalence calculated. Confidence interval was calculated using simple proportionfrequency analysis open Epi version 3 software. Results: The age of the patients varies from 3 to 83 years (mean age 53.7 years). 207 (63.49%) cases were male and 119 (36.5%) cases were female. 262 (80.37%) cases had a normal celiac axis anatomy. Eight specific types of celiac axis variations were observed in 48 (14.72%) cases. In the remaining 16 (4.91%) cases, the celiac axis anatomy was ambiguous. CHA originated from the celiac axis, Superior Mesentric Artery (SMA) and aorta in 294 (90.18%), 10 (3.07%) and 6 (1.84%) cases respectively. Out of the 52 replaced Right Hepatic Artery (rRHA), 48 (14.72%), 3 (0.92%) and 1 (0.30%) cases had Right Hepatic Artery (RHA) replaced to the SMA, aorta and GDA, respectively. Except for the one rRHA from GDA, all of them had a retroportal course. Classic branching pattern of hepatic artery was seen in 154 (47.24%). Trifurcation, early branching of RHA and early branching of LHA were found in 49 (15.03%), 4 (1.22%) and 8 (2.45%) respectively. 63 (70%) cases of variations in hepatic artery origin, 15 (16.67%) cases of variations in hepatic artery branching and 12 (13.33%) cases of variations in celiac axis contributed to a total of 90 cases with retroportal hepatic artery. Prevalence of retroportal hepatic artery in the present study is 27.61% (confidence interval 22.82- 32.8) and the most common cause was aberrant RHA origin. Conclusion: Knowledge about the origin and prevalence of retroportal course of hepatic artery will help the surgeon to approach it systematically. Preoperative knowledge of the variations in origin and branching patterns and its influence on the trajectory will help in a better intraoperative identification of these variant vessels.

Morphology and Morphometric Analysis of the Caudate Lobe of Human Liver in Eastern India- A Cross-sectional Cadaveric Study

Introduction: The unique feature of caudate lobe of liver is that it has a dual blood supply. Since it is supplied both by branches of portal vein and hepatic artery, it may undergo compensatory hypertrophy in different hepatic diseases like cirrhosis of liver. In addition, excessive localised growth of the liver may be manifested as accessory lobules. Previous studies in different settings had implied an ethnic predisposition affecting the morphology of the liver. All these factors revealed an urgent need for further research regarding the surface variations and morphometry of the caudate lobe. Aim: To study the morphological variations and morphometric measurements of the caudate lobe of the human liver in eastern India. Materials and Methods: A descriptive cross-sectional study was undertaken on 51 formalin fixed adult human livers in Department of Anatomy, Medical College, Kolkata, West Bengal, India from March 2021 to September 2021. Vernier calliper was used to measure the Transverse Diameter (TD), Vertical Diameter (VD) and Anteroposterior Diameter (APD) of caudate lobe. In addition, the TD and APD diameters of Porta hepatis and TD of the right lobe of liver were also measured. Morphological variations were noted. The morphometric measurements and morphological variations of caudate lobe of liver were entered in Excel sheet which were further transported to IBM Statistical Package for Social Sciences software (SPSS) version 12.0 (free version) for further analysis. Morphometric measurements were analysed by using descriptive statistics. Caudate to right lobe (CRL) ratio was calculated manually. Results: Most common type of shape of caudate lobe was rectangular (37.25%). Mean values (in cm) of TD, VD, APD of caudate lobe were 2.4±0.54, 4.7±0.75, 1.9±0.51 respectively. The value of mean CRL (caudate to right lobe) ratio was 0.30. Conclusion: A detailed anatomical knowledge of the caudate lobe would be helpful to the surgeon to suitably plan hepatic resections and may also guide the radiologist regarding correct interpretation of imaging technique.

Anatomical, Histological, and Ultrasonographical Studies on the Liver of Red Fox (Vulpes vulpes) with its Arterial Blood Distribution and Biliary Ducts

The study aimed to investigate the anatomical and histological characteristics of the Egyptian red fox. We performed liver ultrasonography on eight animals while used two livers for morphological study. To illustrate the hepatic artery branches, two specimens were injected with colored red latex neoprene through the abdominal aorta. The other two specimens were injected with a mixture of lead oxide and colored green latex neoprene through the major duodenal papilla to demonstrate the radiological images of the biliary duct pattern. The last two specimens were used for histological study. The fox's liver had six lobes; left lateral, left medial, quadrate, right medial, right lateral, and caudate lobes. The gall bladder was pear-shaped and was embedded in a fossa between the right medial and the quadrate lobes. The left hepatic duct formed the common bile duct, and the cystic duct union then passed about 0.5-1cm to join with the right hepatic duct. The branches of the proper hepatic artery supply the liver lobes. Histologically, liver parenchyma consisted of lobules; each lobule had a central vein and hepatic cords with hepatic sinusoids in between. Histochemically, hepatocytes were stained with Periodic Acid Schiff and Bests carmine stains. Gall bladder lined by simple columnar cells rests on fibrous propria-submucosa rich in blood capillaries. This study has practical importance in surgical treatment, as in partial hepatic lobectomy and hepatic artery or lobar arteries ligation in case of tumors.

Anatomical Variations of the Celiac Trunk and Hepatic Arteries with a New Classification, Based on CT Angiography.

To analyse the distribution of anatomical variations in both celiac trunk (CeT) and hepatic artery (HA) branching patterns on computed tomography (CT) angiography images; as well as to propose a new classification by unifying the already reported classifications of the CeT and HA vascular anatomy. Observational study. Department of Radiology, Faculty of Medicine, Selçuk University, Konya, Turkey, from February 2019 to March 2020. CT angiography-based evaluation of the CeT and HA branching patterns was performed in patient undergoing routine contrast-enhauced CT of abdomen. Types of variation were determined and classified into five types (1-5) and ten subtypes. Distribution was also sorted by age and gender. Type 1 (classic CeT and HA branching pattern) was detected in 240 (70.6%) out of 340 cases (126 females, 214 males). Sixty-five (19.12%) had Type 2 subtypes, in which HA branching pattern coexists with normal CeT configuration; whereas, Type 3a and 3d, Type 4 and 5 having anomalous CeT variants, with typical HA pattern, were observed in 5.87% (20/340) of the cases. The frequency of the concurrent variations (Type 3b and 3c) was 4.41% (15/340). The least frequent subtypes, Type 4 and 5, were observed in one (0.29%) and three (0.88%) cases, respectively. There was no significant differences in branching types frequency by gender and age (p>0.05). Awareness of the range of anatomical variation in both the CeT and HA branching patterns, especially concurrent variations, is vital when planning surgical and radiological interventions to prevent possible iatrogenic injury and complications. Key Words: Branching pattern, Celiac trunk, Concurrent variations, CT angiography, Hepatic artery.

Percutaneous biliary stone clearance: is there still a need? A 10-year single-centre experience

To evaluate the safety and efficacy of percutaneous biliary stone clearance in a single hepatopancreaticobiliary (HPB) centre. All patients who underwent percutaneous biliary stone clearance between 2010 and 2020 at a HPB centre were identified from the radiology information system. Their demographic data, presentation, previous surgery, number/size of biliary calculi, success and complications were collected from patient records. Unpaired student's t-test was used to compare numerical variables and the Chi-square test was used to compare categorical data. Sixty-eight patients aged between 58.5-91.1 years underwent the procedure, and 42.6% (29/68) had the procedure due to surgically altered anatomy precluding endoscopic retrograde cholangiopancreatography (ERCP). The most common presentation was cholangitis (62%). The success rate of percutaneous stone clearance was 92.7%. The average number of calculi was two (range 1-12). Of the patients included, 4.4% developed pancreatitis, 4.4% developed cholangitis, and 1.5% had hepatic artery branch pseudoaneurysm successfully treated with transarterial embolisation. There was no significant difference in success or complication rates between the different access sites (right lobe, left lobe, roux-loop, T-tube, p=0.7767). Percutaneous biliary stone clearance is safe and effective and will continue to play an important role where ERCP fails or is impossible due surgically altered anatomy.

Liver anatomy, intrahepatic vascular and biliary branching system of the mole rat (Spalax leucodon).

There are many studies on the morphology of the liver and its blood vessels in experimental animals, but such studies are lacking in the mole rat (Spalax leucodon). The aim of this paper was a detailed basic study on the topography, morphology, vascular and biliary branching systems of the liver in the mole rat. Coloured gelatine and mixture of coloured lead oxide and linseed oil were injection contrast masses used to obtain vascular and biliary branching pattern in the liver. It was revealed that the liver of the mole rat had five lobes (left, quadrate, right medial, right lateral and caudate lobes). The left, undivided lobe was the largest lobe of the liver. The quadrate lobe was divided into two components by a deep notch. The gallbladder, of cylindrical shape, was present and attached to the quadrate lobe. The common bile duct was formed by the union of the left and right hepatic ducts. The pancreatic duct joined the common bile duct before it entered the duodenum. In the present study, only the right medial lobe and quadrate lobe always showed a single lobar artery, portal and hepatic veins. The left lobe showed four lobar arteries, portal and hepatic veins. The caudate lobe with its two processes and the right lateral and medial lobes had different arterial and portal blood supply as well as hepatic and biliary drainage of these lobes. The intrahepatic branches of the proper hepatic artery ran parallel to the branches of the common portal vein in the same lobes of the liver. The results of this study are significant for comparative studies among different species of rodents and other experimental animals. Morphology, vasculature and biliary tract of the liver in the mole rat were similar to that of other experimental animals and identified differences may be related to the adaptation to the mode of life and diet of this rodent.

Rare anastomosis between a replaced right hepatic artery and left branch of the proper hepatic artery

Rare anastomosis between a replaced right hepatic artery and left branch of the proper hepatic artery

Plasmalemmal Vesicle-Associated Protein Is Associated with Endothelial Cells Sprouting from the Peribiliary Capillary Plexus in Human Cirrhotic Liver

Introduction: Plasmalemmal vesicle-associated protein (PLVAP) is an endothelial-specific integral membrane glycoprotein that localizes to caveolae and fenestrae in animal models; however, little is known about PLVAP in endothelial cells (ECs) in hepatic sinusoids during liver cirrhosis (LC). Here, we aimed to elucidate PLVAP localization and expression in the human liver during LC progression. Methods: PLVAP protein expression was detected in specimens from normal control livers and hepatitis C-related cirrhotic livers using immunohistochemistry, Western blotting, and immunoelectron microscopy. Results: PLVAP mainly localized to the peribiliary capillary plexus (PCP) and was rarely observed in hepatic artery branches and portal venules in control tissue, but was aberrantly expressed in capillarized sinusoids and proliferated capillaries in fibrotic septa within cirrhotic liver tissue. Ultrastructural analysis indicated that PLVAP localized to thin ECs in some caveolae, whereas PLVAP localized primarily to caveolae-like structures and proliferative sinusoid capillary EC vesicles in cirrhotic liver tissue. Western blot analysis confirmed that PLVAP was overexpressed at the protein level in advanced cirrhotic liver tissue. Conclusion: PLVAP was strongly expressed in the caveolae of proliferated capillaries directly connected with sinusoids linked with the PCP, suggesting that it plays a role in angiogenesis and sinusoidal remodeling in LC.

Right hepatic arterial girdle around the common hepatic duct in liver donors: technical considerations for successful living donor liver transplantation.

Variations in hepatic arterial anatomy can result in multiple arterial trunks in the graft liver. We describe our experience in dealing with five right lobe liver donors where in the right hepatic artery (RHA) branches were passing anterior and posterior to the common hepatic duct (CHD) forming an arterial girdle around it. Five of 771 right lobe living donor liver transplants (January 2012 and March 2020) demonstrated the RHA girdle around the CHD. Three patients had the typical girdle resulting in two graft arteries which were reconstructed using arterial Y grafts. Arterial girdle was formed by the right anterior hepatic artery branches in one patient resulting in 3 graft arteries of which two were reconstructed using a Y graft. One donor had the arterial girdle and an accessory artery from SMA giving rise to 3 graft arteries. Two of them were ligated (brisk back bleed), and one was reconstructed. All donors (median follow-up 17 months, range 6-60 months) had an uneventful postoperative recovery. No vascular or biliary complications were encountered in the recipients. One recipient died due to sepsis and multiorgan failure, while the other 4 recipients recovered uneventfully and continue to have stable graft function. Adhering to safe surgical principles during RHA mobilization, ligation of minor arterial branches, and precise reconstruction of multiple major branches can ensure successful outcomes in the donor and recipient in this scenario.

Anatomical variations of cystic artery: A digital subtraction angiography study

Background/Aim: Branching variations in the cystic and hepatic arteries may lead to bleeding and mortal complications during surgery. This study aimed to demonstrate the relationship between cystic artery (CA) variations and hepatic artery branching patterns among an Anatolian population using Michel’s classification and compare the distribution of these variations among genders. Methods: Angiographies performed between 2014-2017 were retrospectively evaluated and DSA images of 303 patients (84 females and 219 males) were included in this cross-sectional study. Michel’s classifications of the hepatic arteries and CA variations of the patients were noted, and each was analyzed separately, along with gender-related branching differences. Results: Hepatic arteries of 256 patients could be evaluated according to Michel’s classification, the most frequent being Michel’s class I (69.9 %). Thirty patients (9.9%) were excluded from CA-related statistical analyses since they had undergone a cholecystectomy. CAs were not visualized in fifty-five (18.2%) of the remaining patients. Of the 218 patients with apparent CAs, eleven females (19.3%) and twenty males (12.4%) had double cystic arteries (P=0.201). Two hundred and twelve (85.1%) CAs originated from the right hepatic artery (RHA), which was the most common parent artery. No significant relationship was found between Michel’s classification and CA origin among different genders (P=0.532). Conclusion: An overlooked anatomic variation could lead to many iatrogenic complications during diagnostic and therapeutic interventions; thus, variations of the vascular structures have attracted medical professionals’ interest. This study focuses on the variations of the cystic artery and its relationship with hepatic arterial branching variations.

Super-Selective Intra-Arterial Indocyanine Green Administration for Near-Infrared Fluorescence-Based Positive Staining of Hepatic Segmentation: A Feasibility Study.

Despite the increasing number of laparoscopic hepatic procedures for the resection of hepatocellular carcinoma (HCC), intraoperative tumor localization and demarcation remains challenging in comparison to open surgery. In this study, we evaluated the feasibility of positive liver segment staining through the super-selective intra-arterial indocyanine green (ICG) administration. Eight patients presenting with a single HCC underwent an interventional vascular procedure followed by laparoscopic surgery. A microcatheter was advanced into the hepatic artery branches perfusing the HCC followed by digital subtraction angiography and angiography computed tomography (angio-CT). Patients were then transferred to the operating room, and a laparoscopic hepatectomy was performed under ultrasound guidance. A 5mL bolus of ICG with a concentration of .125mg/mL was injected through the microcatheter, and a near-infrared laparoscope was used to detect the fluorescence signal to assess the correspondence between the fluorescence-based demarcation and the intraoperative ultrasound-based demarcation. The duration for the angiography procedure was 32.7 +/- 5.3min, and it took 242 +/- 118min from the end of angiography procedure until the start of the surgical procedure. In all cases, the fluorescent liver segment was corresponding to the angio-CT findings. In 6/8 cases, fluorescence imaging was considered helpful in the identification of the resection line. In 3 patients, the resection line was changed according to the positively stained liver segment. We successfully demonstrated the feasibility of the super-selective intra-arterial ICG administration for fluorescence-based positive staining of hepatic segmentation during laparoscopic surgery for HCC (NCT04266548).

Early gastric cancer with an Adachi type VI (group 26) vascular anomaly diagnosed preoperatively and treated by laparoscopic surgery: a case report

BackgroundIt is important to understand the branching pattern of the celiac artery for a safe surgery. Various branching anomalies of the celiac artery were classified by Adachi in 1928. In Adachi’s classification, type VI (group 26) is a rare anatomical anomaly (0.4%) that requires care when carrying out a surgery in gastric cancer patients with this anomaly. Herein, we reported a case treated successfully with laparoscopic distal gastrectomy with D1+ lymph node dissection for early gastric cancer.Case presentationAn 84-year-old female was referred to our division for an additional surgical treatment for early gastric cancer that was resected by endoscopic submucosal dissection. A three-dimensional computed tomography angiography revealed an angioplany of the common hepatic artery branching from the left gastric artery. According to Adachi’s classification, the anomaly of this patient corresponded to type VI (group 26). Preoperative anatomical information of this rare anomaly helped us to safely perform a laparoscopic distal gastrectomy and lymph node dissection with common hepatic artery preservation. The patient had an uneventful postoperative course and was discharged on postoperative day 11.ConclusionsWe consider that Group 26 anomalies require the most precise anatomical understanding among Adachi classification type VIs, since it affects hepatic blood flow and can cause serious complications. In this time, we reported a successful case to perform laparoscopic distal gastrectomy with safety and accuracy by preoperative understanding of the precise vascular anatomy.

Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma.

Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma.

Successful treatment for intra-abdominal bleeding due to spontaneous rupture of huge liver cyst using transcatheter arterial embolization: a case report

Background: Non-parasitic simple liver cysts are one of the most common benign hepatic lesions. Although most liver cysts are asymptomatic and remain silent throughout the patient’s life, extremely large cysts can become symptomatic by direct compression to adjacent organs. Herein, we report a case of a spontaneously ruptured simple liver cyst, which is a rare presentation of a benign liver cyst. The patient’s liver cyst re-ruptured and was treated with transcatheter arterial embolization (TAE). Case report: A 62-year-old man presented to our hospital complaining of acute-onset lower abdominal pain. He had undergone laparoscopic fenestration of a huge liver cyst in another hospital 2 years prior. Computed tomography (CT) scan showed spontaneous rupture of a large liver cyst. Laparoscopic exploratory laparotomy showed no signs of ongoing intra-abdominal bleeding from the liver cyst; therefore, the operation was completed with peritoneal lavage. The patient was discharged from our hospital on postoperative day 5. Twelve days after the initial presentation, the patient was re-admitted to our hospital complaining of recurrence of lower abdominal pain. CT scan showed an enlargement of the previously ruptured liver cyst, with intra-abdominal bleeding and massive hematoma in the cyst. Extravasation of the cyst’s wall was also detected. Under the diagnosis of intra-abdominal bleeding from the artery in the wall of the huge cyst, emergent TAE was performed. Although the exact spot of extravasation was not detected, the anterior segment branch of the right hepatic artery, which corresponds to extravasation shown on the CT scan, was embolized. The patient was discharged from our hospital after 7 days, and the liver cyst remained stable without abdominal pain for more than 2 months. Conclusions: This case highlights a rare presentation of spontaneous rupture of a liver cyst with massive bleeding and the efficacy of TAE for the conservative treatment of ruptured liver cysts.

One Case of Hilar Cholangiocarcinoma in which Extended Left Hepatectomy Was Carried Out with Combined Resection of the Anterior Segmental Branch of the Right Hepatic Artery Following Coil Embolization

One Case of Hilar Cholangiocarcinoma in which Extended Left Hepatectomy Was Carried Out with Combined Resection of the Anterior Segmental Branch of the Right Hepatic Artery Following Coil Embolization

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

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.

Indocyanine green fluorescence-guided laparoscopic left hemihepatectomy: efficacy of negative staining for precise parenchymal transection and bile duct resection

Purpose: ICG fluorescence imaging is useful to locate segmental boundaries for anatomical resection and to delineate biliary anatomy. Its application in laparoscopic liver surgery is being recently explored and perceived of usefulness given the lack of tactile sensation. This video documents the application of the negative ICG staining technique for an efficient fluorescence guide in pure laparoscopic left hemihepatectomy, for both precise parenchymal transection and bile duct resection. Method: The patient is affected by solitary intrahepatic recurrence of colorectal liver metastasis between Sg 3 and 4 with endobiliary thrombus dilating the left hemiliver biliary tree. The hilar approach is used to isolate the left hepatic artery and ipsilateral portal branch, and the inflow for the left hemiliver is selectively clamped. A solution of 10 mg of ICG diluted in 10 mL saline solution is administered i.v. and the camera switched to the near infrared light. Results: After 2 mins the right hemiliver becomes fluorescent and left hemiliver counterstained on the glissonian surface. The proper transection line is marked, and the transection started. Differently from the traditional vascular demarcation, the ICG fluorescence boundary remains highly visible along the deep transection planes which allows to follow a clear and clean dissection plane during all the transection time. The transection is continued up to the hilar plate until the left portal branch and ipsilateral hepatic artery are encountered, which are both secured with clips before bulldog removal it is ensured that the left hemiliver remains unperfused by ICG, and the two vessels are then interrupted. The left bile duct is identified intraparenchymally, with the endobiliary thrombus inside remaining counterstained, and it is encircled distally to its endobiliary bulging thus allowing precise bile duct section with sufficient free margin at first frozen section. The transection is carried forward up to the identification of the left hepatic vein, which is sectioned by vascular stapler, and the specimen then extracted after biliostatic and hemostatic check. Conclusion: ICG fluorescence imaging with negative staining is useful not only for segmental anatomical resections but safe and efficient technique for both precise parenchymal transection and bile duct resection during anatomical major hemihepatectomy.