Left Lateral Section Research Articles

Laparoscopic left lateral sectionectomy for a patient with right-sided ligamentum teres

BackgroundA right-sided ligamentum teres (RSLT) is a rare congenital anomaly in which the fetal umbilical vein is connected to the right paramedian trunk. RSLT creates difficulty in liver resection with respect to decision-making regarding the resection line, deviation of the vasculobiliary architecture. We report a case in which laparoscopic left lateral sectionectomy (LLLS) was performed to treat colorectal liver metastasis (CRLM) in a patient with RSLT.Case presentationA 63-year-old man with a past history of rectal cancer presented to our institution due to liver metastasis in the left lateral section from rectal cancer. In this patient, an RSLT was diagnosed and LLLS was planned. The lateral superior branch of the portal vein (P2) branched off behind the bifurcation of the portal vein and running separately from the common branch of the lateral inferior branch (P3) and left paramedian branch (P4) so that stapling could not be performed for liver resection. Frequent intraoperative ultrasonography (IOUS) was necessary to identify the root of P2 and P3. The resection line was distant from the falciform ligament and was carefully decided. The lateral superior branch of Glisson (G2) and lateral inferior branch of Glisson (G3) were separately resected. The patient had a favorable clinical course without any complications.ConclusionsThe resection line of LLLS, which is distant from the falciform ligament, should be carefully identified using IOUS due to the deviation of the umbilical portion and falciform ligament. The recognition of portal vein and hepatic vein anomalies and clear identification of the lateral sectional branches are important to complete LLLS in patients with an RSLT.

Laparoscopic left lateral section resection for hydatid cyst of the liver

Background: Hydatid cyst of the liver is still a relatively common problem in endemic regions. Surgery is one of the most effective way of treatment, and it can be performed using both open and laparoscopic routes. Here, we are presenting a video showing left lateral section resection performed for hydatid liver disease. Methods: A 42-year old male patient was admitted to clinic complaining with abdominal pain. Physical examination was normal. His bilirubin levels were slightly high. Abdominal ultrasonography, contrast enhanced abdominal computed tomography revealed a 10 cm, partially exofitic cyst, localized in left lateral section of the liver, reported as hydatid cyst. An ERCP was performed. There was a communication between the left lateral biliary ducts and the cyst. Sphincterotomy was performed. Laparoscopic left lateral sectionectomy was decided. Abdominal exploration was performed using a supraumbilical 10 mm port. After hilar disection and mobilization of the left lateral section, transection line was marked using hook cautery just lateral to the falciform ligament. Paranchymal transection was performed using, bipolar vessel sealing and bipolar radiofrequency ablation devices, clips and endoscopic staplers. Results: Operative time was 70 minutes and estimated blood loss was 100 ml. Postoperative period was uneventful and the patient was discharged on postoperative second day. Conclusion: Laparoscopic surgery is a feasible treatment option depending on the localization and type of the liver hydatid cyst.

Laparoscopic left lateral section resection for hydatid cyst of the liver

Background: Hydatid cyst of the liver is still a relatively common problem in endemic regions. Surgery is one of the most effective way of treatment, and it can be performed using both open and laparoscopic routes. Here, we are presenting a video showing left lateral section resection performed for hydatid liver disease. Methods: A 42-year old male patient was admitted to clinic complaining with abdominal pain. Physical examination was normal. His bilirubin levels were slightly high. Abdominal ultrasonography, contrast enhanced abdominal computed tomography revealed a 10 cm, partially exofitic cyst, localized in left lateral section of the liver, reported as hydatid cyst. An ERCP was performed. There was a communication between the left lateral biliary ducts and the cyst. Sphincterotomy was performed. Laparoscopic left lateral sectionectomy was decided. Abdominal exploration was performed using a supraumbilical 10 mm port. After hilar disection and mobilization of the left lateral section, transection line was marked using hook cautery just lateral to the falciform ligament. Paranchymal transection was performed using, bipolar vessel sealing and bipolar radiofrequency ablation devices, clips and endoscopic staplers. Results: Operative time was 70 minutes and estimated blood loss was 100 ml. Postoperative period was uneventful and the patient was discharged on postoperative second day. Conclusion: Laparoscopic surgery is a feasible treatment option depending on the localization and type of the liver hydatid cyst.

Risk factors of liver dysfunction for donor after extended right lobe graft donation

Introduction: Extended right lobe graft are often used in living donor liver transplantation(LDLT), in the donors with sufficient future liver remnant (FLR) volume. The aim of this study is to review retrospectively and to find risk factors of liver dysfunction for donor after extended right lobe graft donation. Method: From November 2005 to May 2018, a total of 52 living liver donors who underwent extended right lobectomy were included in this study.The subjects were divided into 2 groups.The hazard group was defined as the donors showing at least one of the following criteria:(1)postoperative serum peak bilirubin > 3.0mg/dL; (2) postoperative peak INR > 2.0, (3) posthepatectomy liver failure(PHLF) grade B or C of International Study Group of Liver Surgery(ISGLS), (4) ascites > 500cc on or after pod 5. Other donors with no criteria mentioned above were included in the safety group. Result: In hazard group, they had smaller volume of left lateral section(LLS) compared to safety group and the ratio of left liver volume(LLV) and left lateral section volume(LLSV) to total liver volume (TLV) in hazard group were smaller than in safety group. The mean and median values of the ratio of LLV to TLV(LLV/TLV); 38%, and the ratio of LLSV to TLV(LLSV/TLV); 20%, were used as the cut-off value. In hazard group, there were more patients whose LLV/TLV was less than 38% and whose LLSV/TLV was less than 20%. Using each cut-off values regarded as risk factors, three groups were categorized. This indicates that donors with smaller LLV/TLV or/and LLSV/TLV are more prone to liver dysfunction. Conclusion: The extent of donor hepatectomy must be contemplated based on a careful preoperative evaluation, including the volumetry. In this study, the LLV/TLV less than 38% and/or LLSV/TLV less than 20% were the major risk factors for postoperative liver dysfunction.

Two cases of salvage liver transplantation for the HCC presented initial advanced stage beyond UCSF criteria and shown good prognosis.

Introduction: We tried LDLT for two patients who have advanced HCC. Method: Case 1. A 46-year-old male patient who has chronic hepatitis B carrier were developed a 6cm-sized tumor in left lateral section with tumor thrombus in left portal vein and elevated α-FP and PIVKA II level. He underwent left hepatectomy with tumor thrombectomy and pathologic report showed moderately differentiated HCC invaded to portal vein and bile duct. Two years after surgery, two metastatic pulmonary nodules appeared and were removed by wedge resection. He had stable liver function and no recurrence or metastasis until 9 years after surgery. However, the liver was decompensated cirrhosis with intractable ascites without HCC recurrence for the late 2 years. So, living donor liver transplantation was performed at eleven and half years after initial hepatectomy. The patient recovered completely without any complication after LDLT and has been received of immunosuppression with combination of low dose tacrolimus and everolimus. Case 2. A 56-year old male patient who has chronic hepatitis B carrier developed 10cm sized HCC in his hepatic segment 5-6 combined with portal vein tumor thrombosis. The patient was undergone right hemihepatectomy. The pathology showed moderately differentiated HCC with partial infiltrating type and portal vein tumor thrombosis in the hepatic segment 5&6. Multiple intrahepatic metastasis was developed in the remnant left liver including caudate lobe 4 months after surgical resection. The patient underwent TACE followed by living donor liver transplantation 6 months after initial resection. The patient received immunosuppression with low dose prograf and everolimus daily. Result: The first patient has been doing well his works without tumor recurrence until one and half year after liver transplantation. For the second patient, there was no evidence of recurrence until twenty months after transplantation. Conclusion: Salvage liver transplantation for the HCC presented initial advanced stage beyond UCSF criteria is feasible selectively.

Laparoscopic ALPPS procedure for large hepatocellular carcinoma

Background: ALPPS procedure has been a vital alternative strategy for avoiding post-hepatectomy liver failure (PLF) in extended liver resections over the last decade. Here we aim to share our experience with laparoscopic approach to ALPPS procedure in a patient with large HCC. Methods: A 55 y.o. male patient weighting 68 kg presented with a 22 cm. huge right hemiliver mass extending into the liver segment IV. He was diagnosed with HCC and Hepatitis-B related Child A chronic liver disease. As there was a limited time before progress to unresectability, we decided utilization of ALPPS procedure. Results: The patient underwent laparoscopic ALPPS procedure as the first step. The right portal vein was ligated and the parenchymal transection was performed between liver segment IV and the left lateral section. The first step was completed within 4 hours with 150 ml estimated blood loss. The recovery period was uneventful. CT scan obtained on POD #9 revealed a 25% growth of the future liver remnant, resulting in a volume increase from 620 ml to 775 ml. The second step was undertaken conventionally on POD 11 with minimal blood loss. The patient was developed a grade A PLF and required medical management of ascites for a month. He was discharged home POD 18 with an abdominal drain. Conclusion: Laparoscopic approach may offer significant benefits in patients undergoing ALPPS procedure with its potential to reduce the risk of wound related complications, which may complicate and induce post-hepatectomy liver failure.

Laparoscopic ALPPS procedure for large hepatocellular carcinoma

Background: ALPPS procedure has been a vital alternative strategy for avoiding post-hepatectomy liver failure (PLF) in extended liver resections over the last decade. Here we aim to share our experience with laparoscopic approach to ALPPS procedure in a patient with large HCC. Methods: A 55 y.o. male patient weighting 68 kg presented with a 22 cm. huge right hemiliver mass extending into the liver segment IV. He was diagnosed with HCC and Hepatitis-B related Child A chronic liver disease. As there was a limited time before progress to unresectability, we decided utilization of ALPPS procedure. Results: The patient underwent laparoscopic ALPPS procedure as the first step. The right portal vein was ligated and the parenchymal transection was performed between liver segment IV and the left lateral section. The first step was completed within 4 hours with 150 ml estimated blood loss. The recovery period was uneventful. CT scan obtained on POD #9 revealed a 25% growth of the future liver remnant, resulting in a volume increase from 620 ml to 775 ml. The second step was undertaken conventionally on POD 11 with minimal blood loss. The patient was developed a grade A PLF and required medical management of ascites for a month. He was discharged home POD 18 with an abdominal drain. Conclusion: Laparoscopic approach may offer significant benefits in patients undergoing ALPPS procedure with its potential to reduce the risk of wound related complications, which may complicate and induce post-hepatectomy liver failure.

Liver pecoma: perivascular epithelioid tumor. a case report.

Background: Perivascular epithelioid cell tumors (PEComa) are an unusual mesenchymal tumors family, including the classic angiomyolipoma (AML), lypmphangioleiomyomatosis and clear-cell tumors, that can arise from different locations of the body [1–4]. We present a rare case of a Liver PEComa. Methods: A 58-year-old female with no background of cirrhosis or any other liver disease, who in an abdominal ultrasound, presented an exophytic heterogenic/solid mass of 5x6 cm in the left lateral section. Computed Tomography found a hypodense mass of 6.2x4.9x6.2 cm with fat density areas, quickly enhanced in the arterial phase and becoming less enhanced on venous and delayed phases of imaging, suggesting a PEComa as diagnosis. Laparoscopic Left Lateral Sectionectomy was performed. Pathology findings were a mix of three type of components: Adipose, vascular and perivascular epithelioid cells, HMB-45+, with conclusive findings of an angiomyolipoma. The patient was discharged at the second postoperative day, with no complications so far. Results: Liver PEComas were before considered as benign tumors, with surgical treatment in selected cases. The publications in the medical literature of some cases that confirm a malign transformation of AML have made the surgical indications for this pathology a controversial issue, recommending it in exophytic, >5cm or fast growing tumors [1–3]. Conclusion: Nowadays, liver PEComas are considerate as rare tumors with risk of malignancy in some cases, making the surgical intervention the primary treatment.

Central Hepatectomy with Vascular Reconstruction

Summary Resection /Liver transplant are the only curative options for either primary or secondary liver tumors. The management of large centrally located tumors poses a surgical challenge and is controversial. Traditional resections remove ∼80% parenchyma while non-anatomic parenchyma preserving resections have a risk of massive hemorrhage and margin positivity. There is only minimal evidence that portal venous embolization affects the resectability rate or improves survival. Central hepatectomy leaves adequate parenchyma and with surgical mortality of 0-6%. We present this surgical video of a 37-year-old gentleman with Hep-B related HCC on a non-cirrhotic background. This is a unique and interesting case as we employed the amalgamation of standard techniques of surgical resection as well as liver transplantation in this case. The patient presented following TACE with no response and an AFP level of 55,554 IU/ml. The tumor involved segments IVa, V, VIII, and part of IVb. We preoperatively planned to explant the liver followed by central hepatectomy and then implantation of the left lateral and posterior sector. Intraoperatively, we decided to proceed with parenchyma preserving Right extended Hepatectomy followed by ex-vivo (back bench) posterior sectorectomy and implantation. However, as the blood loss was not significant during the left lateral sectionectomy, we proceeded with in-vivo Central Hepatectomy with vascular reconstruction. Surgery was uneventful. The patient improved well and was discharged on POD10 with healthy wound and AFP of 6114 IU/ml. Histopathology showed negative margins and thrombus in the portal vein showing few scattered nests of tumor cells. At 2-months follow-up, the patient is doing well and is on close follow-up. In case of recurrence, we plan for a salvage transplant as against a repeat liver resection. To conclude, central hepatectomy is an acceptable and safe surgical method to centrally located liver tumors. Vascular reconstruction in major vascular involvement is safe and feasible approach.

Living liver donor surgical complication : single center experience with 512 cases

Introduction: Korea is the one of the most common country to do living donor liver transplantation. But almost big liver transplantation center is in Seoul which is capital of Korea. Beside Seoul, There are no big living donor liver transplantation center except Dague catholic university medical center. We were reached to 500th living donor liver transplantation in 2017. We review our donor complication and find way to reduce the rate of morbidity. Method: Institutional LT database was searched from 2005.05.08. to 2017.12.31. Their medical records and imaging studies were reviewed. Result: From 2005.05.08 we did first living donor hepatectomy, we did 512 living donor hepatectomy until 2017.12.31. Among them, 324 were male and 188 were female. Graft types were Right liver graft in 457 (89.3%), Left liver graft in 47 (9.2%), Left lateral section graft in 2 (0.4%) and Right posterior section graft in 6 (1.2%). Mean age of total donor was 30 years and Mean BMI was 22. Mean hospital days was 10days. All of the donors, surgical complication occurred in 32donors.(6.3%) Minor complication was 10 cases(1.9%). Major complication was 24case.(4.7%) Between major complication, the most common complication was biliary complication (n=17) and the Other complications were small bowel obstruction operation(2), , bleeding control(n=2), pleural effusion drainage(n=2), portal vein stent insertion(n=1). There are no mortality. The most common complication was biliary complication which were 20cases (3.8%). Among them intra-op T-tube insertion were 9 case and 3 case were PTBD insertion and 3case did ERCP. There are re-operation case was just one case, which was immediate right hepatic artery bleeding. Conclusion: Our center’s complication was very low. But still biliary complication is the most common complication. When we meet abnormal biliary anatomy we must be careful and we try to reduced biliary complication.

Case report: Left sided gall bladder associated with chylolymphatic cyst of mesentery of small intestine

Mesenteric cyst and left sided gall bladder both are rare entity. Incidence of mesenteric cyst is 1 per 1,00,000 to 2,50,000, a rare abdominal tumor, among which chylolymphatic mesenteric cyst is further rare. In left sided gall bladder, gall bladder is attached on left lateral sector of liver, left to falciform ligament and interlobar fissure. Left sided gall bladder can be a single anomaly or associated with other anomalies like duplicated gall bladder, hypoplastic bile duct, situs inversus, anomalous pancreatico-biliary ductal junction, absence of quadrate lobe, accessory liver. In our case it was associated with mesenteric cyst which is the first case to be reported to best of our knowledge.

Radiofrequency ablation for subcardiac hepatocellular carcinoma: therapeutic outcomes and risk factors for technical failure.

To compare the therapeutic outcomes and safety of radiofrequency (RF) ablation for subcardiac and non-subcardiac hepatocellular carcinoma (HCC) and to evaluate the risk factors for technical failure of the procedure. This retrospective study was approved by the institutional review board. Between September 2002 and May 2016, 73 patients with subcardiac HCC and the same number of patients with non-subcardiac HCC matched by tumor size were included. Subcardiac HCC was defined as an index tumor that was located ≤ 1cm from the pericardium in axial or coronal images. Cumulative local tumor progression (LTP) was compared between the two groups using the log-rank test. Prognostic factors for technical failure were assessed using multivariable logistic analysis. Technical success rates between both groups were not significantly different (91.8% in the subcardiac HCC group vs. 95.9% in the non-subcardiac HCC group; p = 0.494). The cumulative LTP rates were 15.4% and 19.1% at 3 and 5years, respectively, in the subcardiac HCC group, and 10.7% and 15.5% in the non-subcardiac HCC group, without significant difference (p = 0.862). The distance between the index tumor and pericardium (odds ratio [OR], 0.14; p = 0.023) and tumor in segment IV (reference, left lateral sector; OR, 36.53; p = 0.029) were significant factors for technical failure in patients with subcardiac HCC. RF ablation was an effective treatment for subcardiac HCC. However, tumor location should be considered in the planning of treatment to avoid technical failure. • RF ablation for subcardiac HCC is technically feasible without major complications. • RF ablation was an effective treatment for subcardiac HCC in terms of LTP. • Risk factors for technical failure were distance of the index tumor from the heart (cutoff value of 0.5cm) and the location of the tumor (segment IV).

The results of surgical treatment in patients with liver alveococcosis in a hepato-pancreato-biliary center (a 10-years’ experience)

Background: Aggressive course of liver alveococcosis makes it possible to designate it as a “parasitic liver cancer”. The main treatment method for the disease is surgery. The parasitic mass is resected according to R0 principles, with concomitant plastic surgery of the major vessels and bile ducts to increase resectability.Aim: To assess the potential of surgical treatment in patients with advanced liver alveococcosis using transplantation techniques.Materials and methods: We retrospectively analyzed in- and outpatient medical files of 62 subjects with confirmed liver alveococcosis, who had been treated in the Volga District Medical Centre (Nizhny Novgorod, Russia) from 2008 to 2018. Thirty two (32) patients had advanced liver alveococcosis with involvement of afferent and efferent vasculature and biliary tract. Surgical procedures were used in 50/62 patients (or 4.2% of the total number of liver resections performed during this time interval, n = 1197). Complications occurred in 46% (23 / 50) of the cases. Twenty nine (29, or 58%) patients had been operated before (mostly cytoreductive resections and/or explorative laparotomies). Distant lung metastases were found in 2 (4%) patients.Results: Fifty (50) patients had curative surgical procedures: liver resections in 45, deceased donor orthotopic liver transplantations in 5. Most common were extensive liver resections (more than 4 segments). Resection and reconstruction of the main vessels were necessary in 50% (25 cases) of the patients, including v. cava inferior in 25 cases and the portal vein in 24 cases. In 31 patients, resection and reconstruction of extra-hepatic bile ducts was performed, and in 17 (33%) patients resections of the neighboring organs, such as diaphragm, lung, right adrenal, duodenum, stomach, and colon. In 4 cases, resections were performed ex situ ex vivo, followed by auto-transplantation, including 2 cases with reverse auto-transplantation of the left lateral sector to the right. The incidence of liver failure events grade A and B (by International Study Group of Liver Surgery, ISGLS) did not exceed 10% (4 patients). Complications were seen in 25 cases, including Clavien – Dindo Grade II in 5, Grade IIIb in 13, Grade IVb in 2, and Grade V in 5. The number of bile leakage events (ISGLS) class B was 6 and class C 10. All patients underwent obligatory adjuvant anti-parasitic therapy.Conclusion: At present, surgical treatment of liver alveococcosis remains a method of choice, that requires that the hepato-pancreato-biliary center would have in place a well-developed transplantation program, adequate equipment and well-trained surgical and anesthetic teams.

Stapleless laparoscopic left lateral sectionectomy for hepatocellular carcinoma: reappraisal of the Louisville statement by a young liver surgeon

BackgroundLaparoscopic liver resection has been regarded as the standard treatment for liver tumors located at the left lateral liver sector. However, few studies have reported the results of laparoscopic left lateral sectionectomy (LLS) for HCC, not to mention the feasibility of this emerging technique for the less experienced liver surgeons. The current study would reappraise the Louisville statement by examining the outcome of LLS performed by a young liver surgeon.MethodsWe retrospectively reviewed two separate groups of patients who underwent open or laparoscopic left lateral sectionectomies at Chung Gung Memorial Hospital, Linkou. All laparoscopic hepatectomies were performed by the index young surgeon following a stepwise stapleless LLS. The surgical results and oncological outcomes of laparoscopic vs. open hepatectomies (LH and OH, respectively) with the surgical indication of HCC at left lateral liver sector were further compared and analyzed.Results18 of 29 patients in the laparoscopic group and 75 patients in the conventional open group had primary HCC. The demographic data was essentially the same for the two groups. Statistical analysis revealed that the LH group had smaller tumor size, higher blood transfusion requirement, longer duration of inflow control and parenchymal transection, and longer operation time. However, no significant difference was observed in terms of complication rate, mortality rate, and hospital stay between the two groups. After adjusting for tumor size, LH and OH showed no statistical difference in the amount of blood transfusion, operation time and patient survival.ConclusionsThis study demonstrated that stapleless LLS is a safe and feasible procedure for less experienced liver surgeons to resect HCC located at the left lateral liver sector. This stepwise stapleless LSS can not only achieve surgical results comparable to OH but also can provide a platform for liver surgeons to apply laparoscopic technique before conducting more complicated liver resections.

Hepatocellular carcinoma mimicking liver abscess

Hepatocellular carcinoma (HCC) is the most frequent primary malignancy of the liver which can be presented in many different clinical situations. Beyond the well-known risk factors it can also be seen without any of them. We present the successful management of a patient with HCC mimicking a liver abscess. A 20-year-old woman admitted to the emergency department with high fever, abdominal pain, and elevated white blood count, c-reactive protein level. Ultrasonogarphy and computed tomography of the abdomen revealed a huge heterogeneous mass in the left liver containing air bubbles inside. Liver transaminases were elevated. The further radiologic evaluation through magnetic resonance scan revealed that the mass is a solid tumor with necrotic areas. After intravenous antibiotics and fluid support, the patient was rapidly prepared for surgery. The surgical exploration showed a huge tumor originating from left lateral liver section. Left lateral sectionectomy was performed. The patient was discharged after an uneventful postoperative period. Histopathological examination revealed a HCC with over 90% coagulative necrosis with negative surgical margins. HCC can be presented with different clinical scenarios. Prompt imaging and meticulous radiologic interpretation is the key to success in the management of liver masses presenting with acute abdominal pain and fever.

Intrahepatic pancreatic pseudocyst; a rare complication of pancreatitis

Introduction: Pancreatic pseudocyst is located usually in lesser sac and peripancreatic space and is rarely developed in the liver. The intrahepatic pancreatic pseudocyst(IHPP) following acute pancreatitis is extremely rare with very limited number of clinical reports about IHPP. Methods: A 70-year-old woman was referred because of upper abdominal pain of 3 days' duration. An abdominal CT scan revealed 11x10 cm sized cystic mass in the left lateral section of liver. On EUS findings, a huge hypoechoic lesion with internal echogenicity was noted in the lesser sac. EUS-guided gastrocystostomy was performed and analysis of cystic fluid showed a high level of amylase (21,200 U/L). After the endoscopic procedure, severe abdominal pain developed and physical examination showed peritoneal irritation sign. An emergency operation was performed. Results: On operation findings, a huge cystic tumor was located in the left lateral section of liver without direct communication with pancreas. However, mass-like necrotic tissue was filled with in the hepatoduodenal ligament, hepatogastric ligament, and Glisson sheath of the left hepatic lobe. Left lateral sectionectomy was performed. Pathologic examination confirmed the pseudocyst with findings of non-epithelialized granulation tissue of the cystic wall. Conclusion: IHPP should be considered when a huge intrahepatic cystic lesion is found in patients with recent episodes of pancreatitis. The high level of amylase on cystic fluid analysis plays a key role in the diagnosis of IHPP. Drainage procedure or surgical resection can be considered, if necessary, for the treatment of IHPP.

Клинический случай: компьютерная томография с 3D реконструкцией в планировании двухэтапной резекции печени ALPPS по поводу альвеококкоза

Purpose: To provide case report of alveococcosis of the liver, when ALPPS procedure was planned based on diagnostic information and 3D reconstructions of computed tomography. Material and methods: Computed tomography with bolus intravenous administration of 100 ml of contrast media Ultravist-370 was performed on multislice computed tomography Aquilion 64 Toshiba. Results: The preoperative planning is the crucial part of treatment to minimize or exclude liver insufficiency after resection. The minimal volume of remnant of the liver should be more than 25–30 % for normal parenchyma and more than 40 % in case of chronic pathologic diffuse process in the liver for example steatosis or cirrhosis. If the estimated volume of remnant is not enough to perform resection, two staged hepatectomy should be planned. According to CT data, the parenchyma of segment S2 and most of parenchyma S3, which together constitute the so-called lateral sector of the liver, were preserved. It allowed to plan an extended right-sided resection. However, the volume of the future liver remnant was 410 ml – about 30 % of the functioning part of the liver which was considered insufficient in view of the presence of prolonged biliary hypertension and a decreasing density of the parenchyma. Vascular elements of the left lateral sector – left hepatic artery, left hepatic vein and inferior vena cava were intact, however, there was a possibility of involving the wall of the left portal vein, due to its prolonged contact with the surface of the parasitic lesion. Using the segmentation tool on radiology workstation, a 3D surface model of the liver was built, where the localization of the pathologic lesion and its relationship with the main vessels were visually demonstrated. After preoperative preparation, a decision was made to perform ALPPS procedure. At the first stage intraoperative the adhesion of the parasitic lesion with the left portal vein was confirmed, which required its resection and plastic. Also in addition to the usual volume of the operation, an atypical resection of the S3 segment and Roux-en-Y choledochojejunostomy were performed. On the 7th day after the 1st stage, a control CT scan was performed, at which an increase in the volume of the remnant to 630 ml (46 % of the preserved parenchyma of the liver) was recorded. The hepatic artery, portal and hepatic veins of the future liver remainder were enhanced homogenously; drainage was traced in the area of parenchyma dissection after the second, l stage of the operation, CT was performed in 15 days to exclude liquid accumulations in the abdominal cavity and to assess the condition of the remnant due to a moderate increasing of the level of direct bilirubin up to 98 μmol/l. No pathological changes in the abdominal cavity were revealed, only free pleural effusion was observed in the pleural cavities with partial atelectasis of the lower lobes of the lungs. After conservative therapy the liver insufficiency was resolved. On the 20th day after the operation, the patient was discharged. Conclusion: In the described clinical case, computed tomography with 3D reconstructions made possible to obtain complete diagnostic information that was necessary for the surgeon to assess the resectability of the pathological process and to plan the type of surgical intervention.

Parenchyma-sparing liver resection for hepatocellular carcinoma in left lateral section is associated with better liver volume recovery

BackgroundLeft lateral sectionectomy (LLS) is frequently performed for surgical treatment of hepatocellular carcinoma (HCC) located in the left lateral section. However, no reports have described liver resection for such HCCs using a parenchyma-sparing strategy involving anatomic resection (AR) of segment II (S2 AR) or segment III (S3 AR). MethodsFrom 1994 to 2014, patients who underwent LLS and S2 AR or S3 AR for HCC were included in the analysis. Short- and long-term outcomes and pre- and postoperative LV were assessed. ResultsOf the 89 patients selected, 49 underwent LLS (LLS group) and 40 underwent S2 AR and S3 AR (S2/S3 AR group). The postoperative LV was not significantly smaller than the preoperative LV in the S2/S3 AR group (p = 0.114), whereas the postoperative LV was significantly smaller in the LLS group (p = 0.019). The overall survival (OS) and recurrence free survival (RFS) rates were not significantly different between the groups (OS, p = 0.056; RFS, p = 0.102). ConclusionsParenchyma-sparing liver resection for HCC in the left lateral section is associated with better postoperative LV recovery than LLS with similar oncological outcomes. S2/S3 AR can be a reasonable therapeutic option when LLS results in the removal of more parenchyma than necessary.

Surgical Aspects of Split Liver Transplantation

Introduction Split liver transplantation is the important component of developed liver transplant program, which allows to increase the effectiveness of deceased donation. Nevertheless, at the present time there is absence of common concept of donor selection for liver transsection into two viable fragments. The “classical split” in left lateral section (LLS) and extended right lobe (ERL) is most preperable type of this procedure. The surgical issues of graft splitting discussed are “ in situ/ex situ” division . Purpose to analyze the surgical aspects of obtaining two grafts from the split liver from deceased donors in single center. Materials and methods Since June 2008 to October 2017, 16 cases of split liver transplantation were performed. 12 SLT of them were performed in 2016 and 2017. That allowed to make transplantations of liver fragments in 34 recipients. The age of deceased donors was between 18 and 54 years (25 ± 5 years). In eleven cases, parenchyma transsection was performed completely in situ. During in situ splitting the conversion to ex situ was performed due to the hemodynamic instability of the donor in 3 cases. When parenchyma transsection was finished on the back bench after organ explantation and flashing (ex situ). The liver graft was divided into the LLS and ERL completely ex situ on the back bench (I, IV-VII segments) in 3 cases. The age of LLS recipients ranged from 6 months to 6 years (mean 22 months), weight - from 5 to 16 kg (mean 9,4 ± 3,9 kg). The age of ERL recipients was from 8 to 54 years (mean 17 years), and weight was from 21 to 65 kg (mean 39 ± 11,9 kg). Results The protocol of the deceased donor selection for split liver transplantation was proposed. Small-for-size syndrome wasn’t observed in this series. The follow up without complications was observed in 20 of 32 recipient. 1-, 3-, 5- y graft and recipient survival was 85.3%, 85.3% and 79.4% respectively. Conclusion Split liver transplantation is an effective method viable recipients with terminal stage liver disease. Division of liver in LLS and ERL allows to obtain two quality grafts for transplantation and to prevent small-for size syndrome in recipient. In situ/ex situ splitting doesn’t influence on result.

Retrospective Analysis of Using the Modified in Pediatric Recipients of Left Lateral Segment Liver Graft

Purpose Transplantation of the left lateral section of liver from a living related donor is an effective method of treatment of end stage liver diseases in children. At the same time, the biliary reconstruction remains relevant to this day.The frequency of biliary complications reaches 45%according to world literature. Methods from January 2009 to October 2017 420 left lateral section transplantation in children aged from 4 to 12 months, with body mass from 5 up to 16 kg were performed. There were 404 living related donor and 16 split transplantations. Standard Roux-en-Y procedure for biliary end to side reconstruction with interrupted stitches with PDS 5/0 or 6/0 was used before 2013. Since 2013 a new technique of biliary reconstruction using round ligament of graft for peritonization of biliodigestive anastomosis with several interrupted stitches was proposed. A comparative analysis was carried out by retrospective compare is on two groups of patients: group A (2009-2012) n = 168 with classical Roux-en-Y procedure for biliary reconstruction, and group B (2013-2017) n = 252 with a new method of biliary reconstruction. Results Biliary complication rate was 14,7% in group A (biliary fistula 12,5%, biliary leakage 0.5%, stricture 1.7%). Rate of biliary complications was 9% in group B (biliary fistula 7,5%, biliary leakage 0,2%, stricture 1,3%). Conclusion The proposed surgical technique allows to reduce the amount of biliary complications.