Left Segment Liver Research Articles

Robotic left trisectionectomy using Glissonian approach

Background: The technique of left trisegmentectomy was first published in 1982 and consists in the removal of the left liver (segments 2, 3 and 4) along with the right anterior sector (segments 5 and 8). This procedure is based on the knowledge of the segmental liver anatomy. We present a video of a robotic left trisectionectomy using Glissonian aproach in a patient with a huge HCC initially treated with immunotherapy.

Bile duct anatomical variations: Relevance for liver division and preparing left split liver grafts for pediatric transplantation: Cohort study

Backgroundliver lateral section graft is the most common graft type used for transplantation in children worldwide. Compared to whole liver grafts, a higher rate of biliary complications has been described. Historically, 2 techniques have been described for transection of liver - trans-hilar or trans-umbilical parenchymal transection. Though these techniques allow dividing the biliary system at two distinct positions, the usual surgical strategies do not take advantage of this advantage. Material and methodsA retrospective study was conducted on 40 candidates who volunteered for donation of their left lateral liver section for transplantation, between October 2017 and April 2019. Preoperative imaging was analyzed to depict the arterial and biliary anatomy of the liver and their variations, with a dedicated attention to the left liver (segments 2, 3 and 4). Anatomy of the biliary system was taken into account for defining the optimal surgical strategy - either through a trans-hilar or a trans-umbilical parenchymal transection. ResultsIn 26/40 patients, arterial or biliary variations were much relevant for decision-making on the optimal plane of liver division (trans-umbilical (N = 14) and trans-hilar (N = 26)). This resulted in 23 grafts with a single artery and bile duct, 6 grafts with double arteries and a single bile duct, and 9 grafts with double bile ducts and a single artery; only two grafts had complex anatomy. There was no arterial complication and the overall incidence of biliary problems was 14.7%. All grafts are functioning well at a mean follow-up of 19.6 ± 8.5 months. ConclusionsAnatomical variations are frequent and their knowledge is relevant for procurement of lateral section liver graft. Knowledge of these variation, or -better- preoperative biliary imaging is helpful in guiding parenchymal transection at procurement and preparing optimal liver grafts.

Development of an artificial intelligence system using deep learning to indicate anatomical landmarks during laparoscopic cholecystectomy

BackgroundThe occurrence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is an important medical issue. Expert surgeons prevent intraoperative BDI by identifying four landmarks. The present study aimed to develop a system that outlines these landmarks on endoscopic images in real time.MethodsAn intraoperative landmark indication system was constructed using YOLOv3, which is an algorithm for object detection based on deep learning. The training datasets comprised approximately 2000 endoscopic images of the region of Calot's triangle in the gallbladder neck obtained from 76 videos of LC. The YOLOv3 learning model with the training datasets was applied to 23 videos of LC that were not used in training, to evaluate the estimation accuracy of the system to identify four landmarks: the cystic duct, common bile duct, lower edge of the left medial liver segment, and Rouviere’s sulcus. Additionally, we constructed a prototype and used it in a verification experiment in an operation for a patient with cholelithiasis.ResultsThe YOLOv3 learning model was quantitatively and subjectively evaluated in this study. The average precision values for each landmark were as follows: common bile duct: 0.320, cystic duct: 0.074, lower edge of the left medial liver segment: 0.314, and Rouviere’s sulcus: 0.101. The two expert surgeons involved in the annotation confirmed consensus regarding valid indications for each landmark in 22 of the 23 LC videos. In the verification experiment, the use of the intraoperative landmark indication system made the surgical team more aware of the landmarks.ConclusionsIntraoperative landmark indication successfully identified four landmarks during LC, which may help to reduce the incidence of BDI, and thus, increase the safety of LC. The novel system proposed in the present study may prevent BDI during LC in clinical practice.

Surgical therapy of segmental Caroli’s syndrom – A case of un-usual clinical and radiological results

Background: Caroli’s disease is a rare entity of congenital bile duct disease with cystic or fusiform dilated intrahepatic bile ducts with consecutive cholestasis and recurrent episodes of bacterial induced cholangitis finally leading to liver cirrhosis and potentially CCC.Therapeutic options are based on the treatment of cholestasis finally leading to liver resection or transplantation. Methods: A female pat. was referred to our department with recurrent abdominal pain with cramp-like character. Family history showed frequent occurrence of PSC. Ultrasound and MRI screening showed inhomogeneous structures in the central bile ducts of S II and III with additional choledocholithiasis. Slight elevation of the lab parameters was observed.Additional SpyGlas ERCP revealed a diffuse choledocholithiasis of the sub segmental bile duct S II and III as wellwith completely inconspicuous right-sided bile duct system. Results: We performed a left hemihepatectomy,as PSC was evident within the family. The histological examination revealed an incidental Caroli’s syndrom in the left lateral liver segments with absence of recurrent cholangitis, history of chronic inflammatory bowl disease and intra hepatic bile duct dilation. Conclusion: In conclusion we present an unusual case of left lateral Caroli’s syndrom. Nevertheless recurrence of cholangitis and intrahepatic choledocholithiais as well as the significant elevated risk for a CCC contribute to the curative decision of left sided hemihepatectomy.

Surgical therapy of segmental caroli’s syndrom - A case of un-usual clinical and radiological results

Background: Caroli’s disease is a rare entity of congenital bile duct disease with cystic or fusiform dilated intrahepatic bile ducts with consecutive cholestasis and recurrent episodes of bacterial induced cholangitis finally leading to liver cirrhosis and potentially CCC.Therapeutic options are based on the treatment of cholestasis finally leading to liver resection or transplantation. Methods: A female pat. was referred to our department with recurrent abdominal pain with cramp-like character. Family history showed frequent occurrence of PSC. Ultrasound and MRI screening showed inhomogeneous structures in the central bile ducts of S II and III with additional choledocholithiasis. Slight elevation of the lab parameters was observed.Additional SpyGlas ERCP revealed a diffuse choledocholithiasis of the sub segmental bile duct S II and III as wellwith completely inconspicuous right-sided bile duct system. Results: We performed a left hemihepatectomy,as PSC was evident within the family. The histological examination revealed an incidental Caroli’s syndrom in the left lateral liver segments with absence of recurrent cholangitis, history of chronic inflammatory bowl disease and intra hepatic bile duct dilation. Conclusion: In conclusion we present an unusual case of left lateral Caroli’s syndrom. Nevertheless recurrence of cholangitis and intrahepatic choledocholithiais as well as the significant elevated risk for a CCC contribute to the curative decision of left sided hemihepatectomy.

Hepatic Artery Reconstruction Using 3-in-1 Segmental Resection in Pediatric Living Donor Liver Transplantation: A Case Report and Literature Review

We report a transplant of the left lateral liver segments with 3 arteries for a pediatric recipient from a living donor. A 6-month-old female infant was diagnosed with liver cirrhosis secondary to biliary atresia and scheduled for living donor liver transplantation (LDLT; mother as donor). Left lateral hepatectomy was performed at the donor site. The dissection of the left hepatic artery (HA), which was divided immediately after its origin, showed 3 branches for segments II, III, and IV. The arteries for segment II, segment III, and segment IV were anastomosed to the recipient HA. No postoperative complications were observed. The outcome of this case demonstrates that left lateral segments with 3 arteries can be successfully used if proper surgical techniques are applied. From this experience we can recommend “3-in-1 segmental resection” in the donor can be safely done by skilled microvascular surgeons and this technique should be considered for selected cases where multiple tiny arteries supply the graft.

Laparoscopic Management of Hepatocellular Carcinoma: A Critical Reappraisal.

Following the introduction of the first laparoscopic liver resection, after ∼25 years, a critical reappraisal seems to be warranted. Liver resection represents the first choice for curing early hepatocellular carcinoma (HCC) allowing a curative chance also in selected patients with intermediate stage tumors. The criteria for liver resectability by laparoscopy remains the same for open surgery, which is oncological criteria (absence of extrahepatic tumor location; completely resectable R0 resection), anatomic (resectability of involved segment with its own blood surely and biliary drainage; absence of vascular invasion of portal or hepatic veins) and technical (possibility to leave in place a residual volume ≥40%). Anatomic resections being more challenging than wedged resections, were initially performed mainly for lesions located in the left liver (segments 2, 3, and 4) and segments 5 and 6 of the right liver (anterior and lateral hepatic segments). Left lateral segmentectomy seemed most suited for laparoscopic resection because of the thinness of the liver, the possibility of resection without hilar dissection, ease of stapling the left hepatic vein and portal pedicles of segment II and III by mechanical stapling. Conversely, right hepatectomy seemed most difficult and technically challenging to perform. The analysis of literature confirms that minor liver resections for HCC can be safely conducted also in cirrhotic patients and that laparoscopy, when feasible, should be the approach of first choice. As mentioned, there have been several studies that compared the long-term outcomes of laparoscopic hepatectomy (LH) versus open hepatectomy for HCC, even in cirrhotic patients, showing that laparoscopy does not seem to have any impact on the risk of postoperative HCC recurrence. However, further studies seem to be required, especially for long-term oncological results and for major hepatectomy, before LH become a common alternative to open liver surgery. The practice of performing LH (major) is challenging, due to the significant complexity of these interventions.

Laparoscopic left liver resections: how far can we go?

The aim of this study was to analyse the outcomes of laparoscopic anatomic hepatectomies of the left liver segments. This is a retrospective multicentre study including all patients operated on laparoscopically divided into unisegmentectomy of 2, 3 or 4 (Group 1), left lobectomy (or left lateral sectionectomy LLS) (Group 2), left hepatectomy (Group 3) and extended left hepatectomy (Group 4) between 2000 and 2016. These four groups were compared in terms of demographics, intraoperative data and postoperative outcomes. Among the 190 selected patients, the groups 1, 2, 3, 4 included 25 (13.2%), 116 (61.0%), 27 (14.2%) and 22 (11.6%) patients, respectively. The cohorts were comparable except for the number of lesions (p=0.001) and tumour diameter (p=0.004). The operative time, blood loss and the use of vascular clamping were more frequent in the Groups 3 and 4 (p=0.0001), as is the rate of conversion to laparotomy (p=0.001). Total morbidity was 23.3%, and major complications were more frequent in Group 4 (p=0.0001). The prevalence of hepatic complications (11.6%), intra-abdominal collections (7.4%) and respiratory complications (3.7%) was proportionally correlated to the hepatectomy extension (p=0.0001). All laparoscopic left liver resections seem safe and feasible even though extended hepatectomy is associated with a significant morbidity.

A New Instrument for Intrahepatic Access of Glissonian Pedicles During Anatomical Liver Resections

The knowledge of liver anatomy has led to a rapid evolution based on the intrahepatic distribution of the portal pedicle. One great advance in liver surgery was the used of segment-based liver resections. Techniques based with intrahepatic Glissonian access of portal pedicles were described to safely perform anatomical liver resections. We have earlier described a standardized intrahepatic access to right and left liver segments' pedicles without hilar dissection for anatomical hepatectomies. To improve the intrahepatic Glissonian technique, we designed a new atraumatic instrument for liver pedicle retrieval based on the anatomical liver landmarks. This new instrument was successfully employed in seventeen consecutive liver resections with minimum blood loss and without any complications related to its use. This new instrument, atraumatic retriever, replaces the right angle dissector or Gray clamp. The new instrument can slide easily and smoothly around Glissonian pedicle with a simple movement. This new instrument is a useful adjunct for performing intrahepatic access for liver resections. It can also be used to compass delicate anatomical structures such as esophagus and major abdominal vessels. The retriever can further be used in other common situations, including access for Pringle maneuver, encircling proximal esophagus during total gastrectomies or esophagectomies, and access for total vascular exclusion of the liver. This instrument can also be adapted to be used for laparoscopic liver resections.

Anatomical study of the intrahepatic biliary ducts. Parameters that guide the surgical approach in transplanting the left lobe of the liver.

The techniques of split liver transplantation and transplanting organs from living donors require a thorough anatomical knowledge of biliary drainage, and this is an important factor in preventing complications. forty-five human livers were used to perform this study. Measurements were made between the confluence of the right hepatic duct (RHD) and the left hepatic duct (LHD) and among the following structures: the venous ligament, the vertex of the confluence of the duct of segment II (DSll) and the duct of segment III (DSIII), the insertion of the duct of the segment I (DSI) and the duct of segment IV (DSIV). Then the distance between the vertex of the confluence of DSII and DSIII and the ligamentum venosum was checked. The LHD had less anatomical variation than the RHD. Four drainage patterns were established for the left lobe, and pattern l, in which the confluence of DSll and DSIII is to the left of the ligamentum venosum, is considered to be the most constant one. A single duct of the confluence of DSll and DSIII was found 1, 2 and 2.5 cm to the right of the ligamentum venosum in 65%, 80%, and 95% of the cases, respectively. It was possible to show evidence of four drainage patterns of the left anatomical lobe of the liver. Furthermore, it was possible to establish the ligamentum venosum as an anatomical reference for locating the confluences of the ducts of the left liver segments.

Right diaphragmatic hernia after liver transplant in pediatrics: A case report and review of the literature

Diaphragmatic hernias (DH) are an unusual complication after pediatric liver transplantation; however, they have been reported with increased frequency in the past few years. DHs are responsible for nearly half of the small bowel obstructions requiring surgical intervention in this patient population. It has been suggested that the use of a left lobe liver graft, surgical trauma, malnourishment, elevated intra-abdominal pressures, and mTor inhibitors may predispose to development of DH. The use of a segmental graft may increase the recognition of diaphragmatic hernia because the surgically damaged right hemi-diaphragm often remains exposed to underlying viscera, instead of being covered by the right hepatic lobe. Treatment is surgical reduction, with up to 20% of the patients requiring resection of the herniated intestine. Herein we describe a case of DH after left segmental liver transplant in a two- yr-old boy that presented one month post left lobe split liver transplant with abdominal pain, anorexia, and respiratory distress. Just like in the majority of the reported cases, an urgent laparotomy with primary repair was performed. No resection of the herniated segment of intestine was required. For pediatric patients with otherwise unexplained respiratory or gastrointestinal symptoms after a left lateral segment liver transplant, right-sided diaphragmatic hernias should always be high in the differential diagnosis.

Importance of conserving middle hepatic vein distal branches for homogeneous regeneration of the left liver after right hepatectomy

BackgroundLiver regeneration enables repeat surgical procedures to achieve a potential cure in liver cancer patients. However, data regarding segmental regeneration and liver anatomy after liver resection are scarce. This study examined left liver regeneration after right hepatectomy and the impact of hepatic venous drainage on the regeneration of the paramedian sector (Couinaud's segment IV). MethodsTwenty patients in whom right hepatectomy with conservation of the middle hepatic vein (MHV) on healthy liver had been performed were analysed for segmental volumes and vascular anatomy. Volumetric analysis of left liver segments and three-dimensional MHV reconstruction were conducted using pre- and postoperative computed tomography. The volumetric proportions represented by each segment within the left liver were compared and MHV anatomy was analysed to determine its potential role in the regeneration of left liver segments. ResultsAfter right hepatectomy, the proportion represented by segment IV within the left liver decreases by 13%, whereas the proportion represented by segments II and III increases by 15%. This heterogeneous regeneration is particularly observed in patients in whom a venous branch for segment IVb is sacrificed, leading to an altered outflow similar to that observed in MHV deprivation. The risk for venous branch deprivation in IVb is correlated to the depth of the bifurcation of the MHV in liver parenchyma. ConclusionsIt is crucial to conserve the MHV in its distal part if homogeneous left liver regeneration after right hepatectomy that will allow potential repeat liver resection is to be achieved.

Accessory hepatic lobe

The aim of the present communication was to describe an accessory hepatic lobe in two patients and to outline the significance of the timely identification of this very rare anatomic variation for the clinical practice. In the course of right hemihepatectomy, accessory liver lobes were detected in two patients. Their diagnosis was confirmed by histopathology and cholangiography. Both accessory hepatic lobes arose from the left liver segments. The first lobe was detected in a 56-year-old male operated on for a retroperitoneal liposarcoma. It amounted to 15% of the standard liver volume and was attached to liver segments 2 and 3 by a stalk. The second accessory lobe was found out in 45-year-old female operated on for a colon cancer and synchronous liver metastases. It was less than 15 g in weight and attached to the main liver by a mesentery as its bile duct drained into an extrahepatic duct. The accessory hepatic lobes require timely diagnosis. They should be kept in mind in cases with acute surgical abdomen.

Hepatitis B virus‐induced liver fibrosis and cirrhosis: The value of liver and spleen volumetry with multi‐detector spiral computed tomography

To study the correlation of liver and spleen volume with the degree of liver fibrosis and cirrhosis induced by hepatitis B virus infection. 128 participants who had undergone liver and spleen volumetry were enrolled. The control group consisted of 41 participants who were potential living liver donors. The liver fibrosis group consisted of 63 histologically proved liver fibrosis patients who were further divided into two subgroups: 44 patients with slight liver fibrosis, and 19 patients with advanced liver fibrosis. The liver cirrhosis group consisted of 24 patients. The following parameters were determined by multi-detector spiral computed tomography (MSCT) examination: total liver volume (TLV), right liver lobe volume (RV), left lateral liver segment volume (LLV), left medial liver segment volume (LMV), caudate lobe volume (CV), and spleen volume (SV). The ratios of CV to TLV (C/T), RV to TLV (R/T), LLV to TLV (LL/T), LMV to TLV (LM/T), and SV to TLV (S/T) were calculated. TLV, RV, LMV tended to decrease and SV, C/T, S/T tended to increase gradually with the increased degree of fibrosis. C/T >or= 3.34% and S/T >or= 47.36% were identified as the cut-off values of fibrosis >or=F3 (advanced liver fibrosis) and cirrhosis, respectively. Their sensitivities were 68.4% and 87.5% and their specificities were 59.1% and 89.5%, respectively. Variations in liver and spleen volume correlated with the degree of liver fibrosis and cirrhosis and could be used in the non-invasive follow-up of the development of liver fibrosis.

Living Related Liver Transplantation in Crigler-Najjar Syndrome Type 1

Four children underwent living related liver transplantation because of Crigler-Najjar syndrome type 1. Three were infants aged 2, 8(1/2), and 15 months, and weighed 5, 8, and 10 kg, respectively. Pretransplantation unconjugated bilirubin concentration was 22 to 30 mg/dL despite 12 to 14 hours of phototherapy daily. Patient 1, the 2-month-old infant, with unconjugated bilirubin concentration of 30 mg/dL, had a high-pitched cry, suggestive of bilirubin encephalopathy; results of neurologic examination were normal. Plasmapheresis and urgent liver transplantation were performed. Patient 4, a 13-year-old girl, had learning difficulties at school and attended a special class. Three patients received left lateral liver segments, and 1 patient received a left lobe. Biliary reconstruction was completed with duct-to-duct anastomosis. Bile leakage developed at the anastomosis in 2 patients, which was treated successfully with cholangioplasty. In all patients, the unconjugated bilirubin concentration normalized by day 1 posttransplantation, and no phototherapy was necessary. After transplantation, the 2-month-old infant with suspected encephalopathy exhibited hypotonia, spasticity of the lower extremities, and lack of head control. He died after vomitus aspiration during sleep at 10 months posttransplantation. The other 3 patients are alive with normal neurodevelopmental milestones. Irreversible brain damage may occur early in the course of Crigler-Najjar syndrome type 1. Urgent treatment including plasmapheresis, exchange transfusion, phototherapy, and liver transplantation may not reverse brain damage. Young infants must be evaluated carefully for subtle signs and symptoms of bilirubin encephalopathy. Liver transplantation is curative if performed before development of neurologic dysfunction.

Laparoscopic resection of left liver segments using the intrahepatic Glissonian approach

Recent advances in laparoscopic techniques have resulted in growing indications for laparoscopic hepatectomy. However, this procedure has not been widely developed, and anatomic segmental liver resection is not currently performed due to difficulty controlling the segmental Glissonian pedicles laparoscopically. This study aimed to report a novel technique for laparoscopic anatomic resection of left liver segments using the intrahepatic Glissonian approach based on small incisions according to anatomic landmarks such as Arantius' and round ligaments. Nine consecutive patients underwent laparoscopic liver resection using the intrahepatic Glissonian technique from April 2007 to June 2008. Five patients underwent laparoscopic bisegmentectomy 2-3, one laparoscopic left hemihepatectomy, two resections of segment 3, and one resection of segment 4. One patient required a blood transfusion. The mean operation time was 180 min (range, 120-300 min), and the median hospital stay was 3 days (range, 1-5 days). No patient had postoperative signs of liver failure or bile leakage. No postoperative mortality was observed. The main advantage of the intrahepatic Glissonian procedure over other techniques is the possibility of gaining a rapid and precise access to the left Glissonian sheaths facilitating left hemihepatectomy, bisegmentectomy 2-3, and individual resections of segments 2, 3, and 4. The authors believe that the intrahepatic Glissonian technique facilitates laparoscopic liver resection and may increase the development of segment-based laparoscopic liver resection.

Intrahepatic Glissonian approach for anatomical resection of left liver segments

Intrahepatic Glissonian approach for anatomical resection of left liver segments

Hepatic artery reconstruction with inferior mesenteric vein graft in pediatric living donor liver transplantation

We report a transplant of the left lateral liver segments with two arteries for a pediatric recipient from a live donor. A six-month-old female patient was diagnosed with liver cirrhosis secondary to biliary atresia and scheduled for LDLT (father as donor). Left lateral hepatectomy was performed at the donor site. The dissection of the left HA, which divided immediately after its origin, showed two branches for segments II and III. The artery for segment III was anastomosed to the recipient HA. The artery for segment II was too short for direct anastomosis with the gastroduodenal artery. After an unsuccessful attempt to use of the recipient's saphenous vein, the recipient's IMV was used as an interposition graft. No post-operative complications were observed. The outcome of this case demonstrates that left lateral segments with two arteries can be successfully used if proper surgical techniques are applied. From this experience we can recommend the IMV as an alternative to the saphenous vein for an interposition graft.

Anatomic Resection of Left Liver Segments—Reply

Anatomic Resection of Left Liver Segments—Reply

Anatomic Resection of Left Liver Segments

Anatomic Resection of Left Liver Segments