Middle Hepatic Vein Research Articles

Right hepatic trisectionectomy combined total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma: A surgical case report (with video).

BackgroundExtended resection such as right trisegmentectomy combined with total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma (CCA) is still challenging for all Hepato-pancreato-biliary surgeons.PresentationA 45-year-old female with advanced hilar CCA involved the right intrahepatic bile ducts in continuity with the left medial sectional bile duct without PV invasion had undergone right trisegmentectomy combined with total caudate lobectomy with non-touch technique. Dissection of the hepatic peduncle by Lorta-Jacob Procedure, ligation, and resection of the right hepatic artery (RHA) and the right portal vein (PV), before that determine whether portal bifurcation's tumor infiltration or not. Mobilization of the right liver lobe, ligate all the short hepatic veins from the caudal to cranial direction, as well as the right hepatic vein (RHV) and the middle hepatic vein (MHV). Complete caudate lobectomy with right–left approach. Determine hepatic parenchyma cut, left cholangiostomy to the division of the subsegments 2,3, stitch formation of the subsegments 2,3 bile duct. Determine negative upper section of the biliary tract. The operative time was 432 min, and the blood loss was 750 ml. Postoperative recovery was uneventful without any major complications but developed intra-abdominal abscess that required percutaneous drainage.DiscussionExtended resection procedures such as extend right/left trisectionectomy, hepato-pancreaticoduodenectomy (HPD) and/or combined vascular resection are only curative treatment for advanced hilar CCA. There hadn't been any reported cases describing step-by-step right trisegmentectomy combined with total caudate lobectomy with non-touch technique with clear illustrations and videos yet.ConclusionCareful preparation with preoperative biliary drainage as well as precise evaluation of the functional capacity of the future liver remnant, as well as meticulous experience of surgeons in hepatic anatomy and non-touch resection technique are key points for success in extended resection for advanced hilar CCA.

Konjenital portosistemik şantların BT anjiyografi ve doppler ultrason ile değerlendirilmesi

Aim: The aim of the study was to describe the Doppler ultrasonography and computed tomography findings that should be considered in the diagnosis and treatment of congenital portosystemic shunts.Methods: Archive retrospectively scanned. In consideration of shunts: communication type and aneurysm were defined. Additional imaging modalities were utilized.Results: 11 patients were included in the study. The ages ranged from 0 to 158 months. There were two patients with shunt connecting segment-4 portal vein - middle hepatic vein, two patients with segment-3 portal vein - left hepatic vein, two patients with left portal vein – middle hepatic vein, two patients with portal vein - left renal vein, two patients with portal vein -inferior vena cava, and one patient with portal vein - perirectal venous plexus.Conclusion: Some classifications used in congenital portosystemic shunts are insufficient in guiding treatment. Elaborate definition of the imaging findings including the involved vessels, type of communication, and presence of aneurysm or dilated vessels is of the prime importance for tailoring clinical management of the patients.

Do Respiratory Maneuvers Affect The Hepatic Vein Waveforms And Maximum Velocity?

Aim: To assess the effect of respiratory maneuvers on hepatic vein waveforms and flow velocity in patients without liver or cardiac disease. Methods: This prospective cross-sectional study was conducted in the Radiology Department of Pakistan Kidney and Liver Institute and Research Center, Lahore (PKLI & RC) after approval from Institutional Review Board (IRB). The sample size of 70 patients was selected using the WHO sample size calculator, after applying the inclusion and exclusion criteria. Doppler waveforms and maximum velocities (Vmax) of the middle hepatic vein were recorded during normal respiration, after quiet expiration, and following breath-hold after deep inspiration. The waveforms were classified as triphasic, biphasic, or monophasic. Results: The maximum velocities (Vmax) during normal respiration, after quiet expiration, and following deep inspiration were 26.67±9.41, 24.08±6.77 and 19.31±.61 respectively. During normal breathing, the middle hepatic vein waveforms were triphasic, biphasic and monophasic in 80%, 6%, and 14% of the patients respectively. After quiet expiration, these percentages were 82%, 4% & 14% respectively and following breath-hold after deep inspiration, these percentages were 41%, 14% and 45%, respectively (p<0.05). Conclusion: The hepatic venous velocities were lower after deep inspiration. Their waveforms showed significant change from triphasic pattern to monophasic pattern following deep inspiration. Therefore, the respiratory variations must be considered during hepatic vein Doppler ultrasound assessment. Keywords MeSH: Hepatic veins, velocities, waveforms, inspiration, expiration.

THE ANATOMICAL GROUNDING OF ISOLATED LOBAR PORTOCAVAL PERFUSION OF THE LIVER

With the development of perfusion technologies in oncology, the problem of finding the optimal ways to perfusates injections has become fundamental, and in this regard, the study of the features of liver angioarchitectonics in normal and pathological conditions does not lose its relevance. The aim of our study was to study the features of the portal architectonics of the liver in relation to the possibility of its isolated lobar perfusion. Using the methods of color perfusion (n=50), separate injections of a hardening mass and the preparation of corrosive preparations (n=3), microfocus angiography (n=8), transparenchymal sections and light microscopy (n=5), 53 liver preparations explanted from non-embalmed corpses of people who died from diseases not directly related to the liver pathology. As a result of the study, it was found that the border of the zones of blood supply by the lobar branches of the portal vein after the introduction of dyes passes along the lateral border of the fourth segment of the liver in the projection of the main trunk of the middle hepatic vein, and not along the falciform ligament. According to the distribution criterion of the portal vein branches, the anatomical and surgical concepts of the interlobar boundaries of the liver do not coincide. Macro- and microscopically visible interlobar intraorgan portal anastomoses are normally absent, which indicates the relative isolation of the lobar portal blood flow of the liver. The intrahepatic bed of the proper hepatic artery has a rich architectonics in the surface layers of the parenchyma and abundantly supplies the liver capsule with blood. When performing transparenchymal sections, the boundaries of the blood supply zones of the lobar branches of the portal vein coincided with the interlobar boundaries in all cases of observation. It was also noted that the topography of the border of the blood supply zones with the lobar branches of the portal vein to match the diaphragmatic surface of the liver and in its parenchyma. Thus, it seems possible to reliably determine the indicated boundary by the pattern on the surface of the liver preparation. The relative autonomy of the channels of the lobar portal vein branches can be used to develop techniques for vascular isolation of the lobar portal blood flow in the liver to assess its selective isolated perfusion.

Outflow reconstruction of left lateral graft with two widely spaced hepatic veins in pediatric living donor liver transplantation

BackgroundLiving donor liver transplantation using the left lateral segment of the liver is the most common type of pediatric liver transplantation. An appropriate surgical approach is crucial for decreasing the risk of vascular complications using these grafts with anatomical variations. MethodsBetween January 2017 and December 2020, 631 living donor liver transplantations using left lateral segment grafts were performed at Tianjin First Central Hospital. The grafts from 162 (25.7%) donors have 2 hepatic vein openings. A total number of 21 transplantations using left lateral segment grafts with 2 widely spaced hepatic vein openings were performed. In group 1, the unification venoplasty technique with interposition vein graft was used at the back table for the reconstruction of hepatic vein from grafts. In group 2, dual hepatic vein reconstructions were performed, in which venoplasty of recipients’ left hepatic vein, middle hepatic vein, and inferior vena cava was performed to create a large orifice for anastomosis with segment Ⅱ hepatic vein from the graft. Segment III hepatic vein from the graft was anastomosed with the recipient’s right hepatic vein. The incidence, treatment, and outcomes of hepatic venous outflow obstruction were compared between the 2 groups. ResultsThe median follow-up time was 12.8 months. There was no significant difference in the incidence of hepatic venous outflow obstruction between the 2 groups. ConclusionDual hepatic vein reconstruction is an alternate surgical option for grafts with 2 widely spaced hepatic veins, and it is associated with ideal graft recovery and vascular condition. However, long-term follow-up is still needed to verify the efficacy and safety of this approach.

Peritoneum for Middle Hepatic Vein Conduit During Living Donor Liver Transplantation.

I have read with interest the article “Parietal Peritoneum as a Novel Substitute for Middle Hepatic Vein Reconstruction During Living Donor Liver Transplantation” published in your journal by Hong et al.1 The use of the parietal peritoneal graft as a venous conduit is not new and has been used as a substitute for several veins for this purpose. It has been shown to be beneficial in a rapid and effective way to repair the venous defects in the portomesenteric veins, hepatic vein, and vena cava.2-4 In the study of Hong et al, the parietal peritoneum was used for the middle hepatic vein during right lobe living donor liver transplantation. The authors wrote that the parietal peritoneum has never been used for this purpose before: “However, to the best of our knowledge, clinical use of the parietal peritoneum as a substitute for middle hepatic vein reconstruction, an essential procedure during LDLT using the right liver graft, has never been described.” During a living donor right lobe liver transplant, I have used the parietal peritoneum to correct the flow problem in the middle hepatic vein before. The result was successful, and I reported it in 2015.5 I just respectfully wanted to remind them of my experience on this occasion. I congratulate and support the authors’ success using the parietal peritoneum for middle hepatic vein conduits.

Dorsal vs ventral approach to the middle hepatic vein during laparoscopic left hemihepatectomy: multicenter retrospective observational study.

Left hemihepatectomy requires exposure of the middle hepatic vein (MHV) at the cutting-surface. Two procedures are used to approach the MHV: a conventional ventral approach and a laparoscopy-specific dorsal approach. This multicenter retrospective observational study aimed to evaluate the perioperative outcomes of these two procedures. Clinical records of 38 consecutive patients that underwent laparoscopic left hemihepatectomy in four university hospitals between 2016 and 2021 were retrospectively reviewed. Outcome measurements were operative blood loss, operating time, trend of postoperative laboratory data within 7days after hepatectomy, and postoperative complications. Quality of MHV exposure was also evaluated and compared by three-grade evaluation (excellent/good/poor) using recorded still images of the cut-surface of the remnant liver (n = 35). Dorsal and ventral approaches were performed in 9 and 29 patients, respectively. Median operating time was 316min (dorsal) and 314min (ventral) (P = 0.71). Median operative blood loss was 45ml (dorsal) and 105ml (ventral) (P = 0.10). Two patients in the ventral approach group had bleeding in excess of 500ml, which was not seen in the dorsal approach group. Excellent/good/poor MHV appearance on the cutting-surface was observed in 5/3/1 patients in the dorsal approach group, respectively, and in 7/8/11 patients in the ventral approach group, respectively (P = 0.03). In the ventral approach group, significant increases of aspartate aminotransferase (on postoperative day 1 and day 4/5) and of alanine aminotransferase (on postoperative day 2/3 and 4/5) were observed (P < 0.05). Postoperative complications were observed only in the ventral approach group (n = 3). The dorsal approach could achieve safe and precise anatomical left hemihepatectomy with operation time and operative blood loss comparable to the conventional ventral approach.

Importance of reconstruction of middle hepatic vein tributaries of right-lobe grafts in living donor liver transplantation: demonstration of the reconstruction technique.

The aim of the present study on living donor liver transplantation (LDLT) using a right-lobe graft without the middle hepatic vein (MHV) was to investigate the clinical impact of MHV tributary reconstruction using our criteria and techniques. The medical records of 40 patients who underwent adult LDLT using a right-lobe graft without the MHV between April 2008 and December 2020 were retrospectively reviewed. In this cohort, the criterion for MHV tributary reconstruction was estimated drainage volume of each MHV tributary greater than 100mL. The drainage vein of segment 8(V8) was reconstructed as the common orifice of the right hepatic vein and V8 using a venous patch graft, and that of segment 5 was reconstructed using artificial vascular grafts. The outcomes were compared between the groups with and without MHV tributary reconstruction. Factors associated with postoperative massive ascites were also investigated. Twenty patients underwent MHV tributary reconstruction. There were no significant differences in the amount of postoperative ascites, Clavien-Dindo classification ≥ III postoperative complications, and 90-day in-hospital mortality between the groups (P = 0.678, P = 1.000, and P = 0.244, respectively). On multivariate analyses, a low-estimated functional graft-to-recipient weight ratio, which was calculated using estimated graft volume minus the territory of MHV tributaries that was not reconstructed, was identified as an independent predictor of postoperative massive ascites (odds ratio, 40.479; 95% confidence interval, 3.823-428.622). The present study suggests that selective MHV tributary reconstruction might be useful for achieving successful graft function.

Laparoscopic Segmentectomy IV Using Hepatic Round Ligament Approach Combined with Fluorescent Negative Staining Method

Laparoscopic segmentectomy, which maximizes the preservation of the functional hepatic reserve and the possibility for future repeat hepatectomy while ensuring adequate surgical margin, is a feasible alternative to hemihepatectomy for hepatocellular carcinoma (HCC) (Vigano et al. in Ann Surg 270(5):842-851, 2019, Ishizawa et al. in Ann Surg 256(6):959-964, 2012). Herein, we present a video of laparoscopic segmentectomy IV for HCC using hepatic round ligament approach combined with fluorescent negative staining method. A 44-year-old male with history of chronic hepatitis B virus (HBV) infection for 22 months was referred for treatment of a single HCC in segment IV. The procedure was performed according to the following steps: (1) lowering the hilar plate based on Laennec's capsule (Sugioka et al. in J Hepatobiliary Pancreat Sci 24(1):17-23, 2017) after cholecystectomy; (2) cutting the Glisson's pedicles to segment IV along the fissure for the round ligament; (3) the first parenchyma transection was along the falciform ligament, while cutting some deep pedicles to segment IV; (4) clamping the left Glisson's pedicle and using fluorescent negative staining method (Abo et al. in Eur J Surg Oncol 41(2):257-264, 2015, Funamizu et al. in J Hepatobiliary Pancreat Sci, 2021, Xu et al. in Surg Endosc 34(10):4683-4691, 2020); (5) the second parenchyma transection was performed along the boundary of negative fluorescence region to expose the middle hepatic vein (MHV) using a combination of cranial and caudal approaches. The operative time was 190 min, and blood loss during operation was 80 mL. The histopathologic examination showed a solitary HCC, 2.5 cm in diameter, with negative surgical margin and no microvascular invasion. The patient had an uneventful postoperative recovery and was discharged on postoperative day 5. The round ligament approach combined with fluorescent negative staining method for laparoscopic anatomic segmentectomy IV is a feasible and effective technique.

Pure laparoscopic versus open right donor hepatectomy including the middle hepatic vein: a comparison of outcomes and safety.

PurposeAnalyses on pure laparoscopy in donor hepatectomies, including the middle hepatic vein (MHV), are still scarce. This study aimed to compare the outcomes of donor right hepatectomy, including the MHV, when performed laparoscopically with conventional open surgery.MethodsData from living donors who underwent donor right hepatectomy between January 2012 and December 2020 were retrospectively analyzed. The intraoperative and postoperative complication rates of the pure laparoscopic donor right hepatectomy (PLDRH) with MHV inclusion (PLDRHM) group were compared with the conventional open donor right hepatectomy with MHV inclusion (CDRHM) group and the PLDRH without MHV inclusion [PLDRHM(–)] group.ResultsCompared to the CDRHM group, the PLDRHM group had a longer bench time (P < 0.001) and higher Δ%, calculated as [(preoperative value – postoperative value)/preoperative value] × 100, of AST (P < 0.001), ALT (P < 0.001), and total bilirubin (P = 0.023), but shorter hospital stay (P = 0.004) and a lower rate of complications (P = 0.005). Compared to the PLDRHM(–) group, the PLDRHM group had fewer male donors (P < 0.001) and a lower body mass index (P < 0.001), estimated total liver volume (P < 0.001), and real graft weight (P < 0.001). Results of laboratory changes, hospital stays, and complication rates were similar between the 2 groups.ConclusionPLDRH with the inclusion of the MHV in selected donors and recipients is feasible and safe when performed by surgeons experienced in laparoscopic surgery, with favorable complication rates compared to CDRHM and PLDRHM(–).

Classification of Left Hepatic Vein Anatomy and Customised Outflow Reconstruction Techniques for Left Lateral Segment Grafts in Paediatric Liver Transplantation

Introduction: Anatomical variations of left hepatic vein (LHV) are commonly encountered in paediatric liver transplantation. Meticulous reconstruction is required to prevent hepatic venous outflow obstruction (HVOO). We share our experience of classifying LHV anatomy and customising outflow reconstruction in left lateral segment (LLS) grafts with complex anatomy. Methods: We retrospectively studied 296 paediatric LLS transplants done over a 10 year period. Donor Computed Tomographic images of segment 2 (V2) and 3 (V3) venous drainage, reconstruction techniques used in grafts obtained and surgical outcomes were thoroughly analysed. Results: Three unique variations of LHV were described as in table below and ROC curve analysis (AUC 0.98, p 0.0001) was done to subdivide type 1 LHV. The venous outflow in the LLS graft was classified as graft A with single orifice and graft B with 2 orifices. LHV types 1b, 2 and 3 gave rise to graft B necessitating customised reconstruction techniques as described in table below. We formulated a bespoke algorithm for selecting appropriate reconstruction techniques depending upon donor LHV anatomy (picture). On follow up for a minimum of 1 year, none of the patients developed early or late HVOO. The incidence of early graft dysfunction (p 0.64), acute cellular rejection (p 0.93), intractable ascites (p 0.97), major complications with Clavien-Dindo score ≥3b (p 0.35) and overall survival (p 0.62) were similar between graft A and graft B. Conclusion: Identifying anatomical variations of LHV and tailoring outflow reconstruction, helps to increase the donor pool without compromising surgical outcomes.Tabled 1Type Of LHVn (%)Reconstruction doneType 1a: V2 and V3 join to form a common trunk of length >9mm which joins middle hepatic vein (MHV)Type 1b: V2 and V3 join to form a common trunk of length <9mm which joins middle hepatic vein (MHV)254 (85.8%)16 (5.4%)NoneSimple / extension venoplasty (10), Conjoint Unification venoplasty (6)Type 2: V2 and V3 open separately into IVC6 (2%)Simple / extension venoplasty (2), Conjoint Unification venoplasty (4)Type 3: V2 joins IVC, V3 joins MHV20 (6.8%)Simple / extension venoplasty (2), Conjoint Unification venoplasty (12), Extension unification venoplasty (3), Extension with separate caval anastomosis (3) Open table in a new tab

Learning Curve of Graft Bench Operation in Living Donor Liver Transplantation: A Cumulative Sum Analysis

Introduction: The middle hepatic vein (MHV) reconstruction is a critical issue for successful living donor liver transplantation. we analyzed the learning curve of MHV recontruction and described the factors affecting the learning curve, and the postoperative outcomes. Methods: Data from donors undergoing bench surgery between January 2019 to May 2020 retrospectively reviewed. To overcome operator-dependent bias, data from procedures performed by only a single surgeon (Jeong-Moo Lee) were included. The learning curve was evaluated using the cumulative sum (CUSUM) method based on operative time. Result: A total of 111 bench surgery were evaluated. The mean operative time was 64.0±15.8 minutes, and the reconstructed MHV graft patency rate was 88.3% in recipient CT taken 7 days after liver transplantation. Portal vein stenosis occurred in 3 cases (2.7%). Hepatic artery complications were 4 (3.6%) and biliary complications were 18.1%, and no graft failure occurred during the study period. Univariable analysis showed that portal vein variation, presence of more than 2 factors of contributing difficulty were associated with a significantly higher risk of prolonged operative time.These factors are also significantly associated with prolonged operative time in multivariable analysis. Conclusions: At least 10 cases of learning curve are required for successful bench surgery in routine case of LDLT. Multiple portal vein orfice is related with longer operative time and learning curve for the bench operation.

Laparoscopic S4/S8 Hepatectomy with MHV Exposure in Central-to-Peripheral Direction

Introduction: It is difficult to expose middle hepatic vein (MHV) because of the risk for massive bleeding. To overcome this problem, we challenged new operative procedure to expose MHV in central-to-peripheral direction. Our surgical procedure and outcomes showed in this study.

The Clinical Implication of Hepatic Venous Territory Mapping in Living Donor Liver Transplantation Using Right Liver Graft

Background: We designed this study to evaluate the clinical implication of hepatic venous territory mapping in living donor liver transplantation. Method: Living donor liver transplantation cases performed using right liver graft since 2017 were included. Hepatic venous mapping using Volume viewer application in the AW server 3.2 was started since January 2019. Comparison between transplantation cases with venous mapping and cases without mapping were performed. Among patients with hepatic venous mapping, cut-off point for graft occlusion were analyzed. Results: Among 754 patients included to the study, 213 patients underwent hepatic venous mapping. Inferior hepatic vein reconstruction rate and patency rate were similar between the no mapping group and mapping group (25.2% vs. 28.8%, P=0.402 and 92.5% vs. 96.8%, P=0.412), respectively. While middle hepatic vein reconstruction rate was higher in the mapping group (67.3%) compared to the no mapping group. (55.8%, P=0.013) However, patency rate was higher in the no mapping group (63.5%) compared to the mapping group (51.1%, P=0.041). In patients with V5 reconstruction, median volume (177cm3, IQR 152-259 vs. 147cm3, IQR 113-199, P=0.006) and median percentage of V5 territory (22.3%, IQR 17.1-29.7 vs. 18.4%, IQR 14.9-21.8, P=0.001) were higher in the patent graft compared to occluded graft. A cut-off point of 150cm3 (sensitivity=0.824, specificity=0.533, AUC=0.680, P=0.006) and 20.0% (sensitivity=0.647, specificity=0.711, AUC=0.716, P=0.001) were chosen based on Youden’s index in area-under receiver operating characteristic analysis. Conclusions: Hepatic venous mapping provided objective measure for performing venous outflow reconstruction in living donor liver transplantation using right liver graft with increased reconstruction rate of the middle hepatic vein territory.

Advantages of Extrahepatic Glissonean Approach in the Donor Operation in Living Donor Liver Transplantation

Introduction: To eliminate biliary complications in living donor hepatectomy, we introduced the extrahepatic glissonean approach combined with liver hanging maneuver (GA+LHM) since 2017. Method: Surgical procedures are as follows: Prior to liver transection, we encircle the extrahepatic Glissonean pedicle at the graft liver side with a tape. Then, we introduce a hanging tape from the encircled Glissonean pedicle to the groove between middle hepatic vein and right hepatic vein. Liver parenchymal transection is facilitated with the LHM. After the completion of transection, hepatic artery and portal vein of the graft liver are isolated in the hilum. The remaining structure is the hilar plate including the hepatic duct(s). After intraoperative cholangiography, bile duct, hepatic artery, portal vein, and hepatic vein are divided in this order and the graft liver is procured. We analyzed the short-term outcomes of the donor using Clavien–Dindo classification: For bile leakage, the International Study Group of Liver Surgery definition was used. Results: GA+LHM was successfully performed in a total of 44 consecutive living donor hepatectomy (right lobe graft in 28, left lobe graft in 15, and left trisegmental lobe +S1 graft in 1). There were no Grade Ⅲa≦ complications and bile leakage until discharge. Biliary stricture occurred in 1 (2%) patient who was readmitted and required endoscopic biliary stent placement. Conclusions: GA+LHM presumably prevents heat and mechanical injury of the bile ducts of the remnant liver by minimization of hilar dissection, thereby contributes to eliminating bile leakage in living donor hepatectomy.

DEVELOPMENT AND FORMATION OF THE TOPOGRAPHY OF THE INFERIOR VENA CAVA AND PULMONARY VEINS DURING THE EIGHTH MONTH OF PRENATAL HUMAN ONTOGENESIS.

The aim: To determine the topographic features and morphometric parameters of the pulmonary veins and inferior vena cava in human fetuses during the eighth month of intrauterine development. Materials and methods: A morphometric and histological research of 25 human fetuses in the eighth month of prenatal ontogenesis (271.0 - 310.0 mm parietal-coccygeal length) was conducted. The topographic features of the inferior vena cava and pulmonary veins during the eighth month of intrauterine development were established, and their length and diameter, as well as the change in the angle of their formation, were morphometrically determined. The formation of the topography of these veins is due to the formation of the chest and abdominal organs and continues throughout the entire fetal period of development. Results: The inferior vena cava is formed at the level of the body of the IV lumbar vertebra in the eighth month of the intrauterine period of human development. The initial part of the trunk of the inferior vena cava obliquely "crosses" the common iliac artery from the left to the right. At this level, the vein is located to the right and slightly behind the aorta. In fetuses of the given age group, the right adrenal gland borders the inferior vena cava only at the level of the lower 2/3 of its medial edge. At the level of the subhepatic section of the inferior vena cava, 4-5 pairs of lumbar veins flow into it. In most cases, the ductus venosus flowed into the inferior vena cava independently between the middle and left hepatic veins. Compared to other sections of the inferior vena cava, the lumen of its diaphragmatic section, which passes through the opening in the dorsal part of the tendinous center of the diaphragm on the right, increases. During this period, it was established that the pulmonary veins lie completely in the heart cavity and are surrounded by a serous membrane. In all fetuses, two pulmonary veins flow from each lung into the left atrium. The level of confluence of the venous ducts of the pulmonary veins and their number varies individually. Pulmonary veins and their ducts lie more superficially and do not repeat the passage of the corresponding bronchi and arteries, lying, as a rule, within the limits of interlobular, intersegmental, and intersubsegmental connective tissue membranes. Conclusions: In this age group, changes in venous vessels and complications in the structure of their walls and their ducts continue. The passage and branching of the bronchial tree and arterial branches (starting with the segmental branches) are almost completely identical. A significant increase in the number of small ducts was found in the system of pulmonary veins. There is an increase in the morphometric indicators of the size of the inferior vena cava in comparison with its other parts. In the wall of the pulmonary veins and inferior vena cava, all three tunics are clearly visible, which in structure are close to the definitive one.

Anastomosis of Portal Vein and Bile Duct Anomaly in Living Donor Liver Transplantation

Introduction: Type 2 portal vein and bile duct anastomosis during living donor liver transplantation. Case: 44 years old man was admitted for generalized weakness. He suffered from CVH-B for 20 years and 2years ago diagnosed LC with HCC. Donor was 27-year-old son. GRWR was 1.48. Preoperative donor CT scan was revealed trifurcation of portal vein and low-lying right posterior hepatic duct. Middle hepatic vein branches were double in S5 and single in S8 level. Donor hepatectomy was performed as modified right hepatectomy (weight = 850gm). During bench operation neo-middle hepatic vein was reconstructed by use of iliac vein allograft. Lumens of graft portal vein were double. So left saphenous vein autograft patch was fenced to the graft portal veins for making single lumen. Graft was transplanted to recipient from right hepatic vein, portal vein, neo-middle hepatic vein and then right hepatic artery. Bile ducts were make common cannel in manner of V-shaped plasty then anastomosed to recipient bile duct. Total operation time was 632 minutes cold ischemic time was 40 minutes for bench operation. Maximal AST/ALT was 230/207IU/ml at POD #1 then normalized at POD #5. Postoperative CT revealed patent portal vein, neo-middle hepatic vein and hepatic artery. Patient was discharged at POD #34. There was no stricture or stenosis in all anastomosis site. Conclusion: In the living donor liver transplantation, there were many anatomical difficulties in anastomosis due to anatomical variation especially in portal vein and bile duct. Portal vein fencing and bile-ductoplasty can be a good choice.

Middle hepatic vein reconstruction with a large shunt vessel for right lobe graft in living donor liver transplantation

Middle hepatic vein reconstruction with a large shunt vessel for right lobe graft in living donor liver transplantation

Modified median hepatic fissure approach for resection of liver tumours located in the angle between the root of the middle and right hepatic veins

BackgroundLiver tumours between the root angle of the middle and right hepatic veins are a special type of liver segment VIII tumour. In this study, we designed a modified median hepatic fissure approach to remove these tumours. The safety and effectiveness of the approach were evaluated.Materials and methods From April 2015 to November 2019, 11 patients with liver tumours between the angle of the middle and right hepatic veins underwent this modified median hepatic fissure approach. We retrospectively analysed data from the perioperative periods of these 11 patients, including general condition, operation time, intraoperative bleeding, and postoperative complications. Disease-free survival and overall survival were assessed.ResultsOf the 11 patients, 9 patients had primary hepatocellular carcinoma and 2 had colorectal liver metastases. The average intraoperative blood loss was 285 mL (150–450 mL). Two patients developed postoperative bile leakage, but there were no significant serious complications, such as intraabdominal bleeding and liver failure, in any of the patients. The liver function returned to the normal range on the 5th day after surgery. Of the 11 patients, 5 have survived for more than 3 years (45.5%), and 4 have been disease-free for more than 3 years (36.3%).ConclusionsFor liver tumours between the root angle of the middle and right hepatic veins, the modified median hepatic fissure approach is a safe and feasible method.

Intrahepatic Glissonean Approach for Laparoscopic Bisegmentectomy 7 and 8 With Root-Side Hepatic Vein Exposure.

Laparoscopic anatomic liver resections of the posterosuperior segments are technically demanding procedures.1-5 The segments are located in a deep-seated area of the liver surrounded by the ribs and the diaphragm, making forceps manipulation difficult. To overcome this limitation, an intrahepatic Glissonean approach and exposure of the hepatic veins from the root side was applied.6-10 The authors describe the technical aspects of performing a bisegmentectomy 7-8. Liver parenchymal transection was initiated from the ventral aspect of the root of the middle hepatic vein, which often runs in the intersegmental plane, identifying the Glissonean pedicle of segment 8 (G8). After dissection of the G8, segmentectomy 8 was performed through identification of the ischemic area. After complete mobilization of the right lobe, the Glissonean pedicle of segment 7 (G7), which runs relatively near the liver surface,9, 10 was marked using ultrasonography. After division of the G7, a wide dissection between the caudate lobe and segment 7 was performed and connected to the previously dissected plane from the dorsal side of the right hepatic vein (RHV). Finally, bisegmentectomy 7-8 was performed with RHV resection because of tumor invasion. The operation time was 510 min, and the estimated blood loss was 150 ml. The patient was discharged on postoperative day 10 without any complications. Application of the intrahepatic Glissonean approach and exposure of the major hepatic veins from their roots using unique laparoscopic principles allows a safe performance of bisegmentectomy 7-8.