Retrohepatic Tunnel Research Articles

The Dorsal Approach to Laparoscopic Major Hepatectomy

Introduction: This new technique, a modification of the caudal approach of Soubrane, involves a posterior to anterior transection of the liver for laparoscopic major hepatectomies. It was conceived to enable a standardised technique, and to broaden the indications for laparoscopic resection particularly for larger tumours and with anatomical variations of the porta. Methods: As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral, enabling safe stapling. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, maintaining good surgical orientation especially for tumours close to the midline or cava. Similar concepts apply for a left hemihepatectomy, with dissection beginning in the in the Arantius groove. Results: 31 major resections (23 right +/- extended, 8 left +/- extended) have utilised this technique. 2 required conversion, and 1 required transfusion. R0 resection was achieved in 29 cases. Median hospital stay was 6 days. With this technique conversion rate has decreased from 29% to 6% (P = 0.032) and selection of a laparoscopic approach for major resections increased from 24% to 60% (P < 0.001). Conclusion: The dorsal approach to laparoscopic major hepatectomy is a novel technical variation that enables a safe, standardised technique and an expanded set of indications for a laparoscopic approach.

Laparoscopic right hepatectomy with an anterior approach for large hepatocellular carcinoma using a right para caval liver hanging maneuver

Introduction: Laparoscopic right hepatectomy (LRH) for large hepatocellular carcinoma (HCC) with an anterior approach is a complicated procedure. We gradually introduce a modified liver hanging maneuver (LHM) through the retrohepatic tunnel on the right side of the inferior vena cava with the assistant of a Goldfinger Dissector. Method: Between January 2012 and June 2018, 39 patients with large HCC underwent LRH were enrolled in this study. The first 27 patients did not apply the LHM technique (the non-LHM group); the following 12 patients implemented the LHM technique (the LHM group). Perioperative and survival outcomes were compared. Result: The preoperative variables were almost comparable between the two groups. The median tumor size was 12.0 (IQR 10.0-13.0) cm in the LHM group and 12.6 (IQR 9.9-15.0) cm in the non-LHM group (P=0.541). Ten patients (83.3%) in the LHM group and 20 (74.1%) in the non-LHM group had tumor size >10 cm (P=0.693). The median duration of retrohepatic dissection is 14.5 (IQR 12-16) minutes. Total blood loss was significantly greater in the non-LHM group than that in the LHM group (460 vs. 200 ml, P<0.001), especially during the procedure of hepatic parenchyma transection (300 vs. 100 ml, P<0.001). As a result, the operative time was longer (415 vs. 312 min, P<0.001), and intraoperative transfusion rate was higher (55.6% vs. 16.7%) in the non-LHM group than that in the LHM group. Two cases (7.4%) converted to an open approach in the non-LHM group, while no patients experience conversion in the LHM group (P=1.000). However, postoperative complications and long-term survival were comparable between the two groups. Conclusion: The LHM can be quickly established in the laparoscopic approach with the assistant a Goldfinger dissector through the retrohepatic tunnel on the right side of the inferior vena cava. Application of the LHM can increase the safety of LRH for large HCC.

Robotic Repeat Right Hepatectomy for Recurrent Colorectal Liver Metastasis

Repeat hepatectomy often is required for primary and metastatic tumors. The purpose of this video was to present a robotic repeat hepatectomy for recurrent colorectal metastasis after multiple previous open surgeries. A 64-year-old man underwent open left colectomy complicated by anastomotic leak. He was reoperated for colostomy, which was reverted. One year later, he underwent open metastasectomy. Recently, he presented a recurrence in the right liver, and a robotic right hepatectomy was indicated. This approach used five trocars. The operation began with adhesiolysis. The next step was to dissect and divide the right hepatic artery and the right portal vein. A retrohepatic tunnel is created on the right side of the inferior vena cava for a modified liver hanging maneuver. The liver was pulled upwards and liver transection resumed towards the right hepatic vein. The liver was divided with bipolar forceps under continuous saline irrigation. The right hepatic duct was found inside the liver and was divided. Finally, the right hepatic vein was divided inside the liver parenchyma using a vascular stapler, and robotic right hepatectomy was completed. The operative time for docking was 10min; adhesiolysis took 90min while robotic right hepatectomy was completed in 240min. The Pringle maneuver was not used. Estimated blood loss was 150mL with no need for transfusion. Recovery was uneventful, and the patient was discharged on the fifth postoperative day. Robotic repeat hepatectomy is feasible and safe in experienced hands and may have some advantages over laparoscopic and open repeat liver resections.

The “Dorsal” approach to laparoscopic major hepatectomy enables expanded indications for laparoscopic liver resection

Introduction: This new technique, a modification of the caudal approach of Soubrane, involves a posterior to anterior transection of the liver for laparoscopic major hepatectomies. It was conceived to enable a standardised technique, and to broaden the indications for laparoscopic resection particularly for larger tumours and with anatomical variations of the porta. Methods: As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral, enabling safe stapling. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, maintaining good surgical orientation especially for tumours close to the midline or cava. Similar concepts apply for a left hemihepatectomy, with dissection beginning in the in the Arantius groove. Results: 8 cases (6 right hemihepatectomy, 1 extended right hepatectomy, 1 extended left hepatectomy) have utilised this technique. I required conversion to a hybrid approach, and 1 case required transfusion. R0 resection was achieved in all cases. Average length of stay was 5 days. Comparison to 50 consecutive previous laparoscopic major hepatectomies demonstrates larger tumours and fewer conversions with the dorsal approach. Schematic and case videos will be presented. Conclusion: The dorsal approach to laparoscopic major hepatectomy is a novel technical variation that enables a safe, standardised technique and an expanded set of indications for a laparoscopic approach.

The “Dorsal” approach to laparoscopic major hepatectomy

This new technique is a modification of the caudal approach of Soubrane. After a long experience of over 600 laparoscopic hepatectomies, this posterior to anterior procedure has enabled us to perform major hepatectomy more easily, via a standardised technique, for larger tumours, and for anatomical variations of the porta. As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral. A small hepatotomy anterior to the right inflow then allows stapling of the right hepatic inflow without blind force or risk of compromise to the confluence. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, with subsequent division of the anterior parenchyma. This maintains good surgical orientation, especially for tumours close to the midline or cava, and for the middle hepatic vein. This also aids haemostasis by allowing the application of pressure in a postero-anterior direction. After completion of the parenchymal transection, the right hepatic vein is divided, followed by the hepatocaval ligament, accessory hepatic veins, and peritoneal attachments. The same concepts can be applied to left and extended left hepatectomy. This technique has enabled expanded indications for a laparoscopic approach to major hepatectomies as well as a standardized operative technique. Schematic and case videos will be presented.

Laparoscopic liver hanging maneuver through the retrohepatic tunnel on the right side of the inferior vena cava combined with a simple vascular occlusion technique for laparoscopic right hemihepatectomy

BackgroundLaparoscopic hepatectomy has been performed in many hospitals, with the development of the laparoscopic operation technique. However, performing complex laparoscopic hepatectomy, such as right hemihepatectomy, is still a challenge. The aim of this study was to describe the application of a simple vascular occlusion technique and new liver hanging maneuver (LHM) in complex laparoscopic hepatectomy, which are both advocated by Chen Xiaoping for open hepatectomy.MethodsThe clinical data of 29 consecutive patients who underwent laparoscopic right hemihepatectomy (LRH) from October 2014 to October 2016 were retrospectively analyzed. During operation, the vascular occlusion technique without hilus dissection and LHM through the retrohepatic avascular tunnel on the right side of the inferior vena cava were used.ResultAll 29 operations were successfully performed laparoscopically, while adopting Chen’s methods. The study consisted of 23 patients with hepatocellular carcinoma, four patients with intrahepatic cholangiocarcinoma, and two patients with hepatic metastasis of colonic carcinoma. The tumor size was 12.4 ± 1.9 cm. The operation time of LRH was 190.3 ± 49.9 min. The intraoperative blood loss of LRH was 281.7 ± 117.8 mL; five patients required blood transfusion, and the amount of blood transfusion was 300.0 ± 89.4 mL. No case was converted to open surgery, and no death occurred. All resulted in R0 resections. The median free margin was 20.1 ± 10.8 mm. The time of postoperative oral diet intake was 2.10 ± 0.96 days. The complication rate was 17.2%. The average hospital stay after operation was 10.0 ± 2.9 days.ConclusionComplex hepatectomy is a bloodless procedure that can be performed under a laparoscope safely using Chen’s methods of vascular occlusion technique and LHM.

Anatomy of the retrohepatic tunnel in a Chinese population and its clinical application in liver surgery

Liver hanging maneuver (LHM) is an important technique in liver surgery. However, applied anatomy of the retrohepatic tunnel for the surgical approach in Chinese population needs further study. In this study, to explore the basic anatomy of retrohepatic tunnel and its clinical application in a Chinese population, a total of 32 formalin-fixed cadavers were dissected, related parameters were measured, and their clinical applications were discussed. The length of the retrohepatic tunnel was (60.6 ± 9.9) mm. The width of the retrohepatic tunnel superior opening was (13.8 ± 3.9) mm. The width of the retrohepatic tunnel inferior opening was (15.2 ± 7.4) mm. The hepatic short vessels were distributed along the middle and lower 1/3 of hepatic inferior vena cava (HIVC), with a slight predominance on its left wall. A few hepatic short vessels were distributed along the upper 1/3 of the HIVC. We concluded: the anatomy of the retrohepatic tunnel provides a basis for use of LHM in liver surgery; more hepatic short vessels from hepatic caudate lobe can be preserved via right approach. The retrohepatic tunnel can be used as a good surgical approach in liver surgery; its application also has important significance in laparoscopic minimally invasive liver surgery.

New concepts and techniques of hepato-pancreato-biliary surgery

Surgery is the most effective and preferred treatment for hepato-pancreato-biliary (HPB) tumors. The improvement of HPB surgery technique mainly focus on reducing the amount of bleeding, improving the safety of operation, simplifying the operation, reducing the complications and mortality all the time. As one of the largest HPB centers in China, hepatic center of Tongji hospital has set up a series of new concepts and new techniques of HPB surgery since 1980s. We proposed a new classification standard of hepatocellular carcinoma (HCC) to guide the surgical procedures and evaluation of prognosis. According to this method, HCCs lager than 5 cm were defined as lager (>5 cm and ³ 10 cm). Traditionally, the large/huge HCC patients were thought can’t tolerate hepatectomy because of the insufficient residual liver volume. However, we confirmed the feasibility and safety of the resection of large/huge HCC and applied it in clinic concurrently in 1990s, which greatly extended the inclusion criteria for operation. Serious intraoperative bleeding is another constraint for resection of large/huge HCC. In order to reduce the intraoperative bleeding and increase the safety of major hepatectomies, three new bleeding control techniques for hepatectomy were established: Infrahepatic inferior vena cava clamping combine with occlusion of the portal triad; tying up of inflow and outflow vessels without dissecting the hilus of the liver; and implementation of the liver double-hanging maneuver through the retrohepatic avascular tunnel on the right side of the inferior vena cava. According to the AASLD and the EASL guidelines for HCC management, patients with portal vein tumor thrombosis (PVTT) are excluded from either surgical treatment or TACE, and only palliative therapies are recommended. However, our studies confirmed treating PVTT patient by indicated surgical protocol according to the location and extension of PVTT is safety and effective. Based on the guideline set by western countries, liver resection is contraindicated in patients with portal hypertension. But in China, 85%–90% patients with HCC showed various degrees of liver cirrhosis, and a large proportion of these patients presented clinical signs of portal hypertension. Thus, we set up a surgical treatment strategy (limited liver resection plus splenectomy with or without devascularization of gastroesophageal varices) for HCC combined with portal hypertension. There are still controversies on the optimal extent of hepaticresection to achieve a high percentage of R0 resection for hilarcholangiocarcinoma. We proposed a new concept that treats hilar cholangiocarcinoma using minor liver resection which showed lower operative morbidity and good prognosis. We also created new surgical procedures such as new intrahepatic cholangiojujunostomy for multiple intrahepatic biliary ductal openings and the inserting bilio- jejunostomy for iatrogenic bile duct injury were all invented and proved to be available in clinic. In order to diminish pancreatic leakage, we established Chen’s U-suture technique for end-to-end invaginated pancreaticojejunostomy following pancreaticoduodenectomy. Many end-stage liver disease patients died due to severe shortage of organ donors. To address the shortage, we are the first to establish auxiliary partial orthotopic liver transplantation technique in the world and applied it in clinic successfully.

Can retrohepatic tunnel be quickly and easily established for laparoscopic liver hanging maneuver by Goldfinger dissector in laparoscopic right hepatectomy?

The liver hanging maneuver (LHM) is rarely applied in laparoscopic right hepatectomy (LRH) because of the difficulty encountered in retrohepatic tunnel (RT) dissection and tape positioning. Thus far no report has detailed how to quickly and easily establish RT for laparoscopic LHM in LRH, nor has employment of the Goldfinger dissector to create a total RT been reported. This study's aim was to evaluate the safety and feasibility of establishing RT for laparoscopic LHM using the Goldfinger dissector in LRH. Between March 2015 and July 2015, five consecutive patients underwent LRH via the caudal approach with laparoscopic LHM. A five-step strategy using the Goldfinger dissector to establish RT for laparoscopic LHM was adopted. Perioperative data were analyzed. The median age of patients was 58 (range, 51-65) years. Surgery was performed for one intrahepatic lithiasis and four hepatocellular carcinomas with a median size of 90 (40-150) mm. The median operative time was 320 (282-358) min with a median blood loss of 200 (200-600) ml. Laparoscopic LHM was achieved in a median of 31 (21-62) min, and the median postoperative hospital stay was 14 (9-16) d. No transfusion or conversion was required, and no severe liver-related morbidity or death was observed. The Goldfinger dissector is a useful instrument for the establishment of RT. A five-step strategy using the Goldfinger dissector can quickly and easily facilitate an RT for a laparoscopic LHM in LRH.

Research progress of liver hanging maneuver

Liver hanging maneuver was firstly introduced by Belghiti et al in 2001,since then,the new technique has aroused widespread interest.The fatal weakness of liver hanging maneuver is bleeding resulting from blind dissection of the anterior plane of the inferior vena cava.In this review,the anatomic basis of retrohepatic tunnel and the surgical techniques were summarized to provide surgeons with suggestions in hepatectomy,liver transplantation or operations for hepatic trauma,so as to reduce the incidence of complications and raise the safety and success rate. Key words: Hepatectomy; Liver transplantation ; Liver hanging maneuver

Efficacy and Safety of Right Hemihepatectomy Through the Right Retrohepatic Tunnel

We wished to study the efficacy and safety of the retrograde ligation of short hepatic veins (SHVs) and the right hepatic vein (HV) through the retrohepatic tunnel in patients who underwent hemihepatectomy due to large hepatic carcinoma in the right lobe of the liver. Right hemihepatectomy was performed in 23 patients with tumors larger than 8 cm in diameter. The liver was separated at the secondary porta, and the interspace between right HVs and middle HVs was expanded. The right hepatic portal vein and hepatic artery were freed and ligated, followed by the retrograde dissection of SHVs and the right HV along the right retrohepatic space anterior to the inferior vena cava. A blocking belt was set at the left side of the midline, after which the right liver was cut off. The procedure was successfully completed in all patients. The average amount of intraoperative blood loss was 640 ml. The change in hepatic function was observed on the third postoperative day. Twenty-two patients exhibited satisfactory results; one patient died from postoperative hepatic failure. In conclusion, this procedure can be safely performed in most hemihepatectomy patients with liver tumors.

Application of double liver hanging maneuver in anatomical right Hemihepatectomy

Objective To introduce the application of double liver hanging maneuver in anatomical right hemihepatectomy and share our own experience. Methods Twenty-four patients underwent right hemihepatectomy using double liver hanging maneuver, and the data were collected prospectively after operation. Another 49 patients underwent right hemihepatectomy using the traditional methods,serving as the control group. Results Retrohepatic tunnel was constructed in 27 patients, double liver hanging maneuver was successfully performed in 24 anatomical right hemihepatomy and failed in 3 patients due to the near proximity between the tumor and the middle line. Compared with the control group, blood loss was much less (t=3. 191 ,P＜0.05), ALT and liver function recovered more quickly postoperatively and the difference in operative duration between the 2 groups was not significant (t=-1. 695,P＞0. 05). There was about 1-2 cm wide space located between retrohepatic IVC and dorsal liver when the 2 tapes were tracted, and no injury in hepatic short veins and retrohepatic IVC occurred during the operation. Conclusion The double liver hanging maneuver can make anatomical right hemihepatectomy more accessible and safe. Key words: Liver neoplasm; Anatomica hemihepatectomy; Double liver hanging maneuver; Retrohepatic tunnel

Resecting Iarge hepatocellular carcinoma through retrohepatic tunnel:a report of 38 cases

Objective To investigate the possibility and the changing of the method of surgical excision for large hepatocellutar carcinoma(HCC).Methods The clinical data of 38 cases with large HCC treated in our hospital from May 2003 to December 2006 were retrospectively analyzed.The av-erage diameter of the 38 cases was 14.4 cm(10.5-27 cm).The hepatic artery and portal vein of the trouble side were ligated firstly in the operation and then the retrohepatic tunnel established.We took the method of the former approach to resect tumors retrogradely.Results The operation was success-fully conducted in all the 38 cases and the average amount of bleeding was 850ml(300-2700 ml).No death occurred during hospitalization.The 1-,2-and 3-year survivaI rates were 78.9%,57.9%and 39.5%.respectively.Conclusion It is safe to resect the large HCC through the retrohepatic tunnel. Key words: Carcinoma hepatocellular; Hepatectomy; Retrohepatic tunnel

The preliminary experience of Belghiti's liver hanging manoeuvre in right hepatectomy with anterior approach

Aim: To summarize the experience of Belghiti's liver hanging manoeuvre in right hepatectomy.Methods: Nine cases of right hepatectomy were performed with Belghiti's liver hanging manoeuvre from June 2002 to May 2005. They included seven cases of large hepatocellular carcinoma located in the right liver lobe with diameters from 8 to 12 cm (two have encroached diaphragm and lateral peritoneum) and two cases of recurrent pyogenic cholangitis with hepatolithiasis fully packed in the right liver lobe. The key step of this manoeuvre was to develop a retrohepatic tunnel between the anterior surface of the inferior vena cava and the liver parenchyma. A tape was then passed though the tunnel and the liver was resected under tape suspension.Results: The retrohepatic tunnel was established and the suspending tape was passed though the tunnel successfully in all cases. The mean time for this procedure was 21 min. Mean intraoperative blood loss was 380 mL. The middle hepatic veins were protected from damage in eight cases. There were no operative deaths or morbidity, except one case that developed postoperative bile leakage, which was cured by drainage.Conclusion: Belghiti's liver hanging manoeuvre is a preferred surgical method for right hepatectomy, with its reliable anatomic background and satisfactory primary clinical results.

Right hepatectomy using the liver double-hanging maneuver through the retrohepatic avascular tunnel on the right of the inferior vena cava

The key to Belghiti's liver-hanging maneuver is to develop a retrohepatic tunnel. This procedure requires a blind dissection of the plane anterior to the inferior vena cava (IVC), with the inherent risks of damaging the short hepatic veins and consequential bleeding. The aim of this article is to describe a liver double-hanging maneuver with the advantage of being technically simple and safe. The operator uses his or her right index finger to dissect the space from below upward between the hepatic parenchyma and the anterior and superior edge of the right adrenal gland, which is situated just on the right side of the IVC. The operator then uses his left index finger to dissect the retrohepatic space from above downward on the right side of suprahepatic IVC, which is lateral to where the right hepatic vein joins the IVC. The retrohepatic tunnel is built when the 2 fingers touch each other. A kidney pedicle forceps is used to place 2 tapes around the liver for suspension. In all, 65 patients underwent right hepatectomy using this maneuver. The study included 62 patients with hepatocellular carcinoma (tumor size: mean +/- SD, 10 +/- 3.7 cm), and 3 patients had hepatic cavernous hemangioma, with a maximum diameter of 12.6 cm, 14.4 cm, and 22.6 cm, respectively. No major bleeding was encountered during the creation of the retrohepatic tunnel, with a success rate of 100%. To develop the retrohepatic tunnel in the space on the right of the IVC is absolutely bloodless, and it is technically easy and safe.

Dissecting giant liver hemangioma through retrohepatic tunnel: a report of 8 cases

目的 探讨肝后下腔静脉前间隙入路在特大肝血管瘤切除中的意义.方法 回顾性分析潍坊市人民医院肝胆、血管外科2004年2月至2006年9月利用肝后下腔静脉前间隙入路行8例特大肝血管瘤切除的临床资料和随访情况.结果 利用此入路手术均取得成功,术中出血少,术后恢复快,并发症少.结论 肝后下腔静脉前间隙可作为一良好的肝特大血管瘤的手术入路。

Safe Modification of the Liver-Hanging Maneuver by Endoscopic-Assisted Dissection of the Retrohepatic Tunnel

As a safer approach to right hepatectomy, Belghiti et al. (J Am Coll Surg 193:109-11, 2001) described a liver-hanging maneuver. However, this procedure is performed blind, with the risks of damaging the small retrohepatic veins and consequential bleeding. To overcome this problem, we modified the procedure so that, instead of performing blind dissection using a long vascular clamp, we use a flexible choledochoscope to dissect the retrohepatic space filled by loose alveolar tissue anterior to the inferior vena cava (IVC). The avascular path is identified by a combination of saline irrigation and gentle movement of the tip of the choledochoscope. Cotton tape can then be passed around the liver parenchyma to elevate the liver away from the anterior surface of the IVC. This modification of Belghiti's liver-hanging maneuver allows direct vision along the plane anterior to the IVC, thus avoiding injury to the retrohepatic veins.

Anatomy and clinical application of retrohepatic tunnel

目的 探讨肝后下腔静脉前间隙的解剖基础及其在肝脏外科的临床应用价值.方法 对10例尸肝(包括完整的下腔静脉)进行解剖,测量肝后下腔静脉前间隙的相关解剖数据.经肝后下腔静脉前间隙入路行6例巨大肝癌、血管瘤切除及1例背驮式肝移植病肝切除.结果 肝上静脉窝内肝静脉间的距离平均为(16.75±3.93)mm.肝后下腔静脉前间隙的长度平均为(57.76±9.65)mm.肝后下腔静脉前间隙的宽度平均为(9.17±2.30)mm.7例手术均取得成功无相关并发症发生,与其它手术入路相比有显著意义.结论肝后下腔静脉前间隙有其解剖基础,在肝脏外科中可作为一良好的手术入路。

Anatomical justification of Belghiti's 'liver hanging manoeuvre' in right hepatectomy with anterior approach.

In cases of right hepatectomy for huge tumour encroaching onto the diaphragm, the 'anterior approach' is the most common surgical procedure undertaken. The 'liver hanging manoeuvre' has been described previously as an adjunct to this procedure. It involves the dissection of a retrohepatic avascular plane anterior to the surface of the inferior vena cava. A tape is then passed through and the liver is resected under suspension. Cadaveric specimens were used to identify the structural relationship of the avascular plane and also to determine whether it is truly avascular. Thirteen cases were analysed. The mean length of the avascular tunnel was 6.4 +/- 1.0 cm. The median number of accessory hepatic veins within the tunnel was two (zero to three). At the caudal half of the tunnel, the median number of veins was two (zero to three). As for the cranial half of the tunnel, there were two cases with one vein in each. The key to the liver hanging manoeuvre is to develop the retrohepatic tunnel. However, our study showed that it is not absolutely avascular. During the blind dissection, there is a chance of damaging a retrohepatic vein. This may result in troublesome haemorrhage within the confines of the tunnel. Video-assisted dissection of this region may help in visualisation, and hence control, in order to avoid bleeding.