Right Hepatic Vein Research Articles

Combining occlusion of the right hepatic vein with the Pringle maneuver in laparoscopic anatomic right posterior liver resection.

Laparoscopic right posterior anatomic resection (LRPAR) presents challenges due to uncontrollable hemorrhage from the inferior vena cava and the risk of carbon dioxide (CO2) gas embolism. However, there is a lack of research specifically addressing the safe exposure of right hepatic vein (RHV). Herein, we introduced a novel technique of combining occlusion of the RHV with the Pringle maneuver and presented the outcomes of our initial series. All consecutive patients who underwent LRPAR using this novel technique were enrolled in this study from March 2021 to January 2024. The demographic characteristics, perioperative outcomes and follow-up data were collected and analyzed. A total of 12 patients underwent LRPAR using the technique of double occlusion during study period. All the procedures were performed laparoscopically, with no conversions to open surgery. The median operative time was 203min (range of 172-279min) and the median blood loss was 200ml (range of 50-280ml). No patient received a blood transfusion during the perioperative period. Of note, the main trunk of the RHV was fully exposed on the cutting surface in all cases, and no evidence of CO2 gas embolism was observed following double occlusion. None of the patients suffered from Clavien-Dindo grade II or higher postoperative complications, and the perioperative mortality was nil. The median postoperative stay was 5days (range of 5-7days). The median hospitalization cost was 43,048.5 RMB (40,240.35-57,921.53 RMB). At a median follow-up period of 24months (range of 4-35months), all patients were alive with normal daily living and no disease recurrence was observed. Combining occlusion of the right hepatic vein with the Pringle maneuver appears to be a feasible and expected technique for securing the exposure of RHV in LRPAR. Further follow-up and well-designed prospective comparative studies are needed to validate the feasibility and efficacy of this technique.

Mistaken Identity: Misidentification of Other Vascular Structures as the Inferior Vena Cava and How to Avoid It.

While point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) is broadly perceived as having value in intravascular volume status assessment, this has not been borne out in large-scale meta-analyses containing heterogenous populations of acutely ill patients. While the limitations of IVC POCUS could be largely due to the complexity of the relationship between IVC appearance and volume status, another confounder not widely appreciated is the ease with which the aorta or right hepatic vein (RHV) can be mistaken for the IVC. While misidentification of the aorta as the IVC has been recognized elsewhere, misidentification of the RHV for the IVC has not and, in our experience, occurs frequently, even in the hands of experienced sonographers. We demonstrate how these errors occur and provide guidance on how to systematically avoid them.

Laparoscopic right upper transversal hepatectomy: Strategies for right hepatic vein resection and reconstruction

ObjectiveThe right upper transversal hepatectomy (RUTH) is considered a complex technique of parenchymal-sparing hepatectomies. The intraoperative management of the right hepatic vein (RHV) is still controversial because it may cause obstruction of outflow in the remnant hepatic segment. The aim of this study is to present our experience of laparoscopic RUTH and the strategy of RHV resection and reconstruction in different settings. MethodsFive patients who underwent laparoscopic RUTH for liver tumor were enrolled retrospectively. Clinical and pathological features of the patients, peri-operative treatment, as well as short- and long-term outcomes were collected for analysis. ResultsLaparoscopic RUTH was successfully performed in all five patients. Two individuals underwent RUTH while preserving RHV. Among the remaining patients who underwent RUTH with RHV resection, one patient underwent RHV reconstruction but the others did not. Immediate or long-term venous related complications did not occurred in a median follow-up period of nine months. ConclusionsLaparoscopic RUTH surgery for tumors in the right upper region of the liver is safe and feasible. The strategic workflow we proposed for the resection and reconstruction of the RHV offers a reliable method for preserving liver parenchyma and reducing the risk of postoperative liver failure.

Evaluation of ventral branches of segment VI portal vein relative to the right hepatic vein in laparoscopic right anterior sectionectomy.

The right intersectional plane and the right hepatic hilum were noted too often exhibit anatomical variations, making difficult the laparoscopic right anterior sectionectomy (LRAS). We analyzed the anatomical features employing 3D-CT images of 55 patients, and evaluated these features according to the course of ventral branches of segment VI of the portal vein (PV, P6a) relative to the right hepatic vein (RHV). P6a run on the dorsal side of RHV in 32 patients (58%, Dorsal-P6a) and the ventral side of RHV in 23 (42%, Ventral-P6a). Ventral-P6a had more patients with S6 partially drained by middle hepatic vein (MHV, 39% vs. 0%, P < 0001), the narrower angle between the anterior and posterior branches of PV (73.1° vs. 93.8°, P = 0.006), the wider angle between the RHV and inferior vena cava (54.3° vs. 44.3°, P < 0.001), and more steeply pitched angle between S6 and S7 along the RHV (140.6° vs. 162.0°, P < 0.001) compared to Dorsal-P6a. In LRAS for Dorsal-P6a patients, the transection surface was relatively flat. In LRAS for Ventral-P6a patients, the narrow space between anterior and posterior glissons makes difficult the glissonean approach. The transection plane was steeply pitched, and RHV was partially exposed. S6 was often partially drained to MHV in 39% of the Ventral-P6a patients, which triggers congestion during liver transection of a right intersectional plane after first splitting the confluence of this branch.

Caudo-dorsal approach combined with the occlusion of right hepatic vein and Pringle maneuver in laparoscopic anatomical resection of segment 7.

Laparoscopic anatomical resection of segment 7 (LARS7) remains a technically challenging procedure due to the deep anatomical location and the potential risk of injury to the right hepatic vein (RHV). Herein, we initiated an innovative technique of caudo-dorsal approach combined with the occlusion of the RHV and Pringle maneuver for LARS7 and presented the outcomes of our initial series. Since January 2021, the patients who underwent LARS7 by using this novel technique were enrolled in this study. The critical aspect of this technique was the interruption of communication between the RHV and the inferior vena cava. Meanwhile, the Pringle maneuver was adopted to control the hepatic inflow. A total of 11 patients underwent LARS7 by using this novel technique, which included 8 hepatocellular carcinoma, 2 bile duct adenocarcinoma and one focal nodular hyperplasia. The median operative time was 199min (range of 151-318min) and the median blood loss was 150ml (range of 50-200ml). The main trunk of the RHV was fully exposed on the cutting surface in all cases and no patient received perioperative blood transfusion. No procedure was converted to open surgery. Of note, no indications of CO2 gas embolism were observed in these cases after the introduction of double occlusion. Only one patient suffered from postoperative complications and healed after treatment. The median postoperative stay was 5days (range of 4-7days). The 90-day mortality was nil. At a median follow-up period of 19months, all of the patients were alive without any evidence of tumor recurrence. The caudo-dorsal approach combined with the occlusion of RHV and the Pringle maneuver may be a feasible and expected technique for safe exposure of RHV in LARS7. Further validation of the feasibility and efficacy of this technique is needed.

Laparoscopic hepatectomy for hepatocellular adenoma using the hepatic vein as anatomic markers,How I do it.(with video)

TechniqueHepatocellular adenoma (HCA) is a benign monoclonal tumour that originates from mature hepatocytes.Liver resection is recommended in case of overt malignant transformation to hepatocellular carcinoma.However, hepatobiliary surgeries are technically challenging in patients with giant HCA (GHCA) owing to the risk of catastrophic intraoperative bleeding and difficulty with its control during laparoscopic treatment. We present a technical note on the utilization of the hepatic vein as anatomical landmarks for laparoscopic removal of giant hepatic glands, without intraoperative ultrasonography and with the aid of an augmented reality navigation system during surgery. ResultsThis video shows aA 37-year-old man was recommended treatment for a progressively increasing HCA (from 3 to 10 cm in a year) involving the right hepatic vein (RHV), inferior vena cava (IVC) and middle hepatic vein (MHV), resulting in the invisibility of the above intrahepatic anatomic markers in CT. Laparoscopic hepatectomy was performed using the hepatic vein as anatomic markers in a treatment centre specialising in minimally invasive surgeries. The procedure involved fully mobilising the right liver, transecting the parenchyma along the demarcation line in the caudal-to-cranial direction, exposing the involved caudal MHV, isolating and transecting the involved RHV and preserving the integrity of the involved IVC. ConclusionsLaparoscopic hepatectomy for intractable GHCA using the involved intrahepatic anatomic markers is feasible and effective. It reduces pre-operative haemorrhage and open conversion rates while maximising postoperative hepatic function.

Exploring the utility of EUS in Budd-Chiari syndrome: a multicenter multiobserver prospective cohort study

Background and aimsThe diagnosis of Budd-Chiari syndrome (BCS) is essentially radiological and is needed to plan appropriate therapy. We therefore conducted this proof of concept study to assess the utility of EUS in assessing anatomy of BCS. MethodsA prospective multi-centre observational study including 50 consecutive patients with a diagnosis of BCS were enrolled. All patients underwent a detailed EUS examination by three independent endosonographers, blinded to the anatomical details of BCS and others’ findings. This was compared to each other and to conventional angiography (where available) or Magnetic resonance venography (MRV). Outcomes assessed include inter observer agreement, sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy in diagnosing pathological lesions of BCS. ResultsFifty BCS patients (Mean age 34 years ; range 13-65 years) underwent EUS. Results showed good agreement among endosonographers for diagnosing right hepatic vein (RHV) (kappa=0.716) and left hepatic vein (LHV) lesions (kappa=0.722), moderate agreement for middle hepatic vein (MHV) lesions (kappa=0.660) and very good agreement for inferior vena cava (IVC) lesions (kappa=0.823). EUS demonstrated high sensitivity, positive predictive value, low inter-observer variability, and overall diagnostic accuracy for BCS lesions. ConclusionsIn conclusion, EUS is a safe and accurate diagnostic tool for BCS. It can provide accurate mapping of hepatic veins, intrahepatic collaterals, and the IVC.

Laparoscopic right posterior sectionectomy for a large hepatocellular carcinoma close to inferior vena cava.

Approximately 20% of hepatocellular carcinomas (HCC) occur in noncirrhotic livers. Resection may be considered for patients with HCC, provided sufficient future liver remnant is available, regardless of the tumor size. Tumors located posteriorly near the right hepatic vein (RHV), or inferior vena cava can be managed through anterior or caudal approaches. RHV is typically conserved during right posterior sectionectomy. When a large posteriorly placed tumor causes chronic compression on RHV, the right anterior section drainage is redirected preferentially to the middle hepatic vein. The division of RHV in such instances does not cause congestion of segments 8 and 5. The technical complexity of laparoscopic right posterior sectionectomy arises from the large transection surface, positioned horizontally. We describe in this multimedia article, a case of large HCC in segments 6 and 7, which was successfully treated using laparoscopic anatomic right posterior sectionectomy.

Prediction of Esophageal Varices in Viral Hepatitis C Cirrhosis: Performance of Combined Ultrasonography and Clinical Predictors.

This study is aimed at evaluating the diagnostic performance of clinical predictors and the Doppler ultrasonography in predicting esophageal varices (EV) in patients with hepatitis C-related cirrhosis and exploring the practical predictors of EV. We conducted a prospective study from July 2020 to January 2021, enrolling 65 patients with mild hepatitis C-related cirrhosis. We obtained clinical data and performed grayscale and the Doppler ultrasound to explore the predictors of EV. Esophagogastroduodenoscopy (EGD) was performed as the reference test by the gastroenterologist within a week. The prevalence of EV in the study was 41.5%. Multivariable regression analysis revealed that gender (female, OR = 4.04, p = 0.02), platelet count (<150000 per ml, OR = 3.13, p = 0.09), splenic length (>11 cm, OR = 3.64, p = 0.02), and absent right hepatic vein (RHV) triphasicity (OR = 3.15, p = 0.03) were significant predictors of EV. However, the diagnostic accuracy indices for isolated predictors were not good (AUROC = 0.63-0.66). A combination of these four predictors increases the diagnostic accuracy in predicting the presence of EV (AUROC = 0.80, 95% CI 0.69-0.91). Furthermore, the Doppler assessment of the right hepatic vein waveform showed good reproducibility (κ = 0.76). Combining clinical and Doppler ultrasound features can be used as a screening test for predicting the presence of EV in patients with hepatitis C-related cirrhosis. The practical predictors identified in this study could serve as an alternative to invasive EGD in EV diagnosis. Further studies are needed to explore the diagnostic accuracy of additional noninvasive predictors, such as elastography, to improve EV screening.

Do Respiratory Maneuvers Affect Rght Hepatic Vein Waveform and Maximum Velocity in Post LDLT Recipients?

AIM: Â To evaluate the effect of respiratory maneuvers on right hepatic vein (RHV) Doppler waveform and its maximum velocity in Living donor liver transplant (LDLT) recipients. METHODS: This was a prospective cross-sectional study performed at Pakistan Kidney and Liver Institute and Research Centre (PKLI&amp; RC), Lahore Radiology department. The sample size of the study, calculated according to WHO sample size calculator, was 30 patients after applying the inclusion and exclusion criteria. Most of these patients were analyzed during their first post-operative week while staying in the surgical intensive care unit (SICU). The Doppler waveform and maximum velocity of RHV were recorded during normal gentle breathing, following breath-hold after deep inspiration and then after quiet expiration. The waveforms that were recorded were triphasic, biphasic, or monophasic in the pattern. To assess the RHV flow quantitatively, the Damping Index was also calculated during all these three respiratory maneuvers as follows (DI=Minimum velocity/maximum velocity) RESULTS: The maximum velocities during normal respiration, after quiet expiration and after breath-holding following deep inspiration were 125 cm/sec, 105 cm/sec and 94 cm/sec. The waveforms observed during gentle breathing were triphasic in 77%, biphasic in 10%, and monophasic in 13% of the patients. After quiet expiration, these were triphasic in 80%, biphasic in 6%, and monophasic in 13% of patients. However, after breath-hold following deep inspiration, the waveforms observed were triphasic in 42%, biphasic in 13%, and monophasic in 45% of the patients. (P &lt;0.008) CONCLUSION: The study showed that not only did the RHV waveforms show significant change from triphasic pattern to monophasic pattern, but also the peak velocities were lower following expiration. Therefore, during the Doppler ultrasound assessment of post-LDLT recipient patients, respiratory variations must be taken into consideration.

Prevalence and clinical significance of the Sg6/Sg7 intersegmental veins based on re-evaluation of the Couinaud classification for the right posterior portal vein.

Although Segment 6(Sg6) and Segment 7(Sg7) are two independent units, there are currently no clear anatomical boundary markers between Sg6 and Sg7. This study aimed to identify intersegmental veins (ISV) in the intersegmental plane of Sg6 and Sg7, and evaluate the prevalence of ISV, and its clinical significance in anatomical hepatectomy. We analyzed data from 180 patients undergoing abdominal computed tomography (CT) examination, and simultaneously performed 3D reconstruction models of the liver for each patient. The right posterior portal vein was analyzed and re-typed. Furthermore, the existence of ISV was defined, and prevalence and confluence patterns of ISV were analyzed. The author attempted to apply ISV to laparoscopic S6/S7 segmentectomy. We sorted data from the right posterior portal vein and divided it into six types. The ISV could be identified in 82.2% (148/180) of the patients, which were derived from the right hepatic vein (RHV) (91.9%) and right posterior inferior vein (IRHV) (8.1%). Ten ISV-guided laparoscopic Sg6/Sg7 segmentectomy were successfully carried out, seven patients underwent Sg6 segmentectomy, and three patients underwent Sg7 segmentectomy. There was no perioperative mortality. The median operative time was 223min (range 181-260min). The median blood loss was 200ml (range 150-310ml). The R0 resection rate was 100%. The ISV may be a candidate vessel to distinguish the boundary of the right posterior sector; it is expected to be a landmark in the liver parenchyma of anatomical hepatectomy.

Study of the Intersegmental Veins Between S5 and S8 Based on 3D Reconstruction

BackgroundAnatomic resection (AR) is a surgical method for treating hepatocellular carcinoma, and identifying intersegmental planes between segments 5 (S5) and 8 (S8) remains challenging. This study aims to find reliable intersegmental veins (IVs) between them as anatomical landmarks using 3D reconstruction analysis. MethodsWe retrospectively evaluated 57 patients who underwent multidetector-row CT scans from September 2021 to January 2023. The portal vein watershed of S5 and S8 and hepatic veins were reconstructed using 3D reconstruction analysis software. We counted and analyzed the IVs running within the intersegmental plane between S5 and S8, examined their features, and analyzed the location of the junctions between IVs and middle hepatic veins (MHVs). ResultsAmong the 57 patients, 43 patients (75.4%) had IVs between S5 and S8. Most patients (81.4%) had a single IV joining the MHV, while 13.9% had two IVs, one joining the MHV and the other joining the right hepatic vein (RHV). The majority of IV-MHV junctions were found in the lower part of the MHVs. The most clearly identifiable junctions between the IVs and MHVs occurred slightly below the midpoint of the horizontal planes of the second hepatic portal and the center of the gallbladder bed. ConclusionOur study identified IVs between S5 and S8 in the liver as potential anatomical landmarks during AR for hepatocellular carcinoma surgery. We found three types of IVs and provided insights on how to locate their junctions with MHVs for easier surgical navigation. However, individual anatomical variations must be considered, and preoperative 3D reconstruction and personalized surgical planning are crucial for success. More research with larger sample sizes is needed to validate our findings and establish the clinical significance of these IVs as landmarks for AR.

Hepatic Vein-Guided Approach in Laparoscopic Anatomic Liver Resection of the Ventral and Dorsal Parts of Segment 8.

Laparoscopic ventral and dorsal segmentectomies 8 are an option for parenchymal-sparing liver resection. However, laparoscopic anatomic posterosuperior liver segment resection is technically demanding because of its deep location and the many variations in the segment 8 Glissonean pedicle (G8). In this study, we describe a hepatic vein-guided approach (HVGA) to overcome these limitations. For ventral segmentectomy 8, liver parenchymal transection was initiated at the ventral side of the middle hepatic vein (MHV) and continued exposing it toward the periphery. The G8 ventral branch (G8vent) was identified on the right side of the MHV. Following G8vent dissection, liver parenchymal transection was completed by connecting the demarcation line and G8vent stump. For dorsal segmentectomy 8, the anterior fissure vein (AFV) was exposed peripherally. The G8 dorsal branch (G8dor) was identified on the right side of the AFV. Following G8dor dissection, the right hepatic vein (RHV) was exposed from the root. Liver parenchymal transection was completed by connecting the demarcation line and RHV. Between April 2016 and December 2022, we performed laparoscopic ventral and dorsal segmentectomy 8 in fourteen patients. No complications (Clavien-Dindo classification, Grade ≥ IIIa) were observed. An HVGA is feasible and useful for standardizing safe laparoscopic ventral and dorsal segmentectomies 8.

Central Pericystectomy for Hydatid Cyst Treatment

BackgroundCompared to open resection for hepatic hydatid cysts, a laparoscopic approach may combine the benefit of reduced morbidity with complete cyst removal. Nonetheless, intraoperative cyst rupture during a laparoscopic approach due to reduced tactile feedback is a valid concern.1-3 Today, the laparoscopic experience remains limited even in high incidence regions.4 Here, a structured approach to laparoscopic pericystectomy is demonstrated. PatientA 37-year-old male from Uruguay presents with worsening abdominal pain, nausea, and vomiting. A 4-phase liver CT shows a large complex liver cyst (8.8 × 8.2 × 11.3 cm), encompassing the left hepatic lobe while abutting right hepatic vein (RHV), anterior fissure vein (AFV) and inferior vena cava (IVC). Further, the cyst causes mass effect on the hepatic vein vasculature. CT appearance is consistent with a large hydatid cyst with distorted hepatic anatomy resulting in compensatory hypertrophy of segments II, VI and VII. Appropriate institutional review board (IRB) and inform consent was obtained. TechniqueFollowing neoadjuvant albendazole for 4 weeks to minimize any effects in case of inadvertent cyst spillage, the patient tested negative for echinococcal antibody. For surgical planning, the patient’s anatomy was modeled to optimize the understanding of the complex spatial relationship between cyst, portal pedicle and hepatic veins. Further, port sites were preoperatively modelled to optimize port placement in the context of the altered anatomy from compensatory hepatic hypertrophy. During surgery, with the patient in a modified French position, the liver was completely mobilized. Then, a parenchymal transection plane was developed guided by RHV, AFV and IVC, while biliary radicals entering directly into the cyst were controlled individually. The complex transection plane resulted in preservation of the unaffected liver segments I, II, VI and VII. ConclusionThe multimodal approach demonstrated here included pretreatment with albendazole followed by safe laparoscopic pericystectomy. In the preoperative setting, albendazole can reduce the risk of recurrence if spillage occurs during surgery. In inoperable patients, it has been previously shown to be an effective monotherapy for small (< 5 cm) CE1 and CE3a cysts.5 For preoperative planning, an automated image reconstruction software (Fujifilm Synapse 3D) is used. The software creates a 3D model of the liver segmentation and vessels from contrast-enhanced CT and MR images. In addition to modelling the liver, port placement in relation to the liver is being simulated prior to surgery to optimize port placement at the time of surgery. During the case, the parenchymal transection is guided by RHV, AFV and IVC. The common postoperative complication of persistent biliary leakage was avoided by controlling each biliary radicals entering the cyst from the liver parenchyma. Biliary leaks are a common complication and have been positively correlated with the cyst diameter (~ 79% of cysts with diameter of 7.5 cm or greater have cysto-biliary fistula).6 In this context, indocyanine green may help to identify relevant biliary radicals entering the cyst or aid in recognizing bile leaks. If the stepwise approach described here is followed, minimally invasive pericystectomy represents a safe alternative to open surgery, harnessing the advantages of minimal risk of recurrence due to complete cyst removal and low morbidity.

Relationship of the Presence of the Inferior Right Hepatic Vein with the Right Hepatic Vein Diameter and CT Liver Volumetry.

Background Right hepatic venous anatomy, right lobe volume, and percentage of remnant liver are issues to be considered in preoperative planning especially transplantation. Objectives The aim of this study was to investigate the relationship of the presence of the inferior right hepatic vein (IRHV) with the right hepatic vein (RHV) diameter, right lobe volume, and percentage of remnant liver. Materials and Methods In t his cross-sectional study, the computed tomography (CT) images of 90 patients who underwent triphasic CT for being living liver donation were evaluated retrospectively. The number and diameter of IRHVs and the diameter of main RHV were recorded. For the liver volume analysis, a deep learning-based automatic liver segmentation (Hepatic VCAR) program was used. A virtual hepatectomy plane was drawn, where the right and left liver volumes were found and the percentage of the left lobe to the total liver volume was calculated. Pearson's correlation analysis was used for correlation analysis and Student's t -test was used to compare parameters. Results A total of 74 IRHVs were detected in 53 (58.88%) of 90 patients. There were no differences in the percentage of remnant left lobe volume, right lobe volume, and RHV diameter between the IRHV (+) and (-) groups. The RHV diameter had a weak negative correlation with the IRHV diameter, and a weak positive correlation with the right lobe volume. Conclusions The percentage of remnant left lobe volume, right lobe volume, and RHV diameter did not differ in liver donors with and without an IRHV. The RHV diameter had a weak negative correlation with the IRHV diameter and a weak positive correlation with the right lobe volume.

Laparoscopic modular extended right posterior sectionectomy for hepatocellular carcinoma guided by projection plane extension from the right hepatic vein

BackgroundExtended right posterior sectionectomy (ERPS) preserves more liver parenchyma than right hepatectomy when hepatocellular carcinoma (HCC) is in the right posterior section (RPS) and part of the right anterior section (RAS), but the difficulty lies in the precise determination of the cutting plane, especially under laparoscopy.[Torzilli et al. in Annals of surgery. 247:603–611, 2008] If the right hepatic vein (RHV) is not invaded by the tumor, it can help to divide the ventral and dorsal plane (VP, DP) as surgical landmark.[Makuuchi in International Journal of Surgery. 11:S47–S49, 2013] (Fig. 1) This study presented a laparoscopic modular ERPS (LMERPS) guided by projection plane extension from the RHV. MethodsA 56-year-old man was seen with HCC in the (RPS) and segment 8 following two laparotomies. After releasing intraperitoneal adhesions, the short hepatic veins were severed to expose the inferior vena cava (IVC). The right posterior Glission pedicle (RPGP) was clamped to control RPS inflow and allow determination of the demarcation line (DL) between the RPS and RAS using ICG fluorescence staining.[Chen et al. in Annals of surgical oncology. 29:2034–2040, 2022] Intraoperative ultrasound identified the RHV projection to satisfy the requirements of oncologic treatment. The VP and DP were incised along the DL and RHV projection. The RHV was exposed fully on the cutting plane and the tumor was completely removed finally. ResultsThe operation was completed in 265 min, with a blood loss of 50 ml. The diagnosis was HCC with a negative resection margin. The patient was discharged on postoperative day 8 without any complications. ConclusionLMERPS guided by a projection plane extending from the RHV is feasible and effective. Graphical Abstract [Display omitted]

Upper Transversal Hepatectomy with Two Hepatic Veins Reconstruction: Combining Parenchymal-Sparing Liver Surgery with Transplantation Techniques for Colorectal Liver Metastases

BackgroundColorectal liver metastases (CRLM) involving two or three main hepatic veins pose a surgical challenge. For these lesions, compelled surgical strategies have usually included major and/or extended liver resections according to the two-stage hepatectomy (TSH) strategy. More recently, a one-stage transversal hepatectomy resecting the posterosuperior liver segment (7,8,4 superior) along with one or more hepatic veins has been described, such as showed herein in a didactical video. MethodsThe patient is a 78-year-old woman with two large CRLMs located into segment 2 and into segment 8. Magnetic resonance imaging and computed tomography showed tumour stability after chemotherapy. The lesion of segment 2 is close to the left hepatic vein while the lesion of segment 8 infiltrates the middle (MHV) and the right hepatic veins (RHV). ResultsUnder intermittent pedicular clamping, resection of the segment 7, 8, 4 superior along with the right and middle hepatic veins is performed. Reconstruction of the veins was performed with 2 cryopreserved autologous saphenous grafts. Postoperative course was uneventful and postoperative CT scan showed patency of the two venous graft reconstructions. ConclusionsSurgery for CRLM has evolved over the last two decades shifting from large anatomical resections to parenchymal-sparing resections. Sparing liver parenchyma allows surgical radicality while reducing the risk of liver failure and allowing repeated liver resection. Associating vascular reconstruction to parenchymal-sparing surgery reduces the risk of venous congestion of the spared liver parenchyma.

Accessory Hepatic Vein Stenting in the Management of Budd-Chiari Syndrome: A Case Report

The Budd-Chiari Syndrome (BCS) is associated with hepatic venous outflow obstruction. A 22-year-old female patient presented with abdominal pain and backache for 12 days, along with generalised weakness. Physical examination revealed pitting pedal oedema and abdominal distension. An abdominal ultrasound with Doppler Ultrasonography (USG) was performed, revealing liver parenchymal disease with gross ascites and occlusion of all three Hepatic Veins (HV), suggestive of BCS. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) of the liver, as well as a right hepatic venogram using Digital Subtraction Angiography (DSA), showed chronic total occlusion at the ostium. An Accessory Hepatic Vein (AHV) was identified, joining the Right Hepatic Vein (RHV) to the Inferior Vena Cava (IVC). The accessory RHV exhibited high-grade stenosis (approximately 90-95%) at its junction with the IVC. Recanalisation of the AHV (balloon dilatation/stent insertion) was performed. Post-procedure accessory hepatic venogram showed a patent stented segment with a significant reduction in adjacent venous collaterals. No procedure-related complications were observed. The present case highlights the importance of AHV stenting in BCS patients, as it helps maintain normal physiology, in contrast to Direct Intrahepatic Porto-systemic Shunt (DIPS), which alters normal physiology by allowing portal venous blood to mix directly into the systemic circulation, bypassing the liver parenchyma.

Hepatic vein anatomy related to Laennec's capsule for liver resection.

Laennec's capsule is the proper membrane covering the entire surface of the liver parenchyma, including around the Glissonean pedicles and hepatic veins. Laennec's capsule around the hepatic veins has been clinically reported to comprise two layers: the hepatic and cardiac Laennec's capsules. However, where the cardiac Laennec's capsule is derived from and the two capsules' separability are still unclear. This study aimed to investigate the anatomy of the two capsules using cadaveric specimens. Histopathological examinations of autopsy specimens from four cadavers were conducted. Each specimen was sliced in the longitudinal section to include the pericardium, right hepatic vein (RHV), and inferior vena cava (IVC). Additionally, long-axis specimens of the RHV were obtained to determine the separability of the capsules and to examine the extent to which the capsules extended along the RHV. Laennec's capsule was estimated using elastic fiber staining. The cardiac Laennec's capsule is derived from the pericardium (parietal and visceral) and diaphragm and runs parallel with the IVC and hepatic veins associated with the hepatic Laennec's capsule. The two capsules were separable micro- and macroscopically. The hepatic Laennec's capsule was observed from the root to the peripheral side and the cardiac Laennec's capsule from the root to the middle side of the hepatic vein. The existence of the two layers of Laennec's capsule around the hepatic veins was confirmed histologically and they were separable. Identification and decollement of these layers would contribute to establishing safe and feasible anatomic liver resection techniques.

Counterclockwise modular laparoscopic anatomical mesohepatectomy using combined glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches.

Although laparoscopic anatomical hepatectomy (LAH) is widely adopted today, laparoscopic anatomic mesohepatectomy (LAMH) for patients with hepatocellular carcinoma (HCC) remains technically challenging. In this study, 6 patients suffering from solitary liver tumors located in the middle lobe of the liver underwent counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches. In this process, the Glissonean pedicle approach (Takasaki approach) was first used to transect the liver pedicles of segment right anterior (G58) and segment 4 (G4). Second, the hepatic vein-guided approach was performed along the umbilical fissure vein (UFV) to sever the liver parenchyma from the caudal to cranial direction, and the middle hepatic vein (MHV) and anterior fissure vein (AFV) were then disconnected at the root. Last, the hepatic vein-guided approach was once more performed along the ventral side of the right hepatic vein (RHV) to transect the liver parenchyma from the cranial to anterior direction, and the middle lobe of the liver, including the tumor, was removed completely. The entire process was applied in a counterclockwise fashion, and the exposure or transection sequence was G58, and G4, followed by UFV, MHV, AFV, and finally, the liver parenchyma along the ventral side of RHV. The counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches was feasible in all 6 cases. The median duration of the operation was 275 ± 35.07 min, and the mean estimated blood loss was 283.33 ml. All of the 6 patients recovered smoothly. The Clavien-Dindo Grade I-II complications rate was up to 33.33%, mainly characterized by postoperative pain and a small amount of ascites. No Clavien-Dindo Grade III-V complications occurred, and the mean postoperative hospital stay was 6.83 ± 1.47 days. Follow-up results showed that the average disease-free survival (DFS) was 12.17 months, and the 21-months OS rate, DFS rate and tumor recurrent rate were 100%, 83.33% and 16.67% respectively. Counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches takes the advantages of the two approaches, is a novel protocol for LAMH. It is thought to be technically feasible for patients with a centrally located solitary HCC. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. A multicenter, large-scale, more careful study is necessary.