Right Hepatic Vein Research Articles

Standardized upfront Glissonean approach and liver hanging maneuver reduces bile leakage from the hepatic hilum in living donors.

Biliary complications after hepatectomy in living donors have yet to be eradicated. We hypothesized that a standardized upfront Glissonean approach and liver hanging maneuver (GH) would prevent mechanical and thermal injuries to the hilar plate of the remnant liver by determining the point of bile duct division and the final destination of hepatectomy preceding liver parenchymal transection (safety) and facilitate liver transection deep within the parenchyma and allow maximum length of hilar structures (rationality). GH was implemented in 2016 and its incidence of bile leakage was retrospectively compared against the conventional technique. GH comprises six steps: (1) development of the retrohepatic avascular plane between the right hepatic vein (RHV) and the middle hepatic vein (MHV) and isolation of the hepatic vein(s); (2) isolation of the right or left Glissonean pedicle with the corresponding Glissonean pedicles of the caudate lobe; (3) for right liver grafts and left liver grafts with the caudate lobe, passage of the tape for the liver hanging maneuver along the retrohepatic avascular plane and above the hilar plate, and for left liver grafts without the caudate lobe and for left lateral section grafts, passage of the tape from between the RHV and the MHV, along the Arantius ligament, and to the right of the umbilical portion; (4) liver transection; (5) isolation of hilar structures; and (6) graft procurement. Until 2020, 62 consecutive living donors underwent GH (success rate, 100%). The incidence of bile leakage from the hepatic hilum (0%) was significantly lower than that among 59 donors who underwent the conventional technique in 2011-2015 (9%; p = 0.01). In conclusion, GH is highly effective in reducing bile leakage from the hepatic hilum in living donors.

Long-Term Patency of All-in-One Sleeve Patch Graft Venoplasty in 16 Patients Who Underwent Living Donor Liver Transplantation with a Right Liver Graft: A 10-Year, Single-Center, Retrospective Study.

BackgroundThis retrospective study from a single center aimed to evaluate the long-term patency of all-in-one sleeve venoplasty (ASV) in 16 patients who underwent living donor liver transplantation (LDLT) with a right liver graft (RLG) between 2009 and 2019. ASV unifies the right hepatic vein (RHV), short hepatic vein (SHV), and middle hepatic vein (MHV) of an RLG. ASV enables wide side-to-side anastomosis to the recipient inferior vena cava (IVC).Material/MethodsOf 2875 patients who underwent LDLT with an RLG from August 2009 to July 2019, 16 (0.5%) patients underwent ASV. We analyzed the ASV techniques applied to these patients, as well as patient long-term outcomes.ResultsType 1 ASV unified 1 RHV, 1 IRHV, and 1 MHV conduit (n=12 [75.0%]). Type 2 ASV unified 1 RHV, multiple IRHVs, and 1 MHV conduit (n=4 [25.0%]). All patients are currently alive, with a mean follow-up period of 70.1±41.9 months. No patient underwent retransplantation. Follow-up computed tomography showed SHV occlusion in 1 (6.3%) patient at 4 months, resulting in 1-, 3-, and 5-year SHV patency rates of 93.8% each. MHV occlusion was identified in 6 (37.5%) patients, with 1-, 3-, and 5-year MHV patency rates of 81.3%, 68.8%, and 68.8%, respectively (P=0.037). No patient underwent endovascular stenting of the SHV or MHV. Patency rates were significantly higher for SHV than MHV (P=0.037).ConclusionsASV using various vascular patches is a useful technique enabling secure reconstruction of an RLG in grafts with complex hepatic vein anatomy or recipients with poor IVC condition.

A comprehensive framework of the right posterior section for tailored anatomical liver resection based on three-dimensional simulation system.

BackgroundThe anatomical right posterior sectionectomy (ARPS) is a technically challenging procedure. We aimed to develop and validate a novel framework of the right posterior section for a safe and tailored anatomical liver resection (ALR) based on a three-dimensional (3D) simulation system.Methods3D hepatectomy simulations of healthy participants who underwent contrast-enhanced computed tomography of the upper abdomen were retrospectively reviewed to develop the framework according to the relationship between the simulated plane determined by the right posterior portal pedicle (RPP) and the course of the right hepatic vein (RHV) trunk. The framework was validated in the practice of ARPS for hepatocellular carcinoma (HCC) prospectively.ResultsScans from 336 eligible participants were assessed. The framework was summarized into four types: normal, caudal-redundant, cranial-deficient, and combined types, accounting for 43.4% (146/336), 25.3% (85/336), 18.5% (62/336), and 12.8% (43/336) respectively. The caudal-redundant type was associated with the variable portal branches of the RPP or segment 6 branch across the ventral side of RHV. The mean aberrant volume proportion in type IIa was significantly greater than that in type IIb (P<0.001), which were 7.0%±3.5% and 4.4%±1.8% respectively. The cranial-deficient type was associated with the aberrant segment 7 portal pedicle originating from the right portal trunk or the dorsal portal branch of segment 8 crossing over to the RHV. The median aberrant volume proportion in type IIIa was significantly greater than that in type IIIb (P<0.001), which were 10.9% (8.5–13.3%) and 4.0% (3.0–6.1%), respectively. The combined type represented a combination of the caudal-redundant type and the cranial-deficient type. The framework provided instructions on tailored ARPS in 6 patients with HCC by maximizing lesion removal and functional liver remnant with favorable perioperative outcomes.ConclusionsPrecise preoperative planning with an individualized surgical approach based on our framework allows safe anatomical liver resections for cases with lesions in the right posterior section.

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.

Correlation between anthropometric data and preparatory maneuvers difficulties during laparoscopic right liver resections: a single center prospective study.

The difficulty of laparoscopic right liver resections (LRLR) is mainly associated with their poor accessibility. Anthropometric data rather than BMI was reported to predict transection time and blood loss. Aim of the study was to evaluate the correlation between anthropometric data and preparatory manoeuvres difficulties during LRLR. All patients who underwent LRLR requiring full right liver mobilization from November 2019 to March 2021 were prospectively included in the study. Data on surgeons' difficulty perceptions on liver mobilization (LM), isolation of right hepatic vein (RHVI), liver manageability and visibility were rated with a 5-point scale. Data on cranio-caudal liver diameters (CCliv), CHALLENGE Index (CCliv/latero-lateral abdomen diameter), times needed to LM and RHVI were collected. Sixty-five patients (29 wedge and 36 anatomical resections) with a median BMI of 25.5 were analysed. One patient required open conversion due to oncological reason. No correlations between BMI and CCliv or CHALLENGE Index were found. Larger CCliv diameter correlated with longer time for both RHVI (r = 0.589, p = 0.002) and LM (r = 0.222, p = 0.049). Higher CHALLENGE index correlated with longer time for RHVI (r = 0.589, p = 0.002). The CHALLENGE index showed a linear correlation with difficulty to the isolation of RHV (r = 0.327, p = 0.045), whilst the liver manipulation difficulty increased with latero-lateral liver diameter (r = 0.244, p = 0.033). BMI had no correlation with the duration of preparatory maneuvers neither with surgeons' difficulties. Anthropometric data can help to anticipate the difficulty of preparatory maneuvers during laparoscopic right liver resections.

Parietal peritoneum as a vascular substitute for the reconstruction of donor inferior vena cava in living donor liver transplantation

Living donor liver transplant is technically more difficult than deceased-donor liver transplant because of the shorter and narrower vascular stumps and presence of multiple biliary ducts in partial liver grafts. Division of the vascular structures quickly and precisely is a prerequisite to decrease ischemia time as well as to prevent narrowing in donor vascular structures. Intraoperative vascular complications of donor hepatectomy are under-reported. Here, we report a case of inadvertently cut donor inferior vena cava (IVC) during the division of right hepatic vein (RHV) leading to narrowing of IVC which was repaired successfully using a parietal peritoneal patch from the falciform ligament.

Transjugular Liver Biopsy: A Case of a Phrenic Vein Mimic of the Right Hepatic Vein.

Proposed by Charles Dotter[1] and expanded upon by Hanafee and Weiner,[2] transjugular liver biopsy (TJLB) is a well-established, validated, and safe alternative to percutaneous hepatic tissue sampling in patients with acute or chronic hepatic dysfunction who are at risk for hemorrhage. Here, the authors describe a case in which a right phrenic vein mimic of the right hepatic vein (RHV) resulted in nontargeted sampling of diaphragmatic skeletal muscle and a small hemothorax.

En Bloc Resection of a 60cm Recurrent Dedifferentiated Liposarcoma Involving the Liver, Right Kidney and Ascending Colon

This case report was about a giant recurrent dedifferentiated liposarcoma which invaded the intraperitoneal space to the posterior sector of liver, attaching the right hepatic vein (RHV) and inferior vena cava (IVC). It had already encased the right kidney, right ureter, right colon and mesocolon. The whole IVC was compressed and pushed to the left side and ventral side of the abdominal space by this giant tumour. The posterior approach cannot be done due to the heavy giant tumour (about 28 Kg) and change of anatomy landmarks. By anterior approach to cut into the liver parenchyma, dissection and exposure along the surface of RHV can advance to the IVC surface. Small venous outflow tracts from the tumour to the surface of RHV and IVC were exposed, ligated and separated. After the junction of RHV and retrohepatic IVC was exposed, cranial to caudal dissection using an ultrasonic aspirator along the ventral, lateral and posterior surface of IVC can separate the IVC wall from the tumour clearly. Further dissection downward along the surface of the twisted IVC was useful to separate the tumour from the posterior side of pancreatic head, portal vein, superior mesentery vein (SMV), and the root of right renal vein. In conclusion, an anterior approach of hepatotomy for RHV first and then IVC is a useful method for this giant tumour if the posterior approach for IVC exposure cannot be done.

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.

Quantitative analysis of contrast-enhanced ultrasonography following living donor liver transplantation: early diagnosis of middle hepatic venous occlusion.

This study aimed to evaluate whether a quantitative contrast-enhanced ultrasonography (CEUS) study is feasibleto diagnose middle hepatic venous occlusion after living donor liver transplantation (LDLT). FromDecember 2018 to July 2019, the CEUS study on the first postoperative day had been conducted in patients who underwentLDLT. 46 patients were finally included in the study. To obtain CEUS parameters from time-intensity curves (TICs) on the hepaticparenchyma, the two regions of interests (ROIs) were located in the right hepatic vein (RHV) territory and middle hepaticvein (MHV) territory of the right hepatic graft. The measured CEUS parameters were wash-in slope (WIS), peak intensity(PI), time to peak (TTP), and area under the curve (AUC). The subjects were classified into the occlusion and non-occlusiongroups. In each group, the parameters measured in the RHV and MHV territories were compared with paired-sample Student'st-tests. Hepatic venous occlusion was diagnosed in 25 patients (54%). The WIS, TTP, and AUC of the MHV territory(2.95 dB/sec; 22.39 sec; 204.27 dB·sec, respectively) were significantly different from those of the RHV territory (2.16 dB/sec; 25.81 sec; 165.66 dB·sec; all p<0.05). There were no statistically significant differences in PI between the MHV and RHVterritories (19.08 dB vs. 18.27 dB, respectively; p=0.259). In the non-occlusion group, there was no parameter which wassignificantly different between MHV and RHV territories (p>0.05). The parametric analysis of CEUS can helpdiagnose middle hepatic venous occlusion after LDLT.

Laparoscopic Anatomic Liver Resection of the Dorsal Part of Segment 8 Using an Hepatic Vein-Guided Approach

Laparoscopic anatomic liver resection is considered highly challenging, especially in segment 8 (S8), owing to the limited angle of the laparoscope and limited manipulation of the surgical instrument1,2. Additionally, resection is technically difficult when approaching the more peripheral branches since the Glissonean pedicle of S8 has several variations3 and is far from the hepatic hilum. The hepatic vein (HV)-guided approach involves entering from the cranial side of the liver while overcoming these difficulties with the unique view and techniques of laparoscopy4,5. We describe laparoscopic anatomic resection of the dorsal part of S8 using the HV-guided approach for hepatocellular carcinoma. The drainage vein of segment 8 (V8), which often runs between the ventral and dorsal parts of S86,7, was exposed from the confluence of the middle HV to the periphery. The dorsal Glissonean branch of S8 (G8dor) was identified by deep dissection of the parenchyma on the right side of the V8. The right HV (RHV) was exposed toward the periphery after dissecting the G8dor. Liver parenchymal dissection was completed by connecting the demarcation line and the RHV. The total operation time was 319 min, estimated blood loss was 5mL, and the patient was discharged on postoperative day 6 with no complications. Laparoscopic anatomic resection of the dorsal parts of S8 could be safely performed by exposing the HVs from their roots and using the HVs as a landmark to identify the intrahepatic Glissonean pedicles.

Major vessel bleeding control experience in laparocopic major hepatectomy

Laparoscopic hepatectomy (LH) is worldwidely spread, because LH needs small incision which cause less pain. But during LH, it is hard to control major bleeding. Patient could be in dangerous situation. So we will propose some tips to make control major bleeding during LH. The first case had 2.5 cm hepatocellular carcinoma in segment 5/6. We planned to laparoscopic right hemihepatectomy. After surgery, he had no special event. And he had discharge, at pod 6. The second case underwent low anterior resection due to rectosigmoid colon cancer 6 years ago. He had 3 cm metastatic colon cancer in liver. We planned to laparoscopic right hemihepatectomy. during surgery, uncontrolled massive bleeding happened, he arrested. So open conversion was done. And he had discharge, at pod 5. In the first case, there was bleeding during ligation of vessel by hemoloc. We couldn't recognized bleeding focus. So more liver parenchymal dissection was done. We found that inferior vena cava (IVC) which is base of right hepatic vein (RHV) inferior wall was laceration. The operative used laparoscopic surgical stapler for division of RHV and bleeding control. In the second case, liver parenchyma was dissection fully and ready to division the RHV. Operator dissect posterior wall of RHV by golden finger and dissector. At this moment, IVC which is base of RHV was laceration. operator tried to control bleeding by suture IVC. But the patient arrested. Open conversion operator was done. We suggest laparoscopic surgical stapler rather than manual suture, during massive bleeding.

Systematic Extended Right Posterior Sectionectomy (SERPS) for secondary liver tumors, a tale of two cases

The role of liver resection in secondary liver tumors are growing along with the consequences of Post Hepatectomy Liver Failure (PHLF). Systematic Extended Right Posterior Sectionectomy (SERPS) is offered as an alternative to resect secondary liver tumors in segment 6-7 with vascular invasion towards right hepatic vein (RHV) compared to the right hepatectomy procedure in the past. The goal of SERPS procedure itself is maintaining appropriate oncological border, while minimizing the risk of PHLF. We aim to describe two patients with liver metastases in segment 6-7 with RHV vascular invasion, due to GIST and colorectal cancer metastases, which undergone USG guided SERPS in 2020. We reported the patients' primary tumor characteristics, adjuvant chemotherapy, surgical outcomes, PHLF incidence measured with ISGLS criteria, and liver metastases recurrencies in 3 months post-operative. No tumor recurrencies and mortalities due to primary tumors or complications were detected in 3 months post-operative follow-ups. No PHLF incidence were detected. SERPS is a safe and promising alternative for secondary liver tumors at segment 6-7 and RHV vascular invasion. Thus, minimizing the risk of PHLF by saving larger volume of future liver remnant.

Surgical relevance of anatomic variations of the right hepatic vein.

BACKGROUNDVariations in the anatomy of hepatic veins are of interest to transplant surgeons, interventional radiologists, and other medical practitioners who treat liver diseases. The drainage patterns of the right hepatic veins (RHVs) are particularly relevant to transplantation services.AIMThe aim was to identify variations of the patterns of venous drainage from the right side of the liver. To the best of our knowledge, there have been no reports on RHV variations in in a Caribbean population.METHODSTwo radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center. Venous outflow patterns were observed and RHV variants were described as: (1) Tributaries of the RHV; (2) Variations at the hepatocaval junction (HCJ); and (3) Accessory RHVs.RESULTSA total of 118 scans met the inclusion criteria. Only 39% of the scans found conventional anatomy of the main hepatic veins. Accessory RHVs were present 49.2% and included a well-defined inferior RHV draining segment VI (45%) and a middle RHV (4%). At the HCJ, 83 of the 118 (70.3%) had a superior RHV that received no tributaries within 1 cm of the junction (Nakamura and Tsuzuki type I). In 35 individuals (29.7%) there was a short superior RHV with at least one variant tributary. According to the Nakamura and Tsuzuki classification, there were 24 type II variants (20.3%), six type III variants (5.1%) and, five type IV variants (4.2%).CONCLUSIONThere was significant variation in RHV patterns in this population, each with important relevance to liver surgery. Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.

Pediatric living-donor liver transplantation using right posterior segment grafts

BackgroundThe right posterior segment (RPS) graft was introduced to overcome graft size discrepancy in living donor liver transplantation (LDLT). However, it was very rarely used in pediatric patients. Here we presented 4 pediatric LDLT cases receiving RPS graft between January 2015 and April 2020 in our center. A total of 1868 LDLT procedures were performed in this period.MethodsRecipients included 1 boy and 3 girls with a median age of 45 months (range from 40 to 93 months). They were diagnosed with progressive familial intrahepatic cholestasis, propionic academia, ornithine transcarbamylase and biliary atresia, respectively. Four donors were all mothers with a median age of 32.5 years (31–38 years). Computer tomography angiography indicated posterior right branches branched off separately from main portal veins (type III variation). Three of these donor livers had 1 orifice of right hepatic veins (RHV). In the remaining 1 donor liver, the RHV showed 3 orifices and an outflow patch plastic was performed. Inferior right hepatic veins weren’t found in four donor grafts. The median graft weight was 397.5 g (352–461 g) and the median graft-to-recipient weight ratio was 2.38% (1.44–2.80%).ResultsPostoperative complications occurred in neither donors nor recipients. Within the median follow-up duration of 29 months (14–64 months), four children are all alive with normal liver function.ConclusionIn summary, for older children weighed more than 15 kg with donors’ variation of type III portal veins, the use of RPS grafts could be a feasible and favorable option.

Living donor liver transplantation for Budd\u2012Chiari syndrome with right posterior segment graft and patch plasty using the superficial femoral vein: a case report

BackgroundIn living donor liver transplantation (LDLT) for patients with Budd‒Chiari syndrome (BCS), there are several concerns about reconstruction of the inferior vena cava (IVC) and hepatic veins. Herein, we report the case of a patient with BCS who underwent LDLT with right posterior segment graft (RPSG) and patch plasty for reconstruction of the hepatic venous outflow, using the patient’s own superficial femoral vein (SFV).Case presentationA 19-year-old man, who was diagnosed with primary BCS, underwent LDLT. His main hepatic veins were totally obstructed, and membranous stenosis was seen in the IVC. The LDLT donor was his mother; however, liver volumetric analysis showed that only her RPSG was appropriate. In the recipient surgery, 16 cm of the left SFV was harvested and was cut longitudinally and opened. The right hepatic vein (RHV) of the RPSG was anastomosed to the sidewall of the SFV graft. After explantation of native diseased liver was completed, the stenotic and thickened wall of the IVC was widely resected, and a large anastomotic orifice was created. Patch cavoplasty was performed with the RHV‒SFV graft patch. After portal reperfusion started, hepatic venous outflow was satisfactory, and there was no venous graft congestion. Both his postoperative course and his long-term course after discharge were uneventful.ConclusionsIn LDLT for BCS patients, ingenuity is required for the reconstruction of venous outflow. The SFV patch can be safely harvested from liver transplant recipients and is suitable for venous reconstruction. In addition, RPSG is an alternative type of liver graft for LDLT if a conventional right- or left-lobe graft cannot be used.

Preserving inferior right hepatic vein enabled bisegmentectomy 7 and 8 without venous congestion: a case report

BackgroundIn hepatectomy, the preservation of portal perfusion and venous drainage in the remnant liver is important for securing postoperative hepatic function. Right hepatectomy is generally indicated when a hepatic tumor involves the right hepatic vein (RHV). However, if a sizable inferior RHV (IRHV) exists, hepatectomy with preservation of the IRHV territory may be another option. In this case, we verified the clinical feasibility of anatomical bisegmentectomy 7 and 8 with RHV ligation, averting the right hepatic parenchyma from venous congestion, utilizing the presence of the IRHV.Case presentationA 70-year-old man was presented with a large hepatic tumor infiltrating the RHV on computed tomography during a medical checkup. The patient was diagnosed with hepatocellular carcinoma (HCC), T2N0M0, stage III. Right hepatectomy was first considered, but multi-detector computed tomography (MDCT) also revealed a large IRHV draining almost all of segments 5 and 6, suggesting that IRHV-preserving liver resection may be another option. The calculated future remnant liver volumes were 382 mL (26.1% of the total volume) after right hepatectomy and 755 mL (51.7% of the total volume) after anatomical bisegmentectomy 7 and 8; therefore, we scheduled IRHV-preserving anatomical bisegmentectomy 7 and 8 considering the prevention of postoperative liver failure and increased chance of performing repeat resections in cases of recurrence. Preoperative three-dimensional simulation using MDCT clearly revealed the portal perfusion area and venous drainage territories by the RHV and IRHV. There was an issue with invisibility of the anatomical resection line of segments 7 and 8, which was completely dissolved by intraoperative ultrasonography using Sonazoid and the portal dye injection technique with counter staining. The postoperative course in the patient was uneventful, without recurrence of HCC, for 30 months after hepatectomy.ConclusionsIRHV-preserving anatomical bisegmentectomy 7 and 8 is a safe and feasible procedure utilizing the three-dimensional simulation of the portal perfusion area and venous drainage territories and the portal dye injection technique.

Urgent intraoperative endovascular stent placement to resolve acute hepatic or portal venous obstruction during liver surgery: a case series

BackgroundAcute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed.Case presentationWe report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively).ConclusionsThe IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.

Extended left trisegmentectomy combined with the three main hepatic veins ligation and inferior vena cava (IVC) resection for intrahepatic cholangiocarcinoma (ICC)

Purpose: ICC represents 10-15 % of all malignant hepatic neoplasms. Tumours infiltrating confluence of hepatic veins and IVC are often considered inoperable, especially in elderly patients, since maintainance or reconstruction of venous outflow would require ante situm resection or total vascular exclusion (TVE). Methods: We present the case of a 75 yo woman with history of pulmonary embolism in chronic oral anticoagulant treatment, incidentally diagnosticated with a hepatic mass infiltrating the confluence of hepatic veins and IVC. An extended left trisegmentectomy was performed, with ligation of the three main hepatic veins and IVC resection. Venous outflow of the remnant was guaranteed by preservation of the right inferior hepatic vein (RIHV). Results: Two units of packed red blood cells were transfused. Post operative course was complicated with grade A liver failure. Patient was discharged in 8 pod with normal liver function tests. Diagnosis of biliary type adenocarcinoma pT2N0M0 G2 was made after histological examination. Conclusion: RIHV draining the posteroinferior area of the right liver is described in 17-20 % of population. In 1987, Makuuchi proposed theoretically four types of hepatectomy with resection of the main right hepatic vein (RHV) and preservation of the RIHV. In 1991, Blumgart performed first the procedure, calling this new operation subtotal hepatectomy. Only 9 cases have been described in literature ever since. In 3 of these cases the IVC was also infiltrated. In 3 cases, the surgical procedure was preceded by left portal vein and/or RHV embolization to obtain liver remnant hypertrophy. In 2 cases the operation was performed in 2 steps (ALLPS). In our case, we combined the anterior approach with a modified Hanging Manouver to suspend and resect the liver cranially to the RIHV outlet, then proceeding with ligation of the three main hepatic veins and IVC resection on a tangential clamping. In this way it was possible to perform surgery without total vascular exclusion (TVE). This approach was well tolerated hemodynamically and more feasible than ante situm resection or TVE. Critical aspects remain the section line irregularity and the hepatic congestion due to the venous outflow block which causes more venous bleeding during the parenchymal transection. Another aspect of the procedure is the evaluation of the liver remnant congestion, which in our case was excluded by a clamp test of the posterior hepatic artery and of the RHV stump.

Parenchymal-Sparing Hepatectomies for Colorectal Liver Metastases

Introduction: Parenchymal-sparing hepatectomies (PSH) have been performed widely for the patients of colorectal liver metastases (CLM) to preserve much liver parenchyma and allow for future re-resection. Herein, we divide PSH into 3 types of hepatectomies,ⅰ)limited anatomical resection,ⅱ)tumor-vessel detachment resection, andⅲ)tumor enucleation locating at the deep part of liver parenchyma from the parenchymal slit. In this presentation, we show each case, and evaluate the feasibility. Case1: In this case, the tumor was located at the boundary of S1 and S4. The tumor was 2cm in size, and involving the main trunk of middle hepatic vein (MHV). To preserve lateral section and left hepatic vein, we selected anatomical S1/S4 resection concomitant with MHV resection. Case2: The second patient had a tumor in S7, which was adjacent to the right hepatic vein (RHV). To preserve the venous return from the posterior section, we performed partial resection by detaching the tumor from the RHV. Case3: The last patient had multiple CLMs in bilateral lobe. Most tumors were located in the shallow part of liver parenchyma and dissected by partial resections. However, one tumor in S8 was located at the deep part of liver. Hence, we made parenchymal slit and enucleated the tumor. Results: We archived R0 resection in all cases. Postoperative mortality and morbidity were nil. Conclusions: PSH can be classified into 3 types. All types of PSH are feasible and can be performed safely.