Right Hepatic Vein Research Articles

Serial cardiac MRIs in adult Fontan patients detect progressive hepatic enlargement and congestion.

The progression of hepatic disease in adult Fontan patients is not well understood. They reviewed the experience with serial cardiac MRIs (CMR) in adult Fontan patients to determine if hepatic anatomic markers of prolonged Fontan exposure were present and if clinical predictors of progressive hepatic congestion could be identified. A retrospective cohort study of all adult Fontan patients who had undergone at least two CMRs was performed. Hepatic dimensions, inferior vena cava (IVC) size, right hepatic vein (RHV) size and spleen diameter were determined from images acquired at the time of clinically guided CMR. Two radiologists with expertise in hepatic imaging graded congestion and liver size independently using post-gadolinium contrast sequences. Twenty-seven patients met inclusion criteria. Over a mean time of 5.1 years between CMRs, there was a significant increase in mean lateral-medial hepatic dimension (P = .005), mean RHV diameter (P = .004), and mean splenic diameter (P = .001). Serial post-gadolinium imaging was available in 25/27 (93%) patients of which 15/27 (55%) showed evidence of progressive hepatic congestion across serial studies. Progressive hepatic congestion was associated with single ventricle ejection fraction (SVEF) less than 50% (P = .008), and larger indexed end-diastolic (EDVI) and end-systolic volume (ESVI). RHV diameter was the only anatomic variable significantly correlated with time from Fontan completion (P = .004). Serial CMRs detected progressive liver and hepatic vein enlargement in our cohort of adult Fontan patients over a mean time of 5.2 years. Progressive hepatic congestion occurs in a significant number of adult Fontan patients and may be associated with ventricular enlargement and decreased ventricular function by CMR.

Identification of intra-hepatic communicating veins through the arch sign on CT-scan.

Knowledge of vascular outflow is essential in liver surgery. Communicating veins between the right hepatic vein (RHV) and the middle hepatic vein (MHV) have been described and allowed us to perform new surgical procedures. The aim of this study was to predict the existence of intra-hepatic venous anastomosis by identifying communicating veins on 2D CT-scan imaging. We retrospectively analysed data from 32 patients operated on for liver tumours between 2004 and 2013 who underwent a bisegmentectomy VI-VII enlarged to the RHV and/or a bisegmentectomy VII-VIII and/or a left hepatectomy enlarged to the MHV and who had pre and post-operative CT-scans. Patients with cirrhosis were excluded. We first analysed post-operative images and, in patients with a proven collateral vein, looked for evidence of this on pre-operative imaging. We then validated this pre-operative sign against post-operative imaging. Collaterals from both the RHV and the MHV formed an arch visible on pre-operative imaging which predicted the development of intrahepatic venous anastomosis in 20 patients. In 14 patients, a perfect match between the arch sign and development of collaterals was observed (n=28). Sensitivity, specificity, negative and positive predictive values were 87, 80, 80, and 87%, respectively. Positive and negative likelihood ratio tests were 4.3 and 0.16, respectively. Communicating veins between the RHV and the MHV are frequent and can be predicted by the arch sign on 2D CT-scan. Hence the arch sign can be very useful when planning liver surgery.

Venous drainage map of the liver for complex hepatobiliary surgery and liver transplantation

BackgroundInflow and outflow patency of the liver parenchyma is required to maximize the metabolic function of the liver. However, the definition and distribution of hepatic venous drainage regions has yet to be reported. The aim of this study was to define major hepatic venous tributaries and investigate the mean drainage volume of each territory. MethodsThree-dimensional (3D) simulations from the livers of 100 healthy donors were reviewed for living donor liver transplantation to determine the distribution of the significant hepatic venous tributaries and the drainage patterns of each segment. ResultsThe left hepatic vein (LHV), middle hepatic vein (MHV), and right hepatic vein (RHV) contributed a mean drainage of 20.7%, 32.7%, and 39.6% of the entire liver, respectively. Accessory hepatic veins accounted for remaining 7.0%. The middle right hepatic vein (MRHV) and inferior right hepatic vein (IRHV) accounted for a mean total drainage of 8.0% and 10.6%, respectively, when they present. In addition, major tributaries of hepatic veins were clearly detected, and their typical distributions were described. ConclusionsKnowledge of hepatic venous territories is necessary for complex hepatobiliary surgery. This “venous drainage map” may provide useful information for complex liver surgery and transplantation.

Approach to hepatocaval confluence during laparoscopic right hepatectomy: three variations on a theme.

Due to technical challenges and reduced pool of candidates, laparoscopic major hepatectomies remain relatively limited: In particular, right hepatectomy is technically more challenging than left since it requires liver mobilization, dissection of inferior vena cava (IVC) and hepatocaval confluence (HepCC), and section of right hepatic vein (RHV). Among 53 laparoscopic right hepatectomies (San Raffaele Hospital; 2013-2015), the approach to HepCC was standardized by three techniques: (1) primary approach to IVC and RHV with complete mobilization of right hemiliver; (2) anterior approach with hanging maneuver without liver mobilization (partial anterior approach-PAA); and (3) anterior approach without hanging maneuver without liver mobilization of right hemiliver (total anterior approach-TAA). The technique was defined preoperatively based on tumor size/position, IVC/RHV compression, and HepCC dislodgement. Type of parenchyma and risk of lesion rupture were also evaluated. Primary approach to IVC and RHV Before liver transection and after liver mobilization, IVC dissection is performed, and RHV is isolated and suspended on a vessel loop. RHV is sectioned after parenchymal transection. no compression by tumor of IVC/RHV, no HepCC dislodgement, soft parenchyma, no risk of lesion rupture. PAA IVC and HepCC are dissected free before transection, without previous liver mobilization; a tape is positioned in front of the anterior aspect of IVC, to perform the hanging maneuver. RHV section is performed after parenchymal transection. huge masses without compression of IVC/RHV, no HepCC dislodgement, liver stiffness, risk of lesion/parenchyma rupture. TAA Both IVC and RHV dissections are performed at the end of parenchymal transection, without previous mobilization of right lobe. huge masses with compression of IVC/RHV, HepCC dislodgement. Different approaches are available for HepCC dissection during laparoscopic right hepatectomy: Liver parenchyma characteristics, tumor size, and relationship with HepCC should be considered in surgical planning, to achieve satisfactory outcomes.

Three-Dimensional Computed Tomography Scan Analysis of Anatomical Variations in the Hepatic Veins

Hepatic venous anatomy is a significant component of liver segmental anatomy, and its high variability is a challenge for hepatobiliary surgeons. This was a retrospective study of 98 consecutive patients with no cirrhosis or malignant tumors. IQQA-Liver software was used to display and analyze three-dimensional (3D) images of the hepatic veins and their branches and variations. The average liver volume was 1272.65 ± 322.04 mL; the left hepatic veins drained the smallest parts (21.13 ± 5.41%) of the liver compared with the right (35.58 ± 12.41%) and middle hepatic veins (34.64 ± 8.76%). The most common pattern was that the left hepatic veins shared a common trunk with the middle hepatic veins in 51cases (52.0%). The visualization rate of the inferior right hepatic vein (IRHV) was 43.9%, and its drainage volume was 179.27 ± 128.79 mL. In 11.2% of patients, the drainage volume for the IRHV was larger than for the right hepatic vein (RHV). The patterns of the left hepatic and middle hepatic veins were also observed and classified. Umbilical hepatic veins appeared in 75 cases (76.5%), and anterior fissure hepatic veins appeared in 74 cases (75.5%).The rate of the presence of a separate segment 4 vein was 15.3%, and 77 patients had obvious superficial veins. There was a statistically significant correlation between the diameter of the IRHVs and the drainage volume of the IRHVs and RHVs. More detailed information about the anatomical features and variations of hepatic venous veins in Chinese people was provided using 3D reconstructions, and this will assist in more precise liver surgeries.

Impact of Different Dominant Hepatic Vein Patterns in Left-Lobe Donors of Adult Living Donor Liver Transplantation

ObjectiveOptimal hepatic venous tributary flow is correlated with liver function and regeneration. In left-lobe graft living donor liver transplantation, the stump of segment 5 and 8 hepatic veins (S5V and S8V) are ligated without performing hepatic tributary reconstruction. The aim of this article was to evaluate the different dominate hepatic vein patterns that affect left-lobe living donor safety. Materials and MethodsA total of 44 donors who underwent left-lobe hepatectomy were divided into 2 groups, middle hepatic vein (MHV) dominance (group 1) and right hepatic vein (RHV) dominance (group 2), according to the dominant venous territory drainage from S5V and S8V or RHV. The clinical pathological data, postoperative laboratory data, complication, remnant liver volume and remnant liver regeneration rate at 6 months after surgery were compared. ResultsNo difference was found in blood loss, postoperative liver function such as alanine transaminase value, complications, and hospital stays between groups. Group 1 had slightly higher total bilirubin level than group 2 (1.99 vs 1.79; P = .49). Group 2 had significantly better remnant liver regeneration rate than group 1 (89.2% vs 82.5%; P = .026). ConclusionIt is important to recognize the dominant MHV group. Ligation large S5V and S8V in dominant MHV donors led to lower remnant liver regeneration in our series. This might be critical in extremely small RHV territory and potential large remnant liver congestion donors. Adjusting surgical planning, such as hepatic vein reconstruction, in this kind of donor might be appropriate for donor safety.

Laparoscopic anatomic liver resections for hepatocellular carcinoma

Aims: Liver resection is the most important treatment for patients with hepatocellular carcinoma (HCC), offering a possibility of cure. Because of the risk of portal metastases through microscopic vascular invasion, anatomic liver resection is generally assumed to be superior to non-anatomic resection. Aim of the video is to demonstrate how anatomic resections for HCC can be effectively performed laparoscopically thanks to laparoscopic ultrasound (LUS) guidance. Methods: Our technique of LUS guided liver resection is showed. A first scan is performed to complete staging and defining the relationships of the tumor and intrahepatic vasculo-biliary pedicles. To be always aware of the liver anatomy, both in planning the resection and during transection, the planes where main vascular structures run are marked with the electrocautery on the liver surface. When all the vessels are identified and marked, the resection lines are designed on the liver surface with the electrocautery. Results: The first case is a segmentectomy of Sg3. Sg3 pedicle and left hepatic vein are marked. The resection is carried with ultrasound dissector. At the end of the resection left hepatic vein (LHV) is exposed on the liver surface. Segment 2 is spared without any remnant ischemic parenchyma.The second case is a resection of Sg4b. LUS shows the tumor infiltrating a Sg4b main pedicle while superior pedicles are free. Segment 4 superior and inferior pedicles and right hepatic vein (RHV) are marked on liver surface. The resection is completed sparing the superior pedicle of Sg4 and exposing the RHV on the liver surface. The last case is a Sg5 segmentectomy. Two Sg5 pedicles are marked as well as right and middle hepatic vein. The section line is traced along the lines of the structure that will be spared and across the ones that will be cut and the resection is completed. Conclusions: LUS guided laparoscopic anatomic liver resections are feasible and safe.

Simultaneous implantation of bilateral liver grafts in living donor liver transplantation by fusion venoplasty

Small-for-size syndrome is a serious complication after living donor liver transplantation (LDLT). LDLT using dual grafts offers an alternative to solve this problem. In case of a right and left liver graft adopted for dual graft LDLT, sequential implantation of the right graft followed by the left graft is the usual approach. However, left hepatic vein and portal vein anastomosis could be challenging when the right subphrenic space is occupied by the right liver graft, and this problem could be avoided by simultaneous implantations of bilateral grafts. In this video, the technique of simultaneous implantation of bilateral living donor liver grafts via fusion venoplasty (FV) in a 59-year old patient with acute liver failure was presented. We performed FV at the backtable to join the right hepatic vein (RHV) and middle hepatic vein (MHV) to create one venous outflow in the right liver graft, the left liver was approximated to the right liver graft at the backtable followed by FV joining the left hepatic vein to the R/MHV venous cuff before anastomosis with the inferior vena cava. The right and left portal veins were then joined together to create one common orifice before anastomosis with the recipient's main portal vein. The graft right and left hepatic artery were anastomosed with the recipient's right and left hepatic artery respectively. Biliary reconstruction was performed via a duct-to-duct anastomosis for the right liver graft and a hepaticojejunostomy for the left liver graft. [Bilateral liver grafts after fusion venoplasty]

Reconstruction of hepatic venous tributary in right liver living donor liver transplantation: The importance of the inferior right hepatic vein.

Special care must be taken in hepatic vein reconstruction to avoid outflow block in living donor liver transplantation (LDLT) with a right liver graft. We have used cryopreserved homologous veins to reconstruct the right hepatic vein (RHV), middle hepatic vein (MHV), MHV tributaries (V5 and V8), and inferior right hepatic vein (IRHV). The reconstruction of V5, V8, and IRHV was based on the estimated congestive volume, calculated by the computed tomography volumetry, to secure the functional graft volume of 40% of the recipient standard liver volume. Among 262 right liver LDLT recipients, the number of reconstructed RHVs, MHVs, V5s, V8s, and IRHVs was 262, 48, 110, 111, and 147, respectively, and the overall patency was 95%, 100%, 36%, 58%, and 86%, respectively. Although the patency of the RHVs and MHVs was satisfactory, that of the V5s, V8s, and IRHVs was suboptimal. Patency of the IRHVs (86%, 126/147) was significantly better than that of both V5s (36%, 40/110) and V8s (58%, 64/111; P < 0.001). In addition, the estimated volume drained by IRHVs was significantly greater than that of V5s and V8s (IRHV, 176 ± 92 mL; V5, 105 ± 49 mL; V8, 127 ± 60 mL; P < 0.001). The patency of IRHV was significantly improved by applying the double inferior vena cava method (93%, 94/101) when compared to the direct anastomosis to vena cava (68%, 25/37; P < 0.001). The IRHV functioned as a main drainage route in cases of an obstructed RHV. In conclusion, reconstruction of the IRHV is recommended, not only to improve the functional reserve of the graft, but also to secure multiple drainage routes of the graft.

EUS-guided portal pressure gradient measurement with a novel 25-gauge needle device versus standard transjugular approach: a comparison animal study

Portal hypertension (PH) is a serious adverse event of liver cirrhosis. The hepatic venous pressure gradient (HVPG) accurately reflects the degree of PH and is the single best prognostic factor in liver disease. Currently, portal pressure gradient (PPG) measurement is performed at interventional radiology (IR) with a standard transjugular approach requiring radiation and intravenous contrast. The aim of this study was to develop a novel EUS-guided system using a 25G FNA needle and compact manometer to directly measure PPG and to evaluate its performance and clinical feasibility. Experiments were performed in 3 swine that were under general anesthesia. Manometry was performed in venous (baseline and PH) and arterial (aorta) systems. The PH model was created by rapid Dextran-40 infusion peripherally. Under EUS guidance a 25G FNA needle with attached manometer was used to puncture (transgastric-transhepatic approach) and measure pressures in the portal vein, right hepatic vein (RHV), inferior vena cava (IVC), and aorta. With the IR approach, RHV (free and wedged), IVC, and aorta pressure were measured with an occlusion balloon. Pressure correlation was divided into 3 groups; low pressure (baseline), medium pressure (noncirrhotic portal hypertensive model), and high pressure (arterial). Correlation between the 2 methods of measurement was charted in scatter plots, and the Pearson's correlation coefficient (R) was calculated. EUS identification, access, and manometry was successful in all targeted vessels. There was excellent correlation (R, .985-.99) between EUS and IR methods in all pressure ranges. No adverse event occurred. This novel technique of EUS-PPG measurement using a 25G needle and novel manometer was feasible and demonstrated excellent correlation with the standard transjugular method throughout low, medium, and high pressure ranges.

Endoscopic Ultrasound-Guided Portal Pressure Gradient (PPG) Measurement: A Simplified Novel Technique Using 25-Gauge FNA Needle With Compact Transducer Versus Standard Transjugular Approach: A Comparative Animal Study: Presidential Poster

Introduction: Portal hypertension (PH) is a serious complication of liver cirrhosis. The hepatic venous pressure gradient (HVPG) accurately reflects the degree of PH and is the single best prognostic factor in liver disease. HVPG can guide medical therapy and predict liver decompensation as well as cancer risk. Currently, measurement of PPG is performed using an invasive transjugular approach requiring radiation and IV contrast; and it provides only an indirect measurement. We present the first study of a novel, simple EUS-guided system using a 25g FNA needle and compact manometer to directly measure PPG with simultaneous comparison to the standard transjugular method. Methods: Experiments were performed in 3 swine under general anesthesia. Baseline and portal hypertensive venous manometry was performed. The PH model was created by rapid Dextran-40 infusion. Using a linear echoendoscope, a 25g FNA needle with attached manometer was used to puncture (transgastric-transhepatic approach) and measure pressures in the portal vein (PV), right hepatic vein (RHV), and inferior vena cava (IVC). Pressure measurements in the aorta were also performed. Manometric data was obtained from the RHV (free and wedged), IVC and aorta with an occlusion balloon. All EUS and transjugular manometric data were captured simultaneously, in real time, at each corresponding vessel. Pressure correlation was divided into three groups; low pressure (baseline), medium pressure (PH model) and high pressure (arterial). Scatter plots and Pearson's correlation coefficient (R) were used. Results: EUS identification, access and manometry were successful in all targeted vessels. There was excellent correlation between EUS and transjugular approach at all pressure ranges. R co-efficient was 0.99 (Arterial, venous-graph 1), 0.986 (all veins-graph 2) and 0.985 (PV+HV only-graph 3). No adverse event occurred despite repeated vascular punctures. No bleeding was seen at EUS or on fluoroscopy, despite presence of PH. Necropsy was not performed.Figure 1Figure 2Figure 3Conclusion: This novel technique of EUS-PPG measurement using a 25G needle and novel manometer was feasible and demonstrated excellent correlation with the standard transjugular method throughout low, medium and high pressure ranges. There were no adverse events acutely. Clinical trials are currently underway.

Non-contrast-enhanced MR portography and hepatic venography with time-spatial labeling inversion pulses: comparison at 1.5 Tesla and 3 Tesla.

BackgroundA 3 Tesla (3 T) magnetic resonance (MR) scanner is a promising tool for upper abdominal MR angiography. However, there is no report focused on the image quality of non-contrast-enhanced MR portography and hepatic venography at 3 T.PurposeTo compare and evaluate images of non-contrast-enhanced MR portography and hepatic venography with time-spatial labeling inversion pulses (Time-SLIP) at 1.5 Tesla (1.5 T) and 3 T.Material and MethodsTwenty-five healthy volunteers were examined using respiratory-triggered three-dimensional balanced steady-state free-precession (bSSFP) with Time-SLIP. For portography, we used one tagging pulse (selective inversion recovery) and one non-selective inversion recovery pulse; for venography, two tagging pulses were used. The relative signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were quantified, and the quality of visualization was evaluated.ResultsThe CNRs of the main portal vein, right portal vein, and left portal vein at 3 T were better than at 1.5 T. The image quality scores for the portal branches of segment 4, 5, and 8 were significantly higher at 3 T than at 1.5 T. The CNR of the right hepatic vein (RHV) at 3 T was significantly lower than at 1.5 T. The image quality scores of RHV and the middle hepatic vein were higher at 1.5 T than at 3 T. For RHV visualization, the difference was statistically significant.ConclusionNon-contrast-enhanced MR portography with Time-SLIP at 3 T significantly improved visualization of the peripheral branch in healthy volunteers compared with1.5 T. Non-contrast-enhanced MR hepatic venography at 1.5 T was better than at 3 T.

A study of the right intersectional plane (right portal scissura) of the liver based on virtual left hepatic trisectionectomy.

Left hepatic trisectionectomy is a challenging procedure. For an anatomically correct resection, it is necessary to have understanding of the right intersectional plane; however, little is known on this issue. The purpose of this study was to investigate the 3D anatomy of the right intersectional plane and to enable safe and precise left trisectionectomy. A virtual left trisectionectomy was performed using 3D-processing software, in patients who underwent computed tomography. The reconstructed images were reviewed, and attention was paid to the extent of the right hepatic vein (RHV) exposure on the transected plane and the type of the inferior right hepatic vein (IRHV). Of the 200 study patients, 109 (54.5 %) patients showed complete exposure of the RHV on the transected plane, whereas the remaining 91 exhibited partial exposure. In the 109 patients with complete exposure, 58 (53.2 %) patients had no IRHV and the remaining 51 had a small IRHV. None of the patients had a large IRHV. In contrast, of the 91 patients with partial exposure, only 10 (11.0 %) patients had no IRHV, 35 (38.5 %) had a small IRHV, and 46 (50.5 %) patients had a large IRHV. The incidence of IRHV types was significantly different between the two groups (P < 0.001). The RHV does not always run along the right intersectional plane, i.e., the vein is not always fully exposed on the transected plane even after anatomically correct left trisectionectomy. The extent of the RHV exposure is closely related to the type of the IRHV.

Living Donor Liver Transplantation Using a Right Liver Graft With Additional Vein Reconstructions for Patient With Situs Inversus

Living donor liver transplantation (LDLT) using a right liver graft with additional vein reconstructions has not been previously reported in a situs inversus (SI) patient. A 60-year-old man with SI was referred for LDLT for end-stage cirrhosis secondary to hepatitis B. The calculated regional volumes of the individual hepatic vein territories in the right liver graft suggested that the middle hepatic vein (MHV) tributaries and the inferior right hepatic veins (IRHVs) should be reconstructed in addition to the right hepatic vein (RHV). On the back-table, the recipient's recanalized umbilical vein graft was anastomosed to the V5 opening, and the other side of vein graft was anastomosed to the RHV and V8 opening to create a large single orifice. After total hepatectomy, the right liver graft was placed in the left subphrenic space at the reversed position. The common orifice of hepatic venous drainage from RHV, V8 and V5 was anastomosed to the anatomical RHV conduit of the recipient, followed by IRHV anastomosis to the inferior vena cava. Postoperative course was almost uneventful, and no vascular complications were experienced. Even for SI patients, LDLT using a right liver graft with reconstructions of the MHV tributaries and the IRHVs is feasible.

Simplified one‐orifice venoplasty for middle hepatic vein reconstruction in adult living donor liver transplantation using right lobe grafts

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). The aim of this report was to introduce evolution of our MHV reconstruction technique and excellent outcomes of simplified one-orifice venoplasty. We compared clinical outcomes with two reconstruction techniques through retrospective review of 95 recipients who underwent LDLT using right lobe grafts at our institution from January 2008 to April 2012; group 1 received separate outflow reconstruction and group 2 received new one-orifice technique. The early patency rates of MHV in group 2 were higher than those in group 1; 98.4% vs. 88.2% on postoperative day 7 (p = 0.054) and 96.7% vs. 82.4% on postoperative day 14, respectively (p = 0.023). Right hepatic vein (RHV) stenosis developed in three cases in group 1, but no RHV stenosis developed because we adopted one-orifice technique (p = 0.043). The levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in group 2 were significantly lower than those in group 1 during the early post-transplant period. In conclusion, our simplified one-orifice venoplasty technique could secure venous outflow and improve graft function during right lobe LDLT.

Multiple Hepatic Vein Reconstruction Using an All-in-one Sleeve Patch Graft Technique in Living Donor Liver Transplantation: A Case Report

Maintaining hepatic inflow and appropriate venous drainage is important for maximizing the capacity of the retrieved graft in liver transplantation. Here, we report a successful case of multiple hepatic vein (HV) reconstruction using an all-in-one sleeve patch graft of the autologous great saphenous vein to ensure adequate blood flow through the HV. A patient with hepatocellular carcinoma caused by hepatitis C virus–induced cirrhosis underwent living donor liver transplantation using a right lobe graft. A preoperative dynamic computed tomography scan and intraoperative findings revealed that the graft had three middle HV tributaries, a superficial vein, segment VIII HV (V8), and segment V HV (V5). The openings of the superficial vein and V8 were located very close to that of the right hepatic vein (RHV) in the cutting surface. Each HV had significant diameter and drainage territory requiring reconstruction. An autologous great saphenous vein was used to create a sleeve patch to incorporate the close-packed HV openings. The autologous sleeve patch graft was sutured to the openings of the RHV and the superficial vein and the hole created on the sleeve patch graft was anastomosed to the openings of V8 directly on the back table to create an all-in-one sleeve patch. For the V5 reconstruction, the recipient's intrahepatic portal vein graft was used to create an interpositional conduit from the recipient's V5 to the inferior vena cava. The postoperative course was uneventful and postoperative studies revealed good graft function with excellent blood flow in the HV.

Radical but Conservative Liver Resection for Large Centrally Located Hepatocellular Carcinoma: The Mini Upper-Transversal Hepatectomy

In patients with hepatocellular carcinoma (HCC) in a diseased liver, surgery should be offered in a parenchyma-sparing fashion. This approach seems unfeasible for large and deeply located lesions. Ultrasound study of the tumor-vessel relationship and hepatic inflow and outflow opens new technical solutions: herein is described a new operation based on this approach.1 (-) 3 METHODS: A 69-year-old man with a large centrally located HCC (Barcelona Clinic Liver Cancer stage C) underwent surgery. The HCC was located in segments 7, 8, and part of 5, extensively compressing and dislodging the anterior (P5-8) and posterior (P6-7) Glissonean pedicles at their origin. The lesion involved the right hepatic vein (RHV) and was in contact with the middle hepatic vein at the caval confluence. An inferior RHV (IRHV) was preoperatively evident. After a J-shaped thoracophrenolaparotomy, the liver exploration with the aid of intraoperative ultrasound confirmed the tumoral contact without vascular invasion with P5-8 and P6-7 and disclosed multiple communicating veins between the middle hepatic vein and RHV, warranting with the IRHV the segment 5-6 outflows. A resection of segments 7 and 8 with RHV resection, together with complete tumor detachment from P5-8 and P6-7, was performed. The specimen was removed combining the crush-clamping method for the parenchyma division and a peeling-off technique by means of blunt scissor dissection for the tumor vessel detachment. The postoperative course was uneventful. The patient was alive without recurrence at 12months after surgery. This video is the first live demonstration of the previously reported radical but conservative policy, adding to the latter the technical solutions provided by detection of accessory veins such as the IRHV and communicating veins.1 (-) 4.

Intrahepatic venous anastomoses with a focus on the middle hepatic vein anastomoses in normal human livers: anatomical study on liver corrosion casts

The aim of this study is to present the anatomical data about intrahepatic venous anastomoses found in normal human livers. The focus is on the middle hepatic vein (MHV) anastomoses, because their existence or non-existence could be of crucial importance in tumour resections as well as in split or living donor liver transplantations. The frequency of livers with intrahepatic venous anastomoses was determined on 164 corrosion casts and the diameter of each anastomosis was measured. Additionally, the type of connection and the position within the liver (liver segment) was determined for each MHV anastomosis. Intrahepatic venous anastomoses were found in 46 % (75/164), whereas MHV anastomoses were found in 28 % (44/164) of liver casts. Most commonly (39/44), MHV had anastomotic connections with the right hepatic vein (RHV), and also with the inferior RHV, the left hepatic vein and the short subhepatic vein. In more than three quarters of liver casts, MHV-RHV anastomoses were found in liver segment 8; in 45 % of cases, there was more than one anastomosis in this liver segment. The diameter of MHV-RHV anastomoses found in segment 8 was ≥1 mm in 90.6 % of cases. As MHV anastomoses were present in more than a quarter of all examined liver casts, we believe that detailed anatomical data presented in this article, together with up to date radiologic technics which enable even 3D reconstruction of venous anastomoses in the liver, could contribute to the clinician's decisions when planning surgical procedures.

Detection of intrahepatic veno-venous shunts by three-dimensional venography using multidetector-row computed tomography during angiography

The hepatic vein (HV) can be removed during hepatectomy if there is an effective intrahepatic veno-venous shunt (vv-shunt). We evaluated the efficacy of vv-shunt detection by three-dimensional (3D) venography reconstructed from multidetector-row computed tomography (MDCT) during angiography. 3D venography was reconstructed using computer software in 88 patients with intrahepatic tumors. We found that 12 patients had one shunt [4 right hepatic vein (RHV)-middle hepatic vein (MHV) and 12 RHV- inferior right hepatic vein (IRHV)] and 1 patient had 2 shunts (RHV-MHV and -IRHV), confirming a clinically efficient vv-shunt in 14.8% of the patients. In one patient with an RHV-IRHV shunt, the preserved RHV-IRHV shunt worked well and prevented congestion of the postero-caudal subsegment after central bisegmentectomy with partial resection of the RHV ventral trunk for huge hepatocellular carcinoma (HCC). Although the vv-shunt detection rate by 3D venography is low, a visualized vv-shunt proved to be efficient. Thus, invasive occlusion venography is avoidable if a vv-shunt is seen on 3D venography.

Surgical impact of an inferior right hepatic vein on right anterior sectionectomy and right posterior sectionectomy

In hepatocellular carcinoma, anatomical resection is important because of portal spread. In right anterior sectionectomy (RAS) and right posterior sectionectomy (RPS), the right hepatic vein (RHV) may not correspond with the intersectional plane if an inferior RHV (IRHV) is present. The aim of this study was to evaluate the influence of the IRHV on the exposure of the RHV retrospectively. One hundred ninety-one patients underwent RAS or RPS by the Glissonean pedicle transection method. The calibres of the RHV and IRHV were measured and assessed the extent of exposure of RHV. One hundred seventeen patients underwent RAS and 74 underwent RPS. The calibre of the RHV averaged 8.0 mm and that of the IRHV, 6.2 mm. Exposure of the RHV was divided into three groups: no exposure 31 (16.2%) (with IRHV, 20 patients; without IRHV, 11 patients), upper half exposure 49 (25.7%; with IRHV, 24; without IRHV, 25) and full exposure 111 (58.1%) (with IRHV, 16; without IRHV, 95). The effect of the IRHV on exposure of the RHV was substantial (P < 0.001). The IRHV can affect the course of the RHV and its exposure. Therefore, in RAS and RPS, it is important to evaluate the existence of the IRHV.