Short Hepatic Veins Research Articles

Influence of tumor thrombus morphology on the surgical complexity in renal cell carcinoma with inferior vena cava tumor thrombus: a single-center, large-sample study from China

BackgroundThe morphology of tumor thrombus varies from person to person and it may affect surgical methods and tumor prognosis. However, studies on the morphology of tumor thrombus are limited. The purpose of our study was to evaluate the impact of tumor thrombus morphology on surgical complexity.MethodsWe retrospectively reviewed the clinical data of 229 patients with renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus who underwent surgical treatment at Peking University Third Hospital between January 2014 and December 2021. The patients were divided into floating morphology (107 patients) and filled morphology (122 patients) tumor thrombi groups. Chi-square and Mann–Whitney U tests were used for categorical and continuous variables, respectively. Postoperative complications were evaluated using the Clavien–Dindo surgical complication classification method.ResultsPatients with filled morphology tumor thrombus required more surgical techniques than those with floating morphology tumor thrombus, which was reflected in more open surgeries (P < 0.001), more IVC interruptions (P <0.001), lesser use of the delayed occlusion of the proximal inferior vena cava (DOPI) technique (P < 0.001), and a greater need for cut-off of the short hepatic vein (P < 0.001) and liver dissociation (P = 0.001). Filled morphology significantly increased the difficulty of surgery in patients with renal cell carcinoma with tumor thrombus, reflected in longer operation time (P < 0.001), more surgical blood loss (P <0.001), more intra-operative blood transfusion (P < 0.001), and longer postoperative hospital stay (P < 0.001). Filled morphology tumor thrombus also led to more postoperative complications (53% vs. 20%; P < 0.001).ConclusionCompared with floating morphology thrombus, filled morphology thrombus significantly increased the difficulty of surgery in patients with renal cell carcinoma with IVC tumor thrombus.

Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (L-ALPPS) After Conversion Therapy for BCLC-B Hepatocellular Carcinoma: A Video Article.

Despite the ALPPS technique remains a controversy, various ALPPS techniques have made many attempts.1-6 This video discusses the technical tips for L-ALPPS after conversion therapy. A 56-year-old, HCC patient who performed the abdominal CT showed a 6.0*5.7-cm-sized mass with intrahepatic metastasis. After four cycles of conversion therapy, the patient achieved a radiologic complete response. However, the standardized, remnant liver volume ratio (SRLVR) was only 34%. Thus, L-ALPPS was contemplated. After full mobilization, intraoperative ultrasonography marked the main trunk of MHV. The concept of "Laennec membrane anatomy" was introduced.7 The anterior pedicle (AP) and the posterior pedicle (PP) were elastically suspended along the Laennec membrane. The conventional hilar dissection approach was used to isolate and suspend RHA and the right portal vein (RPV). Then, IRHV and short hepatic vein were clipped and cut. The Pringle maneuver was used intermittently during the parenchymal transection. Hepatic resection was performed from the caudal to the cranial side along MHV after RPV was ligated. The RHV was elastically suspended after hepatic resection. The omentum was used to cover the resection surface. Stage 2, preoperative SRLVR increased to 68.3%. The adhesion of the right hemiliver was bluntly separated. AP, PP, and RHV were divided by the stapler respectively. Operation time and bleeding volume for stage-1 surgery and stage-2 surgery were 240 min and 80 min, 200 ml and 250 ml, respectively. The postoperative recovery was uneventful. L-ALPPS as a surgical option seems to be feasible and safe for intermediate-advanced HCC after conversion therapy.

Collateral circulation caused by end-stage hepatic alveolar echinococcosis

BackgroundHepatic alveolar echinococcosis (HAE), as a benign parasitic disease with malignant infiltrative activity, grows slowly in the liver, allowing sufficient time for collateral vessels to emerge in the process of vascular occlusion.MethodsThe portal vein (PV), hepatic vein and hepatic artery were observed by enhanced CT and the inferior vena cava (IVC) by angiography, respectively. Analysis of the anatomical characteristics of the collateral vessels helped to look into the pattern and characteristics of vascular collateralization caused by this specific etiology.Results33, 5, 12 and 1 patients were included in the formation of collateral vessels in PV, hepatic vein, IVC and hepatic artery, respectively. PV collateral vessels were divided into two categories according to different pathways: type I: portal -portal venous pathway (13 cases) and type II: type I incorporates a portal-systemic circulation pathway (20 cases). Hepatic vein (HV) collateral vessels fell into short hepatic veins. The patients with IVC collateral presented with both vertebral and lumbar venous varices. Hepatic artery collateral vessels emanating from the celiac trunk maintains blood supply to the healthy side of the liver.ConclusionsDue to its special biological nature, HAE exhibited unique collateral vessels that were rarely seen in other diseases. An in-depth study would be of great help to improve our understanding related to the process of collateral vessel formation due to intrahepatic lesions and its comorbidity, in addition to providing new ideas for the surgical treatment of end-stage HAE.

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]

Resecting liver segments VII–VIII without reconstructing the right hepatic vein

Aim. To improve outcomes of treatment for neoplasms in segments VII-VIII of the liver adjacent to the main stem of the right hepatic vein and/or to its forming large branches.Materials and methods. In the period of 2016–2022, the resection of segments VII and/or VIII of the liver and the right hepatic vein, as well as its forming branches without reconstruction was performed in 24 patients. Surgical indications were liver metastases of colorectal cancer in 15 cases, hepatocellular cancer (cholangiocarcinoma) in six cases, angiomyolipoma in one case, uterine cancer metastases in one case and primary retroperitoneal tumor metastases in one case. Minor liver resections were additionally performed in 11 cases. Results. There were no intraoperative signs of impaired venous drainage. After surgery bile in the drains was detected in three patients, and a biliary fistula was formed in one case. No other complications were identified. No fatalities were registered after surgery. The late postoperative period revealed no specific complications related to a disturbance of venous drainage through the right hepatic vein.Conclusion. Existing and emerging collaterals can provide adequate venous drainage to the middle hepatic vein, short hepatic veins after resection of liver segments VII and VIII with resection of the right hepatic vein stem and its forming branches without reconstruction, even if the lower right hepatic vein is missing, and without complete obstruction of the right hepatic vein before surgery.

Applied anatomical study and clinical application of the caudate lobe boundary and ductal system of the liver

Objective: To explore the relationship between the hepatic caudate lobe boundary and the ductal system so as to guide the identification of the anatomical relationship during liver surgery. Methods: The specific parts were observed and the liver parenchyma was removed according to 41 cadaveric liver autopsy specimens. The critical relationship between the hepatic caudate lobe and other ducts was observed to explore the reticular duct structure. Results: The plane formed by the hepatic hilar plate and Arantius ligament served as the boundary between the caudate lobe and other hepatic lobes. The caudate lobe hepatic portal vein was composed of numerous small branches from its left and right branches. The portal vein adjacent to the vena cava was mainly derived from the left branch, and to a lesser extent from the right branch. Blood was drained straight from the caudate lobe vein into the inferior vena cava via the short hepatic vein. There were three or four bile duct branches in the caudate lobe. The main source of arterial blood flow were the left and right branches of the hepatic artery. An avascular zone of loose connective tissue was found between the caudate lobe and the retrohepatic inferior vena cava. Conclusion: The hepatic caudate lobe is an independent lobe. During hepatic caudate lobe surgery, the plane formed by the hepatic hilar plate and Arantius ligament can serve as the boundary between the caudate lobe and other hepatic lobes and be used for anatomical site identification. The duct system of the caudate lobe's is complicated, but it also has its own distinct regularity.

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.

Laparoscopic Left Hepatectomy with Resection of the Spiegel Lobe Using the Modified Caudate Lobe-First Approach.

Laparoscopic left hepatectomy with resection of the Spiegel lobe remains a technically demanding procedure as it is a deep-seated area surrounding the inferior vena cava (IVC). Mobilization of the Spiegel lobe requires safe exposure of the ventral side of the IVC while dissecting the short hepatic veins from the IVC. Additionally, wide space is needed to isolate the left Glissonean pedicle (Glt). We used a modified caudate lobe-first approach to overcome this challenge Maeda (J Hepato-Bil Pancreat Sci 25:335-41, 2018), Li (J Gastrointest Surg 23:1084-5, 2019), Homma (Surg Endosc 33:3851-7, 2019). The ischemic area was confirmed after isolating the left and middle hepatic artery and left portal vein. After mobilizing the left lateral section, the Spiegel lobe was divided from the notch, which is the boundary between the caudate lobe and the Spiegel lobe, toward the middle hepatic vein (MHV). The Spiegel lobe was safely detached from the IVC with a short hepatic vein transected with the caudo-dorsal view. The Glt could be easily isolated due to the wide space on the ventral side of the IVC. After dividing the left hepatic duct, the MHV was exposed continuously from the root to the periphery, and parenchymal transection was completed by connecting the demarcation line and MHV. The total operation time was 430 min, and estimated blood loss was minimal. The patient was discharged on postoperative day 6 without complications. The modified caudate lobe-first approach can be used to safely perform laparoscopic left hepatectomy combined with the Spiegel lobe resection.

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.

Parenchymal-sparing approaches for resection of tumors located in the paracaval portion of the caudate lobe of the liver-utility of limited resection and central hepatectomy.

Resection of liver cancer involving the paracaval portion (PC) of the caudate lobe is challenging because the PC is located deepest in the liver. This study aimed to elucidate the utility of two parenchymal-sparing approaches of limited resection and central hepatectomy for resecting tumors located in the PC. In 2018 and 2020, 12 out of 143 patients underwent hepatectomy for tumors located in the PC of the liver. In six patients, limited resection (LR) of the PC after full mobilization of the liver off the inferior vena cava (IVC) was performed for tumors excluding the hilar plate or large hepatic veins (large HVs), including major hepatic veins or thick short hepatic veins. In six patients, central hepatectomy (CH) using liver tunnel was performed for tumors involving or close to the hilar plate and/or large HVs. During CH, the surgical view of the cranial side of the hilar plate was wide enough to perform combined resection of the large HVs in front of the IVC. Five of the six CHs were performed with resection of the LHVs. No LRs were accompanied with resection of the LHVs. The CH was associated with longer Pringle's time (76 min vs. 29.5 min, p = 0.015) and blood loss (1104 ml vs. 370 ml, p = 0.041). The preserved liver parenchyma volumes were 82% and 95% of the total liver volume after CH and LR, respectively. Our parenchymal-sparing approach for resection of liver cancer located in the PC is feasible for curative resection.

A practical study of the hepatic vascular system anatomy of the caudate lobe.

This study aimed to examine the inflow and outflow vascular system of the caudate lobe and determine its relevance to hepatobiliary surgery. A total of 41 cadaveric liver specimens were dissected in 2019 to evaluate the inflow and outflow vascular system of the caudate lobe. The Glisson's pedicles of the paracaval portion were mainly from the right pedicle in 14 cases (34.15%), mainly from the left pedicle in 22 cases (53.66%), and equally from the left and right pedicle in 5 cases (12.19%). Many thick branches of the portal vein were found behind the plane consisting of the hilar plate and Arantius ligament, but none of them were thicker than 1 mm in front of the plane. All of the veins of the caudate lobe drained into the inferior vena cava (IVC) via the anterior face. There was an avascular zone without short hepatic veins (SHVs) consisting of loose connective tissue between the retrohepatic IVC and caudate lobe, with its length and width being 45-97 mm and 6-15 mm, respectively. The plane consisting of the hilar plate and Arantius ligament can be regarded as the boundary between the caudate lobe and the other lobes. There is an avascular zone without SHVs consisting of loose connective tissue between the retrohepatic IVC and caudate lobe.

Resection of liver segments VII-VIII: is right hepatic vein reconstruction advisable?

To improve the treatment outcomes in patients with primary and metastatic liver tumors localized in segments VII-VIII involving the right hepatic vein and its branches. There were 16 surgical interventions including resection of liver segment VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction. All procedures were carried out at the Department of Liver and Pancreatic Tumors of the Blokhin National Medical Cancer Research Center for the period 2016-2020. The cause of surgery was colorectal cancer liver metastases in 8 patients, hepatocellular carcinoma in 2 cases, angiomyolipoma in 1 case and metastases of uterine cancer in 1 patient. Minor liver resection was additionally performed in 5 cases. Median surgery time was 150 (80-220) min, intraoperative blood loss - 400 (100-2000) ml. Afferent blood flow was blocked in 4 patients for 14 (12-25) min. None patient had intraoperative signs of impaired venous outflow. Biliary fistula in postoperative period occurred in 1 patient. No complications were noted in other cases. Median postoperative hospital-stay was 13 (9-19) days. There were no specific complications in long-term postoperative period that could be associated with venous outflow blockade through the right hepatic vein. Existing vessels and intrahepatic collaterals de novo can provide adequate venous outflow into the middle hepatic vein and short hepatic veins during resection of liver segments VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction and the absence of inferior right hepatic vein.

Minimally Invasive Living Donor Right Hepatectomy: Initial Experience in a Southeast Asian Transplant Center

Introduction: While laparoscopic left lateral sectionectomy is increasingly adopted in pediatric donors, laparoscopic donor right hepatectomy (LDRH) is only performed in a small number of highly experienced centers. We report our initial experience with LDRH as a medium-sized liver transplant center. Methods: Retrospective analysis of living donor adult liver transplantations (LDLT) between January 2018 and December 2019 was conducted. A total of 25 LDLTs were performed, of which 7 were LDRH. Patients with anatomical variation seen on pre-operative imaging were excluded from LDRH. All cases performed were without the middle hepatic vein. Results: Amongst LDRH cases, 3 (42.9%) were performed via laparoscopic-assist while the remaining cases (57.1%) were pure LDRH. There were 4 males (57.1%) in this group, and the median age was 41 years old (29-53 years old). Most patients (57.1%) had a body mass index of less than 25kg/m2. Median graft volume was 798mls (622-1115mls), while the median total liver volume was 1364mls (949-1728mls). Median operative time was 435 minutes (391-592 minutes) and estimated median blood loss was 300 mls (150-900 mls). The first two cases in this series were planned conversions, while the other was due to short hepatic vein bleeding. There were no post-operative morbidity and mortality reported and all patients were discharged within the first week after surgery (4-7 days). Conclusion: LDRH is safe and feasible in a medium-sized liver transplant center. Careful case selection and planned conversions can mitigate the initial steep learning curve. Larger sample size and long-term follow up data is required.

Regeneration of caudate lobe after living donor liver transplantation : Comparison with a surrogate model of left lobe graft.

Background : The aim of this study is to clarify the regeneration of the CL (caudate lobe) without any reconstructions of short hepatic veins (SHVr) after LDLT (living donor liver transplantation) and compare the regeneration of the CL after right hepatectomy (Rt. Hx), as the surrogate model of extended left lobe graft (Ex LLG) with complete SHVr. Methods : Eleven Ex LLGs with CL were included in this study. SHVr was not performed in all cases. The volumetry was performed before, one month and six months after LDLT. Seven patients who underwent Rt. Hx were also included in this study as the surrogate model. Results : In Ex LLGs with CL, the regeneration rate of the large CL (> 30 ml) was worse than that of small CL (< 30 ml). In the surrogate model, the regeneration rate of the CL was not worse than other segments. However, the regeneration rate of the large CL was also worse than that of small CL even in the presence of complete SHVr. Conclusions : The regeneration of the large CL was worse than that of the small CL regardless of the presence or absence of SHVr, indicating that SHVr in Ex LLG with CL might not be necessary. J. Med. Invest. 68 : 330-333, August, 2021.

Venous drainage of the left liver: an evaluation of anatomical variants and their clinical relevance

To evaluate the variations in venous drainage from the left liver. A retrospective evaluation was performed of all consecutive abdominal computed tomography (CT) examinations at a tertiary referral facility between 1 January and 30 June 2018. Osirix (Pixmeo SARL, Bernex, Switzerland) was used to examine the major hepatic veins and their tributaries in each scan. The classification of variants as proposed by Nakamura and Tsuzuki was used to describe the findings. The following information was collected: ramification pattern, number, length and diameter of middle (MHV) and left (LHV) hepatic vein tributaries. Two researchers collected data independently, and the average measurements were used as the final dimensions. Of 102 examinations evaluated, only 27 demonstrated the conventional venous drainage patterns. The LHV and MHV combined to form a common trunk that emptied into the inferior vena cava (IVC) in 75 (73.5%) cases. The common trunk had a mean length of 8.89 mm and mean diameter of 20.18 mm. Other patterns included Nakamura and Tsuzuki type I (27.5%), type II (29.4%) and type III variants (16.7%). In addition, 4.9% of patients had absent superior middle veins and 80% had supernumerary short hepatic veins (4%). Only 26.5% of patients in this population had conventional venous drainage from the left liver. Surgeons and radiologists in hepatobiliary practice should be aware of these variants in order to minimise morbidity when performing invasive procedures.

Robotic anatomic isolated complete caudate lobectomy: Left-side approach and techniques

BackgroundTo demonstrate the surgical procedures and techniques of the robotic anatomical isolated complete caudate lobectomy. MethodsA retrospective analysis was performed on the demographic, operative, postoperative outcomes of seven patients who underwent robotic anatomical isolated complete caudate lobectomy at our department from January 2018 to November 2019. Mobilization of the left lateral and Spiegel lobe, dissection of the short hepatic veins and liver parenchyma transection from the dorsal plane of middle and right hepatic vein were crucial procedures for the robotic left-side approach. Anatomic complete caudate lobectomy was defined as total removal of the caudate lobe, in which the dorsal middle and right hepatic vein, the inferior vena cava and its right side were fully exposed on the raw surface. ResultsAll patients successfully underwent the robotic anatomical isolated caudate lobectomy with a left-side approach without conversion to laparotomy, and without Clavien-Dindo Grade III or higher complications. The average tumor diameter was 65.00 ± 10.61 mm, the average operation time was 212.00 ± 74.53 min, the median bleeding loss was 100 mL, and the average postoperative hospital stay was 8.71 ± 4.89 d, respectively. There were four patients with primary hepatocellular carcinoma, one with tumor recurrence five months after surgery and three patients were free of recurrence. All patients survived at the last follow-up. ConclusionRobotic anatomical isolated complete caudate lobectomy with a left-sided approach is safe and feasible for selected patients.

Research progress in the Hepatobiliary Surgery operation of hepatic hilar plate system

An estimate of about 50% of new liver cancer cases worldwide occur in China every year.Surgical resection is still the major treatment choice for longer survival of patients with hepatocellular carcinoma. Blocking hepatic blood flow and reducing intraoperative bleeding ensure the success of the operation. Anatomic separation of hepatic hilar region is the precondition of hepatic inflow occlusion. The hepatic hilar plate system involves a thick layer of connective tissue covering the hepatic inflow ducts of hepatic hilar region. The descending part of hilar plate assists in reducing the anatomical difficulty of the hepatic hilar region. The "forth porta hepatis" that is hidden in the hepatic hilar plate system involves the accumulation area of "short hepatic portal veins" .The communicating branch vessels between the hepatic inflow vessels form the anatomical basis in reducing the indocyanine green fluorescence stain effect.The relatively fixed position of the hepatic portal plate is considered as a positioning marker for accurate liver resection. The intrahepatic Glisson sheath is connected with thick connective tissue of the hepatic portal panel system, and is regarded as the physical barrier in limiting the proliferation and hypertrophy of hepatocytes and continuation of hepatic portal panel system in the liver.This paper summarizes the anatomy and application of hepatic hilar plate system during hepatobiliary surgery.

V10-09 CHALLENGING RENAL CELL CARCINOMA CASES WITH INFERIOR VENA CAVA INVOLVEMENT: FROM EXTIRPATION TO CAVAL REPLACEMENT

You have accessJournal of UrologyAdrenal Surgery & Kidney Cancer II (Advanced Kidney Cancer & Vascular Reconstruction) (V10)1 Apr 2020V10-09 CHALLENGING RENAL CELL CARCINOMA CASES WITH INFERIOR VENA CAVA INVOLVEMENT: FROM EXTIRPATION TO CAVAL REPLACEMENT Kathryn Scott* and Gennady Bratslavsky Kathryn Scott*Kathryn Scott* More articles by this author and Gennady BratslavskyGennady Bratslavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000935.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In this video presentation we describe three complex cases of renal cell carcinoma (RCC) with inferior vena cava (IVC) involvement managed robotically by a urologic oncologist. METHODS: Robotic assistance was used to treat three different cases of RCC with IVC involvement. In all 3 cases radical nephrectomy was performed and combined with IVC thrombectomy or resection with either IVC repair or replacement. The first case demonstrates a large right renal mass with an 11cm level III IVC thrombus. This was excised using robotic assistance and the IVC was primarily repaired. The second case demonstrates management of a large right renal mass invading into the liver and abdominal side wall and having an IVC thrombus. Using robotic assistance we performed partial hepatectomy (segment VI), IVC thrombectomy, radical nephrectomy, and abdominal wall resection in the order listed above. The final case demonstrates management of recurrent RCC after right partial nephrectomy 5 years prior to diagnosis with direct invasion of the IVC. A nephrectomy with IVC resection was performed. In this case the IVC is replaced with a vascular graft. RESULTS: All the presented cases were completed robotically by a single urologic oncologist. All patients were discharged to home 36-48 hours postoperatively. There were no perioperative complications. All patients are alive and have no local recurrence as of follow-up at 5, 1.5, and 1.5 years later, respectively. This video focuses on important technical aspects of each case. Important teaching points included stress the importance of mobilization of the caudate lobe via ligation of short hepatic veins, allowing IVC to back bleed during completion of the closure to avoid catastrophic events of clot or air embolus, management of the liver invasion, and IVC closure/replacement techniques. Additional technical caveats are highlighted during the narrative of this video presentation. CONCLUSIONS: Robotic assistance may expand the armamentarium for complex cases in urologic oncology allowing for benefits of a minimally invasive approach and minimizing hospital stay. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e933-e933 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kathryn Scott* More articles by this author Gennady Bratslavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-11 ROBOT-ASSISTED LEVEL II AND III INFERIOR VENA CAVA THROMBECTOMY: STEP-BY-STEP OF TWO DIFFERENT TECHNIQUES

You have accessJournal of UrologyKidney Cancer I: Partial Nephrectomy & Kidney Preservation Strategies (V01)1 Apr 2020V01-11 ROBOT-ASSISTED LEVEL II AND III INFERIOR VENA CAVA THROMBECTOMY: STEP-BY-STEP OF TWO DIFFERENT TECHNIQUES Gilberto Rodrigues*, Arnaldo Fazoli, Luís Tanure, Giuliano Guglielmetti, Maurício Cordeiro, Rafael Coelho, and William Nahas Gilberto Rodrigues*Gilberto Rodrigues* More articles by this author , Arnaldo FazoliArnaldo Fazoli More articles by this author , Luís TanureLuís Tanure More articles by this author , Giuliano GuglielmettiGiuliano Guglielmetti More articles by this author , Maurício CordeiroMaurício Cordeiro More articles by this author , Rafael CoelhoRafael Coelho More articles by this author , and William NahasWilliam Nahas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000826.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inferior vena cava (IVC) thrombectomy (TE) is one of the most challenging urological surgeries. Beyond the great morbidity when done by the open approach that often requires large incisions and multiple organs mobilization, it usually involves serious risks of bleeding and embolism. Minimally invasive surgery is becoming promising in this scenario, especially with the emergence of robot assisted (RA) platforms. Few series were reported so far. METHODS: This video presents the surgical technique of two different cases of IVC-TE. Initially, a 45 years old female with an unremarkable previous history presenting a right renal tumor with a level II IVC-tumoral thrombus (TT), reaching the inferior liver border. Then, a 78 years old male, previously asymptomatic with an incidental large (18cm) left renal tumor presenting level III IVC-TT, a few centimeters from the diaphragm. Both underwent to RA IVC-TE with daVinci Si. RESULTS: The first case underwent to level II RA-IVC-TE, of note, right renal artery was clipped into the interaortocaval space, preventing possible neovascular injuries around the renal tumor, whereas there was a suspicion of an angiomyolipoma (AML). The operative time (OT) was 97 min, estimated blood loss (EBL) 150 ml, no intraoperative complications and length of stay (LOS) was 2 days. Pathology report confirmed AML. The second patient underwent to level III left RA-IVC-TE. Important to emphasize, the large tumor distorted the hilum, changing usual anatomy and making it hard to find the left renal artery. After properly identification of the vessels, a vascular stapler was applied to the left renal vein with a TT segment inside. Then, left nephrectomy was completed and the patient was repositioned to left lateral decubitus. Left renal stump was retrieved and IVC-TE was performed. It was required to clip some short hepatic veins and to mobilize both left and right hepatic lobe to reach the cranial limit of the TT inside the retrohepatic vena cava segment. Perioperative period was uneventful. OT was 258 minutes, EBL 400ml, LOS 3 days. Pathology report was unclassified renal cell carcinoma, ISUP 3, 16cm in larger axis, T3bN0. CONCLUSIONS: RA platform provides the ability to apply open principles safely with great perioperative outcomes. The increased dexterity from the instruments and the tridimensional images make vascular dissection in tight regions easier. Different TT level and side tumor require different strategies to control the renal hilum. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e93-e93 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gilberto Rodrigues* More articles by this author Arnaldo Fazoli More articles by this author Luís Tanure More articles by this author Giuliano Guglielmetti More articles by this author Maurício Cordeiro More articles by this author Rafael Coelho More articles by this author William Nahas More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-12 ROBOT-ASSISTED LAPAROSCOPIC CAVECTOMY WITHOUT IVC REPLACEMENT FOR RIGHT RCC AND INFERIOR VENA CAVA THROMBUS

You have accessJournal of UrologyAdrenal Surgery & Kidney Cancer II (Advanced Kidney Cancer & Vascular Reconstruction) (V10)1 Apr 2020V10-12 ROBOT-ASSISTED LAPAROSCOPIC CAVECTOMY WITHOUT IVC REPLACEMENT FOR RIGHT RCC AND INFERIOR VENA CAVA THROMBUS Alberto Olivero*, Quingbo Huang, Yang Fan, Baojun Wang, and Xin Ma Alberto Olivero*Alberto Olivero* More articles by this author , Quingbo HuangQuingbo Huang More articles by this author , Yang FanYang Fan More articles by this author , Baojun WangBaojun Wang More articles by this author , and Xin MaXin Ma More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000935.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Right Robot-assisted cavectomy without IVC replacement for inferior vena cava thrombus (RAC-IVCT) has been reported in limited series. This video aims to introduce and describe the surgical technique and report the surgical outcomes. METHODS: An explanatory case of a male patient with right side level II IVC thrombus with infiltration in IVC wall, is reported. The patient was positioned in a modified left lateral decubitus position with a 70 degrees bump. A 12-mm port was placed at about 2–3 cm to the upper right of the umbilicus for the camera. Three 8-mm robotic ports for the first, second, and third robot arm were placed at about 3 cm medial to the right midclavicular line under the costal margin, at about 3 cm lateral to the right midclavicular line near McBurney’s point, and at 6–8 cm lateral to the second robot port. Three assistant ports were used. Initially, triangular and coronary and hepatocolonic ligaments were dissected. The cephalic IVC including the thrombus was adequately exposed from the renal ostium in the cranial direction as necessary, by dividing and clipping some short hepatic veins. After cava exposure, the limits of the thrombus were confirmed using a laparoscopic ultrasound probe. A vessel tourniquet was placed above the upper limit of the thrombus. The cephalic IVC was stapled using 12-mm Endo GIA, leaving minimal cava caudal to the SPH to limit turbulence and potential thrombosis. Subsequently, the left renal vein was dissected circumferentially, looped, and stapled. The right renal artery was exposed and ligated in the interaortocaval space. The main collaterals were carefully preserved under intraoperative ultrasound guidance when stapling the caudal IVC. Finally, radical nephrectomy with simultaneous en-bloc resection of the involved IVC was completed. RESULTS: We registered no perioperative complications. The operative time was 225 minutes. Blood losses were 500cc. On the third postoperative day, the abdominal drain has been removed, and in seventh POD the patient was discharged. One more accurate outcomes analysis of the initial series of patients undergone RAC-ICVT is included in the video. CONCLUSIONS: Right RAC-IVCT is safe and feasible in selected patients with well-established IVC collateral circulation. A longer follow-up is needed to assess the oncological outcomes. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e934-e934 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alberto Olivero* More articles by this author Quingbo Huang More articles by this author Yang Fan More articles by this author Baojun Wang More articles by this author Xin Ma More articles by this author Expand All Advertisement PDF downloadLoading ...