Technique Of Hepatectomy Research Articles

Laparoscopic Right Hepatectomy In A Cirrhotic Patient: Anterior Approach And Extrafascial Pedicle Control

Presenter: Jaime Kruger MD | Hospital das Clinicas - University of Sao Paulo Background: Laparoscopic liver resections have gained progressive acceptance among liver surgeons. The second international consensus on minimally invasive liver operations indicated that major liver resections are increasingly being performed. Due to the complexity of such operations, most of them are performed in specialized tertiary academic centers. Along with the complexity of major resections, patient's characteristics such as liver cirrhosis may increase procedure difficulty and demand different approaches in order to successfully perform the operation. Methods: Video describing surgical technique for laparoscopic right hepatectomy. A 53 years-old male patient with hepatitis-C related cirrhosis was diagnosed with a right lobe hepatocellular carcinoma. The patient had normal liver function and no signs of portal hypertension. A totally laparoscopic right hepatectomy was performed, five ports were placed, a 10 mm 30 degree scope was used and pneumoperitoneal was set to 12 mmHg. Due to an enlarged an stiff liver an anterior approach was applied to avoid difficult mobilization and reduce hemodynamic stress. Pedicle was managed with an extrafascial extra hepatic approach and parenchymal transection was carried out with ultrasonic scalpel. Results: Operative time was 360 minutes, estimated blood loss was 500 mL, no blood transfusion was required. Patient was discharged from ICU on 1st POD and from hospital on the 7th POD. The patient developed transient liver insufficiency (5th POD total bilirubin 2.05 mg/dL) and was discharged with improving clinical and biochemical tests. Pathology report confirmed a moderately differentiated HCC, 80 mm in the largest diameter associated with satellite nodules and microvascular invasion. The patient recurred 12 months after resection and was managed with TACE, being alive 30 months after operation. Conclusion: Cirrhotic patients benefit from laparoscopic liver resection, which Results in lesser blood loss and fewer liver-related complications. Anterior approach allows less liver mobilization with theoretical benefits of less hemodynamic stress and fewer microscopic tumor spillage into venous circulation. Extrafascial pedicle control is an interesting technical option for tumors located far from the pedicle as it Results in complete control of the portal triad without prolonged hilar dissection.

Surgical Treatment of a Primary Tumour and Liver Metastases in a Patient With Intracranial Haemangiopericytoma

Cancers exhibit a spectrum of behaviours ranging from aggressive malignancy to those which progress in an almost benign fashion. An appreciation of this aspect of tumour biology is crucial when planning patient management as non-curative debulking procedures for slower growing tumours often still confer a survival benefit. The present report is a case in point.
 Haemangiopericytoma is a rare cancer whilst clear indications for an ALPPS procedure are still evolving. Inherent to the patient groups in whom ALPPS is considered is the presence of advanced underlying disease. Many of these patients would previously not be considered for liver resection or have progressed beyond resectability by the time sufficient hypertrophy of their future liver remnant had been achieved using conventional two-stage hepatectomy techniques.
 ALPPS offers another treatment option for these patients, although at a cost. Early experience reported unacceptably high morbidity and mortality rates following ALPPs resection and suggested that tumour type and patient fitness were key factors in determining outcome. The patient must be fit enough to withstand two major operations 1-2 weeks apart. The slow growing nature of the tumour in the present case combined with the fit, motivated patient meant that, despite developing post-operative liver insufficiency, Mr X still recovered well.
 As is so often the case in surgery, patient selection is key

ALPPS for hepatocarcinoma under cirrhosis: a feasible alternative to portal vein embolization.

Hepatocellular carcinoma (HCC) is one of the most common and malignant tumors. Preoperative portal vein embolization (PVE) is currently the most accepted treatment before major hepatic resection for HCC in patients with liver fibrosis or cirrhosis and associated insufficient future liver remnant (FLR). In the last decade, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique has been described to obtain an increase of volume regarding PVE and a decrease of drop out. The initial excessive morbidity and mortality of this technique have decreased drastically due to a better selection of patients, the learning curve and the use of less aggressive variations of the original technique in the first stage. For both techniques a complete preoperative assessment of the FLR is the most important issue and only patients with and adequate FLR should be resected. ALPPS could be a feasible technique in very selected patients with HCC and cirrhosis. As long as it is performed in an experienced center could be used as a first choice technique versus PVE or could be used as a rescue technique in case of PVE failure.

The technique and outcomes of central hepatectomy by the Glissonian suprahilar approach

IntroductionCentral hepatectomy (CH) is technically challenging and seldom-used to treat centrally located tumors. However, CH is a parenchyma-sparing resection that may decrease the risk of postoperative liver failure. This retrospective study presents our technique of CH and assesses the outcomes. MethodsAll CH performed in our department over two decades (1997–2017) were identified. Indications and short-term outcomes were compared between the two decades. Long-term outcomes were assessed. ResultsSixty-four patients underwent CH using a suprahilar approach for hepatocellular carcinoma (HCC: n = 30), metastasis (n = 23), intrahepatic cholangiocarcinoma (IHCCA: n = 9) or other diseases (n = 2). CH represented 6% of 1004 major hepatectomies, (7.4% (n = 35) before 2007 vs 5.4% (n = 29) after 2007). The mean operating time was 219 ± 56 min. A perioperative blood transfusion was required in 14 patients (22%). Intraoperative bile duct injuries occurred in 5 patients (8%), and they were repaired. One patient died postoperatively (1,5%). Ten patients (16%) experienced a major complication. Nine patients (14%) suffered from bile leakage, of which 6 healed spontaneously. Only one patient had low grade liver failure. The R0-resection rate was 69%. After 2007, there were no bile duct injuries (0/29 vs 5/35, p < 0.05), and the average hospital stay was shorter but not significantly (11 vs 14 days). Actuarial 5-year survival was 56% for HCC patients and 34% for those with colorectal metastasis ConclusionsCH is associated with significant biliary morbidity and may increase positive surgical margins. Nevertheless, it should be recommended in selected patients to avoid the risk of postoperative liver failure.

A Tailored Strategy for Recipient Hepatectomy: Left Portal Flow Preserving High Hilar Dissection

BackgroundLee et al. (Liver Transpl 10(9):1158–1162, 2004) reported high hilar dissection (HHD) technique as a novel method for recipient hepatectomy to overcome limitations of conventional hilar dissection (CHD). HHD allowed performing multiple tension-free biliary anastomoses and easy reconstruction of double portal vein orifices. However, longer anhepatic phase is its main drawback. We describe a new modification of original HHD, called left portal vein flow preserving HHD (LFP-HHD). The new technique aims to gain the balance between CHD and original HHD. MethodsThe detailed technique of recipient hepatectomy by LFP-HHD is shown in the electronic video file. It involves high intrahepatic division of hilar structures while maintaining portal drainage through maintained left portal vein (LPV). Control of right hemi-liver inflow allows for division of right hepatic vein, and safe dissection of inferior vena cava (IVC) and hilar structures. According to coordination with donor surgery, the liver could be easily explanted. DiscussionLFP-HHD has the same principle of original HHD allowing for multiple tension-free well-vascularized biliary anastomoses. LFP-HHD allows for shortening of anhepatic phase duration as portal venous drainage is continued through maintained LPV avoiding prolonged total portal clamping with bowel edema or the need for temporary porto-caval shunt. On the other hand, the number and the length of the hilar structures can be decreased compared with the original HHD technique. However, the level of division of the hilar structures is acceptable in most of the cases. ConclusionLFP-HHD is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions.

Modified Technique of Total Hepatectomy in Polycystic Liver Disease With Caval Flow Preservation: The Exposure Left Lateral Sectionectomy

Liver transplantation (LT) for polycystic liver disease (PLD) is rare, extremely challenging and hemorrhagic, without standard approach. Moreover, LT for PLD presents the highest mortality rate (12% to 18%) among all causes of LT. In this setting, the combination of difficult mobilization of a heavy polycystic native liver with narrow access to inferior vena cava and fragile venous wall may lead to venous tearing and cataclysmic bleeding during dissection. The aim of this study was to evaluate a modified technique of total hepatectomy to limit hazardous liver manipulation and improve exposure of inferior vena cava in patients with massive hepatomegaly related to PLD: the exposure left lateral sectionectomy (ELLS). From 2011 to 2018, ELLS was performed during LT for PLD. Key technical points for safe and fast ELLS include avoidance of left triangular ligament section and placement of a tape behind the left lateral section allowing its ascension and prior dissection of the hepatic pedicle to limit bleeding. The transection plane is mainly composed of cysts, with limited parenchyma, which allows for rapid and bloodless transection using electric scalpel. Fifteen patients had ELLS with no postoperative death or intraoperative complication. Median ELLS duration was 16 minutes, and no massive bleeding occurred during this step. During total hepatectomy, median blood loss was 500 mL, and no patient required total caval clamping. All patients were alive at the end of the follow-up. ELLS during LT for PLD facilitates total hepatectomy with vena cava and caval flow preservation.

A Single Center Experience for a Feasibility of Totally Laparoscopic Living Donor Right Hepatectomy.

PurposeDonor safety is the most important problem of living donor liver transplantation (LDLT). Although laparoscopic liver resection has gained popularity with increased surgical experience and the development of laparoscopes and specialized instruments, a totally laparoscopic living donor right hepatectomy (LDRH) technique has not been investigated for efficacy and feasibility. We describe the experiences and outcomes associated with LDRH in adult-to-adult LDLT in order to assess the safety of the totally laparoscopic technique in donors.MethodsBetween May 2016 and July 2017, we performed hepatectomies in 22 living donors using a totally laparoscopic approach. Among them, 20 donors underwent LDRH. We retrospectively reviewed the medical records to ascertain donor safety and the reproducibility of LDRH; intra-operative and post-operative results including complications were demonstrated after performing LDRH.ResultsThe median donor age was 29 years old and the median body mass index was 22.6 kg/m2. The actual graft weight was 710 g and graft weight/body weight (GRWR) was 1.125. No donors required blood transfusion, conversion to open surgery, or reoperation. The postoperative mortality was nil and postoperative complications were identified in two donors. One had fluid collection in the supra-pubic incision site for graft retrieval and the second had a minor bile leakage from the cutting edge of the right hepatic duct stump. All the liver function tests returned to normal ranges within one month.ConclusionLDRH is a feasible operation owing to low blood loss and few complications. However, LDRH can be initially attempted after attaining sufficient experience in laparoscopic hepatectomy and LDLT techniques.

Pure Laparoscopic Living Donor Right Hepatectomy Using Real-Time Indocyanine Green Fluorescence Imaging

IntroductionIn recent decades, the quantitative and technological development of laparoscopic liver resection has resulted in an extension into the transplantation area.1,2 However, laparoscopic living donor hepatectomy is still in its infancy due to technical difficulties and extreme caution regarding donor safety.3 Several experienced major centers have demonstrated the feasibility and safety of laparoscopic living donor hepatectomy, and recent advances in laparoscopic imaging technology support this move.4 In particular, indocyanine green near-infrared fluorescence imaging helps determine the correct liver parenchyma anatomical resection and the exact point of bile duct division.4-6 This video demonstrates the technique of pure laparoscopic living donor right hepatectomy and the usefulness of indocyanine green fluorescence imaging. MethodsThe donor was a 32-year-old gentleman who decided to donate part of his liver to his wife who was suffering from viral liver cirrhosis and hepatocellular carcinoma. His BMI was 20.3 kg/m2 and the preoperatively estimated donor’s right liver volume was 836 ml, representing 63.6% of his entire liver. With the recipient’s weight of 57 kg, the graft-to-recipient weight ratio (GRWR) was 1.6%. The liver had classic hilar anatomy except that the right posterior intrahepatic duct was joined separately to the left main hepatic duct. The patient setting and the placement of the trocars were the same as for our conventional laparoscopic right hepatectomy technique.7 After right hepatic artery and portal vein isolation and clamping, 2.5 mg of indocyanine green was injected intravenously. ResultsTotal operation time was 370 min and estimated blood loss was 150 ml without transfusion. Indocyanine green fluorescence imaging clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. His postoperative course was uneventful, and he was discharged on postoperative day 7. ConclusionReal-time indocyanine green fluorescence imaging may be particularly helpful for delineating the anatomical surgical plane and determining the appropriate division point of the hepatic duct during laparoscopic living donor hepatectomy.

A Tailored Strategy for Recipient Hepatectomy: Left Portal Flow Preserving High Hilar Dissection

Summary: High hilar dissection (HHD) technique was reported as a novel technique for recipient hepatectomy. It allowed performing multiple tension-free duct to duct biliary anastomoses, hence reducing biliary complications. However, longer anhepatic phase is its main drawback. We describe a new modification of HHD technique, called left portal vein flow preserving HHD (LFP-HHD). It involves high intrahepatic division of hilar structures while maintaining the portal venous drainage through the left portal vein. Control of right hemi-liver inflow allows for division of the right hepatic vein, and further dissection of the retro-hepatic inferior vena cava easily and safely. Dissection of the anterior hilar structures can be accomplished. According to the co-ordination with the donor and bench surgery, the liver could be easily explanted. LFP-HHD technique is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions. It overcomes limitations of original HHD technique without compromising its merits.

Anterior approach for right hepatectomy and right anterior sectionectomy with hanging maneuver for large hepatocellular carcinoma: A single-center experience in Vietnam (with video)

Introduction: Right hepatectomy and right anterior sectionectomy for large hepatocellular carcinoma via the anterior approach without prior liver mobilization is an accepted technique and the liver hanging maneuver facilitates this procedure. Hepatic parenchymal transection remains a critical part of this operation during which excessive blood loss can occur. Control of blood loss is important in hepatectomy as excessive bleeding and blood transfusion are associated with increased postoperative morbidity/ mortality rates and compromised long term oncological outcomes in these patients. Objective: To report the surgical and preliminary outcomes of major right hepatectomy and right anterior sectionectomy for large hepatocellular carcinoma (HCC) using the anterior approach with hanging maneuver in single center in Vietnam. Methods: In patients who had large HCC (over 10 cm in size) at the right lobe of liver and underwent hepatic resection such as right hepatectomy or right anterior sectionectomy, the technique of anterior approach with the liver hanging maneuver was used. All consecutive patients who underwent elective right hepatectomy or right anterior sectionectomy in our center using this technique from March 2014 to July 2016 were retrospectively studied. Results: Twenty one patients with hepatitis B-related hepatocellular carcinoma (HCC) with cirrhosis underwent the technique for right hepatectomy and right anterior sectionectomy using the anterior approach with the liver hanging maneuver. The mean blood loss, liver parenchymal transection time and operation time were 280.3 ± 72.6 ml (SD), 49.3 ± 8.1 min, and 291.7 ± 58.2 min, respectively. No patients developed postoperative bleeding or bile leak. There was no 90-day mortality. Conclusion: To achieve complete anatomic hepatectomy in a large hepatocellular carcinoma (HCC), hepatic transection through an anterior approach is required. Liver hanging maneuver is a useful procedure for transection of an adequately cut plane in anatomical liver resection.

Surgical technique and short-term outcomes of laparoscopic repeat hepatectomy

Surgical technique and short-term outcomes of laparoscopic repeat hepatectomy

3,707 hepatectomies over two decades: continuous improvements in perioperative outcomes despite increased complexity

Introduction: As perioperative care and surgical technique for hepatectomy have improved, the indications for and complexity of liver resections have evolved. The resulting effect on short-term outcomes over time has not been well described. Methods: The perioperative outcomes, including comprehensive complication index (CCI), of consecutive patients undergoing hepatectomy at one institution were compared across three successive eras: 1998–2003, 2004–2009, and 2010–2015. Results: Among 3,707 liver resections, there was an increase in the number of hepatectomies performed in each time period (794, 1402, 1511, p< 0.001). Technical complexity increased over time as evidenced by increases in the rates of major hepatectomy (20%, 23%, 30%, p< 0.0001), two-stage hepatectomy (0%, 3%, 4%, p< 0.0001), need for portal vein embolization (5%, 9%, 9%, p=0.001), preoperative chemotherapy for colorectal liver metastases (70%, 82%, 89%, p< 0.0001) and median operative time (180, 175, 225 min, p< 0.0001). Nevertheless, significant decreases over time were observed in median blood loss (300, 250, 200 mL, p< 0.0001), transfusion rate (19%, 15%, 5%, p< 0.0001), median length of hospitalization (7, 7, 6 days, p< 0.0001), rates of CCI ≥26.2 (20%, 22%, 16%, p< 0.0001) and 90-day mortality (3.1%, 2.6%, 1.3%, p=0.008). On multivariable analysis, hepatectomy in the most recent era was associated with lower incidence of CCI < 26.2 (OR 0.69, 95% CI 0.57–0.84, p< 0.0001). Conclusion: In this single institution review of hepatectomies over the past 18 years, improvements in perioperative outcomes, including a decrease in the CCI, were consistently observed despite a continuous escalation in case complexity.

A modified liver hanging maneuver in pure laparoscopic extended left hepatectomy (with video).

Laparoscopic extended left hepatectomy has rarely been reported because of technical difficulties. In this study, we describe the surgical technique of laparoscopic extended left hepatectomy using a modified liver hanging maneuver (LHM). The upper end of the hanging tape was positioned to the lateral aspect of the left hepatic vein (LHV), and the pathway was positioned with the ligamentum venosum. The liver was transected from the Cantlie line to the right side of the middle hepatic vein (MHV) without using the hanging technique. The lower end of the tape was repositioned to the groove created along the right side of the MHV after the initial parenchymal transection. The remnant liver was transected using the hanging maneuver. The hanging tape encircled the common trunk of the LHV and MHV. Three patients underwent laparoscopic extended left hepatectomy using the LHM. The median operation time was 310 minutes (range, 260 to 350 minutes), and the median estimated blood loss was 110 mL (range, 90 to 260 mL). The median postoperative hospital stay was 7 days (range, 7 to 8 days). No postoperative morbidity or mortality was observed. This modified LHM may be a safe and useful method for laparoscopic extended left hepatectomy.

SEALIVE: the use of technical vessel-sealing devices for recipient hepatectomy in liver transplantation: study protocol for a randomized controlled trial

BackgroundThe surgical technique used in liver transplantation has undergone constant evolution in an effort to develop a safe, highly standardized procedure. Despite this, the initial step of recipient hepatectomy has not been the focus of clinical research thus far. Due to advanced coagulopathy in liver transplant recipients, this part of the operation still carries the risk of severe hemorrhage. This trial is designed to compare an electrothermal bipolar vessel sealing device (LigaSure™) and an ultrasound dissector (HARMONIC ACE®+7) with standard surgical techniques during the recipients’ hepatectomy in liver transplantation.Methods/designIn a single-center, prospective, randomized, controlled, parallel, three-armed, confirmatory, open trial, LigaSure™ and HARMONIC ACE®+7 will be compared with standard surgical techniques that use titanium clips and conventional knot-tying ligations during recipient hepatectomy in liver transplantation. Intraoperative total blood loss is the primary endpoint of the trial. Secondary endpoints include blood loss during hepatectomy, the duration of both the hepatectomy and the entire surgical procedure, and blood transfusion requirements of the procedure. To generate reliable data, intraoperative blood loss will be recorded with respect to all rinse fluids during surgery, ascites, and by weighing used swabs. At 80% power and an alpha of 0.025 for both of the experimental groups, 23 subjects will be analyzed per protocol in each study arm in order to detect clinically relevant reduction of intraoperative blood loss. The intention-to-treat analysis will include 69 patients. The follow-up period for each patient will be 90 days for safety reasons, whereas all clinical outcomes will be measured within the first 10 postoperative days.DiscussionTo our knowledge, this is the first prospective, randomized trial comparing two innovative technical methods of vessel sealing and dissection with standard techniques for recipient hepatectomy. This will be done to detect relevant reduction of intraoperative blood loss during liver transplant. The results of the trial are expected to improve patient outcome and safety after liver transplant and to increase the general safety of this procedure.Trial registrationClinicalTrials.gov, NCT 03323242. Registered on October 26, 2017.

Extra-glissonian Approach for Total Laparoscopic Left Hepatectomy: A Prospective Cohort Study.

Laparoscopic liver resection under hemihepatic vascular inflow control has advantages over Pringle's maneuver, especially in patients with cirrhosis. From January 2016 to August 2016, 7 patients who underwent total laparoscopic left hepatectomy under hemihepatic vascular inflow occlusion using the extra-glissonian approach were included in this study. All were hepatitis B carriers and 4 had cirrhosis. The mean operation time was 247 minutes. The mean transection time was 110 minutes. No patient needed additional Pringle's maneuver. The mean intraoperative blood loss was 74 ml and no patient required blood transfusion. No open conversion happened. Postoperatively, no patient developed complications and there was no perioperative mortality. The mean resection margin was 2 cm. The mean hospital stay was 6 days. Upon a mean follow-up of 9 months, no patient developed tumor recurrence. The technique of total laparoscopic left hepatectomy using extra-glissonian approach was safe and feasible. The early surgical outcomes were good.

Techniques of parenchyma-sparing hepatectomy for the treatment of tumors involving the hepatocaval confluence: A reliable way to assure an adequate future liver remnant volume

Parenchyma-sparing hepatectomy techniques allow a lesser volume resection (<3 adjacent segments) for tumors involving the hepatic veins at the hepatocaval confluence, assuring adequate volume of the future liver remnant. We report the ability to perform parenchyma-sparing hepatectomy as planned from the preoperative imaging and the type of vascular intervention used to preserve hepatic outflow. We analyzed 60 consecutive parenchyma-sparing hepatectomies in 54 patients for 7 primary and 53 metastatic tumors (48 colorectal), located in segments I, VII, VIII, or IVa and involving the hepatocaval confluence. Patients had a median of 2 (range: 1-18) lesions with median diameter of 4cm (range: 1.2-16.5), which were bilateral in 43%. A parenchyma-sparing hepatectomy was performed in all of the 60 cases, only one case required the resection of 3 adjacent segments. In 16 (27%) hepatic veins-resections, the outflow was assured by preservation of the inferior-right-hepatic veins in 3 (5%), of the communicating-veins in 4 (7%), of the middle-hepatic veins in 3 (4%; middle-hepatic veins patch-reconstruction in 2 cases), by polytetrafluoroethylene-grafts in 4 (7%), and by hepatic veins-anastomosis in 2 (3%). In 15 (25%) cases, the hepatic veins were resected tangentially and reconstructed by direct suture venorraphy. In 29 (48%) cases, the hepatic veins were skeletonized from the tumor. Grade IIIb to IV complications occurred in 7%, median hospital-stay was 9days, and 90-day mortality occurred in one cirrhotic patient. Median overall and disease-free survivals were 72 and 16months (median follow-up: 34months). A lesser volume parenchyma-sparing hepatectomy rather than a formal major hepatectomy for tumors involving the hepatocaval confluence can be performed with a low rate of major complications (7%). Parenchyma-sparing hepatectomy should be considered in highly selected patients when evaluating liver resection for tumors involving the hepatocaval confluence based on appropriate and accurate preoperative imaging.

New concepts and techniques of hepato-pancreato-biliary surgery

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

Reconstruction of the Outflow Tract in Cross-Auxiliary Double-Domino Donor Liver Transplantation.

Auxiliary liver transplantation is accepted as an effective manner to expand the liver donor pool. A difficult surgical technical challenge of the procedure is hepatic vein reconstruction of the graft. To resolve this problem, complex techniques are used to perform an innovative outflow tract reconstruction in the world's first cross-auxiliary double-domino donor liver transplantation with two whole liver grafts. The inferior vena cava-sparing hepatectomy technique was applied at harvest in the two domino liver donors. For each donor, the three major hepatic veins (right, middle, and left) were joined together to create one single orifice, but there was no sufficient tissue to perform a direct anastomosis. The hepatic vein was reconstructed with the use of a longitudinally opened iliac vein graft from a cadaveric donor to prolong the outflow tract for the piggyback suturing. This new technique might provide an innovative surgical approach for reconstructing the complex outflow tract of domino transplantation.

Effects of limited hepatectomy on liver regeneration and function recovery of cirrhotic rat model

Objective To assess the effects of limited hepatectomy on liver regeneration and function recovery of cirrhotic animal model. Methods Cirrhotic rat models were first prepared by intraperitoneal injection of CCL4. After that, the cirrhotic animal models underwent 20% hepatectomy (n=30). The cirrhotic animals that underwent sham operation (n=30) and normal animals that underwent 20% hepatectomy (n=30) were used as control groups. From the time when cirrhotic models were prepared to 3 months after 20% hepatectomy, the hepatic function, coagulation function were tested regularly. Western blotting and real-time PCR were carried out to test the protein and gene expression of TGF-β, HGF and PCNA. Results Hepatic fibrosis and cirrhosis were observed during the preparation of cirrhotic rat models by intraperitoneal injection of CCL4. The hepatic function and coagulation function of cirrhotic models were partly recovered 3 month after 20% hepatectomy. The gene and protein expression levels of TGF-β in the liver of animal model get higher during the preparation of cirrhotic rat models. However, the gene and protein expression levels of TGF-β get lower in cirrhotic model undergoing 20% hepatectomy, when compared with that in cirrhotic animals (sham operation) and normal animals (20% hepatectomy). Furthermore, the gene and protein expression levels of HGF and PCNA get higher in cirrhotic model undergoing 20% hepatectomy, when compared with that in cirrhotic animals (sham operation) and normal animals (20% hepatectomy). Conclusions Experimental limited hepatectomy facilitates the liver regeneration and function recovery of cirrhotic animal model, which may provide a novel method for the prevention and treatment of cirrhosis using limited hepatectomy technique. Key words: Liver cirrhosis; Hepatectomy; Liver regeneration

A totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy assisted with radiofrequency (radiofrequency assisted liver partition with portal vein ligation) for staged liver resection.

In order to induce liver hypertrophy to enable liver resection in patients with a small future liver remnant (FLR), various methods have been proposed in addition to portal vein embolisation (PVE). Most recently, the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique has gained significant international interest. This technique is limited by the high morbidity associated with an in situ liver splitting and the patient undergoing two open operations. We present the case of a variant ALPPS technique performed entirely laparoscopically with no major morbidity or mortality. An increased liver volume of 57.9% was seen after 14 days. This technique is feasible to perform and compares favourably to other ALPPS methods whilst gaining the advantages of laparoscopic surgery.