Technique For Hepatic Resection Research Articles

Anterior Glissionian approach: A novel technique for hepatic resection and our experience

Introduction and Aim: Glisson's capsule encloses most of the liver and hepatic pedicles take a layer of this capsule as they enter the liver parenchyma. Biliary and vascular anatomy is highly variable. Anterior glissionian technique was described by Ton That Tung of Vietnam where in the hepatic pedicles are identified and followed by the virtue of the thin shining glisson's capsule and ligated or clipped at the appropriate place as desired by the extent of resection.

Techniques of hepatic resection.

Liver resections are high risk procedures performed by experienced surgeons. The role of liver resection in malignant disease has changed over the last 100 years with great improvement in morbidity, mortality and long term survival. New understanding in liver anatomy, improved perioperative care, anesthesia techniques, and technological advances has improved this aspect of patient care. With improved techniques, patients previously considered unresectable have an opportunity to undergo curative surgery. This review article describes the various approaches and techniques for liver resection. The relevant anatomy and terminology of hepatic resections is discussed, as well as the role of anatomic vs. nonanatomic resection. Methods of vascular control are examined and the multiple strategies of parenchymal transection are compared, as well as minimally-invasive techniques. Finally, a brief review of the authors' practice in terms of surgical technique is offered.

Present state of the surgical treatment of hepatic metastasis of colorectal origin: a practical view

Hepatic resection is the only real possibility of cure for a selected group of patients with hepatic metastasis of colorectal cancer. Survival obtained in these patients is of some 30-40% after 5 years and some 20-25% after ten years following surgery; no other treatment approaches these results. The key for obtaining these results is the treatment of these patients by a multidisciplinary team, a team that must include the participation of surgeons specially trained in the techniques of hepatic resection. The present review describes: the pre-operational staging of hepatic metastasis of colorectal origin by diagnostic imaging techniques, the selection criteria for surgery, the standards of the surgical technique and the adjuvant treatment that forms part of the Protocol of the Hepatobiliary Surgery Section of the Hospital of Navarra, based on our experience in 150 hepatectomies and on the best scientifically available evidence.

Chemotherapy for colorectal cancer prior to liver resection for colorectal cancer hepatic metastases does not adversely affect peri‐operative outcomes

Systemic chemotherapy is being used increasingly in patients with colorectal cancer. The effects of prior systemic adjuvant or palliative chemotherapy on morbidity following hepatic resection for metastases are not well defined. To assess the peri-operative impact of systemic chemotherapy on liver resection for colorectal cancer hepatic metastases. Ninety-six resections for colorectal cancer hepatic metastases performed from July 2001 to July 2003 (93% > or =2 segments) were reviewed. Pre-operative demographics, peri-operative features, and post-operative outcomes were collected prospectively. Type of chemotherapy and the temporal relationship of chemotherapy to the liver resection were analyzed. Fifty-three of 96 patients (55%) received a mean of 5.7 cycles (6.1 months) of systemic chemotherapy prior to hepatic resection, with a median interval of 12 months from end of chemotherapy to liver resection (range 1-75 months). Thirty-five received 5-fluorouracil/leucovorin (5-FU/LV) alone, nine had irinotecan (CPT-11) in addition to 5-FU/LV, and nine were not specified. Pre-operative age, sex, co-morbidities, ASA score, biochemical and liver enzyme profiles, tumor number, and extent and technique of hepatic resection were the same in the chemotherapy and non-chemotherapy cohorts. Mean tumor size was smaller (4.5 cm vs. 5.8 cm) and synchronous metastases were half as common (25% vs. 49%) in the chemotherapy group. Liver resection operative time was equivalent (270 min) in the two groups. Higher estimated blood loss (EBL) (1,000 ml vs. 850 ml), but fewer transfusions (23% vs. 15%) were associated with the chemotherapy group. Although not statistically significant, post-operative liver enzyme peaks were higher in the chemotherapy group (AST = 402 U/L vs. 302 U/L, P = 0.09 and ALT = 433 U/L vs. 312 U/L, P = 0.1). Peak changes in INR and serum bilirubin did not differ. Complications and length of stay (LOS) did not differ between the groups. The only post-operative death was in the non-chemotherapy group. Interestingly, hepatic steatosis was present in 28% of the non-chemotherapy cases and 57% of the chemotherapy resection specimens (P = 0.005) and was marked (>30%) in 7% and 10%, respectively. Further analysis of the chemotherapy group based on the interval between completion of chemotherapy and the hepatic resection (<6 months, 7-12 months, 1-2 years, and >2 years) revealed a trend towards worse outcomes in most categories for those in the >2 years cohort. When comparing the 5-FU/LV alone, to the CPT-11 group there were no significant differences except higher intra-operative blood loss in the group receiving 5-FU/LV alone (1,295 ml vs. 756 ml, P = 0.01). Despite variations in biochemical function and hepatic steatosis, short-term clinical outcomes are not affected by the administration of chemotherapy prior to hepatic resection. Furthermore, there is no detrimental effect of close timing of chemotherapy prior to resection, and there are no appreciable differences between irinotecan containing regimes and more traditional 5-FU-only based therapies, although the subset sample sizes were small in this study.

One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery.

A technique of hepatic resection is described and the results of 150 resections are reviewed. Hepatic transection was performed, under intermittent portal inflow occlusion, using ultrasonic aspiration to skeletonize portal branches and venous tributaries. Control of venous haemorrhage during resection was optimized by argon beam coagulation and lowering central venous pressure to between 0 and 4 cmH2O by extradural blockade and systemic nitroglycerine infusion. One patient with jaundice died in hospital, giving a mortality rate of 0.7 per cent. There were no deaths in patients without jaundice and cirrhosis. Fifteen patients (10.0 per cent) had significant complications, nine medical and six surgical, including three bile leaks (2.0 per cent). Mean blood loss was 814 ml for the whole study but only 434 ml in the last 4 years. During this latter period mean blood transfusion in hospital was 0.5 units and mean postoperative haemoglobin value fell by 0.7 g per 100 ml. Hepatic resection can be performed with the same degree of confidence and similar low morbidity as any other major surgical procedure.

Symptomatic non-parasitic cysts of the liver.

Abstract Eighteen patients with symptomatic non-parasitic cysts of the liver were seen and treated at the Lahey Clinic Foundation between 1950 and 1970. A review of the world literature indicates that the incidence of non-parasitic cystic disease of the liver is undoubtedly higher than is indicated by the number of clinically diagnosed cases. No specific symptom complex was observed. When symptoms do eventually occur they are almost always, in the absence of complications, the result of the space-occupying effect of the cyst either on the liver itself or on adjacent viscera. When biochemical studies of liver function are abnormal it is the result of coincidental or associated liver disease and not of the cyst itself. Although cystic disease of the liver is rarely diagnosed clinically, the possibility should be seriously considered in any patient with an enlarged liver that is associated with few symptoms and little or no impairment of hepatic function. Although radio-isotope scanning and coeliac axis arteriography are being used with increasing frequency and may be of value in the evaluation of this entity, the diagnosis at the present time depends on exploratory laparotomy. The safety of surgery in this series, together with the excellent long-term results, supports our view that symptomatic cysts of the liver should be treated surgically; whenever possible the lesion should be removed by either local excision or formal hepatic resection. In view of this, the authors feel that the management of such cases should only be undertaken by those familiar with the techniques of hepatic resection.

A comparison of the harmonic scalpel with clamp crushing technique for hepatic resection

Introduction: The ultrasonically activated shears (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH) has frequently been used for hepatic resection. However, no studies exist to address its safety and efficacy compared to the traditional clamp crushing technique of liver parenchymal transection. Methods: We retrospectively reviewed all hepatic resections between September 1992 to February 2002 at our institution. Patients were divided into two groups based on the technique of resection: clamp crushing versus harmonic scalpel. Standard clinico-patholog]c data were obtained. In addition, intra-operative courses were reviewed, examining blood loss, blood transfusion, and operative time. Follow-up care was reviewed for bile leaks, bleeding, and abscess formation. Standard statistical analysis was performed. Results: 243 non-cirrhotic patients underwent 248 hepatic resections. Sixtythree percent (N = 157) of liver resections were performed with the harmonic scalpel and 37% (N = 9t) were performed with the clamp crushing technique. The groups were similarly matched for age, gender, diagnosis, and co-morbidity (p = NS). Mean operative time (282 +/10.5 vs. 368+/-17.3 mini p<O.05), blood loss (884+/-73.2 vs. 1264+/-151.8 cc; p<O.05), and blood transfusion (1.1 +/-0.2 v. 2.3 +/-0.4 units; p<0.05) were all lower in the harmonic scalpel group versus the clamp crushing group, respectively. Post-operative complications were similar between the two groups (20% (N= 31) v. 14% (N = 13); p=NS), but there was a trend towards a significant increase in bile leaks in the harmonic scalpel group (p = 0.07). A subset analysis of anatomic resections in the two groups revealed a statistically significant increase of bile leaks in the harmonic scalpel group (p=O.01). Conclusion: The harmonic scalpel can be used safely to perform liver surgery, with decreased operative time and blood loss. However, because of the increased incidence of postoperative bile leaks in anatomic resections, surgeons must be vigilant during liver parenchymal transection when using this device.

The changing face of hepatic resection

Although the first surgical removal of a portion of the human liver was recorded more than two centuries ago, the liver was regarded as a noli me tangere (“do not touch me”) organ until the beginning of this century. This fear still exists in some degree even today. Until 10 to 15 years ago, the operative mortality with major hepatic resections was too great to justify their use if a less dangerous, even though unsatisfactory, alternative was available. This is no longer a supportable point of view in the 1980s. Major hepatic resections can now be performed quite safely, and indications for the operation have become far less restrictive for both malignant and benign hepatic lesions. Increased numbers of hepatic mass-lesions are found today by advanced imaging technology, and physicians and surgeons are asked frequently for their best management. Our main concerns in this monograph are to summarize the essential surgical anatomy of the liver, the basic surgical pathology, and the techniques of hepatic resection. We also report our experience with excisional therapy for benign and malignant hepatic lesions over the last 25 years.

Liver resection in malignant disease.

As more surgeons become familiar with the techniques of hepatic resection and the mortality and morbidity decrease, the indications for resection of malignant disease within the liver broadens. The preoperative assessment of malignant liver lesions, as well as the definition of resectability, are outlined. Indications for operative intervention as well as the results obtained are covered. The personal experience of the authors at the Royal Postgraduate Medical School Hepatobiliary Unit, Hammersmith Hospital, in dealing with malignant lesions of the liver is detailed with respect to procedures performed and postoperative morbidity and mortality. Hepatocellular carcinoma, hilar cholangiocarcinoma, and metastatic colon carcinoma are discussed in detail. The authors' experience with each of these diseases is presented.

A simplified technique for hepatic resection: the crush method.

A new technique of hepatic lobectomy with combined use of hepatic clamp and liver crush clamp is described. It is a simplification of the original finger fracture technique by using instruments instead of fingers for hepatic resection. It provides the unexperienced with a technique of hepatic resection done in the shortest possible time and in an almost bloodless field with safety. Since February 1973 the author has performed 5 hepatic resections with this crush method for primary liver cell carcinoma. The blood transfusion averaged 200 ml and the operation time averaged 1.5 hours. No complication or mortality was encountered and the patients were invariably discharged within 14 days after the operation.