In order to perform surgical treatment for tumors unresectable for anatomical reasons, there are two approaches: one is liver transplantation, and the other is extracorporeal hepatic resection (ECHR). The benefit of liver transplantation is its simple surgical concept, and the benefits of ECHR are that it is immunosuppression-free and that organ donors are unnecessary. The patient was a 39-year-old female referred to our hospital for possible living donor liver transplantation for her huge and multiple unresectable hemangiomas of the liver. Although she had undergone transcatheter arterial embolization 6 months previously, they showed an increase in size. At the time of referral, she demonstrated abdominal distention with shortness of breath. Her laboratory testing showed normal liver function tests, including a total bilirubin level of 1.3 mg/dL, an albumin level of 4.3 g/dL, and a prothrombin time of 13.6 seconds. A computed tomography scan of the abdomen showed 4 huge tumors (Fig. 1). This location of the tumors and their benign origin led us to choose ECHR rather than living donor liver transplantation after detailed informed consent was obtained. As is well known, the chance of receiving a liver graft from a deceased donor is almost zero in Japan. The estimated autograft volume after ECHR was 590 g, representing a graft volume/standard liver volume ratio of 49.6% (Fig. 2). The patient was taken to the operating room, and laparotomy was performed (Fig. 3). The liver was severely enlarged, but the nontumor portion looked like normal hepatic parenchyma. After the dissection of the hilar structures at the mid-hilum, the portosystemic venovenous bypass, using reinforced venous cannulas (Edwards Life Sciences, Inc., Irvine, CA), was established from the inferior mesenteric vein with 16Fr and from the left saphenous vein with 15Fr to the left axillary vein with 14Fr. The patient was started on the bypass at the rate of 4 L/min with a stable circulatory condition. After the division of the proper hepatic artery, the total liver was mobilized from the diaphragm. The common hepatic duct was divided, the vascular clamps were applied and followed by division on the portal vein and suprahepatic and infrahepatic vena cava, and then the total hepatectomy was performed. The explanted liver was flushed with 3 L of normal saline followed by 3 L of University of Wisconsin solution. Intraoperative ultrasound was done on the backtable for the determination of the exact cutting line. After dissection of the vena cava from the dorsal liver with ligation of the short hepatic veins, the huge hemangiomas in segment 1, segment 2 to 3, caudal segment 4, and segment 6 to 7 were resected with a Cavitron ultrasonic surgical aspirator (Valleylab, Inc., Boulder, CO; Fig. 2). After resection, vascular and biliary leakage tests using an injection of University of Wisconsin solution were performed, and the leakage points were repaired with fine sutures. The actual weight of the whole explanted liver was 4770 g, and the auto liver graft after extracorporeal resection was 510 g, representing a graft volume/standard liver volume ratio of 42.3%. The liver graft was placed in an orthotopic position, and then vascular reconstruction was done in the following order: the suprahepatic and infrahepatic vena cava, the portal vein, and the hepatic artery. Reperfusion of the graft was done slowly for thermoregulation and hemodynamic stability. Multiple bleeding
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Jan 1, 2007
Keiko Ikuta + 5
Open Access