|SSAT ''How I Do It'' Series: Liver
The Surgical Management of Hepatic Lesions (HL)
The video shows the surgical management of hepatic lesions (HL)at the hepatocaval confluence (HC) is shown. Major hepatectomies are the usual approach for HL in these complex situations. Our findings on R1 vascular resection, the use of intraoperative ultrasonography to detect communicating veins (CV), and thorachophenolaparomy incision allow us to enhance our rate parenchymal spare resections (PSR) reducing postoperative morbidity and increasing the rate of repeated hepatectomies.
Partial resection and reconstruction of hepatic veins (HV) at the HC is shown in the first video. In the second video, detachment of the HL by means of HV tunneling is shown. In the last video a PSR for a HL infiltrating the middle and right HV at HC is performed thank to the presence of CV that drains the future remnant liver trough only one HV: left HV.
The Two-Surgeon Technique for Hepatic Parenchymal Transection
In this video, we demonstrate the two-surgeon technique used at our institution for transection of hepatic parenchyma. This technique stresses precise dissection of the liver parenchyma, which allows for selective management of each blood vessel and bile duct. Smaller vessels are coagulated with saline-linked cautery; medium size vessels are ligated with clips and transected; larger vessels or ducts can be tied with silk sutures or transected with a linear cutting stapler. This precise dissection allows for improved visualization and ligation of small crossing vessels. In a single institution, retrospective analysis, this technique was associated with decreased duration of inflow occlusion, less blood loss and shorter operative times.
Extended Left Hepatectomy with Right Hepatic Vein Resection/Reconstruction for Metastatic Rectal Cancer in the Liver
This video illustrates the case of rectal cancer with extensive liver metastasis involving three hepatic veins. The patient was a 41-year-old woman who presented with rectal bleeding. Work-ups revealed non-obstructive rectal cancer with liver metastasis. Her liver metastases included 8 small superficial lesions and 2 large central lesions involving all of three hepatic veins. She received systemic chemotherapy with FOLFOXILI with Bevacizumab with excellent response. Thus, we planned extended left hepatectomy with hepatic vein reconstruction following preoperative portal vein embolization. The patient tolerated this complex liver operation and completed laparoscopic low anterior resection for the rectal primary lesion 4 weeks later.
Pure Laparascopic Right Hepatectomy With ICG Immunofluorescence Imagining in Patient With HCC and Cirrhosis
In this video the operation was performed under general anesthesia with patient put into French Position. 10mm port was put in subumbilical area. Four working ports with were inserted in the upper abdomen. Pneumoperitoneum was created at 12mmHg. ICG was injected at 05mg/kg 2 weeks before the surgery. The liver hilum was dissected to expose the right hepatic artery and portal vein individually. A bulldog clamp was applied to the right hepatic artery and portal vein. Doppler ultrasound was performed to ensure the patency of vessels in the left lobe of the liver. The right hepatic artery and portal vein was clipped and divided. The liver parenchymal transection with performed with CUSA and thunderbeat. The right hepatic duct was divided and right hepatic vein was divided with stapler. The right lobe of the liver was delivered via a Pfannestiel incision.
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