Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura University. By.
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Transcript of Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura University. By.
Professor Of SurgeryProfessor Of Surgery Gastroenterology CenterGastroenterology Center
Mansoura UniversityMansoura University..
ByBy
Liver resection were first described centuries ago , but Liver resection were first described centuries ago , but
untill the latter half of the 20 th century , the majority of untill the latter half of the 20 th century , the majority of
such resections were performed foe management of such resections were performed foe management of
either injuries or infections.either injuries or infections.
Today , these procedures are performed not only for Today , these procedures are performed not only for
treatment of acute emergencies but also as potentially treatment of acute emergencies but also as potentially
curative therapy for a variety of BG & MG hepatic curative therapy for a variety of BG & MG hepatic
lesions. lesions.
( Weitz etal , 2007 )( Weitz etal , 2007 )
Hepatic Anatomy Hepatic Anatomy Familiarity with the surgical anatomy of Familiarity with the surgical anatomy of the liver is essential for safe performancethe liver is essential for safe performance
Brisbane 2000 System
First order
Two hemiliuers
Second order
Four sections
Third order
Eight segments
• Seg 5-8
• Rt H.a.
• Rt P.V
• Seg 2-4
• Lt H.a.
• Lt P.V
•Seg I
•Automomy
(Strasberg etal, 2000)
Preoperative Evaluation Preoperative Evaluation
Cross sectional modalities such as CT, MR, Cross sectional modalities such as CT, MR,
US. Play an important role in enhancing US. Play an important role in enhancing
an important role in enhancing the safety an important role in enhancing the safety
and efficacy of hepatic resection and efficacy of hepatic resection
These techniques together with the new These techniques together with the new
PET are essential for staging , patient PET are essential for staging , patient
selection and thereby optimize long-term selection and thereby optimize long-term
surgical outcome . surgical outcome .
( Morris etal ,2006)
Operative Planning Operative Planning Preparation :Preparation :
Cardiopulmonary eval Cardiopulmonary eval
Autologous ( 2 Units )Autologous ( 2 Units )
Correction of anemia or coagulopathy (if present)Correction of anemia or coagulopathy (if present)
Anesthesia :Anesthesia :Basline hepatic functionsBasline hepatic functions
Hepatic Functional deficit ( post op )Hepatic Functional deficit ( post op )
Major intraop b1 loss Major intraop b1 loss
Suitable monitoring Suitable monitoring
Sufficient vas accessSufficient vas access
Anatomic Vs Non-anat Anatomic Vs Non-anat ®®It is the Key decision It is the Key decision
Mg diseases Mg diseases → anatomic → anatomic ®®Better long-term otcome Better long-term otcome
Less % of + ve margins Less % of + ve margins
ExceptionsExceptions Cirrhotics.Cirrhotics. Functioning MetsFunctioning Mets
Bg diseases → Non – anatomicBg diseases → Non – anatomic ResectionResection
Relieve symptomsRelieve symptomsOncertain Oncertain øøPrevent MG transf.Prevent MG transf.
Operative Techniques Operative Techniques
Theoritically , any hepatic seg can be resected in Theoritically , any hepatic seg can be resected in
isolation isolation
However , for Practical purposes there are 6 However , for Practical purposes there are 6
major anatomic resection major anatomic resection
Goldsmith & woodburne terminology ( 1957)Goldsmith & woodburne terminology ( 1957)
Couinaud 16 Couinaud 16 ( Bismuth , 1982)( Bismuth , 1982)
Brisbane 2000 terminology Brisbane 2000 terminology ( strasberg etal , ( strasberg etal ,
2000)2000)
Total vascular Isolation For control Total vascular Isolation For control of Bleeding of Bleeding
Aharanative to pringle maneuver Aharanative to pringle maneuver The liver is isolated by The liver is isolated by
IVCIVC Above Above Below Below
PV.PV.H.A.H.A.
Advantage :Advantage :Little or No bleedingLittle or No bleedingDvration up to one hour.Dvration up to one hour.
Disadvantage :Disadvantage :
Homodynamic in stability Homodynamic in stability
Hypotension Hypotension
Arrythmia ( KArrythmia ( K++))
Caroliac arrest .Caroliac arrest .
Indication :Indication :
Large tumours Large tumours
Tumor compromise IVC or Major Vs.Tumor compromise IVC or Major Vs.
(Pichlmayr et al 2006)
Hanging Maneuver in Major Hanging Maneuver in Major hepatectomies hepatectomies
In the classic techniques complete mobilisation In the classic techniques complete mobilisation
before Vs control & paren transect is carried out before Vs control & paren transect is carried out
..
In cases where the tumor is quite large or In cases where the tumor is quite large or
invading the diaphragm or retro peritoneum invading the diaphragm or retro peritoneum
such mobilization may be difficult such mobilization may be difficult
Moreover , large & soft and vascular tumours Moreover , large & soft and vascular tumours
( HCC ) the early mobilization may ( HCC ) the early mobilization may
↑the risk of tumour ↑the risk of tumour rupture. rupture.
Hanging Maneuver In Major Hanging Maneuver In Major Hepatectomies ( Continue )Hepatectomies ( Continue )
Technique : (ant approach )Technique : (ant approach )The liver parenchyma is transected parenchyma The liver parenchyma is transected parenchyma is transected from the ant surface to reach the is transected from the ant surface to reach the vena cava with legation of the inflow and vena cava with legation of the inflow and outflow vasculaure before mobilisation outflow vasculaure before mobilisation
Modification:Modification:Dissection along the ant surface of IVC and a Dissection along the ant surface of IVC and a tape is passed in this plane to lift the liver . to tape is passed in this plane to lift the liver . to facilitate transection & vascular control facilitate transection & vascular control
(Belghiti etal , 2001)
Resection in cirrhotics. Resection in cirrhotics.
Cirrhotic patientsCirrhotic patientsReduced H. function capacity Reduced H. function capacity
Reduced H. Reserve.Reduced H. Reserve.
At higher risk.At higher risk.
therefore.therefore.
Careful a assessment .Careful a assessment .
Appropriate selection Appropriate selection
Choice of operation.Choice of operation.
Greater attention .Greater attention .
Patient selection Patient selection Base line LFTs.Base line LFTs.
Assessment of hepatic reserve.Assessment of hepatic reserve.Indocyanine green.Indocyanine green.
Aminopyrine . Aminopyrine .
Urea- Nitrogen syn. Urea- Nitrogen syn.
LIdocaine-o( MEG)LIdocaine-o( MEG)
Measurement of PVP gradiont Measurement of PVP gradiont Invasive .Invasive .
Doppler U\SDoppler U\S
Currently in practice → child- Pugh Currently in practice → child- Pugh Score > 8 contraindicateScore > 8 contraindicate
Choice Of The Procedure Choice Of The Procedure
Limited resection is favoured .Limited resection is favoured .
↑↑Functional parenchyma preserved Functional parenchyma preserved
Tumour free margin 1 am accepted Tumour free margin 1 am accepted
Patients with larger tumour mass are more likely to Patients with larger tumour mass are more likely to
tolerate a major resection tolerate a major resection
( > 2 segments )( > 2 segments )
Small , deeply seated tumors Small , deeply seated tumors
Ablative alternative Ablative alternative
Trans plantation Trans plantation
Operative TechniqueOperative Technique
Resections in cirrhotic patients is Resections in cirrhotic patients is
associated with many techniqucel associated with many techniqucel
difficulties that substantially difficulties that substantially ↑ ↑
complexity complexity
Hard parenchyma Hard parenchyma
Distorted anatomic landmarksDistorted anatomic landmarks
Difficult hemostasis & ↑ b1 loss.Difficult hemostasis & ↑ b1 loss.
Exposure & Mobilization Exposure & Mobilization
Ample exposure.Ample exposure.
Trifurcated or thoraco-abd incision Trifurcated or thoraco-abd incision
avoidedavoided
Anterior approach is preferable .Anterior approach is preferable .
Inflow Control Inflow Control At one time it was widely doubted whether the At one time it was widely doubted whether the PM was safe in cirrhotics.PM was safe in cirrhotics.
Many studies verified that the PM ca be per Many studies verified that the PM ca be per formed for extended periods in cirrhotics formed for extended periods in cirrhotics without without ↑either morbidity or mortality ↑either morbidity or mortality
Clamping the portal triad Clamping the portal triad
Vs loop tourniquet Vs loop tourniquet
10 min periods with 5 min breaks. 10 min periods with 5 min breaks.
How Ever
IN our practice
Parenchymal transactionParenchymal transactionIn patient with normal parenchyma most In patient with normal parenchyma most experienced liver surgeons use bunt experienced liver surgeons use bunt dissection with either dissection with either
Clamp- crushingClamp- crushingFinger- FractureFinger- Fracture
The parenchyma is often harder than the The parenchyma is often harder than the underlying resculature & biliary radicals so underlying resculature & biliary radicals so blunt dissection is more likely to tear these blunt dissection is more likely to tear these vessels There Fore vessels There Fore
IN cirrhotics however IN cirrhotics however
Ultrasonic dissector Ultrasonic dissector
Closure & drainage Closure & drainage
Because of the likeihood of Because of the likeihood of
post–op Ascitis , the abd wall is post–op Ascitis , the abd wall is
closed with a heavy continuous closed with a heavy continuous
n. absorbable monofilament n. absorbable monofilament
suture to create a watertight suture to create a watertight
closure. closure.
Post-op CarePost-op Care
Crystalloids – o maintain portal perfusion.Crystalloids – o maintain portal perfusion.
Salt-free Alb .if volume expansion is needed Salt-free Alb .if volume expansion is needed
Diuretics as soon as oral feeding is resumed Diuretics as soon as oral feeding is resumed
Pt is checked twice daily Pt > 17 sec Pt is checked twice daily Pt > 17 sec → FFP.→ FFP.
LFts are LFts are ΔΔ daily daily