Professor Of SurgeryProfessor Of Surgery Gastroenterology CenterGastroenterology Center

Mansoura UniversityMansoura University..

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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