- Email: [email protected]
Caudate Split for Open and Laparoscopic Liver Resections
Caudate Split for Open and Laparoscopic Liver Resections Tammy T Chang, MD, PhD, Carlos U Corvera, MD, FACS Laparoscopic hepatic resections are gaining popularity as laparoscopic techniques and vessel-sealing instruments improve. Anatomic and nonanatomic resections and major lobectomies can now be done safely laparoscopically for both benign1,2 and malignant disease.3-5 Although early experience was limited to laparoscopic left lateral lobectomies (segments 2 and 3) and segmentectomies (eg, segments 4, 5, and 6),6,7 increasingly surgeons are performing formal right and left lobectomies laparoscopically.8,9 Totally laparoscopic right lobectomy (segments 5 to 8) remains technically challenging because of its location and large liver volume, and often requires the assistance of a hand port.10-12 Here, we describe a technique to facilitate the laparoscopic approach to right lobe hepatic resections that is especially useful for cirrhotic livers. We have called this technique the “caudate split” because it involves the partial transection of the caudate process to gain access to the right portal pedicle. In addition to safe and rapid resection of the right lobe laparoscopically, it facilitates right hepatic lobectomies done in the traditional open approach. We find that the caudate split technique is particularly useful in patients with stiff, cirrhotic livers with a retracted hilum and a hypertrophied caudate lobe. The caudate split can also be used to access the left portal pedicle in left hepatic lobectomies that include a caudate lobe resection as required for left-sided hilar cholangiocarcinoma.
biliary tree to expose the portal vein bifurcation. In the cirrhotic patient, this hilar dissection is more difficult because the portal structures are drawn inward by the fibrotic liver. In patients who undergo preoperative RPV embolization, the associated inflammatory response and hypertrophied caudate lobe are often additional obstacles. To overcome these challenges, we describe a technique in which the liver parenchyma of the caudate process is transected approximately 40% to 50% of its total length before division of the RPV. We demonstrate that partial “splitting” of the caudate lobe substantially improves exposure and access to the RPV for more expedient division by a vascular stapler. Technique
To illustrate the individual steps of the caudate split technique and pertinent anatomy, we use a series of intraoperative photographs taken from an open right hepatectomy in which the technique was used. We recognize that for open cases, the need to divide the caudate process to use a stapler is a matter of preference because in most cases it is straightforward to clamp, divide, and oversew the two ends of the vessel. We believe our technique has the greatest application for totally laparoscopic liver resections. We have included two video clips from a totally laparoscopic right hepatectomy to demonstrate the usefulness of the caudate split in a laparoscopic resection. As with traditional right hepatectomies, the right lobe is first fully mobilized from the retroperitoneum. After the right hepatic vein is isolated and controlled, attention is turned to the in-flow structures. Figure 1 illustrates the critical anatomic relationships and operative setup important to the caudate split technique. The main portal vein has been exposed by lateral and upward retraction of the biliary tree. Note the position of the portal vein lying anterior to the caudate process, which itself is anterior to the IVC. The hepatoduodenal ligament is medial to these structures. The right lobe of the liver is also exposed. As seen in Figure 1, the caudate process cradles the main portal vein and its bifurcation (ie, a supporting platform). As a result, access to the portal vein bifurcation is substantially limited by nearly circumferential coverage of liver tissue. The most important element of the caudate split technique is that it divides the liver tissue as an initial step, providing spatial clearance for introduction of a vascular
Rationale
Traditionally, in open right hepatic lobectomy, the steps of the operative approach are isolation of the right hepatic vein, hepatic artery, and portal vein, with transection of the liver parenchyma as the final step. In laparoscopic surgery, isolation and safe division of the right portal vein (RPV) branch are among the most challenging aspects of the operation. Another technical difficulty in the laparoscopic approach is the safe upward and lateral retraction of the Disclosure Information: Nothing to disclose. Received June 31, 2008; Revised August 30, 2008; Accepted September 3, 2008. From the Department of Surgery, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, San Francisco, CA. Correspondence address: Carlos U Corvera, MD, Department of Surgery, University of California, San Francisco, San Francisco Veteran Affairs Medical Center, 4150 Clement St, Surgical Services (112), San Francisco, CA 94121. email: [email protected]
© 2008 by the American College of Surgeons Published by Elsevier Inc.
e7
ISSN 1072-7515/08/$34.00 doi:10.1016/j.jamcollsurg.2008.09.002
e8
Chang and Corvera
Caudate Split for Liver Resections
J Am Coll Surg
Figure 2. Exposure and setup. Figure 1. Illustration of the completed “caudate split” and exposure of the right portal vein.
stapler. In other words, transection of the caudate parenchyma permits the jaws of a vascular stapler to fit comfortably and encompass the RPV for secure division. This spatial relationship is illustrated in Figure 2. To accomplish partial transection of the caudate process, we use two 0.0 Chromic sutures as traction sutures through the liver parenchyma on either side of the intended caudate split (Fig. 1). A bipolar coagulating dissector is used to transect the caudate process between these two sutures. We use the Gyrus PlasmaKinetic bipolar coagulation forceps (Gyrus ACMI) to divide liver parenchyma without the need for inflow occlusion. Studies in animals have shown that the Gyrus can effectively seal vessels up to 5 mm in diameter.13 We have found that this device provides good hemostasis in cirrhotic patients. It is less effective in controlling parenchymal bleeding from friable and steatotic livers, such as after chemotherapy.14 Figure 3 shows the anatomic relationships after the caudate split. The RPV is isolated and encircled by the blue
vessel loop. The caudate process posterior to the RPV is divided with the traction sutures on either side retracting the two halves apart. Posterior to the split caudate process, the IVC is clearly seen. It is important to mention that isolation, ligation, and division of IVC tributaries to the caudate process should be done before initiating the caudate split. This will minimize venous back-bleeding during the transection and will separate the caudate tissue away from the IVC. The RPV can now be easily divided with vascular staplers under full visualization. Depending on operative conditions, the RPV can be taken with a straight linear stapler or, more conveniently, with an articulating stapler. Placement of the stapler is best from the patient’s left pointing toward the right. As demonstrated by Figure 4, this angle allows the jaws of the stapler to fit across the RPV comfortably in the space created by the caudate split and directs the tips of the stapler lateral to the IVC. Figure 5 shows the completed division of the RPV and the split caudate process below. The staple line on the divided RPV is clearly seen.
Figure 3. Intraoperative view of the completed “caudate split” and exposure of the right portal vein.
Figure 4. Division of the right portal vein with an articulating vascular stapler.
Vol. 207, No. 6, December 2008
Chang and Corvera
Caudate Split for Liver Resections
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are done routinely as part of a pedicle isolation maneuver. Our caudate split technique can also be used as part of this maneuver, making identification of the pedicle structures easier. Laparoscopic right hepatic lobectomy remains technically challenging, especially in patients with cirrhotic livers. The technique of the caudate split described in this article should facilitate safe control of the right hepatic pedicle in both open and laparoscopic right hepatic lobectomies.
REFERENCES
Figure 5. Intraoperative view showing the staple line of the divided main right portal vein.
Videos from a totally laparoscopic right hepatic lobectomy illustrates the salient points of our technique. We apply the same operative principles from open operations to laparoscopic resections, which include identification, isolation, and division of the RPV. One video begins with clipping and dividing short hepatic veins from the caudate. The caudate process is then serially transected and the RPV is dissected and completely free from the surrounding tissues. The RPV is encircled with a right-angle clamp and then temporarily occluded with a deployable vascular clamp. The right hepatic artery is isolated, clipped, and divided. A line of perfusion demarcation confirms occlusion of the RPV and the vascular clamp is removed and the RPV branch is divided with a stapler. The jaws of the stapler are placed into the space created by the caudate split. As demonstrated by these photographs and videos, the caudate split is a useful technique in both open and laparoscopic right hepatic lobectomies. This technique is especially valuable for resection of cirrhotic livers with retracted hilar structures. In addition to totally laparoscopic right lobectomies, we have successfully used the caudate split in laparoscopic combined (posterior sectorectomy) or isolated segment 6 and 7 resections. It can also be applied to combined open left and caudate lobe resections. For this approach, the stapler is introduced on the left side of the hepatoduodenal ligament and the jaws are positioned across the main left portal vein just before take-off of the principal branch to the caudate. In essence, the caudate split described in this article is a modification or expansion of a technique familiar to hepatic surgeons and referred to as a simple hepatotomy. For example, these hepatotomies
1. Troisi R, Montalti R, Smeets P, et al. The value of laparoscopic liver surgery for solid benign hepatic tumors. Surg Endosc 2008; 22:38–44. 2. Ardito F, Tayar C, Laurent A, et al. Laparoscopic liver resection for benign disease. Arch Surg 2007;142:1188–1193; discussion 1193. 3. Belli G, Fantini C, D’Agostino A, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results. Surg Endosc 2007;21:2004–2011. 4. Chen HY, Juan CC, Ker CG. Laparoscopic liver surgery for patients with hepatocellular carcinoma. Ann Surg Oncol 2008; 15:800–806. 5. Dagher I, Lainas P, Carloni A, et al. Laparoscopic liver resection for hepatocellular carcinoma. Surg Endosc 2008;22:372–378. 6. Descottes B, Lachachi F, Sodji M, et al. Early experience with laparoscopic approach for solid liver tumors: initial 16 cases. Ann Surg 2000;232:641–645. 7. Lesurtel M, Cherqui D, Laurent A, et al. Laparoscopic versus open left lateral hepatic lobectomy: a case-control study. J Am Coll Surg 2003;196:236–242. 8. Koffron AJ, Auffenberg G, Kung R, Abecassis M. Evaluation of 300 minimally invasive liver resections at a single institution: less is more. Ann Surg 2007;246:385–392; discussion 392–384. 9. Simillis C, Constantinides VA, Tekkis PP, et al. Laparoscopic versus open hepatic resections for benign and malignant neoplasms—a meta-analysis. Surgery 2007;141:203–211. 10. Cho A, Asano T, Yamamoto H, et al. Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection. Surg Endosc 2007;21:1466–1468. 11. Eguchi D, Nishizaki T, Ohta M, et al. Laparoscopy-assisted right hepatic lobectomy using a wall-lifting procedure. Surg Endosc 2006;20:1326–1328. 12. Koffron AJ, Kung R, Baker T, et al. Laparoscopic-assisted right lobe donor hepatectomy. Am J Transplant 2006;6:2522–2525. 13. Pietrow PK, Weizer AZ, L’Esperance JO, et al. PlasmaKinetic bipolar vessel sealing: burst pressures and thermal spread in an animal model. J Endourol 2005;19:107–110. 14. Corvera CU, Dada SA, Kirkland JG, et al. Bipolar pulse coagulation for resection of the cirrhotic liver. J Surg Res 2006;136: 182–186.
biliary tree to expose the portal vein bifurcation. In the cirrhotic patient, this hilar dissection is more difficult because the portal structures are drawn inward by the fibrotic liver. In patients who undergo preoperative RPV embolization, the associated inflammatory response and hypertrophied caudate lobe are often additional obstacles. To overcome these challenges, we describe a technique in which the liver parenchyma of the caudate process is transected approximately 40% to 50% of its total length before division of the RPV. We demonstrate that partial “splitting” of the caudate lobe substantially improves exposure and access to the RPV for more expedient division by a vascular stapler. Technique
To illustrate the individual steps of the caudate split technique and pertinent anatomy, we use a series of intraoperative photographs taken from an open right hepatectomy in which the technique was used. We recognize that for open cases, the need to divide the caudate process to use a stapler is a matter of preference because in most cases it is straightforward to clamp, divide, and oversew the two ends of the vessel. We believe our technique has the greatest application for totally laparoscopic liver resections. We have included two video clips from a totally laparoscopic right hepatectomy to demonstrate the usefulness of the caudate split in a laparoscopic resection. As with traditional right hepatectomies, the right lobe is first fully mobilized from the retroperitoneum. After the right hepatic vein is isolated and controlled, attention is turned to the in-flow structures. Figure 1 illustrates the critical anatomic relationships and operative setup important to the caudate split technique. The main portal vein has been exposed by lateral and upward retraction of the biliary tree. Note the position of the portal vein lying anterior to the caudate process, which itself is anterior to the IVC. The hepatoduodenal ligament is medial to these structures. The right lobe of the liver is also exposed. As seen in Figure 1, the caudate process cradles the main portal vein and its bifurcation (ie, a supporting platform). As a result, access to the portal vein bifurcation is substantially limited by nearly circumferential coverage of liver tissue. The most important element of the caudate split technique is that it divides the liver tissue as an initial step, providing spatial clearance for introduction of a vascular
Rationale
Traditionally, in open right hepatic lobectomy, the steps of the operative approach are isolation of the right hepatic vein, hepatic artery, and portal vein, with transection of the liver parenchyma as the final step. In laparoscopic surgery, isolation and safe division of the right portal vein (RPV) branch are among the most challenging aspects of the operation. Another technical difficulty in the laparoscopic approach is the safe upward and lateral retraction of the Disclosure Information: Nothing to disclose. Received June 31, 2008; Revised August 30, 2008; Accepted September 3, 2008. From the Department of Surgery, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, San Francisco, CA. Correspondence address: Carlos U Corvera, MD, Department of Surgery, University of California, San Francisco, San Francisco Veteran Affairs Medical Center, 4150 Clement St, Surgical Services (112), San Francisco, CA 94121. email: [email protected]
© 2008 by the American College of Surgeons Published by Elsevier Inc.
e7
ISSN 1072-7515/08/$34.00 doi:10.1016/j.jamcollsurg.2008.09.002
e8
Chang and Corvera
Caudate Split for Liver Resections
J Am Coll Surg
Figure 2. Exposure and setup. Figure 1. Illustration of the completed “caudate split” and exposure of the right portal vein.
stapler. In other words, transection of the caudate parenchyma permits the jaws of a vascular stapler to fit comfortably and encompass the RPV for secure division. This spatial relationship is illustrated in Figure 2. To accomplish partial transection of the caudate process, we use two 0.0 Chromic sutures as traction sutures through the liver parenchyma on either side of the intended caudate split (Fig. 1). A bipolar coagulating dissector is used to transect the caudate process between these two sutures. We use the Gyrus PlasmaKinetic bipolar coagulation forceps (Gyrus ACMI) to divide liver parenchyma without the need for inflow occlusion. Studies in animals have shown that the Gyrus can effectively seal vessels up to 5 mm in diameter.13 We have found that this device provides good hemostasis in cirrhotic patients. It is less effective in controlling parenchymal bleeding from friable and steatotic livers, such as after chemotherapy.14 Figure 3 shows the anatomic relationships after the caudate split. The RPV is isolated and encircled by the blue
vessel loop. The caudate process posterior to the RPV is divided with the traction sutures on either side retracting the two halves apart. Posterior to the split caudate process, the IVC is clearly seen. It is important to mention that isolation, ligation, and division of IVC tributaries to the caudate process should be done before initiating the caudate split. This will minimize venous back-bleeding during the transection and will separate the caudate tissue away from the IVC. The RPV can now be easily divided with vascular staplers under full visualization. Depending on operative conditions, the RPV can be taken with a straight linear stapler or, more conveniently, with an articulating stapler. Placement of the stapler is best from the patient’s left pointing toward the right. As demonstrated by Figure 4, this angle allows the jaws of the stapler to fit across the RPV comfortably in the space created by the caudate split and directs the tips of the stapler lateral to the IVC. Figure 5 shows the completed division of the RPV and the split caudate process below. The staple line on the divided RPV is clearly seen.
Figure 3. Intraoperative view of the completed “caudate split” and exposure of the right portal vein.
Figure 4. Division of the right portal vein with an articulating vascular stapler.
Vol. 207, No. 6, December 2008
Chang and Corvera
Caudate Split for Liver Resections
e9
are done routinely as part of a pedicle isolation maneuver. Our caudate split technique can also be used as part of this maneuver, making identification of the pedicle structures easier. Laparoscopic right hepatic lobectomy remains technically challenging, especially in patients with cirrhotic livers. The technique of the caudate split described in this article should facilitate safe control of the right hepatic pedicle in both open and laparoscopic right hepatic lobectomies.
REFERENCES
Figure 5. Intraoperative view showing the staple line of the divided main right portal vein.
Videos from a totally laparoscopic right hepatic lobectomy illustrates the salient points of our technique. We apply the same operative principles from open operations to laparoscopic resections, which include identification, isolation, and division of the RPV. One video begins with clipping and dividing short hepatic veins from the caudate. The caudate process is then serially transected and the RPV is dissected and completely free from the surrounding tissues. The RPV is encircled with a right-angle clamp and then temporarily occluded with a deployable vascular clamp. The right hepatic artery is isolated, clipped, and divided. A line of perfusion demarcation confirms occlusion of the RPV and the vascular clamp is removed and the RPV branch is divided with a stapler. The jaws of the stapler are placed into the space created by the caudate split. As demonstrated by these photographs and videos, the caudate split is a useful technique in both open and laparoscopic right hepatic lobectomies. This technique is especially valuable for resection of cirrhotic livers with retracted hilar structures. In addition to totally laparoscopic right lobectomies, we have successfully used the caudate split in laparoscopic combined (posterior sectorectomy) or isolated segment 6 and 7 resections. It can also be applied to combined open left and caudate lobe resections. For this approach, the stapler is introduced on the left side of the hepatoduodenal ligament and the jaws are positioned across the main left portal vein just before take-off of the principal branch to the caudate. In essence, the caudate split described in this article is a modification or expansion of a technique familiar to hepatic surgeons and referred to as a simple hepatotomy. For example, these hepatotomies
1. Troisi R, Montalti R, Smeets P, et al. The value of laparoscopic liver surgery for solid benign hepatic tumors. Surg Endosc 2008; 22:38–44. 2. Ardito F, Tayar C, Laurent A, et al. Laparoscopic liver resection for benign disease. Arch Surg 2007;142:1188–1193; discussion 1193. 3. Belli G, Fantini C, D’Agostino A, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results. Surg Endosc 2007;21:2004–2011. 4. Chen HY, Juan CC, Ker CG. Laparoscopic liver surgery for patients with hepatocellular carcinoma. Ann Surg Oncol 2008; 15:800–806. 5. Dagher I, Lainas P, Carloni A, et al. Laparoscopic liver resection for hepatocellular carcinoma. Surg Endosc 2008;22:372–378. 6. Descottes B, Lachachi F, Sodji M, et al. Early experience with laparoscopic approach for solid liver tumors: initial 16 cases. Ann Surg 2000;232:641–645. 7. Lesurtel M, Cherqui D, Laurent A, et al. Laparoscopic versus open left lateral hepatic lobectomy: a case-control study. J Am Coll Surg 2003;196:236–242. 8. Koffron AJ, Auffenberg G, Kung R, Abecassis M. Evaluation of 300 minimally invasive liver resections at a single institution: less is more. Ann Surg 2007;246:385–392; discussion 392–384. 9. Simillis C, Constantinides VA, Tekkis PP, et al. Laparoscopic versus open hepatic resections for benign and malignant neoplasms—a meta-analysis. Surgery 2007;141:203–211. 10. Cho A, Asano T, Yamamoto H, et al. Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection. Surg Endosc 2007;21:1466–1468. 11. Eguchi D, Nishizaki T, Ohta M, et al. Laparoscopy-assisted right hepatic lobectomy using a wall-lifting procedure. Surg Endosc 2006;20:1326–1328. 12. Koffron AJ, Kung R, Baker T, et al. Laparoscopic-assisted right lobe donor hepatectomy. Am J Transplant 2006;6:2522–2525. 13. Pietrow PK, Weizer AZ, L’Esperance JO, et al. PlasmaKinetic bipolar vessel sealing: burst pressures and thermal spread in an animal model. J Endourol 2005;19:107–110. 14. Corvera CU, Dada SA, Kirkland JG, et al. Bipolar pulse coagulation for resection of the cirrhotic liver. J Surg Res 2006;136: 182–186.