- Email: [email protected]
Left hepatectomy extended to segment I for hilar cholangiocarcinoma
Journal of Visceral Surgery (2010) 147, e19—e24
SURGICAL TECHNIQUE
Left hepatectomy extended to segment I for hilar cholangiocarcinoma Hépatectomie gauche élargie au segment I pour cholangiocarcinome hilaire J.P. Guinard , F. Muscari ∗, B. Suc Service de transplantation hépatique et de chirurgie digestive, CHU Rangueil, 1, avenue Jean-Poulhès, 31059 Toulouse cedex 09, France Available online 24 July 2010
Introduction Hilar cholangiocarcinoma (HCC) is rare: the only curative treatment is a R0 surgical resection. Only 30% of these tumors are resectable at the time of diagnosis. The essential steps of surgical treatment include resection of the common bile duct and the involved intrahepatic bile ducts combined with routine resection of segments I and IV [1]. Segment IV is the ‘‘roof’’ of the superior biliary convergence (BC) and is most often invaded as are the biliary ducts of segment I which drain into the posterior aspect of the BC. The most widely used classification for cholangiocarcinoma is that of Bismuth and Corlette [2]. Left hepatectomy extended to segment I is performed for left type III HCC and also for type II HCC. En-bloc surgical resection and removal of all cellular-lymphatic tissues in the hepatic hilum should be the rule [3,4].
∗
Corresponding author. E-mail address: [email protected] (F. Muscari).
1878-7886/$ — see front matter © 2010 Published by Elsevier Masson SAS. doi:10.1016/j.jviscsurg.2010.04.001
e20
J.P. Guinard et al.
1
Patient installation
2
Approach and exploration
The patient lies in a dorsal recumbent position, arms spread apart, without any back cushion. Four posts are necessary to fix the retractors. A malleable retractor is used to lift the liver and gain access to the porta hepatis.
The skin incision is made either according to the Makuuchi J-shaped incision (for patients with a narrow costal angle) or bilateral subcostal incision (for patients with a broad costal angle). The abdominal cavity is then explored looking for carcinomatosis or for distant lymph node involvement, which would contraindicate the resection. Intraoperative hepatic sonography is then performed to evaluate intrahepatic spread of disease and to detect contralateral metastases.
Left hepatectomy extended to segment I for hilar cholangiocarcinoma
3
Pedicular dissection
4
Division of the main bile duct
5
Initial preparation for hepatectomy
The lesser omentum is divided at the level of the pars flaccida. Retrograde cholecystectomy is performed; the cystic duct is identified and double ligated. The lymph node at the level of the curve of the hepatic artery is removed for frozen section examination. The hepatic artery is dissected and then encircled with a (red) vascular tape. The peritoneum is incised on the right side of the porta hepatis, following the cystic duct and, after minimal dissection, a (yellow) vascular tape is placed around the common bile duct (CBD). The portal vein, located in the posterior part of the hilum is dissected and encircled with (blue) vascular tapes. It is important to dissect the portal vein and the hepatic artery until reaching the bifurcation to ensure that the right branch of the hepatic artery and portal vein are not invaded before proceeding to excision of the tumor. Lymph node dissection of the hepatic hilum begins on the left border of the hilum above the curve of the hepatic artery and continues in the cellular lymphatic tissues until reaching the celiac artery. All dissected tissues are retracted cephalad and to the left of the porta hepatis and should remain attached to the specimen, ensuring en bloc resection. At the end of this step, all vessels should be skeletonized.
The main bile duct is divided just above the head of the pancreas and the distal stump is closed with 2/0 sutures. Frozen section examination of the bile duct margin is performed. The proximal segment of the main bile duct is retracted cephalad to finish freeing the right branches of the hepatic artery and portal vein.
The suspensory ligament of the liver is divided while depressing the liver until the confluence of the vena cava and the hepatic veins is reached. The pars condensa is divided and if a left hepatic artery is encountered, this is ligated. The left triangular ligament is then divided from left to right, caution being paid to diaphragmatic veins when encountered. The infrahepatic vena cava is then encircled with a vascular tape.
e21
e22
J.P. Guinard et al.
6
Hanging maneuver [3]
7
Control of the common hepatic vein [4]
8
Hepatectomy
Although not indispensible, this maneuver allows the line of division to pass to the right of segment I and to find the correct plane to create a flat plane of division for the hepatectomy. The liver is elevated and the porta hepatis retracted to the left. An aortic clamp is placed between the anterior aspect of the inferior vena cava and the posterior aspect of segment IX. Accessory hepatic veins may have to be ligated to facilitate this passage. After passing the clamp a ‘‘Delbet’’ type drain is placed between the liver and the cava, each limb being held by a Kelly clamp.
The caval hepatic confluence is dissected and a tape is placed around the common hepatic trunk (confluence of the middle and left hepatic veins) to facilitate the future resection of segment I.
Glisson’s capsule is incised with electrocautery under sonographic control. The parenchymal division is performed with pulsed water jet; bipolar coagulation is used for the small vessels, while the larger vessels are ligated with slowly absorbable sutures. All biliary ducts encountered are also ligated with sutures. Intermittent clamping of the porta hepatis (15 min each) can be used if excessive bleeding is encountered. The hilar plaque becomes apparent toward the end of the transection.
Left hepatectomy extended to segment I for hilar cholangiocarcinoma
9
Hilar plaque division
The right hepatic duct is divided as far from the hepatic duct convergence as possible. As the right hepatic duct is short, there are often two (anterior and posterior sectorial) or more ducts involved. Frozen section examination of the right hepatic duct ensures that an R0 resection has been accomplished. Next, the ‘‘hanging’’ Delbet drain is passed in front of the hilar vessels: this elevates the remaining parenchymal bridge behind the hilar plaque and consequently the parenchymal transection can be completed.
10
Division of the left hepatic duct
11
Segment I resection
The previously dissected left branch of the hepatic artery is divided between two ligations. The portal bifurcation is resected between two clamps, one placed on the portal vein and the other on the right portal branch. The right portal branch is then anastomosed to the portal vein with 5/0 non-absorbable monofilament sutures.
The first assistant retracts the left liver to the left and lifts the tape around the common hepatic trunk to expose the attachments between segment I and the vena cava. Segment I is freed from right to left by ligating the accessory hepatic veins between the posterior aspect of segment I and the anterior aspect of the cava as they are encountered, one by one.
e23
e24
J.P. Guinard et al.
12
Division of the common hepatic vein
13
Verification of the transection plane
14
Cholangioenteric anastomosis
The specimen now remains attached only by the common hepatic trunk. The common hepatic trunk is divided with an appropriate mechanical stapler or sutured on a vascular clamp. An en bloc excision is performed, that is the left liver and segment I, the hepatic duct convergence, the portal bifurcation, the common bile duct along with hepatic hilar tissular clearance from the hilum to the celiac trunk.
The liver is checked for bile leakage and all leaking bile ducts are sutured closed. Hemostasis is completed by additional ligations, as needed, and application of warm abdominal pads on the hepatic transection plane for a few minutes (this is called the ‘‘hemostatic pause’’). Occasionally, when hemostasis is insufficient, other hemostatic devices can be employed.
A 70 cm Roux-en-Y limb, prepared from the first jejunal limb, is drawn through the mesocolon. Cholangioenterostomy between the Roux-en-Y limb and the right hepatic duct is performed with 5/0 or 6/0 PDS interrupted sutures, under magnification as necessary. The jejuno-jejunostomy is performed with a 4/0 PDS running suture. All mesenteric openings are closed and the mesocolon is positioned around the jejunal limb in order to prevent postoperative obstruction. A suction drain is then placed under the liver, near the cholangioenterostomy.
References [1] Muscari F. Prise en charge du cholangiocarcinome hilaire. J Chir 2007;144:385—92. [2] Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus liver. Surg Gynecol Obstet 1975;140:170—6.
[3] Capussotti L, Ferrero A, Ribero D. L’hépatectomie droite par abord antérieur. J Chir 2006;143:168—72. [4] Bachellier P, Jaeck D. Résection hépatique segmentaire : technique de la segmentectomie IV. J Chir 1999;136: 257—63.
SURGICAL TECHNIQUE
Left hepatectomy extended to segment I for hilar cholangiocarcinoma Hépatectomie gauche élargie au segment I pour cholangiocarcinome hilaire J.P. Guinard , F. Muscari ∗, B. Suc Service de transplantation hépatique et de chirurgie digestive, CHU Rangueil, 1, avenue Jean-Poulhès, 31059 Toulouse cedex 09, France Available online 24 July 2010
Introduction Hilar cholangiocarcinoma (HCC) is rare: the only curative treatment is a R0 surgical resection. Only 30% of these tumors are resectable at the time of diagnosis. The essential steps of surgical treatment include resection of the common bile duct and the involved intrahepatic bile ducts combined with routine resection of segments I and IV [1]. Segment IV is the ‘‘roof’’ of the superior biliary convergence (BC) and is most often invaded as are the biliary ducts of segment I which drain into the posterior aspect of the BC. The most widely used classification for cholangiocarcinoma is that of Bismuth and Corlette [2]. Left hepatectomy extended to segment I is performed for left type III HCC and also for type II HCC. En-bloc surgical resection and removal of all cellular-lymphatic tissues in the hepatic hilum should be the rule [3,4].
∗
Corresponding author. E-mail address: [email protected] (F. Muscari).
1878-7886/$ — see front matter © 2010 Published by Elsevier Masson SAS. doi:10.1016/j.jviscsurg.2010.04.001
e20
J.P. Guinard et al.
1
Patient installation
2
Approach and exploration
The patient lies in a dorsal recumbent position, arms spread apart, without any back cushion. Four posts are necessary to fix the retractors. A malleable retractor is used to lift the liver and gain access to the porta hepatis.
The skin incision is made either according to the Makuuchi J-shaped incision (for patients with a narrow costal angle) or bilateral subcostal incision (for patients with a broad costal angle). The abdominal cavity is then explored looking for carcinomatosis or for distant lymph node involvement, which would contraindicate the resection. Intraoperative hepatic sonography is then performed to evaluate intrahepatic spread of disease and to detect contralateral metastases.
Left hepatectomy extended to segment I for hilar cholangiocarcinoma
3
Pedicular dissection
4
Division of the main bile duct
5
Initial preparation for hepatectomy
The lesser omentum is divided at the level of the pars flaccida. Retrograde cholecystectomy is performed; the cystic duct is identified and double ligated. The lymph node at the level of the curve of the hepatic artery is removed for frozen section examination. The hepatic artery is dissected and then encircled with a (red) vascular tape. The peritoneum is incised on the right side of the porta hepatis, following the cystic duct and, after minimal dissection, a (yellow) vascular tape is placed around the common bile duct (CBD). The portal vein, located in the posterior part of the hilum is dissected and encircled with (blue) vascular tapes. It is important to dissect the portal vein and the hepatic artery until reaching the bifurcation to ensure that the right branch of the hepatic artery and portal vein are not invaded before proceeding to excision of the tumor. Lymph node dissection of the hepatic hilum begins on the left border of the hilum above the curve of the hepatic artery and continues in the cellular lymphatic tissues until reaching the celiac artery. All dissected tissues are retracted cephalad and to the left of the porta hepatis and should remain attached to the specimen, ensuring en bloc resection. At the end of this step, all vessels should be skeletonized.
The main bile duct is divided just above the head of the pancreas and the distal stump is closed with 2/0 sutures. Frozen section examination of the bile duct margin is performed. The proximal segment of the main bile duct is retracted cephalad to finish freeing the right branches of the hepatic artery and portal vein.
The suspensory ligament of the liver is divided while depressing the liver until the confluence of the vena cava and the hepatic veins is reached. The pars condensa is divided and if a left hepatic artery is encountered, this is ligated. The left triangular ligament is then divided from left to right, caution being paid to diaphragmatic veins when encountered. The infrahepatic vena cava is then encircled with a vascular tape.
e21
e22
J.P. Guinard et al.
6
Hanging maneuver [3]
7
Control of the common hepatic vein [4]
8
Hepatectomy
Although not indispensible, this maneuver allows the line of division to pass to the right of segment I and to find the correct plane to create a flat plane of division for the hepatectomy. The liver is elevated and the porta hepatis retracted to the left. An aortic clamp is placed between the anterior aspect of the inferior vena cava and the posterior aspect of segment IX. Accessory hepatic veins may have to be ligated to facilitate this passage. After passing the clamp a ‘‘Delbet’’ type drain is placed between the liver and the cava, each limb being held by a Kelly clamp.
The caval hepatic confluence is dissected and a tape is placed around the common hepatic trunk (confluence of the middle and left hepatic veins) to facilitate the future resection of segment I.
Glisson’s capsule is incised with electrocautery under sonographic control. The parenchymal division is performed with pulsed water jet; bipolar coagulation is used for the small vessels, while the larger vessels are ligated with slowly absorbable sutures. All biliary ducts encountered are also ligated with sutures. Intermittent clamping of the porta hepatis (15 min each) can be used if excessive bleeding is encountered. The hilar plaque becomes apparent toward the end of the transection.
Left hepatectomy extended to segment I for hilar cholangiocarcinoma
9
Hilar plaque division
The right hepatic duct is divided as far from the hepatic duct convergence as possible. As the right hepatic duct is short, there are often two (anterior and posterior sectorial) or more ducts involved. Frozen section examination of the right hepatic duct ensures that an R0 resection has been accomplished. Next, the ‘‘hanging’’ Delbet drain is passed in front of the hilar vessels: this elevates the remaining parenchymal bridge behind the hilar plaque and consequently the parenchymal transection can be completed.
10
Division of the left hepatic duct
11
Segment I resection
The previously dissected left branch of the hepatic artery is divided between two ligations. The portal bifurcation is resected between two clamps, one placed on the portal vein and the other on the right portal branch. The right portal branch is then anastomosed to the portal vein with 5/0 non-absorbable monofilament sutures.
The first assistant retracts the left liver to the left and lifts the tape around the common hepatic trunk to expose the attachments between segment I and the vena cava. Segment I is freed from right to left by ligating the accessory hepatic veins between the posterior aspect of segment I and the anterior aspect of the cava as they are encountered, one by one.
e23
e24
J.P. Guinard et al.
12
Division of the common hepatic vein
13
Verification of the transection plane
14
Cholangioenteric anastomosis
The specimen now remains attached only by the common hepatic trunk. The common hepatic trunk is divided with an appropriate mechanical stapler or sutured on a vascular clamp. An en bloc excision is performed, that is the left liver and segment I, the hepatic duct convergence, the portal bifurcation, the common bile duct along with hepatic hilar tissular clearance from the hilum to the celiac trunk.
The liver is checked for bile leakage and all leaking bile ducts are sutured closed. Hemostasis is completed by additional ligations, as needed, and application of warm abdominal pads on the hepatic transection plane for a few minutes (this is called the ‘‘hemostatic pause’’). Occasionally, when hemostasis is insufficient, other hemostatic devices can be employed.
A 70 cm Roux-en-Y limb, prepared from the first jejunal limb, is drawn through the mesocolon. Cholangioenterostomy between the Roux-en-Y limb and the right hepatic duct is performed with 5/0 or 6/0 PDS interrupted sutures, under magnification as necessary. The jejuno-jejunostomy is performed with a 4/0 PDS running suture. All mesenteric openings are closed and the mesocolon is positioned around the jejunal limb in order to prevent postoperative obstruction. A suction drain is then placed under the liver, near the cholangioenterostomy.
References [1] Muscari F. Prise en charge du cholangiocarcinome hilaire. J Chir 2007;144:385—92. [2] Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus liver. Surg Gynecol Obstet 1975;140:170—6.
[3] Capussotti L, Ferrero A, Ribero D. L’hépatectomie droite par abord antérieur. J Chir 2006;143:168—72. [4] Bachellier P, Jaeck D. Résection hépatique segmentaire : technique de la segmentectomie IV. J Chir 1999;136: 257—63.