- Email: [email protected]
Right hepatic lobectomy
HOW I DO IT
Right Hepatic Lobectomy
Seymour I. Schwartz, MD, Rochester, New York
Wendel (21 is credited with the first case of a neartotal right hepatic lobectomy performed on a 44 year old woman in 1910. He deliberately tied the right branch of the hepatic artery and the right hepatic duct at the liver hilus but purposely ligated the right portal vein within the hepatic parenchyma. The patient did well and was alive and free of apparent disease 8 months later. In 1949, Wangensteen [z] removed the entire right lobe of the liver for metastatic carcinoma of the stomach. In 1952, LortatJacob and Robert [3] opened the modern era of hepatic surgery by performing an anatomic right lobectomy based on the vascular anatomy with preliminary hilar ligation. In 1953, Julian Quattlebaum [4] reported an operation that he had performed in 1952. It represented the first reported right hepatic lobectomy for primary carcinoma. In 1953, Pack and Baker (51 also reported a total right lobectomy with primary hilar ligation in a patient with carcinoma of the gallbladder. The same year, Mersheimer [6] reported a successful right lobe&my for a primary neoplasm. Digitoclasia, or finger fracture, of the hepatic parenchyma has evolved over the last 30 years. In 1953, Quattlebaum, in his classic article [4], described breaking the liver with the handle of a knife and clamping the vessels within the plane of transection. In 1956, Fineberg and associates [7] reported on right hepatic lobe&my for primary carcinoma of the liver. They carried out a quick parenchymal dissection with the finger or the back of the scalpel. In 1958, Lin et al [8] introduced a new technique in which the thumb and index finger were inserted into the liver tissue after which the surgeon “fractures and crushes the tissue between the fingers, and when resistant vessels or ducts are encountered they are tied and divided.” In 1963, Tung [9] modified this technique by occluding the portal pedicle before finger fracture. Fromfh3DeptvbnentOfSugery,UfliverdtyOfRochester.SchoolOfMediclne and Delltistly, ROdmst~. New YOriL f3equests for reprlnta shcukf be acuresned to SeymOw I. Schwartz, MD, oepartment of svgecy. unh/ersity of Rochestef. SdmOl of h4edkllw3 and Dentktry. Rochester. New York 14642.
666
The indications for right hepatic lobe&my include parasitic and nonparasitic cysts, granulomatous processes, benign primary neoplasms, malignant primary tumors, and secondary tumors that involve the liver by direct extension or metastasis. The technique of planned anatomic resection is generally reserved for lesions that are large or located so that resection along the anatomic plane provides an opportunity for the most complete removal, coupled with the best control of vascular supply. Resection along anatomic lines with vascular control is rarely indicated for trauma patients in whom the preferred approach is limited resectional debridement that permits removal of devitalized tissue and control of bleeding. Advanced cirrhosis generally precludes right hepatic lobe&my since intraoperative bleeding from collateral and parenchymal vessels is significantly increased. The incidence of liver failure with resection is increased because of lack of reserve, hepatic regeneration is impaired, and reported cures for malignant tumors in cirrhotic patients are negligible. Technique Preoperative preparation: An essential feature of the preoperative protocol is angiography of both the celiac and the superior mesenteric arteries to define the extent of hepatic involvement and thus the resectability, and also to demonstrate the vascular anatomy and segmental supply. Computerized tomography performed while radiopaque dye is infused directly into the hepatic artery provides the best definition of intrahepatic pathologic characteristics. The serum albumin level, prothrombin time, activated partial thromboplastin time, and platelet count are all obtained and, if abnormal, are corrected. A cephalosporin is usually instituted on the day of operation. Significant blood loss should be anticipated and an autotransfusion apparatus is made available for use intraoperatively. Operation: The right lobe of the liver is separated from the left lobe along the interlobar plane which is the main portal plane, also known aa Cantlie’s line (Figure 1). It extends from the middle of the gallbladder bed anteroin-
lhaAmukmhnnalot~
Right HeTatic Lobectomy
Rbht
Mlddla
nqxtlc
Hepatlc
V&l
Vdfl
feriorly to the inferior vena cava posterosuperiorly. This interlobar plane describes an angle of approximately 75 degrees with the horixontal plane. The right and left lobes are individualized by this plane, and each receives independent portal and arterial vascularixation and biliary drainage. The middle hepatic vein follows the main portal plane. A right subcostal incision is preferred, either with a left subcoatal extension in a chevron fashion (Figure 2) or with an extenaion craniad over the xiphoid process. The incision should be placed high enough to permit placement of an overhead retractor so that the sternum can be retracted toward the ceiling. The entire right rectus muscle is transected and the oblique muscles are split laterally almost to the tip of the right 10th rib. Transection of the medial portion of the left rectus muscle usually provides sufficient exposure. A thoracic extension placed perpendicular to the right subccstal incision and extending through the seventh intercostal space is rarely used and is reserved for large lesions in the dome of the right lobe of the liver with diaphragmatic involvement or encroachment on the suprahepatic inferior vena cava. Mobilization should be accomplished so that the right lobe can be delivered into the wound. The ligamenturn teres is transected. A clamp can be left on the hepatic end
vobwlw 148, Movmlhf
1984
to facilitate traction. The triangular ligament supporting the right lobe is divided, and the dissection is continued by transecting the anterior and posterior leaflets of the right coronary ligament to the inferior vena cava (Figure 3). This permits the entire right lobe of the liver to be mobilized toward the left At times, complete mobilization is impaired by attachment of two or three small hepatic veins, and these may be ligated at the point where they enter the inferior vena cava. After mobilization, laparotomy pads may be placed behind the right lobe of the liver to make the hilus more accessible. The cystic artery and duct are ligated and divided before dime&ion of the hepatoduodenal structures. It is generally easier to remove the gallbladder at this time, but it is sufficient to dissect the medial half of the gallbtider from the liver bed since it wiIl expose the interlobar fissure. The peritoneal reflection overlying the structures within the hepatoduodenal ligament is incised, and the right main hepatic artery is identified as the fit step of the d&&ion since it is the most anterior structure encountered. A vascular tape is placed around this vessel, and care is taken to ensure that the left main hepatic artery is protected. The right hepatic artery may be displaced and may arise from the superior mesenteric artery. It is readily defined by a preoperative angiogram.
889
Schwartz
F&m
\ I
2. Choke of h#ctshnm tar right hqmtk
Dissection is continued craniad, and the right branch of the portal vein is identified in the posterior portion of the hepatoduodenal ligament. Exposure is frequently facilitated by rotating the mobilized right lobe of the liver anteriorly. A vascular tape is then passed around the right branch of the portal vein, taking care to protect the left main portal vein. The right mainhepatic duct is then dissected free, and a tape is passed around it. This maneuver represents the most craniad step in the dissection. The right hepatic artery, the right portal vein, and the right hepatic duct may then be ligated and divided, or the vascular tapes may be snugged up to provide temporary occlusion (Figure 4). After the structures in the porta hepatis have been ligated and divided or temporarily occluded by the tapes or vascular clamps, there are two potential approaches to the completion of the hepatic lobectomy. The first involves securing the hepatic veins outside the liver as they drain into the inferior vena cava. In this circumstance, the right lobe is rotated in a clockwise fashion, and the veins are isolated from below upward (Figure 5). The main right hepatic vein is large and is best managed by applying a Satinsky or Derra vascular clamp to the anterior aspect of the inferior vena cava so that it incorporates the right hepatic vein. A curved hemostat is applied to the hepatic side of the vein, and the hepatic vein is then transected, and the caval side is sewn with continuous Prolene sutures. The operation is then completed by incising the capsule of the
kbedomy.
Coronary Ligament
h
Bare Area
inferior Vena Cava
m 3. Pw#omal mtiecth Vkw ot the sup&w and dcuat Abdominal Surgery, Futura Pubttahtng Co. wtth pumtsskn.
670
wtfams
Castro hepatlc Ligament
d the a&B Hvu. Raphtud
tmn Modem 1echnlc6 in Sugary.
The Amerkan Jaumal of Sugary
Right Hepatic Lobectomy
I
1
R “epmc Amv
i
PO”., “.I”
Common Blh
cut
F&we 4. -I dhwct&n. Rapbiad fromModun hcMa In 8wgaq.Abdominal Swgaq, Futwa FaMaih~ Co.,
liver and transecting the parenchyma and clamping, dividing, and ligating the vessels and ducts as they traverse the interlobar plane. The second approach, and the one that I generally use, involves transection of the hepatic parenchyma in the interlobar plane beginning anteroinferiorly and progressing posterosuperiorly. A compressive liver clamp may be placed to the left of the lobar plane, but I rarely use it. Glisson’s capsule is incised anteroinferiorly, and the parenchyma is transected by digital dissection which disrupts the hepatic tissue but does not transect the vessels and ducts as they cross the interlobar fissure. These are doubly clamped and transected. The side of the vessel that will remain is ligated with silk, and the vessels on the specimen side are controlled with hemostatic clips. As the fingers divide the hepatic parenchyma in the anteroinferior portion of the liver, branches of the hepatic artery, portal vein, and duct are defined intrahepatically (Figure 6), doubly ligated, and transected. The dissection continues posterosuperiorly to the region where the right main hepatic vein is encountered (Figure 7). The hepatic veins are isolated within the substance of the liver and doubly clamped using a vascular clamp on the caval side of the vein. The vessel is then transected, and the caval side of the transected hepatic vein is closed with continuous vascular sutures. This technique has the advantage of avoiding inadvertent ligation of a hepatic vein that serves as the efferent
rffh-.
/ RIghI Hepatic
Vdfl
I IVC
nrpitic
Vein
Schwartz
F&we 8. Fkger fracture technhpm: antemlnf&or Intraparenchymal dksectkn of pottal sbvctures. Rep&ted hum Modam TaChnb in &gory. Abdomhal Surgery, Fuiura Publkhlng Co. wnhpemItsskn.
Fwre 8. Saquanca ofavank bqwrary occhubn olatructwa~ h hepato&o&nel l@tkn ( 11, anfahw parenchymal dbsectkn (2). parenchymal dlswctkn of pmial stmctures (3), and pa~~~~ol~uc~(4).Rsplhled~[11]~ fwrmkston.
conduit from the remaining left lobe of the liver. It is also more rapid. Transection of the hepatic parenchyma in the interlobar plane may be performed with an ultrasonic scalpel, with a stream of saline solution irrigating the tip [IO]. At 80 to 90 percent of full power, the instrument is used in a probing 672
F@~re 7. Finger frachrre technlqve: posterosuperlor Intraparemchymal dkncthm of rl@t hepatk vein. Rep&ted from Modem Technics In Surgery. Ab&nnlnal Surgery, Futura Pvblkhlng Co. with pwmleskn.
motion, gradually deepening the incision anterior to posterior. The parenchyma is transected, leaving skeletonized vessels that could be controlled readily by clamps or clips. When the larger vessels are approached posterosuperiorly, the power is reduced to about 70 to $0 percent, and the direction of the tip is changed so that it runs parallel to the vessels. After transection of the parenchyma is complete, the specimen is removed. Then the vascular and ductal tapes can be released to determine that the bleeding and bile leaks from the parenchymal surface are completely controlled. If arterial bleeding is encounterd, the hepatic artery is ligated in the hepatoduodenal ligament, and if portal bleeding is encountered, the portal vein is handled in a similar fashion. If there is evidence of bile leak, the hepatic duct can be ligated within the hepatoduodenal ligament; however, this is usually not required. The usual sequence that I follow is the same as that endorsed by Bismuth [I 11 (Figure 8). The raw surface of the liver may be covered conveniently with pedicled omentum, but it is not necessary. The anterior and posterior portions of the remaining Glisson’s capsule can be approximated with interrupted catgut sutures to reduce the raw area and to provide a tamponade effect on the smaller vessels. Soft rubber drains are placed in the subphrenic space that had been occupied by the resected specimen and are brought out through one or two large stab wounds and positioned in a Hollister bag to provide a closed system of drainage. The common bile duct is not drained with a T tube. Postoperative care and complications: Gastric decompression is usually maintained for 1 to 2 days, after which oral intake is begun and rapidly advanced. Glucose The Am&can
Journal of Surgery
Right Hepatic Lobectomy
infusions and albumin are given to maintain normal levels until oral intake is adequate. Antibiotics are generally continued for 3 days. After right lobectomy, hyperbilirubinemia and clinical jaundice are anticipated. They usually begin on the second or third day, and may continue for as long as 3 weeks. Hypoprothrombinemia also develops but rarely reaches critical levels. If it becomes significant, it is readily corrected with fresh frozen plasma. Continued bleeding in the immediate postoperative period is generally caused by ineffective mechanical hemostasis and not by a coagulopathy; thus, it usually requires early reexploration. Persistent leakage of bile or the development of a biliary fistula is extremely rare. The most common complication is that of subphrenic abscess, which usually becomes manifest on the fifth postoperative day. In the past, it has required drainage through the lateral aspect of the major incision, but recently it has been managed successfully by ultrasonographically controlled placement of a pigtail catheter.
Summary Hepatic lobe&my has evolved to the point of being a precise anatomic surgical resection. The sequence of incision, mobilization, hepatoduodenal dissection, and management of the hepatic veins and parenchyma have been individually described herein. The historical background and indications for the
procedure have been outlined, and the perioperative management of the patient considered. References 1. Wendel W. Beltrage zur Chirugie der Leber. Arch Klin Chir 1911;95:887-94. 2. wangwwenoH.Canceroftheesophegusandstanactl(Case 19). New York: American Cancer Society, 1951:92. 3. Lcrtat-Jaccb X Rcbert ffi. Hepatectcmie drctte reglee. Resse Med 1952:60:51 l-49. 4. Cuattfebaum JK. Massive resection of the liver. Ann Surg 1953;137:787-96. 5. Pack GT, Baker HW. Total right hepatic lobectcmy. Ann Surg 1953;138:253-8. 6. MemMmsrwL.SuccessfutrigMhspatklobectomyfaprhnary necpbm:pellminary cbservatbns. Bull New York Med Cell 1953;18:121-4. 7. Fineberg C. Gcktburgh WP, Templeton JY. Right hepatic lcbectcmy for primary carcinoma of the Ilver. Ann Surg 1958;144:882-92. 8. Lin TY. Tsu KY, Mien C, Chen CS. Study on lobectcmy of ths liver: a new technical suggestion on hemihepatectomy of the liver. J Forum Med Ass 1958;11:742-59. 9. Tung TT. A new technic for operation on the liver. Lancet 1963;1:192-3. 10. Hcdgscn WJB, DelGuercio RM. Preliminary experience in liver surgery using the ultrasonic scalpel. Surgery 1984;95: 230-4. 11. Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg 1982;6:3-9.
673
Right Hepatic Lobectomy
Seymour I. Schwartz, MD, Rochester, New York
Wendel (21 is credited with the first case of a neartotal right hepatic lobectomy performed on a 44 year old woman in 1910. He deliberately tied the right branch of the hepatic artery and the right hepatic duct at the liver hilus but purposely ligated the right portal vein within the hepatic parenchyma. The patient did well and was alive and free of apparent disease 8 months later. In 1949, Wangensteen [z] removed the entire right lobe of the liver for metastatic carcinoma of the stomach. In 1952, LortatJacob and Robert [3] opened the modern era of hepatic surgery by performing an anatomic right lobectomy based on the vascular anatomy with preliminary hilar ligation. In 1953, Julian Quattlebaum [4] reported an operation that he had performed in 1952. It represented the first reported right hepatic lobectomy for primary carcinoma. In 1953, Pack and Baker (51 also reported a total right lobectomy with primary hilar ligation in a patient with carcinoma of the gallbladder. The same year, Mersheimer [6] reported a successful right lobe&my for a primary neoplasm. Digitoclasia, or finger fracture, of the hepatic parenchyma has evolved over the last 30 years. In 1953, Quattlebaum, in his classic article [4], described breaking the liver with the handle of a knife and clamping the vessels within the plane of transection. In 1956, Fineberg and associates [7] reported on right hepatic lobe&my for primary carcinoma of the liver. They carried out a quick parenchymal dissection with the finger or the back of the scalpel. In 1958, Lin et al [8] introduced a new technique in which the thumb and index finger were inserted into the liver tissue after which the surgeon “fractures and crushes the tissue between the fingers, and when resistant vessels or ducts are encountered they are tied and divided.” In 1963, Tung [9] modified this technique by occluding the portal pedicle before finger fracture. Fromfh3DeptvbnentOfSugery,UfliverdtyOfRochester.SchoolOfMediclne and Delltistly, ROdmst~. New YOriL f3equests for reprlnta shcukf be acuresned to SeymOw I. Schwartz, MD, oepartment of svgecy. unh/ersity of Rochestef. SdmOl of h4edkllw3 and Dentktry. Rochester. New York 14642.
666
The indications for right hepatic lobe&my include parasitic and nonparasitic cysts, granulomatous processes, benign primary neoplasms, malignant primary tumors, and secondary tumors that involve the liver by direct extension or metastasis. The technique of planned anatomic resection is generally reserved for lesions that are large or located so that resection along the anatomic plane provides an opportunity for the most complete removal, coupled with the best control of vascular supply. Resection along anatomic lines with vascular control is rarely indicated for trauma patients in whom the preferred approach is limited resectional debridement that permits removal of devitalized tissue and control of bleeding. Advanced cirrhosis generally precludes right hepatic lobe&my since intraoperative bleeding from collateral and parenchymal vessels is significantly increased. The incidence of liver failure with resection is increased because of lack of reserve, hepatic regeneration is impaired, and reported cures for malignant tumors in cirrhotic patients are negligible. Technique Preoperative preparation: An essential feature of the preoperative protocol is angiography of both the celiac and the superior mesenteric arteries to define the extent of hepatic involvement and thus the resectability, and also to demonstrate the vascular anatomy and segmental supply. Computerized tomography performed while radiopaque dye is infused directly into the hepatic artery provides the best definition of intrahepatic pathologic characteristics. The serum albumin level, prothrombin time, activated partial thromboplastin time, and platelet count are all obtained and, if abnormal, are corrected. A cephalosporin is usually instituted on the day of operation. Significant blood loss should be anticipated and an autotransfusion apparatus is made available for use intraoperatively. Operation: The right lobe of the liver is separated from the left lobe along the interlobar plane which is the main portal plane, also known aa Cantlie’s line (Figure 1). It extends from the middle of the gallbladder bed anteroin-
lhaAmukmhnnalot~
Right HeTatic Lobectomy
Rbht
Mlddla
nqxtlc
Hepatlc
V&l
Vdfl
feriorly to the inferior vena cava posterosuperiorly. This interlobar plane describes an angle of approximately 75 degrees with the horixontal plane. The right and left lobes are individualized by this plane, and each receives independent portal and arterial vascularixation and biliary drainage. The middle hepatic vein follows the main portal plane. A right subcostal incision is preferred, either with a left subcoatal extension in a chevron fashion (Figure 2) or with an extenaion craniad over the xiphoid process. The incision should be placed high enough to permit placement of an overhead retractor so that the sternum can be retracted toward the ceiling. The entire right rectus muscle is transected and the oblique muscles are split laterally almost to the tip of the right 10th rib. Transection of the medial portion of the left rectus muscle usually provides sufficient exposure. A thoracic extension placed perpendicular to the right subccstal incision and extending through the seventh intercostal space is rarely used and is reserved for large lesions in the dome of the right lobe of the liver with diaphragmatic involvement or encroachment on the suprahepatic inferior vena cava. Mobilization should be accomplished so that the right lobe can be delivered into the wound. The ligamenturn teres is transected. A clamp can be left on the hepatic end
vobwlw 148, Movmlhf
1984
to facilitate traction. The triangular ligament supporting the right lobe is divided, and the dissection is continued by transecting the anterior and posterior leaflets of the right coronary ligament to the inferior vena cava (Figure 3). This permits the entire right lobe of the liver to be mobilized toward the left At times, complete mobilization is impaired by attachment of two or three small hepatic veins, and these may be ligated at the point where they enter the inferior vena cava. After mobilization, laparotomy pads may be placed behind the right lobe of the liver to make the hilus more accessible. The cystic artery and duct are ligated and divided before dime&ion of the hepatoduodenal structures. It is generally easier to remove the gallbladder at this time, but it is sufficient to dissect the medial half of the gallbtider from the liver bed since it wiIl expose the interlobar fissure. The peritoneal reflection overlying the structures within the hepatoduodenal ligament is incised, and the right main hepatic artery is identified as the fit step of the d&&ion since it is the most anterior structure encountered. A vascular tape is placed around this vessel, and care is taken to ensure that the left main hepatic artery is protected. The right hepatic artery may be displaced and may arise from the superior mesenteric artery. It is readily defined by a preoperative angiogram.
889
Schwartz
F&m
\ I
2. Choke of h#ctshnm tar right hqmtk
Dissection is continued craniad, and the right branch of the portal vein is identified in the posterior portion of the hepatoduodenal ligament. Exposure is frequently facilitated by rotating the mobilized right lobe of the liver anteriorly. A vascular tape is then passed around the right branch of the portal vein, taking care to protect the left main portal vein. The right mainhepatic duct is then dissected free, and a tape is passed around it. This maneuver represents the most craniad step in the dissection. The right hepatic artery, the right portal vein, and the right hepatic duct may then be ligated and divided, or the vascular tapes may be snugged up to provide temporary occlusion (Figure 4). After the structures in the porta hepatis have been ligated and divided or temporarily occluded by the tapes or vascular clamps, there are two potential approaches to the completion of the hepatic lobectomy. The first involves securing the hepatic veins outside the liver as they drain into the inferior vena cava. In this circumstance, the right lobe is rotated in a clockwise fashion, and the veins are isolated from below upward (Figure 5). The main right hepatic vein is large and is best managed by applying a Satinsky or Derra vascular clamp to the anterior aspect of the inferior vena cava so that it incorporates the right hepatic vein. A curved hemostat is applied to the hepatic side of the vein, and the hepatic vein is then transected, and the caval side is sewn with continuous Prolene sutures. The operation is then completed by incising the capsule of the
kbedomy.
Coronary Ligament
h
Bare Area
inferior Vena Cava
m 3. Pw#omal mtiecth Vkw ot the sup&w and dcuat Abdominal Surgery, Futura Pubttahtng Co. wtth pumtsskn.
670
wtfams
Castro hepatlc Ligament
d the a&B Hvu. Raphtud
tmn Modem 1echnlc6 in Sugary.
The Amerkan Jaumal of Sugary
Right Hepatic Lobectomy
I
1
R “epmc Amv
i
PO”., “.I”
Common Blh
cut
F&we 4. -I dhwct&n. Rapbiad fromModun hcMa In 8wgaq.Abdominal Swgaq, Futwa FaMaih~ Co.,
liver and transecting the parenchyma and clamping, dividing, and ligating the vessels and ducts as they traverse the interlobar plane. The second approach, and the one that I generally use, involves transection of the hepatic parenchyma in the interlobar plane beginning anteroinferiorly and progressing posterosuperiorly. A compressive liver clamp may be placed to the left of the lobar plane, but I rarely use it. Glisson’s capsule is incised anteroinferiorly, and the parenchyma is transected by digital dissection which disrupts the hepatic tissue but does not transect the vessels and ducts as they cross the interlobar fissure. These are doubly clamped and transected. The side of the vessel that will remain is ligated with silk, and the vessels on the specimen side are controlled with hemostatic clips. As the fingers divide the hepatic parenchyma in the anteroinferior portion of the liver, branches of the hepatic artery, portal vein, and duct are defined intrahepatically (Figure 6), doubly ligated, and transected. The dissection continues posterosuperiorly to the region where the right main hepatic vein is encountered (Figure 7). The hepatic veins are isolated within the substance of the liver and doubly clamped using a vascular clamp on the caval side of the vein. The vessel is then transected, and the caval side of the transected hepatic vein is closed with continuous vascular sutures. This technique has the advantage of avoiding inadvertent ligation of a hepatic vein that serves as the efferent
rffh-.
/ RIghI Hepatic
Vdfl
I IVC
nrpitic
Vein
Schwartz
F&we 8. Fkger fracture technhpm: antemlnf&or Intraparenchymal dksectkn of pottal sbvctures. Rep&ted hum Modam TaChnb in &gory. Abdomhal Surgery, Fuiura Publkhlng Co. wnhpemItsskn.
Fwre 8. Saquanca ofavank bqwrary occhubn olatructwa~ h hepato&o&nel l@tkn ( 11, anfahw parenchymal dbsectkn (2). parenchymal dlswctkn of pmial stmctures (3), and pa~~~~ol~uc~(4).Rsplhled~[11]~ fwrmkston.
conduit from the remaining left lobe of the liver. It is also more rapid. Transection of the hepatic parenchyma in the interlobar plane may be performed with an ultrasonic scalpel, with a stream of saline solution irrigating the tip [IO]. At 80 to 90 percent of full power, the instrument is used in a probing 672
F@~re 7. Finger frachrre technlqve: posterosuperlor Intraparemchymal dkncthm of rl@t hepatk vein. Rep&ted from Modem Technics In Surgery. Ab&nnlnal Surgery, Futura Pvblkhlng Co. with pwmleskn.
motion, gradually deepening the incision anterior to posterior. The parenchyma is transected, leaving skeletonized vessels that could be controlled readily by clamps or clips. When the larger vessels are approached posterosuperiorly, the power is reduced to about 70 to $0 percent, and the direction of the tip is changed so that it runs parallel to the vessels. After transection of the parenchyma is complete, the specimen is removed. Then the vascular and ductal tapes can be released to determine that the bleeding and bile leaks from the parenchymal surface are completely controlled. If arterial bleeding is encounterd, the hepatic artery is ligated in the hepatoduodenal ligament, and if portal bleeding is encountered, the portal vein is handled in a similar fashion. If there is evidence of bile leak, the hepatic duct can be ligated within the hepatoduodenal ligament; however, this is usually not required. The usual sequence that I follow is the same as that endorsed by Bismuth [I 11 (Figure 8). The raw surface of the liver may be covered conveniently with pedicled omentum, but it is not necessary. The anterior and posterior portions of the remaining Glisson’s capsule can be approximated with interrupted catgut sutures to reduce the raw area and to provide a tamponade effect on the smaller vessels. Soft rubber drains are placed in the subphrenic space that had been occupied by the resected specimen and are brought out through one or two large stab wounds and positioned in a Hollister bag to provide a closed system of drainage. The common bile duct is not drained with a T tube. Postoperative care and complications: Gastric decompression is usually maintained for 1 to 2 days, after which oral intake is begun and rapidly advanced. Glucose The Am&can
Journal of Surgery
Right Hepatic Lobectomy
infusions and albumin are given to maintain normal levels until oral intake is adequate. Antibiotics are generally continued for 3 days. After right lobectomy, hyperbilirubinemia and clinical jaundice are anticipated. They usually begin on the second or third day, and may continue for as long as 3 weeks. Hypoprothrombinemia also develops but rarely reaches critical levels. If it becomes significant, it is readily corrected with fresh frozen plasma. Continued bleeding in the immediate postoperative period is generally caused by ineffective mechanical hemostasis and not by a coagulopathy; thus, it usually requires early reexploration. Persistent leakage of bile or the development of a biliary fistula is extremely rare. The most common complication is that of subphrenic abscess, which usually becomes manifest on the fifth postoperative day. In the past, it has required drainage through the lateral aspect of the major incision, but recently it has been managed successfully by ultrasonographically controlled placement of a pigtail catheter.
Summary Hepatic lobe&my has evolved to the point of being a precise anatomic surgical resection. The sequence of incision, mobilization, hepatoduodenal dissection, and management of the hepatic veins and parenchyma have been individually described herein. The historical background and indications for the
procedure have been outlined, and the perioperative management of the patient considered. References 1. Wendel W. Beltrage zur Chirugie der Leber. Arch Klin Chir 1911;95:887-94. 2. wangwwenoH.Canceroftheesophegusandstanactl(Case 19). New York: American Cancer Society, 1951:92. 3. Lcrtat-Jaccb X Rcbert ffi. Hepatectcmie drctte reglee. Resse Med 1952:60:51 l-49. 4. Cuattfebaum JK. Massive resection of the liver. Ann Surg 1953;137:787-96. 5. Pack GT, Baker HW. Total right hepatic lobectcmy. Ann Surg 1953;138:253-8. 6. MemMmsrwL.SuccessfutrigMhspatklobectomyfaprhnary necpbm:pellminary cbservatbns. Bull New York Med Cell 1953;18:121-4. 7. Fineberg C. Gcktburgh WP, Templeton JY. Right hepatic lcbectcmy for primary carcinoma of the Ilver. Ann Surg 1958;144:882-92. 8. Lin TY. Tsu KY, Mien C, Chen CS. Study on lobectcmy of ths liver: a new technical suggestion on hemihepatectomy of the liver. J Forum Med Ass 1958;11:742-59. 9. Tung TT. A new technic for operation on the liver. Lancet 1963;1:192-3. 10. Hcdgscn WJB, DelGuercio RM. Preliminary experience in liver surgery using the ultrasonic scalpel. Surgery 1984;95: 230-4. 11. Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg 1982;6:3-9.
673