- Metastasis (colon, breast, neuroendocrine).
- Hepatocellular carcinoma.
- Gallbladder carcinoma.
- Hepatic sarcoma.
- Biliary cystadenoma.
- Symptomatic hemangioma or focal nodular hyperplasia.
- Hepatic tumor of unknown etiology.
- Distant metastatic disease for primary liver tumors.
- Presence of extrahepatic metastases for metastatic lesions (relative).
- Severe medical comorbidity.
- Inability to achieve negative margins.
- Insufficient estimated liver remnant following resection.
- Significant cirrhosis or portal hypertension.
- Surgical treatment of primary and metastatic hepatic malignancies.
- Treatment of symptomatic benign hepatic mass.
- Bleeding requiring reoperation or transfusion.
- Infection or abscess.
- Embolic events.
- Bile leak or stricture.
- Tumor recurrence.
- Possibility of unexpected findings intraoperatively.
- Need for additional tests or procedures.
- Hepatic dysfunction or failure.
- Intraoperative ultrasound equipment.
- Self-retaining retractor (eg, Omni or Thompson).
- Electrocautery, Cavitron Ultrasonic Surgical Aspirator (CUSA), Hydrojet, automatic clip applier, and possibly Tissue Link, LigaSure, or SonoSurg devices, depending on surgeon preference.
- Nothing by mouth the evening before surgery.
- Preoperative antibiotics.
- Adequate intravenous access (at least two > 16G intravenous lines and central venous pressure [CVP] line at the surgeon's discretion).
- Foley catheter.
- Orogastric tube decompression.
- Anesthesiology consultation and coordination.
- The patient should be supine with arms extended.
- Figure 14–1: Familiarity with hepatic segmental anatomy is important (Couinaud) to allow for resection planning along with intraoperative ultrasound.
- Figure 14–2A, B: Important vascular landmarks for planning of anatomic resections showing hepatic veins and main portal venous branches. Planes of transection for major hepatectomies are as follows:
- Right lobectomy, right trisegmentectomy (extended right lobectomy) (Figure 14–2A).
- Left lobectomy, left trisegmentectomy (extended left lobectomy), and left lateral segmentectomy (Figure 14–2B).
- Figure 14–3: Right hepatic lobectomy or extended right hepatic lobectomy. Identification and isolation of the right hepatic artery and right hepatic duct.
- Figure 14–4: Right hepatic lobectomy or extended right hepatic lobectomy. Identification of right portal vein.
- Biliary and vascular structures can be divided before hepatic transection or after, depending on surgeon preference.
- The portal vein should be oversewn with Prolene suture or secured with a vascular stapler.
- Figure 14–5: Right hepatic lobectomy or extended right hepatic lobectomy.
- Additional mobilization of the right hepatic lobe is performed by reflecting it lateral to medial.
- Caudate hepatic vein branches as well as accessory right hepatic venous branches are ligated.
- The right hepatic vein can be divided before or during parenchymal dissection and oversewn with Prolene or secured with a vascular stapler.
- Figure 14–6: Right hepatic lobectomy.
- Parenchymal transection is performed by using vascular demarcation (if inflow is divided) or along the transection plane as detailed in Figure 14–2 (marked by ultrasound).
- Transection is performed under intermittent inflow occlusion and maintaining a low CVP (3–7 mm Hg). Manual compression can also minimize blood loss from small hepatic veins.
- Transection is initiated with electrocautery followed by CUSA or Hydrojet dissection to identify vascular or biliary radicals. These ...
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