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  • Metastasis (colon, breast, neuroendocrine).
  • Hepatocellular carcinoma.
  • Cholangiocarcinoma.
  • Hepatoblastoma.
  • Gallbladder carcinoma.
  • Hepatic sarcoma.
  • Adenoma.
  • Biliary cystadenoma.
  • Symptomatic hemangioma or focal nodular hyperplasia.
  • Hepatic tumor of unknown etiology.

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  • 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.

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Expected Benefits

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  • Surgical treatment of primary and metastatic hepatic malignancies.
  • Treatment of symptomatic benign hepatic mass.

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Potential Risks

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  • 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.
  • Death.

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  • 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.

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  • 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.

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Patient Positioning

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  • The patient should be supine with arms extended.

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  • 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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