VL01 Video Liver: Open Liver Surgery 
Selection of Video Presentations from Abstract Submissions
VL01-01 Hepato-Cavo-Atrial Confluence Resection without Extracorporeal Circulation to Treat a Third Colorectal Metastasis Recurrence Involving Right Atrium
Nicolo' Roffi, Italy

N. Roffi, L. Urbani
Azienda Ospedaliero-Universitaria Pisana - General Surgery - Liver Metastasis Parenchyma Sparing Surgical Team, Italy

Parenchyma sparing hepatectomy (PSH) allows for several surgeries in case of liver disease recurrence. This video shows treatment of a third colorectal liver metastasis (CRLM) recurrence at the hepato-caval confluence protruding in right atrium.
A 71y female received a first PSH (liver-tunnel) for two metachronous CRLM. One year later a second PSH with double HV reconstruction was performed for a new CRLM involving diaphragm, right hepatic vein (RHV) and middle hepatic vein. Eighteen months after, a third solid lesion appeared involving the hepato-caval confluence and protruding inside right atrium. Extracorporeal-circulation was contraindicated due to patient's general condition, but a multidisciplinary/professional team planned an alternative surgical approach.
J-shaped sterno-thoraco-laparotomy was performed to confirm extracorporeal circulation avoidance by tumor displacement from the right atrium using the “atrial-abdominalization manouvre”. A cadaveric vena cava graft was previously prepared replacing right renal with right iliac vein. Liver outflow was interrupted resecting intrahepatic RHV and middle-left hepatic vein common trunk. Common trunk was anastomosed with cadaveric right iliac vein under total vascular exclusion with caval flow preservation. Then, hepato-cavo-atrial confluence was resected and atrial junction was anastomosed with the cadaveric vena cava and the liver was reperfused (38 minutes from common-trunk-resection to liver-reperfusion). Finally, intrahepatic cava anastomosis was performed. Reconstruction of RHV was not required. Ten-months after surgery the patient is alive and well. Control CT scan documented no pathologic recurrences and regular anastomoses.
This video documented feasibility of hepato-cavo-atrial confluence replacement with a cadaveric graft without using extracorporeal circulation.
VL01-02 Extended Hepatectomy with IVC Resection and Veno-Venous Bypass. Left vs Right

D. Cherqui
Paul Brousse Hospital - Paris South University, Villejuif, France

This video illustrates two extended hepatectomies, one on each side, for intra hepatic cholangiocarcinoma invading the retro hepatic vena cava. Both patients had received neoadjuvant chemotherapy.
Procedures involved caval resection and replacement by PTFE graft, under total vascular exclusion, and veno-venous bypass.
The video clearly shows all steps of surgery.
In the first case, in situ liver cooling was used, whereas in the second case, it was not feasible and topical cooling was used.
We demonstrate here each technical step of these uncommon surgical procedures.
After liver mobilization and IVC control (below and above the liver), portal, arterial and bile duct branches to the future resected liver remnant were controlled and divided. Venous bypass was then placed and parenchymal transection performed under total vascular exclusion.
During the extended left hepatectomy, reconstruction of the right hepatic vein was required. In the extended right case, the left hepatic vein implantation could be preserved and maintained in the upper IVC stump.
The extended left hepatectomy patient had transient postoperative liver insufficiency (peak bilirubin 18 mg/dl and peak INR 2). The patient was discharged on day 18. She is alive and free of disease as of December 2019 (47 months after surgery).
The extended right hepatectomy patient had an uneventful postoperative course and was discharged on day 7. She presented with liver recurrence at 13 months without extrahepatic disease. She was treated by repeat resection but recurred again and eventually died of disease 22 months after surgery.
VL01-03 Complex Liver Resection under Total Vascular Exclusion and Venous Reconstruction with Double Peritoneal Patch
Safi Dokmak, France

S. Dokmak, B. Aussilhou, F. Cauchy, O. Soubrane
HBP Departement and Liver Transplantation, Beaujon Hospital, France

Introduction: Patients necessitating complicated liver resection and venous resection-reconstruction are traditionally operated under total vascular exclusion (TVE), refrigeration and/or extracorporal circulatory bypass can be needed, at higher morbidity and mortality. However these procedures can be performed under short TVE alone and venous reconstruction with the peritoneum. We present the case of a patient who underwent 2 liver resections, both under TVE and with venous reconstruction with the peritoneum.
Methods: Liver resection can be facilitated by the adoption of some surgical principles or techniques including (1) the associated thoracic incision (2) to do short TVE and only for vascular reconstruction, (3) the use of the peritoneum for venous reconstruction, (4) the liver hanging maneuver, and (5) the experience of the surgeon.
Results: 47 year old female with colorectal liver metastases including with one with lateral invasion of the vena cava underwent right hepatectomy with lateral resection reconstruction of the vena cava with a large peritoneal patch. Reconstruction was done under isolated clampage of the vena cava for 16 minutes with transfusion of 2 units of blood. The postoperative course was uneventful. Two years later she was reoperated for recurrence and she underwent rehepatectomy with lateral reconstruction of the left hepatic vein with a peritoneal patch under isolated clampage of the hepatic pedicle for 25 minutes and TVE for 20 minutes, with no transfusion and uneventful postoperative course.
Conclusion: With improvements in surgical techniques, complicated liver resections can be done under short duration of TVE and venous reconstruction with the peritoneum.
VL01-04 ALPPS Procedure with Full First Stage Transection for Colorectal Liver Metastases
Daniel Cherqui, France

D. Cherqui
Paul Brousse Hospital - Paris South University, Villejuif, France

This video presents a 62 year old man with history of left colon cancer pT4N0. 6 months after surgery he was diagnosed with large liver metastases located in the right lobe. The left lateral segment and segment 1 were free of disease. He received 6 cycles of triplet Fofoxiri chemotherapy with a 30% Recist response rate. CEA drops from 132 to 18 after chemotherapy. PET CT shows no extrahepatic disease. Future liver remnant volume is measured at 230 mL which is 0.3% of patient body weight. Because of small FLR, ALPPS Procedure was scheduled.
The video clearly shows all steps of surgery.
First stage surgery included:
- Exploration including ultrasound
- Complete liver mobilization
- Complete liver transection on the right border of the round and falciform ligament
- Middle hepatic vein division
- Ligation of the right portal vein.
Postoperative course of stage 1 was uneventful. CT scan and HIDA scan were performed at day 7 showing excellent FLR hypertrophy to 413 mL representing 30% of total liver volume and 0.6% of patient body weight.
Second stage was performed at day 8 and consisted in completion hepatectomy removing segments 4-8. It was quick and straightforward thanks to full transection at stage 1.
- Reopening of previous incision
- Division of right hepatic artery
- Division of right bile duct
- Division of right hepatic vein
- Drainage and abdominal closure.
Postoperative course was uneventful. The patient received 12 chemotherapy.
VL01-05 The ALPPS Procedure for the Resection of Large Hepato Cellular Carcinoma with Chronic Hepatitis B Condition
Madhusudhan Chinthakindi, India

M. Chinthakindi
Department of Surgical Gastroenterology and Liver Transplantation, Osmania Medical College/Hospital, Hyderabad, India

Introduction: The Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) is the most recent modification for hepatectomies that allow resection of advanced liver tumors in two steps by making of a rapid future liver remnant hypertrophy. In the first step the liver parenchyma is transected along the intended line of resection and to this a portal vein ligation of the larger liver lobe is added. After a waiting period of 1-2 weeks the second step is performed in which the deportalized liver is removed. Here we present a video on the ALLPPS procedure for very large HCC in a chronic hepatitis B patient.
Case History: A 60 Yrs., Male presented with Weight loss and loss of appetite for 3months.Triphasic CT Abdomen with volumetry revealed a 16 x12 x10 cm mass involving right lobe and segment IVA and IVB. Future Liver Remnant volume (FLR) was 22%. Patient underwent stage I ALPPS (Liver partition and division of rt. portal vein). We kept a plastic sheet between two raw areas of liver surfaces and red sling applied to rt. hepatic artery for future easy identification. On 10th Post-operative day CT showed hypertrophy of future liver remnant (FLR 33%). In second stage, the dense sub hepatic adhesions were present. We did right extended hepatectomy after ligating the right hepatic artery.
Conclusion: The ALPPS is a very useful technique for resection of rapidly growing liver tumours like HCC in a chronic liver disease background without post hepatectomy liver failure.
VL01-06 Extended Right Hepatectomy with IVC Resection for Treatment of a Huge HCC
Renato Cano, Brazil

R. Cano
HPB Surgery, Ipanema Federal Hospital, Rio de Janeiro, Brazil

We present a case of a 44 yo female patient presenting with progressive abdominal pain, weight loss and palpable abdominal mass. CT scan showed a huge heterogeneous hyper vascular mass evolving the entire right liver, measuring 25 x 16.2 x 14.2 cm, determining compression of the right hepatic vessels and significant compression of the retrohepatic vena cava by more than 90% of its caliber. The patient underwent enlarged right hepatectomy with retrohepatic vena cava resection and reconstruction with a 20mm PTFE vascular prosthesis. The technique used was total vascular exclusion of the liver, with a total ischemia time of 23 minutes. The patient had a uneventful postoperative course, remained in intensive care for two days and was discharged on the sixth postoperative day. Histopathological analysis of the surgical specimen confirmed hepatocellular carcinoma.
VL01-07 Central Hepatectomy Combined with Caudate Resection Using IVC Half Clamping Technique for a Large HCC
Yoshihiro Sakamoto, Japan

Y. Sakamoto, R. Matsuki, M. Kogure, T. Nakazato, Y. Suzuki, T. Mori
Kyorin University Hospital, Japan

Resection of a large hepatocellular carcinoma (HCC) located in the central part of the liver could be associated with massive bleeding from the hepatic veins or inferior vena cava (IVC). Our central bisegmentectomy including 5 knacks will be useful.
The patient was an asymptomatic 60's year old male with a HCC sized 15cm in diameter located in S458. The three major hepatic veins were strongly compressed by the tumor on dynamic CT scan. The IVC was taped and the total liver was fully mobilized from the IVC (1st knack). Injection of blue dye and ICG into the anterior portal vein revealed the boundary between the anterior and posterior sections, visualized using a fluorescence camera (2nd knack). Transection of the liver was started to divide the boundary between the right anterior and posterior section toward IVC. The surface of the RHV was fully exposed on the dissecting plane to its root, removing the part of the paracaval portion, making a liver tunnel in front of the IVC (3rd knack). The IVC half clamping technique was used if necessary (4th knack). After division of the right anterior glissonean pedicle, the right glissonean pedicle was taped in en bloc manner (5th knack). Then, the liver transection along the right-side of the falciform ligament was done, and the middle hepatic vein was finally divided, and the specimen was extracted. The operative time was 10h 15m, and the blood loss was 1500ml, and no blood transfusion was done. The patient was discharged on day 19.
VL01-08 Anterior Approach for Right Side Hepatectomy in Case of Urological Malignancies
Atsushi Nanashima, Japan

A. Nanashima
Division of HBP Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan

Anterior approach (AA) for right hepatectomy is a useful option for liver cancers with a large size or surrounding invasion. Right hepatectomy or posterior sectionectomy is required for cases with urological malignancies infiltrating hepatic parenchyma. Conventional mobilization of the right liver is obviously difficult in case the combined liver resection is necessary. We herein succeeded radical resection of combined hepatectomy with urological malignancies using AA. One was an advanced renal carcinoma and another was a pheochromocytoma with caval invasion. Laparoscopic mobilization in the retroperitoneal space was accomplished first and, the thoraco-laparotomy was subsequently applied for hepatectomy. Liver hanging maneuver was applied for AA. After completing hepatic parenchymal transection, the combined en-block resections were accomplished in both cases. AA is an alternative option and useful procedure for safety and curability in case of combined right side hepatectomy with advanced stage urological malignancies.
VL01-09 Extended Left Hepatectomy with Bile Duct Resection and Duct to Duct Reconstruction
Daniel Cherqui, France

D. Cherqui
Paul Brousse Hospital - Paris South University, Villejuif, France

This video presents a 51 year old man with 10 X 6 cm intrahepatic cholangiocarcinoma occupying segments 1-5 and 8. There is no invasion of the IVC. There are no enlarged lymph nodes and imaging including PET-CT does show show extrahepatic disease. Tumor parkers were normal. No neodjuvant therapy was used.
The video clearly shows all steps of surgery.
Surgery included:
- Exploration including ultrasound
- Complete liver mobilization
- Lymphadenectomy
- Division of the left portal pedicle
- Division of the right anterior portal pedicle
- Resection of the biliary confluence
- Left hepatectomy extended to segments 1, 5 and 8
- Biliary reconstruction by duct to duct anastomosis between the common bile duct and the right posterior duct.
Pathology showed moderate to well differentiated intrahepatic cholangiocarcinoma with no lymph node invasion, PT2 N0. Resection was complete with lowest margin < 1 mm.
There were no postoperative complications. The patient received adjuvant therapy with capecitabin for 6 months. He is alive and free of disease free at 4 years.
VL01-10 Left Hemihepatectomy, Caudate Lobectomy and Combined IVC Tangential Excision for HCC Adherent to the Posterolateral Wall of IVC
Yang Won Nah, Korea, Republic of

Y.W. Nah1, T.Y. Lee2, J.C. Hwang2, J.H. Suh3
1Department of Surgery, Ulsan University Hospital, Korea, Republic of, 2Department of Radiology, Ulsan University Hospital, Korea, Republic of, 3Department of Pathology, Ulsan University Hospital, Korea, Republic of

For hepatic tumors invading or adherent to the retrohepatic inferior vena cava (IVC), hepatectomy combined with IVC resection is required to get a R0 resection. The techniques for IVC reconstruction after resection are usually dictated by the degree of the IVC involvement by the tumor. Direct repair, patch graft and conduit graft are among the choices. The authors report here a 61 years old patient who underwent hepatectomy combined with IVC resection for double HCC's that one was located at the caudate lobe, encircling almost 180 degree of the retorhepatic IVC and the other at the inferior tip of segment 4.
Method: Left hemihepatectomy, caudate lobectomy and en bloc IVC tangential excision was performed and got a tumor-free resection margin. The operative planes between the caudate lobe (or IVC ligament) and the retroperitoneum (diaphragm, crural ligament and prevertebral fascia) as well as the caudate lobe and IVC should be clearly secured to get a sound IVC margins in this complex operation. The defect in the postero-left lateral IVC wall after resection was patch repaired with Bovine pericardium. The details of the operative procedure will be presented with a video.
Results: The operation took 395 minutes. Intraoperative blood loss was 1,000 g. No blood product was given perioperatively. There was no serious postoperative complication. The patient was discharged 14 days after the operation.
Conclusion: Through a well-planned surgery based on preoperative imaging studies, retrohepatic IVC resection and repair combined with partial hepatectomy can be performed safely with adequate oncologic outcome.
VL01-11 Right Trisectionectomy after Future Liver Remnant Modulated by Terminal Branches Portal Vein Embolization Combined with TACE Treatment
Xu An Wang, China

X.A. Wang1, S.Y. Peng2, C.Y. Huang3, Y.Y. Zhang3
1Xinhua Hospital Shanghai Jiaotong University School of Medicine, China, 2The 2nd Affiliated Hospital of Zhejiang University, China, 3Yuebei People's Hospital, China

In order to develop a new technique that can possess the merit of ALPPS and PVE, but avoiding their drawbacks, we proposed Terminal Branches Portal Vein Embolization (TBPVE) technique to modulate future liver remnant (FLR) volume for staged hepatectomy. As compared to ALPPS, its a minimally-invasive way to partition the liver, the intra-hepatic portal venous communication can be totally blocked by embolization of small portal branches. TBPVE may also increase arterial perfusion of the tumor bearing liver after occlusion of portal blood flow. Because liver tumors are mainly vascularized by the hepatic artery, therefore TBPVE may potentially stimulates tumor growth. In order to overcome this risk, Transarterial chemoembolization (TACE) procedure was performed with TBPVE simultaneously. After the TBPVE procedure, only a single surgical operation is required.
In this video, we performed TBPVE combined with TACE for a hepatitis-B related HCC patient with a insufficient FLR volume, the increment of FLR was 88.4% on day-7 and 120.8% on day-14, the patient underwent right trisectionectomy successfully and recover smoothly.
VL01-12 Anatomical Resection of Segments of IV, V, VIII for Hepatocellular Carcinoma
Xiangcheng Li, China

X. Li1, H. Wang2, C. Li2, X. Wu3, Z. Wu2, X. Wang3
1Surgery, Jiangsu Province Hospital, Nanjing Medical University, China, 2Nanjing Medical University, China, 3Jiangsu Province Hospital, Nanjing Medical University, China

Background: Hepatectomy is still the first choice for hepatocellular carcinoma. Most patients with hepatocellular carcinoma have underlying cirrhosis. Postoperative hepatic dysfunction or even hepatic failure is complicated after extended hepatectomy. The extension of resection is difficult to decide for tumor in the middle lobe of liver. Right or left trisegmentectomy is not appropriate for patients with middle lobe tumors with cirrhosis. It is necessary to remain sufficient functional liver for patients with a high risk of postoperative liver dysfunction. Here, we described the successful case of HCC via segment IV, V, VIII anatomical resection.
Methods: A 27-year-old male was admitted to hospital with no obvious symptom. The liver function was normal while AFP was 24200 ng/mL. Preoperative imaging assessment showed the tumor was located in the middle lobe. Surgical plan was made to perform anatomical resection of segments of IV, V, VIII. Right hepatic parenchyma was dissected according to the demarcation line after the anterior branch of right hepatic artery and right portal vein was occluded. Left hepatic parenchyma was dissected according to left interlobar fissure. Segments of IV, V, VIII were completely excised after transection of the MHV.
Results: Surgical procedure cost 4h with 350ml bleed loss. This patient obtained rapid recovery without severe postoperative complications. Postoperative CT and laboratory examination were normal.
Conclusion: Anatomical resection of segments of IV, V, VIII is technically feasible and safe for patients with HCC in middle lobe of liver.
VL01-14 Combination of Hanging Liver Maneuver and Intrahepatic Extraglissonian Approach for Anatomic Right Hepatectomy: Technique Standardization
Fabio Makdissi, Brazil

F. Makdissi, V. Jeismann, J. Kruger, F. Coelho, G. Fonseca, P. Herman
Gastroenterology, University of Sao Paulo - Hospital das Clinicas, Brazil

One of the main concerns during liver resections is bleeding. Many methods of vascular control, parenchymal transection, vascular structures division have been described to decrease intraoperative blood loss and complications of hepatectomies. Technical standardizations in surgical procedures are key to increase the safety of surgical procedures and, this may be especilly important in a teaching hospital, with hepato-pancreato-biliary surgery training program.
Intrahepatic glissonian approach and hanging liver maneuver are two different well documented techniques to facilitate anatomic liver resections.
Intrahepatic glissonian approach is a tactic for rapid access and control of glissonian pedicles, without the need for dissection of the glissonian elements. This approach is usually fast, allowing sectoral control of blood inflow to the liver, leading to anatomical ischemic deliniation of the interested area to be resected. This step can be performed before the hepatic parenchyma transection, precluding Pringle maneuver.
Hanging liver maneuver allows to guide the anatomic hepatic parenchymal transection line, helping to control mainly hepatic venous bleeding, and eliminating the need for wide mobilization of the right liver.
The purpose of this video is to describe the main steps and propose a standardization for anatomic right hepatectomy combining two techniques (Hanging liver maneuver and Intrahepatic extraglissonian approach) in a patient with 2 large liver metastasis on the right liver, and with diaphragm invasion.
VL01-15 Resection of Segments of IV, V, VII, VIII with MHV and RHV for Intrahepatic Cholangiocarcinoma
Xiangcheng Li, China

X. Li, X. Wang, Z. Wu, X. Wu, C. Li
Jiangsu Province Hospital, Nanjing Medical University, China

Background: Hepatectomy is still the first choice for intrahepatic cholangiocarcinoma (ICC). For ICC involving MHV and RHV, extensive hepatectomy or even vascular resection and reconstruction is often required for these cases. However, it is very difficult to make surgical decisions, owing to its necessity to retain a suitable remnant liver. Here, we report our experience with IRHV-preserving resection of segments of IV, V, VII, VIII for ICC involving MHV and RHV.
Methods: A 50-year-old female (50kg, 155cm) presented with weakness, who was diagnosed with huge tumor based on CT scan. The preoperative imaging assessment showed the tumor was 12 × 10cm in size involving the MHV, RHV and right anterior hepatic pedicle. The measurement of liver volume showed the volume of the S2/3 was only 266ml and S6 was 300ml. Surgical plan was made to perform right trisegmentectomy preserving IRHV and S6. After the right approach of the hepatic round ligament, the S4, 5, and 8 hepatic pedicles were dissected along the outer sheath. Then, MHV and RHV were divided and closed. IRHV-preserving resection of segments of IV, V, VII, VII was performed.
Results: Operating time was 5h and 25min with 800ml blood loss. The hospital stayed is 12 days. This patient obtained rapid recovery without severe postoperative complications. Postoperative CT and laboratory examination were normal.
Conclusions: IRHV-preserving major right trisegmentectomy resection was technically feasible and safe for patients with huge ICC involving the middle hepatic vein and the right hepatic vein.
VL01-16 Standardization of Technique of Right Hepatectomy Using Hanging Maneuver - Step by Step Fashion!
Swapnil Patel, India

S. Patel, S. Patkar, M. Goel, A. Gupta, A. Parray, A. Arra
Surgical Oncology, Tata Memorial Hospital, Mumbai, India

Aim: Anatomical Liver resections when done in earlier part of learning curve are often accompanied by greater blood loss & increased perioperative complications. The intraoperative complications can often be minimized by the correct sequential application of techniques and available devices.
Material and methods: A 70 year gentleman presented with an incidentally detected liver mass. Viral markers were negative with no stigmata of Portal hypertension & liver cell failure. AFP was 11.22 ng/Ml with other tumour markers being normal. Triphasic CECT Scan showed a 3.9cm arterial enhancing lesion with venous washout in a non-cirrhotic liver. He was diagnosed as Right lobe HCC, BCLC II, HKLC I, Child A with a CTP score of 5. He underwent Right Hepatectomy with the Hanging maneuver approach using the Ligasure & Waterjet devices.
Results: The surgery was uneventful with an operative time of 180 minutes with a blood loss of 1 l. Postoperative course was uneventful and patient was discharged on Post-operative day 7.
Conclusions: Standard anatomical Right hepatectomy can be safely performed by the beginners minimizing the blood loss using sequential steps in an orderly fashion with the correct application of the available devices. Hanging Maneuver provides the shortest possible parenchymal transection plane.
VL01-17 Cavo-Atrial Thrombectomy Prior to Hepatectomy for Hepatocellular Carcinoma with Tumor Thrombus in the Right Atrium Was Successfully Performed in 5 Patients
Shunichi Ariizumi, Japan

S. Ariizumi, Y. Kotera, S. Yamashita, A. Omori, T. Kato, G. Shibuya, S. Katagiri, H. Egawa, M. Yamamoto
Dept. of Gastroenterological Surgery, Tokyo Women’s Medical University, Japan

Background: Hepatocellular carcinoma (HCC) with tumor thrombus (TT) in the right atrium is a critical condition. The general consensus is to perform hepatectomy prior to cavo-atrial thrombectomy because of the risk of uncontrollable bleeding during the liver transection after heparinization. However, sudden cardiac arrest due to the ball-valve effect and pulmonary embolism have been reported in cases of TT. Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium was successfully performed to prevent sudden cardiac arrest and pulmonary embolism.
Methods: In 5 patients with HCC and TT in the right atrium, tumor thrombectomy under cardiopulmonary bypass with heparin and electrical ventricular fibrillation prior to hepatectomy was performed to prevent sudden cardiac arrest or pulmonary embolism. After neutralization of heparin, hepatectomy with tumor thrombectomy in the inferior vena cava was performed.
Results: The total blood loss in 2 patients was 8200 ml and 10000 ml, whereas total blood loss in the other 3 patients was 1000 ml or less. All patients were discharged within 30 days after surgery with no mortality. Four of 5 patients had C-D class II morbidity and 1 patient had C-D class IIIa morbidity.
Conclusions: Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium can be performed safely.
VL01-18 Should Conservative Management Be the First Option in Asymptomatic Segmental Bile Duct Dilatation with Intrahepatic Lithiasis? From a “Watch-And-Wait” Strategy to an Aggressive Approach
Lucas McCormack, Argentina

D. Ramallo, M. Lendoire, N. Dreifuss, A. Valinotti, C. Bras Harriot, L. McCormack
Hospital Aleman of Buenos Aires, Argentina

Introduction: Focal segmental bile duct dilatation due to intrahepatic stricture is a rare condition and often asymptomatic. In this case we change the initial conservative approach towards a major liver resection as a definitive strategy.
Content description: A 57-year-old female patient presented with severe acute cholangitis (positive blood cultures). She has history of cholecystectomy and recurrent choledochal biliary lithiasis. She was under follow-up for isolated and asymptomatic segmental dilatation of intrahepatic bile duct of segment 6. A recent MRI, confirmed hepatolithiasis in segment 6. After admission, a CT scan revealed vascular thrombosis of anterior branch of right portal vein and right hepatic vein. The laboratory demonstrated a rise in CA 19.9 marker up to 93 UI/ml. Although no evidence of liver tumour was present, it was not possible to exclude an intrahepatic cholangiocarcinoma. After 5 days of antibiotic therapy, a liver surgery was performed. A right hepatectomy was performed with intraoperative analysis of margin of the right hepatic ducts. Frozen section rule out the presence of cholangiocarcinoma and therefore, the common bile duct and segment 1 were preserved. An intraoperative cholangiography confirmed the presence of a primary sclerosing cholangitis on remnant liver.
Histologic assessment of liver specimen demonstrated only chronic inflammation surrounding the bile duct and thickening of the wall of the bile duct.
Conclusion: The presence of asymptomatic segmental bile duct dilatation requires investigation and meticulous follow-up to exclude malignancy. Severe acute cholangitis or elevation of tumor markers suggesting malignancy are clear indications for liver.
VL01-19 Right Hepatectomy in Giant Liver Metastases of Ductal Carcinoma in Segment 7 and 8
Adeodatus Yuda Handaya, Indonesia

A. Yuda Handaya1, V.A.P. Werdana2
1Surgery, Gadjah Mada University/Sardjito Hospital, Indonesia, 2Gadjah Mada University/Sardjito Hospital, Indonesia

Introduction: Breast cancer plays a role as the largest contributor to mortality in cancer-related diseases in women throughout the world. Distant metastases occur in one-third of breast cancer patients. Poorly managed liver metastases result in the patient's survival time being only 4-8 months. In some patients, liver resection can be beneficial and increase survival rates, the 5-year survival rate is estimated to be 18% -61% after liver resection.
Case Report: Here we report a 60-year-old woman with advance left breast cancer. After 9x chemotherapy and 30x radiotherapy, the patient had a mastectomy with positive histopathology margin and continue with 8x chemotherapy. MSCT and PET scan showed a segment 7 and 8 liver metastases. The principle of right hepatectomy is to maintain inflow (hepatic artery and portal vein), outflow (hepatic veins and short hepatic vein), and also biliary drainage. Identify the ischemic margin to make sure the adequate future liver reserve to prevent post-hepatectomy liver failure.
Conclusion: Giant ductal carcinoma Liver metastases in segment 7 and 8 is a rare case and challenging, but it is possible to perform.
VL01-21 Right Posterior Sectionectomy (Segment 6 & 7) for a Case of Polytrauma with Grade V Liver Injury
Harischandra Mishra, India

H. Mishra1,2
1GI & HPB Surgery, DNB (Asian Institute of Gastroenterology, Hyderabad), Life Institute of Gastroenterology and Gynaecology, Cuttack, India, 2GI & HPB Surgery, AMRI, Bhubaneswar, India

A 22 year old female with 17weeks of pregnancy had a road traffic accident in which she along with her husband were buried under iron ore upto mid chest level. CECT scan revealed Grade -V hepatic injury with multiple lacerations and contusions involving segment-VI, VII & VIII of right lobe with parenchymal disruption of>3 cm depth. No active contrast extravasation was seen. Mild fluid collection was evident at perihepatic, perisplenic regions, bilateral paracolic gutters and pelvis suggestive of hemoperitoneum. Initially she was treated conservatively elsewhere with blood transfusion and hemostatic agents for 15 days. Then she presented to us with complaints of Severe abdominal pain, reeling of head, Chest pain, malena, nausea and Respiratory distress (R/R - 40-45/min and P/R 130/min, Hb% = 9.5gm/dl with 1unit BT). After failure to further conservative treatment for 2-3 days she underwent Laparotomy with a bilateral subcoastal incision. There was 6 to 7 litres of bilious collection both interloop, B/L paracolic, Pelvic and perihepatic with complete necrosis of large part of segment 6 &7 with bilious leakage. Peritoneal lavage was done along with adhesiolysis of small bowels from DJ flexure to IC junction. Right posterior sectionectomy ( non anatomical of segment 6 and 7) was done, RHV wall was suture ligated along with adjacent liver parenchyma.
In case of persistent hemodynamic instability (Failure of conservative management), Surgery should be the preferred approach. Major Hepatectomy can be performed safely with development of modern electrosurgical units and ICU care.