|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
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.
involved caval resection and replacement by PTFE graft, under total vascular
exclusion, and veno-venous bypass.
clearly shows all steps of surgery.
first case, in situ liver cooling was used, whereas in the second case, it was
not feasible and topical cooling was used.
here each technical step of these uncommon surgical procedures.
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.
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.
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).
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
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
The video clearly shows all steps of surgery.
First stage surgery included:
transection on the right border of the round and falciform ligament
Middle hepatic vein
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
Division of right
Division of right
Division of right
Drainage and abdominal
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
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
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
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
|VL01-08 ||Anterior Approach for Right Side Hepatectomy in Case of Urological Malignancies
Atsushi Nanashima, Japan
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
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
The video clearly shows all steps of surgery.
Division of the left
Division of the
right anterior portal pedicle
Resection of the
extended to segments 1, 5 and 8
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
|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
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.
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.
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.
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
Results: Surgical procedure cost 4h
with 350ml bleed loss. This patient obtained rapid recovery without severe
postoperative complications. Postoperative CT and laboratory examination were
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
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
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
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
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.
thrombectomy prior to hepatectomy for HCC with TT in the right atrium can be
|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.
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
|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
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.