INTRODUCTION

In Le Foie: Études Anatomiques et Chirurgicales, Claude Couinaud first described the anatomic liver segments and nomenclature widely used by surgeons today. His in-depth understanding of the hepatobiliary anatomy helped create the framework for much of liver surgery because it provided a systematic approach for safe resection. The first published hepatectomy was performed by Jean Louis Lortat Jacob in 1952.¹ Since then, the associated morbidity and mortality have decreased tremendously. Improved surgical technique using the “roadmap” laid out by Couinaud has undoubtedly been responsible for most of the decline in operative complications.

In the last few years, surgeons have sought to bridge the gap between excellent operative technique and better outcomes through the use of newer technology. One of the main hurdles of liver surgery and predictors of poor outcomes is operative blood loss. Given the vascular nature of the liver parenchyma, surgeons have employed many devices intraoperatively to help identify and control large vascular structures. Notably, ultrasound has emerged as an essential tool to assess the intraparenchymal liver anatomy intraoperatively. This provides the surgeon with a powerful tool to evaluate the relationship between the large vessels and the planned resection plane. Harnessing ultrasonic energy, the ultrasonic dissector has also revolutionized parenchymal dissection. Using ultrasonic energy to fragment liver tissue, this technique spares blood vessels, which are made of firmer fibrous tissue. Other devices implement a pressurized jet of water to accomplish this same task. The harmonic scalpel, which can be used to precisely cut and cauterize these vessels, also utilizes ultrasonic energy. Most recently, radiofrequency ablation has emerged and been used in conjunction with surgery to provide salvage therapy for large tumors.

While the gamut of surgical instruments continues to grow, certain core surgical principles remain relevant in the discussion of operative morbidity. The use of the Pringle maneuver and measures taken to lower central venous pressure (CVP) are two precepts that are proven to minimize bleeding during resection. In this vain, this chapter proposes other techniques that can be used by the hepatobiliary surgeon to reduce complication rates during right and left hepatectomies and provides a guide to common pitfalls encountered during surgery. However, much of the prevention strategies outlined in our chapter are secondary to an inherent and thorough understanding of the segmental liver anatomy.

OPERATIVE STEPS

OPERATIVE PROCEDURE

A right hepatectomy involves resection of segments 5, 6, 7, and 8.

Operative Incision

Hernia

• Consequence

The use of the Mercedes versus an extended right subcostal incision is a matter of surgical preference. Both give adequate visualization for a right hepatectomy (Figs. 31-1 and 31-2). The midline incision extension to the xyphoid is often the site of hernia formation.

Grade 3 complication

Figure 31-1 A right subcostal incision with a midline incision gives adequate exposure to perform this operation.

Figure 31-2 Incisions for a right hepatectomy are depicted: A→B is a right subcostal incision, A→B→D is an extended right subcostal incision and A→B→C with B→D is a chevron (Mercedes) incision.

• Repair

If the ventral hernia does not pose an incarceration risk, it can be repaired electively or when symptomatic.

• Prevention

A recent study comparing 856 patients with Mercedes incisions with 570 patients with right subcostal incisions demonstrated discrepancies with wound healing. Patients with Mercedes incisions had a higher incidence of hernias, 9.8% versus 4.8%.² However, any incision is prone to herniation without proper surgical technique with regard to reapproximation of the fascia.

Persistent Bleeding from the Superior Epigastric Arteries

• Consequence

The superior epigastric arteries are invested in the rectus muscle near the xiphoid and can be lacerated during upper transverse incisions. These vessels can bleed significantly if they are not controlled.

Grade 1 complication

• Repair

There is a rich collateral bed of vessels in this area. Therefore, ligation of the superior epigastric arteries is permissible.

• Prevention

Surgical exposure is paramount during this operation. Therefore, these vessels can be sacrificed for optimization of the surgical view.

Division of the Falciform and Left Triangular Ligaments

Torsion of the Left Lobe

• Consequence

Extended division of the falciform and left triangular ligaments can lead to torsion, which can disrupt venous outflow that leads to venous congestion and severe liver dysfunction. The left triangular ligament helps to suspend the liver in anatomic position. After a right hepatectomy, the left lobe tends to rotate into the right subphrenic space. Excessive left triangular ligament division can exacerbate this occurrence and lead to torsion. Therefore, it is prudent to maintain the left triangular ligamentous attachments.

Grade 4/5 complication

• Repair

A study that analyzed 44 right hepatic resections concluded that venous outflow was improved when the left lobe was placed in its original anatomic position.³ Thus, it is recommended that after a right hepatectomy, the left lobe of the liver should be fixed into anatomic position.

• Prevention

When possible, an excessive division of the falciform ligament, and especially the left triangular ligament, should be avoided to prevent exacerbation of venous outflow obstruction. If the left lobe shifts from anatomic position after a right lobe hepatectomy, it is advisable to secure the remnant (Fig. 31-3).

Other options are to mobilize the hepatic flexure and allow the right colon to partially fill in the space.

Figure 31-3 The divided falciform ligament is reapproximated to secure the left lobe of the liver using 4-0 Prolene.

Injury to the Suprahepatic IVC

• Consequence

Great care should be taken when cutting the falciform ligament as one approaches the bare area of the liver. The vena cava lies just posterior to the inferior edge of the falciform ligament and may be readily injured with aggressive dissection.

Grade 5 complication

• Repair

The vena cava should be immediately repaired to prevent further blood loss and possible air embolus.

• “The first rule is do not panic.”

• The surgeon should tamponade the injury by placing the index finger of the nondominant hand over the hole.

• Using 4-0 Prolene, place whip stitches until the hole is closed.

• Avoid using clamps to control the bleeding because this will often tear the vessel wall, causing bigger problems. Make an effort to get good visualization of the injury. Placing errant sutures can often lead to narrowing or obstructing the lumen of the vessel

• Prevention

The surgeon should be aware of the anatomy in this area to prevent inadvertent injury to the vena cava.

It is imperative that patients undergoing a right hepatectomy have adequate central venous access to monitor CVP and for resuscitation as necessary.

In the event of moderate blood loss, preoperative autologous blood donation, intraoperative cell savage, and normovolemic hemodilution have been shown to minimize the use of banked blood.⁴

Division of the Right Triangular Ligament and the Right Side of the Coronary Ligament with Mobilization of the Right Lobe of the Liver

Injury to the Right Hepatic Vein or Suprahepatic IVC

Mobilization of the right lobe of liver begins with dissection through the lateral peritoneal reflection of the right triangular ligament. This dissection is carried medially through this relatively avascular areolar tissue plane. Superior mobilization of the right lobe involves taking down the right coronary ligament. As the dissection proceeds medially, care should be taken to avoid injury to the right hepatic vein or the IVC in the bare area of the liver.

• Consequence

Dissection through the superior and medial aspects of this avascular tissue can lead to inadvertent injury to the right hepatic vein or IVC. Transection of the right hepatic vein without ligation poses a serious problem because the surgeon is confronted with controlling a large hole in the IVC without adequate exposure.

Grade 5 complication

• Repair

Any bleeding that is encountered should be controlled and the defect closed with suture.

• Prevention

Again, meticulous dissection in the medial aspects of the coronary ligament can prevent inadvertent venotomies (Fig. 31-4). One of the rare complications with injury to these large veins can be air embolism. During this stage of the operation, it has been proposed that the patient have a positive CVP and be placed in Trendelenberg position to prevent air embolus. However, with increased CVP, bleeding will increase.

Figure 31-4 The dome of the right liver has been exposed by careful dissection of the right triangular and coronary ligaments. The blue rubber tie is placed around the right hepatic vein. The inferior vena cava (IVC) is located posterolateral to this blue rubber tie. The surgeon must be mindful of this structure when dissecting the ligamentous attachments.

Injury to the Diaphragm

Diaphragm puncture can occur with dissection of the infradiaphragmatic plane of the right triangular ligament. Also, sometimes intentional diaphragmatic resection is necessitated by liver tumors that are adherent to the diaphragm.

• Consequence

Diaphragmatic injury can occur during dissection of the bare area of the liver. When this occurs, negative pleural pressure is lost and must be restored.

Grade 1/2 complication

• Repair

Negative pleural pressure needs to be reestablished during the operative case after violation of the thoracic cavity. All diaphragmatic holes can be repaired primarily using a nonabsorbable suture. One technique that is readily used in our hospital to restore a normal pulmonary environment is the use of a small catheter with suction. A red rubber catheter with suction is placed in the defect, and a pursestring suture is cinched down as the catheter is quickly removed.

• Prevention

Careful dissection of the peritoneal reflections of the posterior liver while an assistant rotates the liver medially and inferiorly may decrease the incidence of diaphragmatic injury.

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