Chapter 33 Trisectionectomy
INTRODUCTION
As experience with hepatic resection has evolved since the late 1980s, significant improvements in perioperative morbidity and mortality have been realized. Nonetheless, because it involves the resection of up to 70% to 80% of functional hepatic mass, trisectionectomy places patients at considerable risk for postoperative morbidity. In a study of over 1800 liver resections performed at Memorial Sloan-Kettering from 1991 to 2001, investigators found that the incidence of postoperative morbidity and mortality increased significantly as the number of segments involved in the resection increased. For patients undergoing trisectionectomy at that institution, the complication rate of 75% and operative mortality rate of 7.8% were significantly higher than for patients undergoing less extensive resections.1 When the same authors analyzed a subgroup of 226 patients undergoing only extended hepatic resections, they were able to identify a total of five factors that were most predictive of in-hospital mortality: cholangitis, creatinine greater than 1.3 mg/dl, total bilirubin greater than 6 mg/dl, intraoperative blood loss greater than 3 L, and vena caval resection.2 The presence of any two of these factors was associated with 100% mortality, whereas the absence of any of these factors was associated with only 3% mortality. In the largest series of left hepatic trisectionectomies published to date, from Nishio and colleagues,3 revealed an overall morbidity rate of 46% and a 30-day mortality rate of 7%. Preoperative jaundice and intraoperative blood transfusion were identified by multivariate analysis to be the major risk factors for postoperative morbidity in this group of 70 patients.
Knowledge of the variables most predictive of postoperative morbidity has stimulated a number of modifications in the preoperative and intraoperative management of patients undergoing extended hepatic resection. Preoperative management options such as portal venous embolization and biliary drainage, as well as intraoperative techniques aimed at limiting blood loss, have enabled trisectionectomy to be performed with minimal perioperative mortality and major postoperative morbidity. One analysis of 58 major hepatic resections, including 49 trisectionectomies, reported 0% perioperative mortality and a 43% morbidity rate, with no cases of postoperative liver failure.4 Other groups are reporting similar outcomes, indicating that trisectionectomy for oncologic diagnoses can be performed with minimal short-term mortality.5,6
OPERATIVE STEPS COMMON TO BOTH RIGHT AND LEFT TRISECTIONECTOMY7
OPERATIVE STEPS SPECIFIC TO RIGHT TRISECTIONECTOMY
OPERATIVE STEPS SPECIFIC TO LEFT TRISECTIONECTOMY
OPERATIVE PROCEDURE
Skin Incision
Inadequate Exposure
• Consequence
• Repair
• Prevention
Mobilization of the Liver
Postoperative Pleural Effusion
Pleural effusion is one of the most common complications after major hepatectomy and likely has a multifactorial etiology. A retrospective review of 254 patients undergoing liver resection for hepatocellular carcinoma at one institution found the incidence of patients developing postoperative intractable pleural effusion to be 5.9%.10 The pressure differential between the abdominal and the thoracic spaces, combined with compromise of the diaphragmatic barrier owing liver mobilization, can cause ascitic fluid to traverse the diaphragm and accumulate in the right pleural space. Patients with some degree of underlying cirrhosis are also commonly hypoalbuminemic and may also have high portal venous pressures that are transmitted to the azygous vein, thus promoting transudation into the pleural space.11
• Consequence
• Repair
• Prevention
Control of Inflow Vessels
Hepatic Necrosis due to Hepatic Arterial or Portal Venous Injury or Thrombosis
• Consequence
• Repair
• Prevention
Injury to the Arterial Supply of the Biliary System
• Consequence
• Repair
• Prevention
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