Sur_Atlas of Gastrointestinal Surgery (Cameron) New

)f I

Contents

Gallbladder and Biliary Tract Cbolecystectomy :1 Common Duct Exploration

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Sph inctcroplasty, Including T ransampullary Common Duct Exploration

l."i

Side-to-Side Choledochociuodeno'lomy 28 Resection of a Benign Bile Duct Stricture Wit h i a:IC

).

A

Cystic duct stump

Ampu lla _ - '_ _ _~

dhesions and attachments between the hepatic flexure of the colon and the duodenum are divided sharply, and the duodenum is kocherized (C). Medial attachments between the omentum and duodenum are also divided (D). As much of the duodenum is exposed and mobilized as possible, so the duodenum can be brought up on top of the common duct for a tension-free sideto-side anastomosis.

A

Kochen:zed _

_ __ _ _----y

c:Uxlenu!:J

Head of ~--:'tr-.-------- pancreas

\

31

he first portion of the duodenum is dissected off the anterior surface of the common duct fo r as great a length as possible, Once the duodenum has been completelv mobilized and the extrahepatic bi lia n ' tree exposed along its a nterior. lateral. and medial surfaces. a choledochoromy is performed with the distal end extending to the point where the biliar\' tree passes posterior to the first portion of the duodenum (inset and E), The choledochotomy is initiall y made with a 15 blade: it is then extended with Pott 's scissors, The length of the choledochotomy should be at least 2 em. The diameter of the common duct should be at least 11/2 cm. and preferably 2 em, before this operation can be performed. Once the choledochotomy has been performed, the duct is explored and all calculi are removed (F). These patients generall y \\'ill have had preoperative cholangiography performed either percuta neously or endoscopically. Thus the exact number of stones and their location are often known at the t ime of surgery. However, the various maneu vers that have been previously described for common duct exploration (see pages 10-1, 1are all carried out. Primary common duct s ton es are often bro\\'n , easily crushable, and accompanied by sludge in the biliary tree that is best removed by ir rigation. Once the biliary t ree has been cleared of calculi , a longitudi nal duodenotomy, the same length as the choledochotom y, is performed in the duodenum directly adjacent to, but at right angles with, the choledochotomy (F). This anastomosi s is usuall y performed in one layer. Although synthetic absorbable s utures have been advocated by some biliary surgeons, we use 3-0 silk, with all knots placed on the outside. The apex sut ure in the choledochotoiny is placed firs t. A 3-0 silk is passed from ou tside the bi liary tree to within and then passed from within the duodenum to the out side and secured (F). After this apex suture has been placed, lateral stay sutures of 3- 0 silk are posit ioned. These pass from outside in at the mid port ion of the choledochotomy and from inside out at the two ends of the duodenotomy. These s utures are then gathered in a hemostat as demonstrated (G, see H), holding the two ends of the s ut ure , as well as the mid por tion that passes between the duodenum and the common duct. This nicely aligns t he duodenu m a nd choledochotomy for su bsequent sut ure placement.

T

d

~

_ ___ Common duct

stone

~_ _......_....,._

_ -'-_ _ _ Duodenotomy

Lateral slay suture

/ _ _ _ _ _ Apex suture

\

nterrupted sutures of 3-0 ilk are then placed. alway pa ing from ' in on the common duct ide and from in ide out on the duodenal ide, and cuning each suture as it is placed (H). When this layer has been completed out to the ends of the duodenotomy and the midlateral aspects of the choledochotomy. the tay sutures are secured (1). The anterior row is then placed, by pa sing a UMe firs t from outside in at the mid portion of the duodenotomy and then from inside out at the most proximal portion of the choledochotomy (1). T his suture . gathered in a similar fashion by holdi ng both ends and the mid portion of the suture in a hemostat. Again this nicely aligns the duodenotomy and choledochotomy so that the anastomosis can be completed. The anastomosis is completed with a series of through-and-through interrupted 3-0 silk s utures (J).

I

_.

Posterior

row

Apex Suture

Posterior

row

he final three or four sutures of the side·to·side choledochoduodenostomy are held until all sutures are placed, and then they are secured (K). This is a side·to· side anastomosis, which is performed by pulling the first and second portions of the duodenum on top of the common duct and then carrying out the anastomosis. The anastomosis can easily be palpated through the duodenum when the procedure is completed and should be widely patent (L). The anastomosis is demonstrated diagrammatically in M. The theoretical shortcoming of the procedure is also nicely depicted. There is a segement of biliary tree that extends from the choledochoduodenostomy down to the ampulla. It has been reported that vegetable material from the duodenum can pass into the biliary tract through the side·to·side anastomosis and become impacted distally, producing nonspecific right upper quadrant symptoms referred to as "the sump syndrome." This is a theoretical disadvan tage of the operative procedure, but one that is rarely encountered. The biliary tree is generally not decompressed with aT- tube. The area of the choledochoduodenostomy is drained with either Penrose or closed suction drains.

T

Completed Side-ta_side anastomoSis

Resection of a Bemgn Bile Duct Stricture With Reconstruction Utilizing Silastic Transhepatic Biliary Stents and Hepaticojejunostomy Operative Indications enign bile duct strictures can follow a variety of clinical situations. Scarring and fibrosis of the head of the pancreas in chronic pancreatitis can result in a distal biliary stricture. Rarely, inflammatory disease of the gallbladder can involve the extrahepatic biliary tree and result in a stricture. The majority of benign strictures, however , follow operative trauma, usually during cholecystectomy. If the stricture involves the mid or distal portion of the biliary tree, the repair is straightforward. The proximal biliary segment is dissected, and a mucosa-to-mucosa anastomosis is performed between the common hepatic duct and a Roux-en-Y jejunal loop. Long-term stenting is not necessary, but decompression with aT-tube or a preoperatively placed transhepatic catheter is of benefit for one or two months, during which time healing of the hepaticojejunostomy takes place. Many, if not most, extrahepatic injuries that occur during cholecystectomy, however, involve the common hepatic duct proximally, near or even involving the bifurcation. These high strictures are more difficult to manage. In recent years the majority of patients referred to our institution with postcholecystectomy strictures have had multiple ligaclips in the porta hepatis, and these usually are found to be responsible for the stricture (A). It is our practice to perform preoperative percutaneous transhepatic cholangiography on all patients with suspected strictures. At the time of cholangiography, a Ring catheter is inserted. In most instances, if continuity between the proximal and distal biliary tree has not been totally disrupted, the Ring catheter can be passed through the stricture distally into the duodenum. Occasionally it is necessary to decompress the proximal biliary segment externally for a day or two and then at a second setting pass the catheter distal to the stricture into the duodenum. Identification of the proximal biliary segment and stricture and placement of a trans hepatic Silastic biliary stent, if used, are made much easier at the time of surgery if a Ring catheter is in place.

B

Operative Techniques ost patients with benign biliary strictures will have undergone a cholecy tectomy through a right subcostal incision. Patients are prepped and draped so that the Ring catheter is accessible in the prepped operative field during the procedure. The abdomen i reentered through the old right ubcostal inci ion. Upon Teen' e abdomen multiple adhesion are encountered, particuJarly IHlltUll the tu:;;), colon, stomach, duodenum, and the under surface of the m-a--_ Thse are . both sharply and bluntly (8).

M

A

"'~-------- SlIlIC1Il"'_

x

,/

,/

1

Posterior row of hepaticojelunostomy

Sliasbc

biliary stent

Enterotomy

.

rowol

r., " tio:ojejunostomy Completed

anastomosis _ _ _ _~=--

~~ ----~-----­ _ in

he Roux-en·Y loop is tacked to periportal material on the uode. . surface of the liver to insure that there i no ten ion on the . anastomosis . The Roux·en·Y loop is also tacked to the opening in the transverse mesocolon, to prevent small bowel herniation (CC). The end of the Silastic biliary stent that emanates from the uperior surface of the liver is brought out through a stab wound in the right upper quadrant. It is sutured in place at the skin using 5-0 stainless steel wi re. It is placed to bile bag gravity drainage. A Silastic sump drain is left near the top of the li ver at the egress ite of the transhepatic biliary stent. It is brought ou t through a stab wound in the right upper quadrant. The hepaticojejunostomy is drained with either Penrose or closed suction drains. At five days cholangiography is performed through the Silastic stent. and if no leaks are evident at the anastomosis or at the superior surface of the live.. the stent is clamped. Th is can be accomplished by either placing a three·way stopcock on the end or a heparin lock. The patient is taught to irrigate the tube three times a day with a 20 ml of saline. T he stent is left in for a 12-month period to allow wound healing and contractu re to proceed, in the face of a relatively nonreactive large bore, thick· wa lled Silastic stent. Even though the biliary stents are made of Silastic and are relatively nonreactive, bi liary sludge can collect and occlude side holes. For thi reason the stents are changed every three or four mon ths as an outpatiem procedure. Under fluoroscopy a guidewire is placed into the Roux·en·Y loop through the lu men of the old stent. The old stent is removed and a new one easily slipped in place. At the end of one year the stent can be removed with virtual certainty that a stable anastomosis between the proximal biliary segment and the jejunum has been created th at will function obstruction·free indefi nitely. If the benign stricture involves the hepatic duct bifurcation, it is nee ary to resect the bifurcation and to perform bilateral hepaticoj ejunostomies. Preoperatively Ring catheters shou ld be placed in both the right and left hepatic ducts. Follow ing bifurcation resection , Silastic stents are placed in both the right and left hepatic ducts and bilateral hepaticojejunostom ies performed in the manner just demonstrated.

T

cc

Hepat.cote u'o.5IOI_

Sllasbc bi ary stent In Jejunum

(

-'

I

Transverse colon

\

~

End-Io-side jejunojeJmoslcmy

/

..K€~ection

of a Proximal olangiocarcinoma Ith Reconstruction Utilizing Silas tic Transhepatic Biliary Stents and Bilateral Hepaticojejunostomies Operative Indications it h the frequent use of endoscopic and percutaneou chol angiography over th e past decade, an increasing number pa tients with prox imal biliary tumors have been identified.11Je;e small neoplasms, referred to as Klatskin tumors, are mall ad enoca rcinomas that are near or in volve the hepatic duct bifurcation. Today an y indi vidua l presenting with jaundice, who on CT scan or sonography is found to have dilated intrah epatic ducts with a collapsed extrahepatic biliary tree and gallbladd er, is highl y suspected of ha ving a prox imal cholangioca rcinoma. We fee l tha t such patients should undergo percutaneous cholangiography. with insert ion of Ring catheters into th e right and left hepatic ducts, througlt th e tumor, and distall y into th e duodenum. In ou r ex peri ence virtually al l patients can ha ve these catheters placed bilatera ll y through the tumor and into th e du odenum , despite the initial cholangiogram demonstrating complete obst ruction at the bi furca tion, Patients wit h prox imal cholangioca rcinoma are staged preoperatively with cholangiograph y and angiograph y. If on cholangiograph y tu mor clearl y ex tends up into th e hepatic parenchyma of both lobes, the patients arc palliated with th e I~ i ng ca th eters and not explored. In addit.ion, if angiograph y demonstrates encasement of the common hepatic artery or main portal vein, pati cnts are fcltto be unresectabl e and are not explored. However, if onl y onc branch of the hepatic artery or porta l vein is in volved or tumor extends in to on ly one lobe, pa tients may still be resecla ble if hepatic lobectomy is added . After preoperative staging, approximately 80 percent of pa ticnts presenting with cholangioca rcinomas are cand idates for resection.

W

m

Operative Technique • R "9 catheters

/

atients are prepped and draped so that the surgeon ha access to both Ring catheters in the operati ve fi eld. A right subcostal incision i used.. Atthc time of laparotomy th e abdomcn is explored for evidence of tumor disseminat.ion. In our ex perience li\'er metastases or peritoneal Implants are uncommo n. In addit ion. lymph node in volvement is unu ual.lf a patient is unresectable. it generall y is because of local in volvement of parenchyma of both the right and left lobes or involvement of the common hepatic artery or main portal vein . At the time of laparotomy initially the tumor usually cannot be vi lIalired or even palpated. The gallbladder and extrahepatic biliary tfee appear nonna.I (A). HoweYeI'. if one palpates high in the hilum of the liver. by feeling for the diveJgt1Itt mthe Ring catheters. the area of the bifurcation and tuInm' can be

P

identified

A

B

\

Gallbladder

- - - - ---t-'+

Hepatic flexure of co lon

Duodenum

Tumor invoMlg hepalicdld bifurcalion

WO maneuver greatly aid in exposure and di ection of the hepatic duct bifurcation. The first is mobilization of the gallbladder. If the gallbladder has not been removed previously, the cy tic artery i identified, doubly clamped, divided, and ligated, and the gallbladder imobilized out of the li ver bed (C). This greatly improves acce to the bifurcation. In addition early in the dissection of the porta hepati , the di tal extrahepatic biliary tree is dissected and looped with a vessel loop (C). Identification and dissection of the common duct is facili tated by having the Ring catheters in place, particularly if the patient has been operated upon previously. Once the distal common duct has been mobilized, the anterior wall i opened and the Ring catheters extracted (D). The duct is then completely divided. The distal common duct can either be ligated or closed with inrerruprro 3-0 silk sutures placed in a vertical mattress fashion, as demonstrated here These two maneuvers, mobilization of the gallbladder and early divi ion of die distal common duct, greatly aid in access to and dissection of the bifurcation.

T

GaWb" - , fossa

"If.:--:;--- - -

Mobilized gallbladder

, /I'

! Common _ _ _ __ duct

-

- .~

Tumor involving hepatic duct bifurcation

; ,-

~i>:;:~5t------ Distal common duct

Duodenum _ _~_

- - - CJvip."

"on

?II

arly division of the common duct allows one to dissect the bifurcation both anteriorly and posteriorly as the proximal biliary segment is being retracted in a cephalad direction (F). Retraction is aided by having the Ring catheters in place. The bifurcation of the biliary tree and the tumor rest on the bifurcation of the portal vein and hepatic artery. Dissection of this area without dividing the distal biliary tree, thus allowing retraction of the proximal biliary segment in a cephalad direction, is not only difficult, but also hazardous. As the bifurcation is dissected both posteriorly and anteriorly, the right and left hepatic ducts are identified and dissected and are looped with vessel loops (G). There often is no visible tumor mass. However, by palpating the bifurcation, thickening and firmness are easily identified. One palpates for the Ring catheters above the bifurcation and above tumor through normal right and left hepatic ducts. The right and left hepatic ducts are divided, the Ring catheters are extracted, and the specimen can then be removed (H). The distal common duct margin, as well as the right and left hepatic ducts, are marked with different color sutures to aid the pathologist in checking the microscopic margins (inset). Generally frozen section margins are not sent; these have not proven to be accurate. Often, even with the entire specimen, on permanent section s, the extent of the tumor is difficult to delineate.

E

F Mobilized gallbladder

J ~~~~~,: ""'-1~f--

l

Portal v. bifurcation R. hepalic duel

i!ii;;;~~-=:::::~- R. and I. hepatic aa.

Oversewn _ __ --:_ common duct

Duodenum _ _ __

I

Bifurcation of

/

r. hepatic duct

,

:/

.I

Tumor

R. hepatic duct Specimen

L hepatic dud

Commooducl

oth the right and left hepatic ducts are intubated with Silastic transhepatic biliary sten ts. The Ring catheters that were placed preoperatively are brought in through the chest wall in to the abdominal cavity. In order not to lose the tract if one of the catheters should break or become dislodged, cardiac gu idewires are placed through the Ring catheters. A #12 Coude catheter, with the tip excised, is then passed over the guidewire and Ring catheter and sutured in place (I). By withdrawing the Ring catheters, the right and left hepatic ducts are in tubated with the Coude catheters. T he Silastic trans hepatic biliary stents (#16 French) are then placed over the guidewires into the flanges of the Coude catheters. By withdrawing the Coude catheters, the transhepatic biliary stents are appropriately positioned. The portion of the stents that extend outside the porta hepatis or reside in the liver contain multiple side holes, while the portion of the stent that emanates out through the top of the liver contains no side holes. Horizontal mattress sutures of #1 synthetic absorbable material can be placed around the egress site of the stent on the superior surface of the liver (J).

B

Silastic ,, _---,-_ _ _ _ biliary _ _ _ __

eoude cath eters

Guidewire

(

Mattress suture

stent

t

\, I~I

ften the point of division of the right hepatic duct is close to the bifurcation of the anterior and posterior segments. If this i? the case, the spur is divided and one anastomosis is performed (K). A Roux·enY loop 60 cm in length is then constructed, as demonstrated on pages 48-53. The Roux-en -Y loop is brought into the right upper quadran t via a retrocolic route, on top of the second and third portions of the duoden um. The anastomosis is performed in one layer, using interrupted 4- 0 synthetic absorbable sutures. The entire back row is placed prior to securing any of the sutures. Each suture passes first through the jejunal loop and then through the duct from outside in (inset). Thus the knots of the posterior row wi ll be placed on the inside. However, since we utilize synthetic absorbable material, this is of no long-term concern. Each suture is individually placed on a hemostat, and the hemostats are placed in order on a long clamp (L).

O

i".;:- - - - Hepatic a.

/

Portal v.

\

\

\

I

nce the posterior row of each hepaticojejunostomy has been placed, the sutures are secured. Bilateral enterotomies are made adjacent to the posterior row of sutures using the electrocautery (M). The posterior row of sutures, except for the two end sutures, are then divided, and the Silastic stents are placed in the Roux-en-Y loop via each enterotomy (N). Each interrupted 4-0 synthetic absorbable suture is placed for the anterior layer of both hepaticojejunostomies, before securing the sutures (0 ). These sutures are simple sutures placed through and through the jejun um and then through and through the duct (inset). Once all sutures of the anterior row of both hepaticojejunostomies have been placed, they are tied .

O

o

Roux -en -Y _ _ __ I"I'lllalioop

_ _~

nce the anterior rows of both hepaticojejunostomies have been secured, the sutures are cut. The Roux-en-Y loop is tacked to the undersurface of the liver with interrupted 3-0 silks to insure that there is no tension on the anastomosis. The Roux-en-Y loop is sutured to the rent in the transverse mesocolon with interrupted 4- 0 silks to preven t herniation of small bowel (P). Each Silastic transhepatic biliary stent is brought out th rough a stab wound in the right or left upper quadrant, and is sutu red to the skin with 5-0 stainless steel wire. The stents are connected to allow bile bag drainage through gravity. The egress site of each stent on the superior surface of the liver is drained with a Silastic sump brought out through separate stab wounds in the right and left upper quadrants. The bilateral hepaticojejunostomies are drained with Penrose or closed suction drains brought out through a stab wound in the mid abdomen. The stents are left to gravity drainage for five days, at which time cholangiography is performed. If there are no leaks from the superior surface of the liver or at the anastomosis, the tubes are internalized by placing three-way stopcocks or heparin locks on the ends of the catheters. The patients are then taught to irrigate the stents three times a day with 20 ml of saline. We routinely deliver 5,000 rad of external beam radiotherapy to the area of the tumor bed postoperatively. When this has been completed as an outpatient procedure, the patient is readmitted and iridium 192 seeds are lowered down through the bilateral trans hepatic biliary stents and left in place for approximately 48 hours, to boost the radiation dosage an additional 2,000 rad locally. T he iridiu m seeds are then removed. The transhepatic Silastic biliary stents are left in permanently. The s tents are changed every three or four months as an outpatient procedure. This is carried out under fluoroscopy by placing a guidewire down through the old stent into the Roux-en·Y loop. The old stent is then removed, leaving the guidewire in place. A new stent is easily slipped in place over the guidewire and then the guidewire removed. The stents are left in place permanently because even though substantial prolongation of survival is achieved with this operative procedure, most patients are not cured and eventually local tumor will recur. If the Silas tic stents are not in place, biliary obstruction will result. It is our feeli ng that survival is prolonged by having the most liver parenchyma drained for the longest period of time. We feel this is achieved by leaving the stents in permanently. The stents are well tolerated by patients and require minimal care.

O

p

-

--"'t-~-4+~---

-

- -- - - bEry

Roux-en-Y jejunal loop

Hepaticojejunostomies

=='-:-:-=-==-"::"_':::"~=_---=-_Transverse

me$ocolon tacked to jejunal loop

'N.....I.-_ _ _____ End-to-side jejunojejunostomy

71

Resection of a Proximal Cholangiocar:cinoma With Hepatic Lobectomy and Reconstruction Utilizing a Silastic Transhepatic Biliary Stent and Hepaticojejunostomy Operative Indications

ccasionally patients with proximal cholangiocarcinoma will e tumor extension only up into one lobe or the other (A). In add! - ~ is not infrequent in such instances to have one branch of the r.2 vein or one branch of the hepatic artery encased or occluded _ tumor. Such patients may still be resectable, if hepatic lobectomy is added ~a extirpation of the bifurcation and extrahepatic biliary tree. One i aware . --,1, possibility prior to laparotomy because of preoperative cholangiographica::lc angiographic findings.

O

Operative Technique

I·.

,/

/,

he patient is explored through a right subcostal incision, often , extended up to the xiphoid in the midline or over to the left of ri.ll: abdomen as a left subcostal extension. It is particularly importam that these patients preoperatively have Ring catheters inserted bilaterally. The initial operative procedure is as described for the resection of a proximal cholangiocarcinoma without hepatic lobectomy. The gallbladder is mobilized to improve exposure of the bifurcation (B), and the distal common duct is divided so that the proximal biliary segment can be reflected in a cephalad direction (C) to facilitate bifurcation dissection.

T

li

\.~\-.,,~_ _ _ _

r

Ring caIheIeIs

.

, "' ~)

Gallbladder fossa Cystic a. and duct

- ,,L-_ _

Mobilized gallbladder

Duodenum _ _---:-_

- --

""-- - - - Ring catheters

O Llaix:hotomy

Proximal common duct -------1~

Portal v.

.. ,..L._

Oversewn distal

common duct R and I. hepaoc aa.

_

_ _ L hepa:!ic duct

nce the hepatic duct bifurcation has been mobi lized and dissected off the bifurcation of the portal vein and the hepatic artery, it is seen that tumor extends well up into the left lobe of the liver , probably also involving the left branch of the hepatic artery and portal vein (D). On the right, however, normal duct can be identified by palpating the Ring catheter above tumor at the bifurcation. The right hepatic duct is divided and the Ring catheter exposed and extracted (D). The left branch of the hepatic artery is identified, dissected, doubly ligated, and divided (E). The left branch of the portal vein is dissected free and doubly clamped with straight Cooley clamps; the branch is then divided and the proximal end oversewn with a continuous 5- 0 synthetic non absorbable s uture (F). The distal end up towards the left lobe of the liver can also be oversewn with a continuous 5-0 suture, or it can merely be ligated if length permits.

O

..

I

~

•

• \

J ~,L---

Common dud

L. hepatic duct Divided

r. hepatic _ _.--tlI\

L hepa -ca

duct

Portal v. bifurcation

R. hepatic _ _""-

duel -'-'-_ _ R. and L hepatic aa.

.\ __ _ _ Ring catheter

Distal common duct

E

~_

Tumor extending along _ _ _ _ L hepatic duct

i-- -- - -

Divided L hepatic a.

L branch of portal v. divided

!Il

he left lobe of the liver is mobilized by dividing the triangular and falciform ligaments (G). The hepatic veins are identified, and the left hepatic vein is dissected free (H). The left hepatic vein is doubly clamped with acutely curved Cooley clamps, divided, and each end oversewn with a continous 5- 0 synthetic nonabsorbable suture (I). The left lobe of the liver has now been completely devascularized.

T

G FalcLUi

Suprahepatic inferior

L.lobe of liver

vena cava

Stomach

OIapIvagm

Spleen

- - -- ----...11 ~----------_ L. hepatic v.

Divided I. hepatic v.

71

variety of techniques are available for going through hepatic parenchyma. In this example, parallel rows of # 1 chromic catgut sutures are placed in a mattress fashion approximately 1 cm on either side of the plane that is to be divided between the right and left hepatic lobes. This plane generally extends from the gallbladder fossa to the hepatic veins as they enter the inferior vena cava. The liver parenchyma sutures should be snugged down to compress liver but not so tight as to cut through or necrose liver. The line of division is first marked with electrocautery (J). Generally two or three sutures are placed on each side (K), and then the hepatic parenchyma is divided with the electrocautery (L). Two or three more sutures are then placed and more parenchyma divided with the cautery. This is perhaps the most bloodless way of dividing hepatic parenchyma; generally the entire liver can be transected with virtually no blood loss (M). The catgut is wedged on large liver needles that can be controlled better if most of their curve is straightened. Other methods for dividing hepatic parenchyma, including using the Cavitron, will be demonstrated in other procedures.

A

J

f \

)

Dividing parenchyma

Divided I. hepatic v.

M

Devascularized I. lobe

hen division of the parenchyma has been completed, the specimen is removed from the operative field. The entire extrahepatic biliary tree including the bifurcation has been resected, along with the left lobe of the liver (inset). The tumor involves the bifurcation and clearly extends up into left hepatic parenchyma. Hemostasis is completed on the resected raw area remaining on the right lobe of the liver using both the electrocautery and figure-of-eight sutures of 3-0 synthetic absorbable material. Because the stay sutures are compressing hepatic parenchyma, very little hemostasis is generally required (N).

W

Specimen

L hepatic v.

Tumor extending into I. lobe _ _ _ _ _ of liver

Ring catheter

' -_ _ _ L. hepatic a. '----_ _ L. bran ch of portal v.

./

1 - - - - - Oversewn l. hepatic v.

' - - -_ _ Middle hepatic v.

Liver sutures _ _ _

4 -"--- -

Resected surface of liver

'1"1-1-- --

Caudate lobe

R. hepatic duct Oversewn I. branch of portal v.

____

::~~~~~~~=-R. branch of portal v. "-_ _ _ _ -,,-_ _ _ R. hepatic a. I. hepatic a.

~S~~:-J~t'l0ve,,;e"1n distal common duct

_ _ _ _ _ __ _

Duodenum

tilizing the preoperatively placed Ring catheter, a Silastic transhepatic biliary stent is placed. A guidewire is inserted through the Ring catheter, and then a #12 Coude catheter with the tip excised is placed over the guidewire and sutured to the Ring catheter. The Ring catheter is then withdrawn from the top of the liver, thereby placing the Coude catheter. A #16 Silastic transhepatic biliary stent is then placed over the guidewire and sutured to the Coude catheter. The Coude catheter is withdrawn, thereby placing the Silastic trans hepatic biliary stent (0 ). A Roux-en-Y loop 60 em in length is constructed, as previously demonstrated on pages 48-53. It is brought up into the right upper quadrant in a retrocolic fas hion on top of the duodenum. A hepticojejunostomy is performed using one layer of interrupted 4-0 synthetic absorbable suture. The techn ique of this anastomosis was demonstrated in the prior procedure (see pages 66-69). A horizontal mattress suture has not been placed around the egress site of the Silas tic stent on the superior surface of the liver. This is optional. Some surgeons feel that bile leakage is made less likely by s uch a suture; bile leakage, however, is rare, as long as side holes in the biliary stent are not positioned near the surface of the liver. The end of the Silastic stent that emanates from the superior surface of the liver is brought out through a stab wound in the right upper quadrant, sutured to the skin with 5-0 stainless steel wire, and connected to depend.ent bile bag drainage. The egress site of the biliary stent is drained with a Silastic sump brought out through a separate stab wound in the right upper quadrant. The resected surface of the liver and hepaticojejunostomy are drained with a Silastic sump drain and either Penrose or closed suction drains brought out through separate stab wounds in the mid abdomen. The Roux-en-Y loop is sutured to the rent in the transverse mesocolon to prevent small bowel herniation (P). Postoperatively cholangiography is performed at five days and if no bile leaks are present, the stent is internalized by placing a three-way stopcock or heparin lock on the end of the stent. Patients are taught to irrigate the stents three times a day with 20 ml of saline. Postoperatively patients are given adjuvant therapy with 5,000 rad of external beam radiotherapy to the area of the porta hepatis. When this is completed, the patient is readmitted to the hospital for approximately 48 hours so that iridium 192 seeds can be lowered down through the biliary stent and positioned in the area of the anastomosis. An additional 2,000 rad of radiotherapy are delivered locally. The Silastic trans hepatic biliary stents are left in permanently. Even though an occasional cure is possible, most patients will develop recurrent tumor; thus having the stent in place will prevent recurrent biliary obstruction and prolong urvival maximall y. The stents, however, are changed every three or four months prophylactically because of biliary sludge accumulation and obstruction of the side holes. T his is easily and quickly carried ou t as an outpa .em procedure under fluoro copy in the Catheterization Laboratory.

U

Q

SiIaslic

biliaJy sterol

p Middle hepatic v.

Hepaticojejunostomy

Roux·en-Y jejunal loop

-~a.--!!...,--

Silastic biliary stent

~--'-'-'-----'--_ _

Duodenum

Transverse mesocolon tacked to jejunal loop

Proximal Cholangiocarcinoma: Palliation by Transhepatic Stenting and Hepaticojejunostomy Operative Indications ll patients with proximal cholangiocarcinomas are staged preoperatively by percutaneous cholangiography and angiography. If it appears that a patient is not potentially resectable for cure, palliation is achieved with Ring catheters, and the patient is not explored. Such patients can receive palliative irradiation following tissue confirmation of their disease. Of those patients explored who are thought to be curable, at the time of surgery only half will be resectable. The others at the time of laparotomy will be unresectable because of tumor extension into both lobes or involvemen t of the common hepatic artery or main portal vein . In such instances we feel that it is appropriate to replace the Ring catheters with Silastic transhepatic biliary sten ts and to perform a hepaticojejunostomy. The thick-wall, large-bore Silastic transhepatic biliary stents provide better palliation than the Ring catheters alone. They are more comfortable, are tolerated better by patients, and less frequently are associated with complications such as hematobilia and liver abscess. Because of their internal diameter, they also are less likely to occlude with biliary sludge. Placing these Silas tic stents is not worth a laparotomy in a patient who clearly is incurable by preoperative staging. However, if a patient has been explored with the hope of a curative resection, and it is not possible, this procedure is appropriate and indicated.

A

Operative Technique he patient is explored through a right subcostal incision. T he two Ring catheters are prepped into the field so they are accessible to the surgeon. When tumor extension is found into both lobes of the liver (A), it is important to confirm the diagnosis by biopsy. T his may be difficult on frozen section, because of the fibrotic sclerosing natu re of the tumor. Nevertheless the surgeon should persist so that rad iotherapy can be deli vered postoperatively. In preparation for removi ng the gallbl adder , the cystic artery is identified, doubly clamped, di\'ided, and ligated. At the sa me time the common hepatic duct i mobilized and looped with a vessel loop (B).

T

Cystic duct

8

Gallbtadder

Biopsy of I. hepatic ducl

Encircling common '#'-,,&-_ _ _ _ _ _ hepatic duct vessel loop

DMded cys:x: a

he gallbladder is mobilized, the common hepatic duct is divided, and then the distal common duct is divided, removing the gallbladder and a segment of extrahepatic biliary tree (C). The distal common duct is either ligated or oversewn with interrupted 3-0 silks. One is now left with a short segment of common hepatic duct, cholangiocarcinoma involving the common hepatic duct and bifurcation and extending up into both lobes, and Ring catheters in both the right and left hepatic ducts (D). It is important that the gallbladder be removed. With the large-bore, thick-wall Silastic stents residing in the biliary tree, obstruction of the cystic duct by edema or by the stents themselves is common, and acute suppurative cholecystitis can occur. Since the distal biliary tree is of normal size, it cannot accommodate the two large Silastic stents, and it is necessary to construct a Roux-en-Y jejunal loop as a receptacle.

T

, •

Dividing common dld

Mobilized gallbladder

I. D

Tum or extending into ~d~~:..!.----- bolh lobes

~~~\-_ __ _ _ _ Common hepatic duel -"---,--- -Portal v. ~-i-.-=--=:.....,,---- Hepatic a.

common duct

(

-~

UJ

he curved ends of the Ring catheters are cu t off. The catheters are then brought into the peritoneal cavity through the chest wall. A guidewire is inserted into each Ring catheter to maintain the tract in case a catheter breaks or becomes dislodged during the following manipulations. A #12 Coude catheter with its tip cut off is then placed over the guidewire and Ring catheter and sutured in place (E). The Coude catheters are drawn up through the tumor, thereby dilating it and placing the Coude catheters into the right and left hepatic ducts. Often this is repeated with the next size Coude catheter, for instance #14, before placing the #16 French Silastic transhepatic biliary stent. Wi thou t progressive dilatation, one may have difficulty in placing the Silastic trans hepatic biliary stent. Using progressively larger Coude catheters, the t umor is easily dilated and the Silastic stents placed (F).

T

E

_ _--C.;!-~_

_

_ __

_

_

_

Ring catheters

Tumor extending inIo both lobes 0/ liver

\

.)

Coude catheter

F

I

/. J';r I

'_~ng ,

CloaX Y.

L hepancy.

Lateral segment structures

Posterior segment structures

Left lobe

Medial segment

structures

- -- - - - -- - - Falciform ligament ' -- - - - -_ __ Hepatic a.

t. ..- -- - -- -__

Portal v.

Gallbladder

Inferior vena cava

Common duct

' - -0

-"

he gallbladder, arising from the biliary tree via the cystic duct, rests in a fossa on the undersurface of the liver. If one draws an imaginary line from the gallbladder fossa to the junction of the hepatic veins and the inferior vena cava, that line identifies the junction between the right and left lobes. The falciform ligament identifies the boundary of the medial and lateral segments of the left lobe. Topographically, there are no landmarks that identify the anterior and posterior segments of the right lobe. A more detailed description of the hepatic segmental anatomy of the liver has been made by Couinaud. His French description (inset) designates the caudat~ lobe as segment I. The left lateral segment is divided into superior (II) and inferior (III) segments. The medial segment of the left lobe is designed as IV. The anterior segment of the right lobe is further divided into superior (VIII) and inferior 01) segments, and the posterior segment is likewise further divided into superior (Vll) and inferior (VI) segments. Although this more detailed classification allows one to better describe the location of a lesion in the liver or the boundaries of a nonanatomical resection, it adds little to the classic segmental description for determining major anatomical resections.

T

w.

Caudate lobe _ __ _

;".;... m,rerlO( vena cava

,

.-c

r LeH lobe

Atght lobe

Falciform ligament _ _ __ _--'=~ Quadrate lobe _ _ _ _ __ _--\

Portal v.

Common duct

Inferior vena cava

155

onanatomical Liver Resections Operative Indications

urn

variety of lesions that require liver resection are of a that a formal segmental or lobar resection i not necessary. include both benign and malignant lesions. Another indicatio:J. nonanatomical resection is the presence of the lesion in bo:.b the liver. In unusual circumstances a patient with bilateral lobar 1esi0llS ......~. be considered a candidate for nonanatomical resection. Also, a pati previously undergone a segmentectomy or a lobectomy might presen subsequently with a lesion in the remaining lobe that could be lese r.,1 • a nonanatomical technique. Finally, patients with cirrhosi , who are candidates for a formal hepatic lobectomy, may undergo nonanatomical resections in an effort to preserve liver parenchyma. Hemangiomas, hepatic adenomas, and fibronodular hyperplasia arear;:~g those benign lesions that can require a nonanatomical hepatic resection of symptoms or because of the concern of malignancy. Small or m . colorectal metastases or hepatomas account for the maj ority of maligrrar:; lesions that might require a nonanatomicalliver resection.

A

oo=:se:

Operative Technique variety of incisions can be used , including an upper midline, a .• subcostal, an extended right subcostal, or as pictured here, a "-' subcostal incision. If one is to remove lesions from both lobes of the liver , ;ide exposure is required. An upper hand retractor, attached to a frame tha . anchored to the operating room table, is most helpful in providing €XIXJS::::re. abdomen is explored thoroughly to be certain there is no other intra·alxIDilm2! pathology. If not, one proceeds with the liver resection. There are two broad categories of nonanatomicalliver resections. is close to or involves a portion of the edge of the liver, generally it can removed with a wedge resection. If the lesion is not on or near the anterior of the liver, then a wedge resection is not possible and a tailored nOillmabr.J~"!! resection is performed while being certain that there is at lea tal em =ri!J::u:l normal tissue surrounding the lesion to be removed. Two lesions are pictured here (A). One is in the lateral segmen of L"1f:Je'" lobe of the liver and is amenable to a wedge resection. T he second . straddles the boundary between the medial egment of the left lobe of 0...;.'"' ....'" and the anterior segment of the right lobe of the liver. T hi lesion · DOt amenable to a wedge resection and a nonanatomical resection will hare tailored to remove it.

A

,

line of resectIon

Gallbladder

Duodenum

Stomach

variety of techniques can be utilized in performing liver resections. Several of these techniques will be demonstrated in this chapter. In this instance the technique of placing large compressing liver sutures and using the electrocautery will be demonstrated. After marking out a 1 em margin of normal tissue surrounding the lesion in the lateral segment of the left lobe of the liver, a series of overlapping horizontal mattress sutures are placed. These sutures are #1 chromic catgut on large liver needles. The sutures are more easily placed if most of the curve is removed from the large liver needle (inset). The mattress sutures are placed approximately 1 em away from the previously scored line of resection (B). These sutures are secured so that the liver parenchyma is compressed, but not cut through or crushed. Once the entire wedge has been completely surrounded with the chromic catgut liver sutures, a suture is placed in the liver parenchyma to be removed, for easier handling (C). Then, utilizing the electrocautery, the wedge resection is performed. One has to be careful to maintain at least a 1 em margin surrounding the lesion. If the previously placed liver sutures have been secured appropriately, the wedge resection performed with the electrocautery can be carried out with virtually no blood loss. Once the specimen has been removed, it is sent to pathology to check for the adequacy of gross and microscopic margins. In addition, biopsies for margins may be taken from the remaining liver in any area in which the margin is suspicious (D). Generally the electrocautery will be adequate to achieve any additional hemostasis that is needed, although occasionally suture ligatures are required.

A

Falc fform ligament _ _ _ __ _ _ -:-

/

Stay suture

The llEXI s:e;J --

be

b)- a series of m-erlappmg liver st_~es c::ffi:l~~ E} C!:~1i:" ca:gut on large liver needles_ It - more diffirutt to pIare around a lesion £hat cannot be resected as a wedge. TIle St:l:!mS a;::e frl;H far hemosta i and for preventing bile leaks, but if the ult:ra!;o;tic cssa::3" u ed, many urgeon would not use them. A stay suture is placed in the liver parenchyma [0 be re9::cEd. retraction (F). Using the ultrasonic dissector, the lesion i resected, aI.lo\\ 1 cm margin of normal liver around the lesion. A izable ,-e:,:;eJS radicals are recognized, they are ligated on the liver ide and clipped specimen side (G and inset). It is necessary to employ the suction adjacent to the ultrasOnic crs:se:coc Blood loss may be somewhat increased, compared to u ing the eI'eCInx=:oy liver sutures are not placed first. This technique, however, allows one identify all sizable vascular and biliary structures and to control them sec~:ly_ The lesion is sent to pathology for adequacy of gross and miooscopic margins. Both areas of resection are drained with Penrose, clo ed sump drains.

""-'----___+_ "'~--~---_

Hepatic a

____-+- Falciform ligament

_ _ _ _ _+Portal v.

-"'-- -- - - - - -- t- Biliary tree _-=L - -- - - - - - - - + l n f erior vena cava

Coronary ligament

Falciform ligament

,

L.lobe of liver

Lesion

he line of resection will pass through the bed of the gallbladder. Therefore, the gallbladder is mobilized after identifying the cystic duct and ligating and dividing the cystic artery (B). It is not on ly necessary to remove the gallbladder from the line of resection between the right and left lobes of the liver, but removal of the gallbladder also markedly improves exposure of the porta hepatis. The bifurcation of the biliary tree is identified and dissected, and the left hepatic duct mobilized (C). Several centimeters of the left hepatic duct generally traverse the undersurface of the left lobe of the liver in the hilar plate before entering liver parenchyma, and thus a long segment of left hepatic duct can be mobilized. The left hepatic duct is doubly ligated with 3-0 silk and divided. This allows access to the left branch of the hepatic artery. The hepatic arterial anatomy is variable, and not uncommonly the left hepatic artery arises from the left gastric artery; in most instances, however, it arises from the common hepatic artery and is located between the left hepatic duct and the left branch of the portal vein. The left branch of the hepatic artery is identified, mobilized, triply ligated, and divided (D). This exposes the left branch of the portal vein. It is necessary to dissect the bifurcation of the portal vein, so that one is certain when dividing the left branch of the portal vein that the bifurcation is not encroached upon. Once the left branch of the portal vein has been widely mobilized, it is clamped proximally and distally with straight Cooley clamps. The left branch of the portal vein is divided and oversewn with a continuous 4- 0 synthetic non absorbable suture (E). That portion which extends beyond the Cooley clamps is sutured, first with a continuous horizontal mattress stitch, and then run back with an over·and-over suture. If the distal end of the portal vein on the specimen side is long enough, it may merely be ligated. If not, it is closed in a similar fashion with 4-0 synthetic non absorbable suture.

T

'----~'rr---

Hepatic duct bifurcation

~---1I\S--- Portal v.

,

R. bran ch of portal v.---~=-l

Cystic duct stump Divided I. hepatic duct

Hepa 'c a

L branch of portal v.

L. hepatic a.

Divided '- branch of

portal v.

t has been our practice to not only divide all hilar structures to the lobe to be resected prior to dividing hepatic parenchyma, but also to divide the appropriate hepatic vein or veins. This is an optional step. Many surgeons after dividing the hilar structures will divide hepatic parenchyma and only control the hepatic vein or veins as the final step in removing the lobe. Generally, however, we divide the hepatic vein prior to dividing hepatic parenchyma. With the aid of the upper hand retractor, the hepatic veins usually can be adequately exposed at this point of the procedure. The liver is retracted caudally, and the suprahepatic inferior vena cava is dissected to expose the hepatic veins. The left hepatic vein is easily identified and easily dissected (F). Additional length can be obtained on the left hepatic vein by dissecting down into hepatic parenchyma. . Once an adequate length has been obtained, the left hepatic vein is doubly clamped with acutely curved Cooley clamps. The left hepatic vein is then divided. The ends of the left hepatic vein are oversewn in a fashion identical to the control of the portal vein. Using 4-0 synthetic nonabsorbable suture, each end of the hepatic vein within the Cooley clamp is oversewn, first with a running horizontal mattress suture, and then back with an over·and·over suture (G). The clamps are then removed.

I

cava

v. Diaphragm ~~__________ ~Ee"

L. lobe of liver

l c.oP..INr.(E, ~","'i>ONl~----

R. hepatic a.

Cystic duct

~\

R. hepatic duct

Gallbladder_-f-_~

fossa

f ' - - - - Hepatic a.

Ii-T- - - Common duct R. hepatic a. Divided r. hepatic duct

I

C-.._ _ _

Cystic duct stump

Divided r. branch of portal v. c.o,,-,.,.N

£,

l.,s"'''l)of'l.So

--

, ,.

fter the hilar structures have been dissected and divided, we prefer to control the hepatic veins before dividing hepatic parenchyma. Other liver surgeons prefer to divide the hepatic parenchyma between the right and left lobes first, controlling the major hepatic veins as the last step before removing the specimen. We feel that better hemostasis is achieved and a greater degree of safety ensured if the hepatic veins are divided first. The liver, which earlier had been mobilized out of the retroperitoneum and away from the diaphragm, is once again rotated medially. The entire length of the inferior vena cava posterior to the liver is dissected. There are several small hepatic veins that pass directly from the vena cava into liver parenchyma. These are carefully dissected, doubly ligated, and divided (H). The right hepatic vein is then identified and dissected. This dissection can be somewhat tedious and should proceed very cautiously. An injury to the hepatic vein at this point can result in significant blood loss. If the dissection proceeds cautiously, however, the right hepatic vein ca n always be identified and dissected. The hepatic vein should be mobilized down into hepatic parenchyma for a great enough distance so that two acutely-curved Cooley clamps can be applied. The right hepatic vein is then divided, and each end is oversewn with a continuous 4-0 synthetic non absorbable suture run in one direction in a horizontal mattress fashion and then back in an over-and-over suture (inset). If a sufficiently long segment has been dissected free, the hepatic vei n on the specimen side can be merely ligated.

A

R hepa!lc v Infeoor vena cava _ _ _,

Bare area

~,------ Rlobed

~~~~------- ~ ~

Infenor vena cava _ _ _ __ -.:!-:-:p!-_ _ .....,..., R.

hepatic v. -------I-?---4t.;~

_ __ _ SmaJ""",*

nce the hilar vessels have been divided and the hepatic vein identified and divided, a clear demarcation is visible between the devascularized right lobe and the vascularized left lobe. A variety of means are available to divide the parenchyma between the right and left lobes. In this instance the ultrasonic dissector is used. Stay sutures are placed on either side of the proposed line of division, which has been marked with the electrocautery (I). The stay sutures aid in retracting and exposing parenchyma to be divided with the ultrasonic dissector (I). Sizable vascular and biliary structures are easily identified. The structures on the left lobe side are controlled with either ligatures or suture ligatures, whereas on the specimen side ligaclips are applied (inset). As the dissection proceeds toward the dome of the liver, sizable branches from the middle hepatic vein may be encountered.

O

Ultrason ic dissector

Stay suture

nce the parenchyma has been completely divided, the specimen is removed from the operative field. Additional hemostasis is achieved with the electrocautery or with suture ligatures, as required. Some surgeons feel it is helpful in containing bile leaks to tack the omentum to the resected surface. It is important following a right hepatic lobectomy to reconstitute the previously divided falciform ligament, to insure stability of the liver mass left behind (J). It is possible for the segment to torque and to impair vascular inflow and/or outflow. The specimen (K) is sent to pathology to check for the adequacy of gross and microscopic margins. The resected surface of the liver is drained with Penrose, closed suction, or Silas tic sump drains.

O

R

lei'

:lMded: R branch of porta l v.

R hepatic duct and

Resected right lobe ~-_

R hepaIic w.

lJ~""f------ R

,.."

smacedila

Lesion _ _ _ "

Divided /L--- - -- - portal sIrucIures

~_

_ __

____

G al~~

K

189

Kesec:Oon of Ri'g ht Lobe 0 I •

edial Segment of Left to oe Trisegmentectomy) I

Operative Indications f one adds removal of the medial segment of the left lobe of the right hepatic lobectomy, approximately 75 percent of the pan:ocbymal mass of the liver is removed. Hepatic reserve i uch that if one IeaiKS to 20 percent of normal liver behind, patients can tolerate the opel2tive procedure, and liver regeneration will proceed from the remnant with 00 difficulty. Thus removing the anterior and posterior segments of the along with the medial segment of the left lobe, or trisegmentectomy, tolerated in most individuals in whom the liver remnant, the lateral sel]~:d: .ri the left lobe, is normal. T his procedure is performed for benign and malignant lesions thatoa:~~2 large part of the right lobe and extend into the medial segment of the left or just as commonly for lesions that occur midway between the right and lobes. Benign lesions include large capillary hemangiomas, hepatic aooJQ;:;:=. and fibronodular hyperplasia. The most common malignant lesion wouJdbe hepatoma or metastases from a colorectal tumor. A rare indication fm-ID"'""",--j_ Gastroduodenal a.

Celi ac axi s

~....,..-:+;t----j--I~ . hepatic a.

arising from

- -"-- -cf- Superior mesenteric a.

-'I;:-'[-'r - Second catheter for Pump

van able anatomy

Rectus m.

IngUinal ligament

1& ection of Simple C s of Operative Indications imple cy [ of the liver are common. Many are small (1 an diameter), are asymptomatic, and pose no health risks. Others larger, may be palpable on abdominal exam, or even visiblem inspecting the anterior abdominal wall, and may be sympt'NIGtlic Respiratory compromise and vena caval compression have both been IeIIuted With minimal trauma large cysts may rupture, or be the site of sign;'" ad hemorrhage. In addition, considerable pressure atrophy may occur in Irnlr parenchyma surrounding the cyst. Generally lesions 10 cm or greater in diameter are thought to It11uite surgical removal. Some reports have suggested percutaneou needle 3SIm:lio:;. with introduction of sclerosants, as effective therapy. Secondary infections occurred following aspiration and recurrences have been common, and term efficacy is as yet unproven. Patients with simple hepatic cysts, particularly massive ones where abdominal fullness and early satiety are present, receive excellent relief surgical intervention. Patients with polycystic liver disease may also occasionally be candidates for cyst excision and/ or marsupialization. Poly(;) ta: liver disease is rare and only infrequently results in liver fa ilure. However. occasionally cysts in polycystic livers become so large that they fill most of thf abdominal cavity and patients are unable to eat. Such patients are candi~ for resection, fenestration, and marsupialization of their cysts with techni~ that are identical to those used to manage simple hepatic cysts.

S

Operative Technique atients are generally explored through a right subcostal incision, although a midline incision is satisfactory. Once the peritoneal cavity has been entered, the abdomen is explored. The size, number, and configuration of liver cysts are identified. With CT scanning, generally the exact location and number of simple cysts are known prior to laparotomy. In this instance there is a single giant qst arising from the under surfaces of the right and left lobes of the liver (A). Many surgeons prefer to aspirate the cyst before it is opened to look for die presence of bile or secondary infection. The cyst wall is then opened (B). and contents are aspirated (C). It there is the slightest suspicion that echinococchal cyst disease might be present, prior to opening the cyst the area is fastidiously packed with Mikulicz pads soaked in 20 percent saline. Fluid is then sent to pathology to look for the presence of scoleces. In most instances, however, the solitary thin·walled simple cyst containing clear serous fluid will not be confused with a hydatid cyst.

P

A

A lobe - ----:.1, --; 0/ liver

~-j~--'P:f1.r-~adder

Site of cyst incision

__~~~

'--,..-jt-____

#hrt---

-

Cyst

Stomach

c

B

-'=-_ _ _ _

Cy st _

_

_

_

-;;;-;-_

ith the cyst wall opened, as much of it as possible is excised sharply with scissors or with the electrocautery, leaving a I/2-cm rim attached to the liver (D). An attempt can be made to excise the remaining cyst wall from liver parenchyma. Usually, however, this is time consuming. In addition, vascular and biliary structures often run in hepatic parenchyma immediately underneath cyst wall. The cyst wall should be sent for frozen section to rule out cystadenocarcinoma. T hese lesions are rare, but simple excision would not be adequate if one were present. For a simple cyst, it is unnecessary to excise all of the cyst wall as long as most of the cyst is removed and the remaining wall is in wide contact with the peritoneal cavity. T he remaining edge of cyst wall on the liver is sutured with a continuous over-and-over locking suture of 3-0 synthetic absorbable material. This is to achieve adequate hemostasis and to control any small bile ductules that might be present in unrecognized liver parenchyma extending out on to the base of the cyst wall (E). The abdomen is then closed without drainage of the residual cyst wall. This cyst wall will continue to secrete serous fluid, which will be rapidly and readily absorbed by the peritoneal surfaces. Only if redundant cyst wall is left that can loculate off will there be a risk of recurrence of the cyst. Recurrences are rare.

W

Liver Gallbladder

Residual cyst wall

anagement of Hydatid Cyst Disease of Liver Operative Indications nfestation with Echinococcus granulosa in the Uni ted tates is -However, with frequent travel abroad and with immigrants to thl-SOIElItIJ from the Middle East and South America, hydatid cy t diseaseoftbe is occasionally encountered. The combination of history, clinical presentation, and CT scan findings of a solitary or loculated cyst with a calcified wall can make the surgeon suspicious that hydatid cyst dj,;pase present. Serologic tests can also be of value. Untreated hydatid cyst rliseare result in disaster. Rupture into the biliary tree, into adjacent abdominalOI;S~ or through the diaphragm and into the chest may all result from an undiagnosed or unrrea[ea nyu-a"v· ,.;)~< .

I

Surgical Technique atients can be explored through a right subcostal, an elacron gran

Pancreas

Supenor mesemen:;: v

Inferior vena cava

i.

-

,/

.~

Q

,

f

"

.,

-1

:L

::::c

~

,

~1 ...:.:j ~

large bore needle is passed into the most anterior portion of the prosthesis and the clamps removed slowly from the superior mesenteric vein (Q). The clamp on the inferior vena cava is left in place. This allows the prosthesis to fi ll with blood, with the needle acting as a vent for the release of air. Once the prosthesis has completely filled with blood, the clamp is removed from the inferior vena cava and flow through the prosthesis established (R). T he course of the prosthesis assumes a "C" configuration. The anastomosis between the prosthesis and inferior vena cava is actually partially underneath the third portion of the duodenum. The prosthesis has to pass inferiorly as well as anteriorly to pass below the third portion of the duodenum. It then passes on top of the third portion of the duodenum, on top of the uncinate process, to be anastomosed obliquely to the anterior surface of the superior mesenteric vein. This "C" configuration allows the prosthesis to be anastomosed to the anterior aspect of the superior mesenteric vein well above where the superior mesenteric vein branching occurs (S). Thus one is always assured of superior mesenteric vein with a large diameter. Furthermore, since the anastomosis is oblique, it tends to be very large. In addition, since the anastomosis is to the anterior aspect of the superior mesenteric vein, it technically is easy to perform. This is in contrast to the old "R" shunt, which runs directly anteriorly from the inferior vena cava, below the lower border of the third portion of the duodenum, and joins the posterior aspect of the s uperior mesenteric vein. T he "R" shunt anastomosis is much harder to perform and often is performed to a segment of the superior mesenteric vein that has already branched.

A

Q

Duodenum _____-;_

Superior

i-:r-- - - - - mesenteric v.

---i!;......-- - - - - .. c .. graft

Inferior vena cava - - - --

-t

s Lateral view

_,.~m'n'"r

' ),

/ 1':>,: / 1.-

.. c .. graft

./·~~~~i~----_superior mesenteri c v.

he prosthesis is punctured with a 19-9auge needle connected to intravenous extension tubing. This can either be passed off the head of the table so that pressures may be recorded on electronic equipment by the anesthesiologist. or it can be connected to a manometer by the surgeon and measured directly (T). The first measurement is taken with the prosthesis open and mesenteric systemic flow intact (U). This figure is taken as the decompressed portal pressure. The prosthesis is then clamped on the inferior vena cava side of the manometer M. and this elevated pressure is taken as the undecompressed portal pressure. Finally. the prosthesis is clamped on the superior mesenteric venous side (JI). and this pressure should represen t the pressure in the inferior vena cava. It is also important for the anesthesiologist to record right atrial or superior yena caval pressure. to be certain that the portal pressure drop can be corrected for any gradient that exists between the inferior vena cava at the level of the anastomosis and the right atrium. Taking these pressure measurements at the end of the operative procedure allows the surgeon to proceed with the shunt without the initial delay required for measuring undecompressed portal pressure.

T

T

- - - - - - - Transverse mesocolon

t ---'lI_-i!~~+--- Dacron graft

~....._~~-"~_

Superior mesenteric vein

Duodenum

Inferior vena cava

Superior mesenteric

Superior mesenteric

(~~t Mesenteric vein. See Inferior mesentf7lC ~ Superior mesenteric \'ein Mesentery, Puestow procedure and. Dl331 Mesoatrial shunt indications for , 298 technique for , 298-311 Mesocaval shunt direct indications for, 288 technique for 288-297 interposition indications for, 252-254 technique for, 254-265 Mesocolon, transverse, sutured to gastrojejunostomy, 466, 46i Metastases, colorectal. to liver, 2, 200 Mikulicz pads, packing with massive liver trauma and, 246, 247 pancreatic abscess drainage and . 452, .\53

~h.~'~l~ . :a : . ~ . ~Co:~~a3 :-:::: .

.)?,

+49 Sri C2.!'cino:::la: !pi,-,{r.t llX41WII

()T

o

Pcor-..ac:avai shunt end-t&->ide. Z;;;_ T.6-281 Inter;x>sllioo '"w gnlft. Z~ 4. 286-2S:indications ior. 2-;-4. 276 side-ro-side.282-2" Porta hepatis

O?eraToc ci:.-:~~;;r.:.~. 8. Su also Cbolar:gxgra;>ie.commor. dth..~ c.~lvratlor: ai1d. 10 Operan ...c rraurr.4. Je:-ngn bile duct strictures

anatom y of. 152 clamping of. in Pringle maneu\"er. 2-1-4

and.~

Qyer· and.-o\"er stitch. 338. 339

drainage of. cholecystectomy and. .9

Portal hypertension, shunts and. Su huno:i l Portal pressure, measurement 01. ~6. T:7 Portal vein, 152 hepatic lobectom y and

p Packing

hemostasis and, massive liver trauma and

left , 170, 171 right , 182 , 183

246,247 ' pancreatic abscess drainage and, 452, 453

pancreaticoduodenectomy and, 388. 389 portacaval shunt and

Pain, abdominal pancreas divisum and, 366 pancreaticojejunostomy for

end-to-side, 280, 281 side-t~-side, 282, 283 tri segment ectomy and, 192, 193

end-to-end,342 longitudinal,326

Portasystemic decompress ion , 266. See also

Pancreas

Shunt(s)

drainage of, trauma and, 454- 461,462,467 exposure of, 326-328 insulinoma and, 436-439

Pott's scissors, septotom y with, 22. 23 Pringle maneuver, 244, 245 hepatic vein injury and , 248

Pancreas divisum, accessory duct papillotomy

Prosthesis

for, 366-369

interposition "H" graft and , 274, 2ll6-2ir. knitted, interposition mesocaval shunt and.

Pancreatectomy, distal for chronic pancreatitis, 350- 359 ninety-five percent, 362- 365 for tumor, 428-435 Pancreatic abscess, drainage of, 442- 453 Pancreatic duct dilata tion, 326- 329 Pancreaticoduodenectomy, 362

258-265 mesoatrial shunt and , 302- 305

Proximal cholangiocarcinoma palliation of, transhepatic stem ing and hepaticojejunostom y in, 84 -93

resection of, transhepatic stenting and hepaticojejunostomy in

indications for, 386 technique for, 386-413

bilateral,58- 71 hepatic lobectomy and, 72-

Pancreaticojejunostomy end-to-end indications for, 342 technique for, 342- 349 end-to-side, 406- 409 longitudinal in dications for, 326 technique for, 326- 341

Pseudocyst, pancreatic. See Pancreatic pseudocyst Puestow procedure indications for , 326 technique for, 326- 34 1 Pump, Infusaid, 2

for hepatic artery infusion. 200-205 Pyloric exclusion, pancreatic drainage and. tar

Pancreatic pseudocyst, drainage of into duodenum, 384- 385 into Roux-en-Y jejunal loop, 370-379 into stomach, 380- 383

combined duodenal and pancreatic trauma, 462- 467 Pylorus-preserving Wh ipple procedure indications for , 386 technique for , 386-41 3

Pancreatitis, sphincteropiasty for . See Sphincteroplasty Pancreatotomy, 328 Papillary neoplasms, 386

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Papillotomy, accessory duct, for pancreas divisum, 366-369

Radiotherapy, postoperat iR proximal

Pediatric patients, direct mesocaval shunt for 288

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Perforations, pancreatic, 454, 455 Periampullary carcinoma pancreaticoduodenectomy for, 366 unresectable, palliati';t jY~5SC5 for,

Renal function . l,e\'een shunt and. 312 Rena l ,-ein_ leit. distal splenorenal >hun! and. 2,0

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Perironeal ca'.-1::;. ::'YCc:iC ::.~:5 Pui:;cystic li';::: :" :::~-=alliatioo rio N-i'9 Small bo...e!. di\isioo ai. Puesrm< procedure and. 332, 333

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Roux-en ·Y loo?~. 52. 53 Caroli', dis""", and. 136- 1&3 choledochal Cyst and. 12 4 - 12~ const ru ction of. -t.8. 49 end· to-side jejunojejunostomY and. 50, 51 hepaticojejunosromyand . ben ign bilia ry stricture and, 54- 57 distal stricturing secondary to sclerosing cholangitis and , 114 proximal cholangiocarcinorn a and, 66- 71,

82-83, 90-93 sclerosing cholangitis and, 104 pancreaticojejunostomy and end·to·end,346 longitud inal,330-335 pancreatic pseudocyst drai nage into,

370-379,380 S Saline, hypertonic, as scolecidal agent, 212 Satinsky clamp interposit ion "H" graft and, 286, 287 interposition mesocaval shu nt and, 258, 259 Sclerosi ng cholangitis, 94- 107 di s tal strictu ring secondary to, hepaticojejunostomy for, 108-115 Sclerotherapy, 266, 274 Scolecidal agents, 212 Scoops, for biliary tree exploration, 12 , 13 Sepsis, acute pancreatitis and, 442 Septotomy , sphincteroplasty and, 22, 23 Shun t(s) Le Veen indications fOT, 312 technique for, 312-323 mesoatrial ind ications for, 298 technique for, 298-311 mesocaval direct, 288-297 in terposition, 252-265 place men t of, hepatic vein injury and, 248 po rtacaval end·to·side, 275, 276- 281 " H," 286- 287 ind ica tions fo r, 274, 276 side·to·side, 282- 285 splenorenal, distal, 266-273 Side·to·side choledochoduodenostomy, 28- 37 Side· to-side pancreaticojejunostomy , longitudinal. 336- 341 Side-ta-side ponacayai shunt. 2-; 4. ~~:2 - :?~;:; 5ilastic cuff. mesoatrial Jro5thesis c:::. :=':':2 5!ias::t: :!a:1Shepatic Ji::~:-: S:t:::::-.£' :-2:-.:g:: Jili2ry s:r1c:'''::-': ;:-.::. ~ -.;: C.;. ~ :::·S di3ec.x a:::. =~~