Abstract video:
MESOHEPATECTOMY (SEGMENTS 4, 5 AND 8) UNDER HEPATIC VASCULAR EXCLUSION WITH PRESERVATION OF THE CAVAL FLOW FOR LIVER METASTASIS

Giuliante F, Ardito F, Vellone M, Giovannini I, Nuzzo G.
HPB 2006; 8 (2 Suppl): 67

Mesohepatectomy (removal of liver segments 4, 5 and 8, with preservation of lateral segments) may be indicated for centrally located liver tumors, to avoid extended hepatectomies and the sacrifice of a large amount of functioning parenchyma, especially in patients with cirrhosis or severe steatosis after chemotherapy. This is a complex operation because liver transection is performed in proximity of major vascular and biliary structures of the lateral segments, which must be preserved to avoid ischemic or congestive injury to the remnant liver. Furthermore, the double plane of resection increases the risk of bleeding and the need for blood transfusions. This video shows a mesohepatectomy performed under hepatic vascular exclusion, intermittently applied, with preservation of the caval flow, and demonstrates the safety and efficacy of this vascular control technique.

This is the case of a 78 year old female patient with a centrally located adrenal gland liver metastasis, embedded in the hepatic dome and invading the middle hepatic vein. After bilateral subcostal incision extended to the xiphoid, intraoperative ultrasound excluded the infiltration of portal pedicles. After complete mobilization of the right and left hemiliver, the right hepatic vein and the common trunk of left and middle hepatic veins were encircled by tapes. After lowering the hilar plate, the right anterior portal pedicle was encircled and clamped by a suprahilar approach. Liver transection was performed on the right side along the ischemic demarcation line, and on the left side along the umbilical fissure, by dividing the portal pedicles to segments 5 and 8 intraparenchymally, and that to segment 4 just to the right of the round ligament. Kellyclasia technique and bipolar forceps were used for the transection, and thin transfixed sutures and absorbable clips for hemostasis and biliostasis. Central venous pressure during transection was maintained below 4 mm Hg. Intermittent clamping of the pedicle and of hepatic veins (right hepatic vein and common trunk) resulted in hepatic vascular exclusion with preservation of caval flow. Total duration of clamping was 68 min. The middle hepatic vein was divided intraparenchymally at the end of the resection. No blood transfusions were required, the postoperative outcome was uneventful.