Liver resection indications & methods
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This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
![PORTAL VEIN EMBOLIZATION
Indications
1. Normal liver (ICG retention rate at 15 minutes [ICG R15] <10%) if
FLRV/TLV is less than 40%
2. Injured liver (10% < ICG R15 < 20%), if FLRV/TLV is less than 50%
If ICG R15 exceeds 20%, major hepatectomy is Contraindicated even
after PVE](https://image.slidesharecdn.com/tdyoez4erl6npyjkmyt8-signature-5ad637fb3c053e41151106d5fd77df1246c520c5662955ecc0b8e683c83dd6d2-poli-181120065426/85/Liver-resection-indications-amp-methods-38-320.jpg)
Liver resection indications & methods
- 1. LIVER RESECTION Indications & Methods Dr Harsh Shah MS, FMAS, DNB, MCh (GI) Kaizen Hospital, Ahmedabad
- 2. INTRODUCTION • First successful elective liver resection - 1888 (Langenbuch) • True anatomical right hepatectomy in 1952 (Lortat-Jacob) • Subsequent experience • Not encouraging till 20 years back • Morbidity (30%) & mortality (5%) • Most common complications being bleeding and bile leak • Techniques and Instruments • Large, non-anatomical wedge resections • Possible due to development of new instruments and techniques
- 3. ANATOMY
- 4. BLOOD SUPPLY • 1-1.5 litres per minute • Portal vein – 75% • Hepatic artery – 25% • Bile duct • Three hepatic veins
- 5. INDICATIONS FOR LIVER RESECTION • Benign liver tumours • Hemangioma • Adenoma • Cystadenoma • Malignant liver tumours • HCC • Cholangiocarcinoma • Metastasis • Carcinoma GB • Benign conditions • Intrahepatic stones • RPC • Caroli’s disease • Hydatid cyst • Liver cysts • Liver trauma • LDLT (Living donor liver transplantation)
- 9. LIVER METASTASIS • COLORECTAL • NET • BREAST • GIST
- 10. RIGHT LOBE LEFT LOBE Hemangioma
- 11. HEMANGIOMA • Giant hemangioma - > 10cm • Pain • Signs of inflammatory process – fever, ESR, thrombocytosis • Compression – bile duct, stomach • Thrombocytopenia (KMS) • Rupture
- 12. HEPATIC ADENOMA • Hemorrhage - >5cm size • Malignant transformation (5%)
- 13. CYSTADENOMA • Contains ovarian like stroma • High risk of cystadenocarcinoma
- 20. LIVER RESECTION : STEPS • Pre-op planning • Intra-op assessment • Inflow control • Outflow control • Maintenance of low central venous pressure • Parenchymal transection
- 24. QUESTIONS • Is it amenable to surgical resection ? • Portal vein • Hepatic vein • Is the future liver remnant sufficient ? • Quality of future liver remnant ? • Alcohol • Hep B & Hep C • Fatty liver • Cholestatic
- 25. Future liver remnant Normal - >20% Cholestatic - >30% Cirrhotic - >40%
- 26. LIVER FAILURE • Liver is unique in its ability to ‘regenerate’ • Post hepatectomy liver failure • Incidence – 2-10% • cirrhotic liver – 10-30%
- 27. LIVER VOLUME ASSESSMENT • Right liver (segments V to VIII) contributes two thirds of the total liver volume (TLV) • The left liver (segments II to IV) represents a third of the TLV • Left lateral section (bisegment II/III) contributes approximately half the volume of the left liver or 16% of the TLV
- 28. CT VOLUMETRY • Indications • Extended liver resections • Right hepatectomy in cirrhotics • LDLT • Softwares • LiverAnalyzer (Mevis) • Osiri X
- 31. INDOCYANINE GREEN ELIMINATION TEST • Indocyanine green (ICG) is an anionic organic dye selectively taken up by hepatocytes and excreted unchanged via the bile • Plasma extraction of ICG by the liver is an active process • Values extrapolated to reflect hepatocyte blood flow and functional hepatocyte mass • ICG retention values above 15% at 15 minutes are considered abnormal
- 32. MEGX & GALACTOSE ELIMINATION TEST • Lidocaine is metabolized by hepatocytes and converted to monoethylglycinexylide (MEGX) • Galactose is actively phosphorylated to glucose by hepatocyte • Both tests require uptake and metabolism by the liver to quantify hepatic function
- 33. HEPATOBILIARY SCINTIGRAPHY • Liver uptake and excretion imaging of aminodiacetic acid derivatives (HIDA, DISIDA) with radiolabeled • Reduction in receptor numbers is seen in patients with chronic liver disease • Receptors absent from the surface of hepatocellular carcinoma cells
- 34. HEPATOBILIARY SCINTIGRAPHY • Scintigraphic imaging of the liver has the added advantage of providing an assessment of liver volume • Volumetric analysis is better than that obtained with CT volumetry, because it measures only the functional volume ( kwon et al ,2006) • Stromal and fibrous tissues are excluded because of the lack of the asialoglycoprotein receptors
- 35. Low FLR ??
- 36. METHODS OF LIVER VOLUME AUGMENTATION • Portal Vein Embolization (PVE) • PVE + TACE (Trans Arterial Chemo Embolization) • Staged Hepatic Resection
- 37. WHAT IS PVE ? Embolization of PV on the side to be resected Concept – atrophy hypertrophy complex Leads to hypertrophy of future liver remnant (FLR) Allows major resection without post op liver failure
- 38. PORTAL VEIN EMBOLIZATION Indications 1. Normal liver (ICG retention rate at 15 minutes [ICG R15] <10%) if FLRV/TLV is less than 40% 2. Injured liver (10% < ICG R15 < 20%), if FLRV/TLV is less than 50% If ICG R15 exceeds 20%, major hepatectomy is Contraindicated even after PVE
- 39. TECHNIQUE Three approaches – 1. Laparotomy and through ileocolic vein 2. Transhepatic ipsilateral approach 3. Transhepatic contralateral approach
- 41. EMBOLIZATION MATERIALS No ideal embolization material 1. Gelfoam (gelatin sponge with thrombin) 2. Fibrin glue (fibrinogen + thrombin) 3. Synthetic glue (n-butyl-2-cyanoacrylate) Permanent, massive perivascular fibrosis, difficult dissection 4. Polyvinyl alcohol 5. Coils 6. Iodized oil 7. Absolute ethanol (significant more hypertrophy, increase enzymes) All – similar hypertrophy 2-4 weeks after PVE
- 43. RESULTS OF PVE • PVE leads to an increment of segmental volume in non embolized hemiliver and a decrement of segmental volume in embolized hemiliver maintaining a constant TLV • In case of right hemiliver PVE, regeneration rate of the • Non cirrhotic liver - 12 cm2/day at 2 weeks 11 cm2/day at 4 weeks 6 cm2/day at 32 days • in cirrhotic patients regeneration is slower
- 44. PVE • Volume increase in the non-embolized lobe accompanied by a parallel increment in liver function • Improvement in FLR function apparent from an increase in biliary excretion • Embolized hemiliver atrophy through apoptosis and subsequent cell deletion • Volume increase in non-embolized hemiliver is by hyperplasia rather than cellular hypertrophy
- 45. FACTORS AFFECTING REGENERATION • Regeneration rate depends on embolized hemiliver volume, the greater the FLRV before PVE, the smaller the volume increase after PVE • Hypertrophy modest when biologic materials such as gelfoam and fibrin glue used as a result of the progressive recanalization • Absolute ethanol achieve the highest degree of regeneration but at the expense of marked increases in AST and ALT levels secondary to liver necrosis
- 48. MECHANISM OF ACTION • Embolization Ischemia Necrosis • Ischemia blocks transmembrane pumps limits chemotherapy from washing out of tumor cells (Ramsey D et al, 2002) • Concentration of chemotherapy drug in tumor is 10-100 times greater than given systemically (Konno T et al,1990) • Chemotherapy + lipiodol traps chemotherapy & concentrates in HCC (Ramsey D) • Because most of the drugs is retained in the liver, systemic toxicity is reduced (Daniels JR, 1988)
- 49. TACE Exclusion criteria • Hepatic encephalopathy • PV thrombosis • Serum bilirubin >5mg/dl; serum creatinine >2mg/dl
- 50. PROCEDURE • 7-10ml of chemotherapy solution infused (100mg cisplatin, 50mg doxorubicin & 10mg mitomycin C in a 1:1 or 2:1 volume ratio with ethiodol / lipiodol) • Followed by infusion of 1-2ml of gelfoam / PVA particles (300-500 micron) to slow down arterial inflow & prevent washout of chemotherapeutic agents • End point - entire amount is delivered & slowed arterial flow as compared to initial flow • Forward flow in the HA is to be maintained to preserve patency for re-treatment and minimize theoretical risk of ischemia or infarction
- 53. COMPLICATIONS • Post-embolization syndrome (fever, pain, vomiting, ALT) – 32-80% • Ascites, GI bleed, leucopenia, worsening hepatic function -- <10% • Rare – cholecystitis, ischemic hepatitis, abscess, bacteremia, hepatic, renal failure, death
- 55. CT ANGIOGRAPHY- HEPATIC ARTERY
- 58. MRCP
- 59. SURGERY
- 60. VASCULAR CONTROL • Inflow Vascular Occlusion • Total Vascular Exclusion
- 61. INFLOW VASCULAR OCCLUSION Pringle Maneuver • Oldest and simplest way • Hepatoduodenal ligament encircled with tape • Until pulse in hepatic artery disappears Pringle JH et al, ann surg 1909
- 62. INFLOW VASCULAR OCCLUSION Pringle Maneuver • Advantages • Little general hemodynamic effect • No specific anesthetic management • Disadvantages • Backflow from hepatic veins • Ischaemic-reperfusion injury to the liver parenchyma • Splanchnic congestion Kim YI et al, J hepatobiliary pancreat surg 2003
- 63. INFLOW VASCULAR OCCLUSION Continuous Pringle Maneuver • Up to 60 minutes in normal liver (normothermic conditions) • Up to 30 minutes in pathological (fatty or cirrhotic) livers
- 64. INFLOW VASCULAR OCCLUSION Intermittent Pringle Maneuver • 15-20 minutes clamping, 5 minutes unclamping • 5 minutes clamping, 1 minute unclamping • Advantages • Doubling of ischaemia time • Better tolerated by pathological liver • Disadvantages • Bleeding during unclamping period • Increased overall transection time Torzilli G et al, arch surg 1999 Belghiti J et al, ann surg 1999
- 65. INFLOW VASCULAR OCCLUSION Ischaemic Preconditioning • Endogenous self-protective mechanism Hypothesis: • 10 minutes of ischaemia followed by 10 minutes of reperfusion protection against subsequent transection with complete inflow occlusion Advantage: • Lower serum transaminase levels after surgery • Longer inflow occlusion in steatotic livers Clavien et al, ann surg 2000
- 66. Hemi-hepatic clamping (Half-Pringle maneuver) • Interrupts arterial and portal inflow selectively one lobe • Advantage • Avoids ischaemia in the remnant liver • Avoids splanchnic congestion • Clear demarcation of the resection margin • Disadvantage • Bleeding from the parenchymal cut surface Horgan PG et al, am J surg 2001
- 67. Total vascular exclusion • Complete mobilization of the liver • Encircling of suprahepatic and infrahepatic IVC • Pringle maneuver • Clamping the infrahepatic IVC & suprahepatic IVC
- 68. Total vascular exclusion • Hemodynamic changes • Marked reduction of venous return and cardiac output • Trial clamping of two to five minutes • Ischemia time • 60 minutes in normal liver • 30 minutes in diseased liver • Extended with hypothermic perfusion of the liver Azoulay D et al, ann surg 2005
- 69. Total vascular exclusion • Disadvantages • Hemodynamic intolerance • Post-operative abdominal collections/ abscesses and pulmonary complications • Venovenous bypass if hemodynamic intolerance • Infrahepatic IVC clamp alone with inflow occlusion • Reduce back bleeding Abdalla et al, surg clin north am 2004
- 70. SELECTIVE VASCULAR CONTROL • Inflow occlusion with extraparenchymal control of hepatic veins • Trunks of major hepatic veins can be safely looped in 90% of patients • Loops tightened or vessels clamped after inflow occlusion • Continuous or intermittent • Advantages • Liver lobe isolated from systemic circulation • Caval flow un-interrupted Elias D wt al, hepatogastroenterology 1998 Smyrniotis VE et al, world J surg 2003
- 72. INSTRUMENTS • CUSA • WATER-JET • HABIB PROBE • HARMONIC FOCUS • LIGASURE • VASCULAR STAPLERS
- 73. Cavitron Ultrasonic Surgical Aspirator(CUSA) Pencil-grip surgical hand piece contains a transducer Oscillates longitudinally at 23 KHz Explosion of cells with a high water content (hepatocytes) and fragmentation of parenchyma, sparing blood and bile vessel
- 74. Cavitron ultrasonic surgical aspirator, CUSA (Valleylab)
- 75. Cavitron ultrasonic surgical aspirator, CUSA (Valleylab) • Constant water irrigation • Cools the titanium tip • Washes blood • Suction – in built • Clears the transection plane • No need for vascular control • Non-anatomical resection possible • Less operative time
- 77. WATER-JET ‘Intelligent knife’ • Consists of pressure generating pump connected to a hand-piece • Jet nozzle with a pinhole 0.1 mm • Projects physiologic saline • Suction line connected to a transparent hollow tip • Separates ducts & blood vessels from parenchyma • Splashing (source infection) avoided by • Keep hollow tip into direct contact with liver
- 78. WATER-JET
- 79. WATER-JET • Intrahepatic vessels and bile ducts (>0.2mm) not injured with water jet pressure • 10 kgf/cm2 in normal liver parenchyma • 15-18 kgf/cm2 in cirrhotic patients • Compared with CUSA • Less blood loss • Similar operating time • Less positive margins
- 81. Multiprobe Bipolar Radiofrequency Device (Habib)
- 82. Multiprobe bipolar radiofrequency device (Habib) ‘Bloodless liver surgery’ • The radiofrequency handheld device 2x2 array of 4 needles spaced at the corners of a 6 mm rectangle • 2 variants • Long (120-mm) and short (60-mm) needles • Needles made of stainless steel with a polished titanium nitride nonstick coating • Active portion of long needles is distal 40 mm Ahmet et al, arch surg 2008
- 84. Multiprobe bipolar radiofrequency device (Habib) • Without reduction of central venous pressure • Mark resection line before starting the radiofrequency energy • Radiofrequency power set • 125 W for small vessel coagulation • 75 W around large vessels • Series of coagulations made • Create a band of coagulation
- 85. Multiprobe Bipolar Radiofrequency Device (Habib) The surface of the liver parenchyma left behind • Homogeneous • Without visible bile duct structures or blood vessel Advantages • Less blood loss • No major post-operative morbidity/ mortality Ahmet et al, arch surg 2008
- 86. Harmonic ‘Focus’ • Ultrasonically activated shear • Causes protein denaturation and coagulation by high frequency ultrasound vibration • Ultrasonic generator, foot switch, hand piece • Vibration frequency 55,500 Hz • Simultaneous coagulation (3mm) & cutting • No smoke & minimal lateral spread (0.5mm) • Only for superficial parenchymal transection Kim J et al, am surg 2003
- 87. Harmonic scalpel • Comparison with clamp crush technique • Reduce operative time • Reduce blood loss • Increases biliary fistulae
- 88. BIPOLAR VESSEL SEALING DEVICE, BVSD (LIGASURE) • Bipolar electrothermal energy • Seals off vessels up to 7mm in diameter • Liver tissue crushed between blades • Coagulation energy applied to seal vessels • Lateral thermal spreading is minimal (1mm) • No bile leak • Does not produce smoke interfering with field Strasberg SM et al, J gastrointest surg 2002 Romano F et al, world J surg 2005
- 89. VASCULAR STAPLERS • Inflow & outflow vessel control • Reduced operative time • Use when in trouble !
- 90. LAPAROSCOPY • First anatomical laparoscopic liver resection • 1996 by Azagra • Left lateral sectionectomy for hepatic adenoma • Small and localized tumors on anterolateral segments • Oncological principal has to be followed • Need of intra-operative ultrasound
- 91. LAPAROSCOPY • Laparoscopic assisted hepatectomy (LAH) • Total laparoscopic liver resection (TLLR)
- 92. LAPAROSCOPY • Pneumoperitoneum • Carbon dioxide • Pressure aiming for 6–8 mmHg during transection • 300 laparoscope • Hepatic transection • Harmonic scalpel/ CUSA/Ligasure • Bleeder control • Bipolar coagulation for minor bleeding • Endoclips/ endo GIA staplers for larger structures Gagner et al, surg clin N am 2004
- 93. LAPAROSCOPY • TLLR • Usually possible in patients with tumor size < 5 cm • Wedge resection • Left lateral sectionectomy • Safe procedure in antero-inferior segments Meta analysis by simillis et al, surgery 2007 Sasaki et al, BJS 2009 • Few reports of right hepatectomy Ibrahim et al, J am coll surg 2005 • Can be performed safely in cirrhotic patients Buell et al, J am coll surg 2005
- 94. LAPAROSCOPY Advantages • Decreased operating time • Lower overall cost Francesco et al, surg endosc 2008 • Less pain, early discharge, faster recovery • Less adhesions Topal et al, surg endosc 2008 Sasaki et al, BJS 2009
- 95. LAPAROSCOPY Disadvantages • Chance of gas embolism • Tumor dissemination • Tumor margin
- 96. LIVER RESECTION- COMPLICATIONS • Blood loss • Bile leakage • Post-operative liver failure
- 97. Associating Liver Partition & Portal Vein Ligation For Staged Hepatectomy (ALPPS) Indications • Marginally resectable or primarily non-resectable locally advanced liver tumors of any origin with an insufficient FLR either in volume or quality • Need to perform major liver resections combined with synchronous resection of other organs (i.e. Colorectal cancer and liver metastases, neuroendocrine pancreatic, or intestinal tumors with massive liver metastases)
- 102. CONCLUSION • Tumours & LDLT are major indications for liver resections • PVE, TACE & ALPPS may help us resect tumours previously considered unresectable • Intermittent Pringle maneuver is still the widely used method for inflow control • Surgery without vascular occlusion possible with aid of new instruments – CUSA, Waterjet • Harmonic & Ligasure - for superficial parenchymal transection