Exposure of the left hepatic duct through the hilum or in the umbilical of the liver: anatomic limitations.

Anastomosis to the left hepatic duct approached by dissecting the hilar plate is the most reliable method of drainage of the left side of the liver in that longitudinal incision of the left hepatic duct allows a long cholangiojejunostomy. However, the anatomy is not satisfactory in 30% of cases for adequate drainage of the left side of the liver. To further clarify this surgically important area, 107 vasculobiliary casts were reviewed with regard to the anatomy and relationship between the left biliary ductal and left portal venous systems. In cases in which anatomy is unfavorable for adequate drainage by anastomosis to the left hepatic duct in the hilum, several options are available. The anterior portion of the main portal fissure may be opened to gain wide access to the superior aspect of the biliary plate and reach a posterior duct that is more suitable for anastomosis. An anastomosis to an anterior duct may also be possible with this approach. If left portal ducts are inaccessible by division of the main portal fissure because of a retroportal location, then an anastomosis in the anterior portion of the umbilical fissure may give adequate drainage. Therefore a cholangiogram is imperative before any anastomosis in the hilum or the anterior portion of the umbilical fissure.

A simplified method for controlled left hepatectomy.

Left hepatectomy consists of the removal of the area supplied by the left portal pedicle, separated from the right lobe of the liver by the main portal fissure running from the middle of the gallbladder bed to the left anterior surface of the inferior vena cava; removal of the caudate lobe is optional. During the first step in conventional hepatectomy, the elements of the left portal pedicle are usually dissected in the hilum, and many surgeons remove the gallbladder. The procedure is not always easy to perform and death and morbidity are not negligible. A recent case gave me the opportunity to elaborate on a simple technique: ligation without interruption of the left pedicle in the left end of the hilum, providing immediate hemostasis of the left liver and making resection as easy as that for a cholecystectomy or hysterectomy.

The dorsal sector of human liver: embryological, anatomical and clinical relevance.

The dorsal liver sector has been recognized as the parenchyma surrounding the vena cava and is quite independent of the remaining liver. It is that part of the organ in which the hepatic portion of the vena cava develops and its venous outflow remains strictly connected with the vena cava by means of multiple, not dissectable effluents as well as with the main hepatic veins. Therefore, this sector is a major shunt between the main hepatic veins and the inferior vena cava, which enlarges and ensures venous drainage for survival in cases of Budd-Chiari syndrome. The dorsal sector consists of two segments: a left one (segment I) corresponding roughly to the caudate lobe and a right one (segment IX) in front and on the right of the vena cava, including the so-called caudate process. The identification of a dorsal liver sector and its detailed anatomy is of primary importance for surgical practice, since cholangiocarcinoma of bile duct hilar confluence extends to the dorsal sector and makes resection of this sector necessary for efficient therapy and due consideration of the pedicles of segment I and IX is required to perform successful hemihepatectomy as well as liver partition for split liver grafting.

Sinistroposition of the gallbladder and the common bile duct.

A left lateral bisegmentectomy was performed in a 29-year-old man presenting a primary lymphoma of the liver. Surgical exploration revealed a left-side gallbladder, located under the left lobe of the liver. During hepatic parenchyma dissection, performed strictly at the left of the round ligament and the umbilical portion of the left portal vein, common bile duct was injured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the umbilical portion of the left portal vein before reaching the hepatoduodenal ligament. This case report discusses the embryological mechanism that could explain this uncommon bile duct abnormality, focusing on its consequences during left ruled lobectomy.

[Errors in the topographic diagnosis of liver diseases]. / Erreur dans le diagnostic topographique des lésions hépatiques.

To identify the portal pedicles in liver pathology is difficult: anatomical variations are ignored and only the modal disposition is retained, the obliquity of the liver in situ is ignored: strongly inclined to the right, posteriorly and inferiorly (the anterior sector is above and to the right of the posterior sector, their pedicles in an antero-posterior radiogram are superposed); and the sizes of segments IV and VI are quite variable (embryologic result). This study was made with a collection of 111 vasculo-biliary acrylic casts. The main portal fissure containing the middle hepatic vein follows the axis of the cystic fossa. Actually the position of this axis varies from 18 degrees to the right of the vein (gall-bladder under segment V) and 14 degrees to the left (gall-bladder under segment IV); the fissure reaches the inferior vena cava only at the limit of the upper surface of the liver, the vena cava is separated from the right and left livers by the dorsal sector. The anterior half of the right portal fissure is quite variable, it can reach the anterior liver from the main portal fissure up to the anterior portion of the right margin of the liver (segment VI variation); in 41% of the livers (n = 100), the right hepatic vein is in the right portal fissure; occlusion of the anterior or the posterior right arteries indicates the fissure. The left portal fissure is often confused with the left hepatic fissure (limit between academic left and right lobes). Segments breadths are measured in the upper surface of the liver. The largest segments are VIII, V, III and II; their transversal breadth is also the largest (simple to double). In difficult cases, a tri-dimensional reconstruction of the pedicles should be made from an helicoïdal tomodensitometry.

[Ischemic necrosis of the lesser curvature of the stomach after supraselective vagotomy. Apropos of 2 personal cases and 43 cases published in the literature]. / Nécrose ischémique de la petite courbure de l'estomac après vagotomie supra-sélective. A propos de 2 cas personnels et de 43 observations publiées dans la littérature.

The author presents two personal cases (from a series of 176 operations) of this complication of which 43 cases have already been reported in the literature. Necrosis perforating into the peritoneum is the most dramatic form: fever, pain, abdominal distension and most importantly, the appearance of gastric fluid in the drain (hence the importance of drainage). X-rays show a gas-fluid level in the left hypochondrium. It is important to be aware of this complication, as the prognosis depends on early re-operation (most often an overlapping suture): the mortality is presently 23,5%. One external gastric fistula has been reported. A common form is a necrotic ulcer walled off by neighbouring tissues. It is sometimes quite small, revealed by endoscopy in which case it generally heals with medical treatment. It can be very large requiring operation because of its persistence or because of haemorrhages. In this case, it is most often treated by gastrectomy. The pathogenesis of this condition is uncertain; it seems preferable not to denude the esophagus too much and not to interfere with collateral blood supply: ligature of small vessels, splenectomy, fundoplication has also been implicated. Only one fact is certain: the high incidence in patients with renal failure and hypertension; in no case should these patients be submitted to a highly selective vagotomy.

[Zinc]. / Le zinc.

Zinc is indispensable for life from bacteria to man. As a trace element it is included in numerous enzymes or serves as their activator (more than 80 zinc metallo-enzymes). It is necessary for nucleic acid and protein synthesis, the formation of sulphated molecules (insulin, growth hormone, keratin, immunoglobulins), and the functioning of carbonic anhydrase, aldolases, many dehydrogenases (including alcohol-dehydrogenase, retinal reductase indispensable for retinal rod function), alkaline phosphatase, T cells and superoxide dismutase. Its lack provokes distinctive signs: anorexia, diarrhea, taste, smell and vision disorders, skin lesions, delayed healing, growth retardation, delayed appearance of sexual characteristics, diminished resistance to infection, and it may be the cause of congenital malformations. Assay is now simplified by atomic absorption spectrophotometry in blood or hair. There is a latent lack prior to any disease because of the vices of modern eating habits, and this increases during stress, infections or tissue healing processes. Its lack is accentuated during long-term parenteral feeding or chronic gastrointestinal affections. Correction is as simple as it is innocuous, and zinc supplements should be given more routinely during surgical procedures.

[A "scandal": segment IV and liver transplantation]. / Un scandale: segment IV et transplantation du foie.

Partition right-left lobes keeps segment IV in continuity with the right liver, but interrupts its portal elements which arise from the left portal pedicle. A precise anatomical investigation shows that the venous inflow is totally interrupted. In 12.15% of the cases (n = 107) the biliary duct from segment IV enters close to the upper biliary confluent, into the confluent or the main duct, and can be preserved in such a bipartition; in all other cases the segment is no longer in function and doomed to atrophy. In 10.75% of the livers (n = 99), the segmental artery comes from the right hepatic stem, and the segment is correctly vascularized; but in most cases interruption of both the artery and the portal branches leads to immediate necrosis, which may be lethal. Preservation of both artery and biliary ducts is possible in only 2.15% of the cases (n = 93 casts with correct injection of arteries and ducts). Consequently the partition right-left lobes is possible in only a few cases: cholangiography and arteriography detect the favourable dispositions. In all other cases such partition is forbidden. Procurement of the left lobe from a living donor with preservation of segment IV is rarely possible, such cases being detected by a thorough pre-operative vasculo-biliary investigation: the left lobe is harvested, and segment IV left in situ (2.15% of the cases). Usually the prospective of rapid necrosis or secondary atrophy commands resection of the segment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Absence of portal bifurcation]. / Absence de la bifurcation porte.

Since the first description in 1957, absence of the portal bifurcation has been reported by four different teams, which makes a total of 5 cases and a frequency of 1.90%. Serious complications may occur postoperatively, and this anomaly should be systematically detected. There is a huge portal ring: the main vessel enters the liver, looking like a large right paramedian vein, turns to the right within the parenchyma, reaches the umbilical fissure to send the usual branches of REX' recessus, and ends as a terminal branch for the caudate lobe. The right lateral vein appears as a collateral. Numerous anterior and posterior branches supply segments IV, V and VIII. Two main facts: the portal ring turns around the axis of the middle hepatic vein, which is in the center of the ring. There is a rupture in the portal triad of the left portal pedicle: the vein is intra-hepatic, the artery and biliary duct lie normally in the hilum. The detection of this anomaly should always be done by portography or ultra-sonography. When operating, it is easily detected: there is no portal bifurcation and the left portal vein is missing. The main difficulty is to perform a right hepatectomy. After total vascular by-pass, the portal system is skeletonized and resection achieved. Another solution is to interrupt the portal stem deep in the hilum, divide the main portal fissure along the right margin of the middle hepatic vein and cut the transversal portion of the portal ring.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sub-phrenic abscess: 28 cases, one death (author's transl)]. / Abcéx sous-phréniques. 28 observations: 1 mort.

28 patients were operated on for subphrenic abscess, one patient died. The author emphasises the disadvantages of excessive antibiotics. The diagnosis should be made early in order to avoid severe infective complications. The diagnosis is not difficult. It is nowadays facilitated by echotomography and scannography, which permit one to localise precisely the collection of pus and to detect multiple abscesses. The incision should carefully avoid crossing the peritoneal or pleural cavities. The quality and the permanence of the drainage are the key to success. One should therefore leave in position numerous aspiration drains. One should generally abstain from any suture or digestive anastomosis. It is sufficient to direct the digestive fistula, when present, towards the skin surface. But the best policy is to avoid this operative complication the origin of which is almost always a mistake in the design or installation of the drain at the end of various operations on the abdomen.

[Coagulation and the general surgeon. Its physiology and laboratory tests]. / La coagulation et le chirurgien généraliste. La physiologie et les examens de laboratoire.

Mechanisms of coagulation and appropriate laboratory tests necessary for general surgical procedures are outlined. Physiologic features discussed include: platelet coagulation (with a brief analysis of the release and the role of prostaglandins); the equilibrium between plasma coagulation and lysis, each dependent on activators and inhibitors (a total of 4 enzymatic systems); and finally the role of the liver, lungs, and reticuloendothelial system. However, the two types of coagulation are narrowly intricated. Vessel endothelium prevents or assists platelet adhesion, coagulation, and lysis. An important feature is that total blood coagulates more rapidly than plasma. Physiopathological features described are activation of platelets or their inhibition by anti-aggregants, and induction of coagulation by endothelial lesions or eruption of an autologous or heterologous protease, as well as a brief outline of consumption coagulopathy and disseminated intravascular coagulation, and the concept of hypercoagulability. With respect to laboratory tests it is suggested that an overall picture of coagulation of total blood and not of plasma should be obtained before individual examinations for certain coagulation or lysis elements. Minimum data necessary preoperatively are the coagulation and bleeding times, completed by questioning the patient, the costs of these procedures being insignificant. If laboratory tests are necessary, these should involve a thromboelastogram of total blood, sometimes combined with a test of ADP-induced platelet aggregation. Certain plasma tests can provide complementary confirmatory data. These remarks are obviously applicable to general and digestive surgery only, and not to research investigations or the study of rare phenomena.

[Fistulae in esophageal surgery. (Solidity of the esophageal wall and the role of infection)]. / Essai sur les fistules en chirurgie oesophagienne. (Solidité de la paroi oesophagienne et rôle de l'infection)

The strength of the eosophageal wall has been tested in 20 autopsy specimens: it proved to be as resistant as the stomach and the jejunum. It dépends as elsewhere in the digestive tract on the deep layer of the mucosa (Halstedt's submucosa): the success of an anastomosis depends on the passage of sutures through this submucosa. Vascularization does not seem to be a problem, provided certain precautions are taken. The necrotizing properties of saliva and infection especially in cancerous surgery might be the main causes of fistulas.

[Surgical approach to the posterior surface of the liver (author's transl)]. / Abord de la face postérieure du foie.

Anterior incision does not afford a direct approach to lesions located in the posterior part of the liver, or to right subphrenic and retrohepatic abcesses, and may contaminate the peritoneal cavity in suppurative collections. Posterior incision is a more direct approach. It can be extrapleural and extraperitoneal, or transpleural with exclusion of the pleura when resecting a lower rib; a posterior thoraco-phreno-laparotomy gives a wider exposure. When the pleural cavity has been opened it should be drained and excluded before dealing with the subphrenic lesion. Such an incision is advocated in posterior abscesses of the liver, in those located under the diaphragm or posterior to the liver, as well as in posterior hydatic and biliary cysts. Scannography helps to locate exactly the cavity and makes sure that there is no other cyst or collection. Endoscopic cholangiography supplies valuable information concerning the bile ducts in case of hydatic cyst.