Dorsal approach in laparoscopic extended left hemi-hepatectomy: A case series.

RATIONALE: The utility of the dorsal approach has been reported for laparoscopic left hemi-hepatectomy. PATIENT CONCERNS: The aim of the present study is to show the usefulness of the dorsal approach for laparoscopic extended left-hemi-hepatectomy while ensuring safe identification of hepatic veins and dissection of the dorsal tumor margin. DIAGNOSES: Tumors requiring extended left hemi-hepatectomy. INTERVENTIONS: After mobilization of the lateral sector and division of the Arantius plate, parenchyma above the Arantius plate is removed to expose the root of the middle hepatic vein and left hepatic vein. Each of these veins can be isolated separately either intra- or extra-hepatically. After removing the parenchyma on the cranial side of the left Glissonean pedicle continuous with the exposed hepatic veins, the left Glissonean pedicle is isolated using the Glissonean pedicle transection method. After division of the left hepatic vein and Glissonean pedicle, segment 4 (in which the main part of the tumor is commonly located) is dissected from the anterior plane of the paracaval portion of the caudate lobe by the dorsal approach, along with the hepatic hilum. Following dissection of the dorsal side of the tumor, and division of parenchyma from the anterior edge of the liver, the anterior Glissonean branches and middle hepatic vein are divided safely and the specimen is resected. OUTCOMES: Three patients underwent laparoscopic extended left hemi-hepatectomy, with no open conversions. Operative time and blood loss were 331 (concomitant with another partial hepatectomy), 277, and 315 minutes; and 200, 100, and 100 g, respectively. The postoperative courses were uneventful. LESSONS: The dorsal approach maximizes the advantages of laparoscopic extended left hemi-hepatectomy and can be performed safely.

[Vascular reconstruction and transplantation technologies in liver surgery (part II)]. / Sosudistye rekonstruktsii i transplantatsionnye tekhnologii v khirurgii pecheni (chast' II).

OBJECTIVE: To systematize tactical and technical aspects of liver resections with reconstruction of afferent and efferent blood supply and/or inferior vena cava; to study postoperative outcomes in patients with focal liver lesions using transplantation technologies. MATERIAL AND METHODS: We enrolled 413 patients with parasitic lesions, primary and secondary liver tumors involving great vessels (portal vein, hepatic artery, hepatic veins, inferior vena cava, right atrium). All ones underwent liver resections with vascular resection and reconstruction, as well as liver autotransplantation in vivo, ante situ (ex situ in vivo), extracorporeal liver resections with autotransplantation (ex vivo). RESULTS: We obtained satisfactory immediate results after liver resections using transplantation technologies. CONCLUSION: Transplantation technologies in liver surgery can significantly increase resectability of tumors and survival of patients. Transplantation technologies are an important new surgical strategy and necessary option in modern hepatic surgery.

Double hepatic vein reconstruction during extended anatomical resection of segment 8 for colorectal liver metastasis.

BACKGROUND: Hepatic vein reconstruction (HVR) is occasionally necessary for resecting hepatic malignancies to ensure surgical margins while preserving remnant liver function [1]. Reports of multiple HVR are rare due to the highly technical demanding procedure and high risk of morbidity [2]. We introduce our procedure of double HVR for metastatic liver tumors invading the right hepatic vein (RHV) and middle hepatic vein (MHV). METHODS: The patient was a 66-year-old man with colorectal liver metastasis in segment 8, invading RHV and MHV. Due to impaired liver function, extended right hemihepatectomy was unsuitable. Thus, extended anatomical resection of segment 8 with double HVR was performed. The liver was completely mobilized and the RHV and MHV were secured. After liver parenchyma dissection, the specimen was connected by RHV and MHV (Fig. 1). The MHV was dissected and reconstructed using a right superficial femoral vein graft while the RHV remained connected [3]. Reconstruction of the MHV was performed on the posterior wall of the proximal side, followed by the anterior wall, using 4-point supporting threads. Anastomosis was performed by the over-and-over suture method. On the distal side, two-point supporting threads were applied. After specimen removal, the RHV was resected and reconstructed in the same manner using a left internal jugular vein graft [4]. RESULTS: The patient was discharged on postoperative day 14 with no signs of liver failure. Computed tomography performed six months after surgery revealed no graft occlusion (Fig. 2). CONCLUSION: In appropriately selected patients, this technique may be a useful option for preserving the remnant liver function.

A patient alive without disease 32 months after conversion surgery following lenvatinib treatment for hepatocellular carcinoma with a tumor thrombus originating in the middle hepatic vein and reaching the right atrium via the suprahepatic vena cava: a case report.

Conversion surgery for initially unresectable hepatocellular carcinoma appears to be increasing in incidence since the advent of new molecular target drugs and immune checkpoint inhibitors; however, reports on long-term outcomes are limited and the prognostic relevance of this treatment strategy remains unclear. Herein, we report the case of a 75-year-old man with hepatocellular carcinoma, 108 mm in diameter, accompanied by a tumor thrombus in the middle hepatic vein that extended to the right atrium via the suprahepatic vena cava. He underwent conversion surgery after preceding lenvatinib treatment and is alive without disease 51 months after the commencement of treatment and 32 months after surgery. Just before conversion surgery, after 19 months of lenvatinib treatment, the main tumor had reduced in size to 72 mm in diameter, the tip of the tumor thrombus had receded back to the suprahepatic vena cava, and the tumor thrombus vascularity was markedly reduced. The operative procedure was an extended left hepatectomy with concomitant middle hepatic vein resection. The tumor thrombus was removed under total vascular exclusion via incision of the root of the middle hepatic vein. Histopathological examination revealed that more than half of the liver tumor and the tumor thrombus were necrotic.

Metallic Stents for Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplantation and their Therapeutic Effects.

BACKGROUND: Living-donor liver transplantation (LDLT) is established as a standard therapy for end-stage liver disease; however, vessel reconstruction is more demanding due to the short length and small size of the available structures compared with deceased-donor whole liver transplantation. Interventional radiology (IR) has become the first-line treatment for vascular complications after LDLT. Hepatic venous outflow obstruction (HVOO) is a life-threatening complication after LDLT. The aim of this study of 592 adult-to-adult LDLT cases was to investigate the safety and efficacy of stent implantation for HVOO after LDLT. METHODS: Records of patients who developed HVOO requiring any treatment were collected with special reference to the metallic stent implantation. There were 232 left-side grafts and 360 right-side grafts. Sixteen cases developed HVOO after LDLT with an incidence rate of 2.7%, 5 with a left liver graft (2%), and 11 with a right-side graft (3%). The IR was attempted for 14 cases; among those, 8 cases were treated by stent implantation. RESULTS: The technical success rate of the initial stent implantation was 100%. The pressure gradient at the stenotic site significantly improved from 12.2 (range, 10.9-20.4 cm H2O) to 3.9 cm H2O (range, 1.4-8.2 cm H2O; P = .03). The volume of the congested graft liver decreased significantly from 1448 (range, 788-2170 mL) to 1265 mL (range, 748-1665 mL; P = .01), and the serum albumin level improved significantly from 3.3 (range, 1.7-3.7 g/dL) to 3.7 g/dL (range, 2.9-4.1 g/dL; P = .02). No procedure-related complication was noted, and the long-term stent patency was 100%. CONCLUSION: Metallic stent implantation for stenotic venous anastomosis after LDLT is a safe and effective treatment.

Novel Use of the Falciform Ligament for MHV Reconstruction During Laparoscopic Hepatectomy of Colorectal Liver Metastasis.

BACKGROUND: Laparoscopic hepatectomy (LH) with oncological R0 resection combined with systemic therapy offers the best chance of cure for colorectal liver metastasis. However, tumors in vicinity of major hepatic veins require complex technique. Parenchyma-sparing resection with involved vein resection and peritoneal patch reconstruction could be an efficacious alternative to preserve liver volume for adjuvant chemotherapy and avoid venous congestion of the remnant liver.1,2 METHODS: A 64-year-old female, with history of colon cancer, had new diagnosis of liver metastatic tumor of S8 (2.8 cm), which was considering encroached on middle hepatic vein (MHV) with distal part patent. Thus margin-negative, parenchyma-sparing liver resection with involved vein resection and proximal MHV reconstruction was indicated for oncological radicality. RESULTS: With the patient in modified French position, we dissected falciform ligament and right coronary ligament to expose the crypt between right hepatic vein (RHV) and MHV. Intraoperative ultrasound localized the tumor and resection margin. Parenchymal dissection was performed caudally to cranially, left to right, to ligate dorsal branch of G8 (G8d) and V8 and expose main trunk of MHV. The involved side-wall of MHV was incised after the proximal and distal parts clamped. Peritoneal patch was harvested from falciform ligament to repair MHV side-wall before clamps released. The patient had an uneventful recovery and remained disease-free at 1 year postoperatively with patency of distal MHV by image. CONCLUSIONS: LH with MHV reconstruction by falciform ligament for metastatic lesion is technically demanding but feasible with oncological radicality and volume preservation for adjuvant chemotherapy.

Pediatric living donor liver transplant for Budd-Chiari syndrome using a cryopreserved pulmonary vein graft for retro-hepatic vena cava reconstruction: A case report.

INTRODUCTION: In pediatric patients with Budd-Chiari syndrome (BCS), living donor liver transplantation (LDLT) raises substantial challenges regarding IVC reconstruction. CASE PRESENTATION: We present a case of an 8-year-old girl with BCS caused by myeloproliferative syndrome with JAK2 V617F mutation. She had a complete thrombosis of the inferior vena cava (IVC) with multiple collaterals, developing a Budd-Chiari syndrome. She underwent LDLT with IVC reconstruction with a cryopreserved pulmonary vein graft obtained from a provincial biobank. The living donor underwent a laparoscopic-assisted left lateral hepatectomy. The reconstruction of the vena cava took place on the back table and the liver was implanted en bloc with the reconstructed IVC in the recipient. Anticoagulation was immediately restarted after the surgery because of her pro-thrombotic state. Her postoperative course was complicated by a biliary anastomotic leak and an infected biloma. The patient recovered progressively and remained well on outpatient clinic follow-up 32 weeks after the procedure. CONCLUSION: IVC reconstruction using a cryopreserved pulmonary vein graft is a valid option during LDLT for pediatric patients with BCS where reconstruction of the IVC entails considerable challenges. Early referral to a pediatric liver transplant facility with a multidisciplinary team is also important in the management of pediatric patients with BCS.

Laparoscopic Liver Tunnel for Tumors at the Hepatocaval Confluence.

BACKGROUND: Tumors at the hepatocaval confluence can be treated with parenchyma-sparing surgery, also with minimally invasive approach.1,2 The "Liver Tunnel" was described for tumors involving the paracaval portion of Sg1 in contact or infiltrating the middle hepatic vein (MHV).3 A "Liver Tunnel" with laparoscopic approach is proposed. METHODS: A 48-year-old woman was referred for three synchronous colorectal liver metastases in the paracaval portion of Sg1 in contact with the inferior vena cava and the MHV, in Sg8 ventral and in Sg6, after an urgent left laparoscopic hemicolectomy for an obstructing carcinoma. A laparoscopic Sg1 resection extended to Sg8 ventral were planned after neoadjuvant chemotherapy. Estimated future liver remnant (FLR) was 75% (840 ml) of healthy liver (Fig. 1). In case of right hepatectomy extended to Sg1, estimated FLR was 25% (280 ml) of healthy liver. Fig. 1 3D reconstruction and intraoperative images of Liver Tunnel (A) and Sg6 resection (B). Total liver volume: 1110 ml. Total resected liver volume 270 ml: Liver Tunnel 93 ml; Sg6 177 ml. Liver volumes were measured with HA3D™ technology with Medics3D software (Medics3D, Turin, Italy) RESULTS: Pneumoperitoneum is established, and four operative ports are placed. Sg1 is approached from the left, dividing the Glissonean pedicles and short hepatic veins. MHV is approached cranio-caudally from the dorsal side. The resection continues on the ventral side, according to our "Ultrasound Liver Map technique" with a cranio-caudal approach to the MHV.4 Sg8 ventral pedicles are divided and the resection completed with aid of indocyanine green negative staining. A Sg6 resection is then performed. Operative time was 480 min. Blood loss was 100 ml. The postoperative course was uneventful, and the patient was discharged on fourth postoperative day. The two parenchyma-sparing resections saved an estimated volume of 75% (840 ml) of healthy liver (Fig. 1). The estimated remnant liver volume after a right hepatectomy extended to Sg1 would have been only 25%. CONCLUSIONS: Tumors at the hepatocaval confluence involving Sg1 can be removed with the "Liver Tunnel," which can be performed with minimally invasive approach. The "Laparoscopic Liver Tunnel" pushes further the limit of minimally invasive parenchyma-sparing surgery for ill-located tumors with complex vascular relationship.

Quantitative anatomy of the large variant right hepatic vein: A systematic three-dimensional analysis.

Anatomical variations of the right hepatic vein, especially large variant right hepatic veins (≥5 mm), have important clinical implications in liver transplantation and resection. This study aimed to evaluate anatomical variations of the right hepatic vein using quantitative three-dimensional visualization analysis. Computed tomography images of 650 patients were retrospectively analyzed, and three-dimensional visualization was applied using the derived data to analyze large variant right hepatic veins. The proportion of the large variant right hepatic vein was 16.92% (110/650). According to the location and number of the variant right hepatic veins, the configuration of the right hepatic venous system was divided into seven subtypes. The length of the retrohepatic inferior vena cava had a positive correlation with the diameter of the right hepatic vein (rs = 0.266, p = 0.001) and the variant right hepatic veins (rs = 0.211, p = 0.027). The diameter of the right hepatic vein was positively correlated with that of the middle hepatic vein (rs = 0.361, p < 0.001), while it was inversely correlated with that of the variant right hepatic veins (rs = -0.267, p = 0.005). The right hepatic vein diameter was positively correlated with the drainage volume (rs = 0.489, p < 0.001), while the correlation with the variant right hepatic veins drainage volume was negative (rs = -0.460, p < 0.001). The number of the variant right hepatic veins and their relative diameters were positively correlated (p < 0.001). The volume and percentage of the drainage area of the right hepatic vein decreased significantly as the number of the variant right hepatic vein increased (p < 0.001). The findings of this study concerning the variations of the hepatic venous system may be useful for the surgical planning of liver resection or transplantation.

Laparoscopic anatomical resection of segment II: left lateral section-flip up method to safely and effectively encircle the Glissonean branch and expose the left hepatic vein (with video).

Laparoscopic anatomical resection of liver segment II (S2 segmentectomy) using left lateral section-flip up method is introduced to safely and effectively encircle the Glissonean branch of segment II (G2) and to expose the left hepatic vein (LHV). The left lateral section is completely mobilized and then flipped up. After encircling and clamping the G2 root, indocyanine green is intravenously injected and the demarcation line is clearly confirmed by near infrared fluorescence imaging. After exposure of the LHV from the root to this intersegmental plane between segments II/III, residual parenchymal resection is performed using the clamp crushing method. There are two difficulties concerning S2 segmentectomy. The first is encirclement of the G2 root without interfering with the G3. Compared with the conventional front view of the umbilical portion, the view behind the left lateral section contribute to easy confirmation and direct encircle of the G2 root without dividing the G3 and injuring LHV on the same plane. The second difficulty is that the boundary of the visible liver surface between segments II/III does not match the direction of the LHV. This can cause confusion to the operator aiming to perform precise inner parenchymal resection. Our procedure allows easy access to the LHV root and exposure of the peripheral directing hepatic vein. Hepatic vein-guided approaches will likely be helpful in precise performance of inner parts of liver resection.

Pure Laparoscopic Anatomic Resection of Liver Segment 4 with Middle Hepatic Vein Involvement Using Indocyanine Green Fluorescence Staining.

BACKGROUND: Laparoscopic anatomic resection of liver segment 4 is a technically challenging operation, which is rarely reported owing to the difficulty of defining the demarcation of a hepatic segment 4 on a monitor.1 The portal territory staining method is technically feasible to identify tumors and segment boundaries during hepatectomy.2 Herein, we describe the laparoscopic hepatectomy of segment 4 using the fluorescent-positive staining method. METHODS: A 72-year-old man recurred colorectal liver metastases after colectomy, positron emission tomography (PET)/computed tomography (CT) showed metastases located in segment 4 with involvement of the middle hepatic vein (MHV) and caudate lobe; no other organ metastasis or recurrence occurred. We performed an anatomical hepatectomy 4 with MHV and parenchymal resection of segment 1 (H1'/4-MHV).3 The key point of the procedure was dividing and clamping Glisson's branches for segment 2 and segment 3 using the hepatic round ligament approach; the G2 and G3 were dissected along the right side of round ligament via the extrahepatic Glissonian approach, then the left hepatic artery (LHA) was divided and injected with ICG in the left portal vein (LPV). Finally, transection was performed along the fluorescent stain location line and ischemic demarcation line. RESULTS: The operation time was 263 min; the Pringle lasted 110 min, and the estimated blood loss was 400 g. The patient was discharged on postoperative day 5 without complications. Sigmoid carcinoma and R0 margin were confirmed by histopathology. CONCLUSIONS: Laparoscopic anatomic hepatectomy 4 with middle hepatic vein invasion using indocyanine green (ICG) fluorescence staining is a feasible and effective technique.

Accessory hepatic vein recanalization for Budd-Chiari syndrome: a systematic review and meta-analysis.

BACKGROUND: Budd-Chiari syndrome (BCS) results when the outflow of the hepatic vein (HV) is obstructed. BCS patients exhibiting an accessory HV (AHV) that is dilated but obstructed can achieve significant alleviation of liver congestion after undergoing AHV recanalization. This meta-analysis was developed to explore the clinical efficacy of AHV recanalization in patients with BCS. MATERIALS AND METHODS: PubMed, Embase, and Wanfang databases were searched for relevant studies published as of November 2022, and RevMan 5.3 and Stata 12.0 were used for pooled endpoint analyses. RESULTS: Twelve total studies were identified for analysis. Pooled primary clinical success, re-stenosis, 1- and 5-year primary patency, 1- and 5-year secondary patency, 1-year overall survival (OS), and 5-year OS rates of patients in these studies following AHV recanalization were 96%, 17%, 91%, 75%, 98%, 91%, 97%, and 96%, respectively. Patients also exhibited a significant reduction in AHV pressure after recanalization relative to preoperative levels (P < 0.00001). Endpoints exhibiting significant heterogeneity among these studies included, AHV pressure (I2 = 95%), 1-year primary patency (I2 = 51.2%), and 5-year primary patency (I2 = 62.4%). Relative to HV recanalization, AHV recanalization was related to a lower rate of re-stenosis (P = 0.002) and longer primary patency (P < 0.00001), but was not associated with any improvements in clinical success (P = 0.88) or OS (P = 0.29) relative to HV recanalization. CONCLUSIONS: The present meta-analysis highlights AHV recanalization as an effective means of achieving positive long-term outcomes in patients affected by BCS, potentially achieving better long-term results than those associated with HV recanalization.

Hepatic venous outflow obstruction after adult living donor liver transplantation.

Hepatic venous outflow obstruction (HVOO) is a rare but critical vascular complication after adult living donor liver transplantation. We categorized HVOOs according to their morphology (anastomotic stenosis, kinking, and intrahepatic stenosis) and onset (early-onset < 3 mo vs. late-onset ≥ 3 mo). Overall, 16/324 (4.9%) patients developed HVOO between 2000 and 2020. Fifteen patients underwent interventional radiology. Of the 16 hepatic venous anastomoses within these 15 patients, 12 were anastomotic stenosis, 2 were kinking, and 2 were intrahepatic stenoses. All of the kinking and intrahepatic stenoses required stent placement, but most of the anastomotic stenoses (11/12, 92%) were successfully managed with balloon angioplasty, which avoided stent placement. Graft survival tended to be worse for patients with late-onset HVOO than early-onset HVOO (40% vs. 69.3% at 5 y, p = 0.162) despite successful interventional radiology. In conclusion, repeat balloon angioplasty can be considered for simple anastomotic stenosis, but stent placement is recommended for kinking or intrahepatic stenosis. Close follow-up is recommended in patients with late-onset HVOO even after successful treatment.

Exposure of the hepatic vein trunk via tracing of its branches: a useful surgical procedure for laparoscopic anatomical hepatectomy.

BACKGROUND: Although there are various advantages of laparoscopic liver resection (LLR) over open liver resection, some problems have been reported, such as disorientation and lack of control of bleeding during liver parenchymal dissection. In this study, we discuss a strategy to overcome the disorientation experienced during liver parenchymal dissection, especially in anatomical LLR. TECHNICAL PRESENTATION: This procedure involves hepatic parenchymal dissection from the hepatic vein branch along its trunk to reveal an important landmark in anatomical LLR. Knowing which region of the liver is perfused into each hepatic vein in preoperative 3D simulation allows the tracing of the hepatic vein branch that naturally leads to the hepatic vein trunk. After that, hepatic resection can be easily completed by dissecting the line connected to the other landmarks, the Glisson branch, the root of the hepatic vein, and the liver demarcation line. CONCLUSION: In conclusion, this surgical procedure that traces the branch of the hepatic vein exposes the trunk, which makes it a very useful tool for limited laparoscopic anatomical hepatectomy.

Complications of e-PTFE Grafts in LDLT; Evaluation of Case Series.

BACKGROUND: The expanded polytetrafluoroethylene (ePTFE) grafts are used to drain anterior sector veins during the living donor liver transplantation procedure. We aimed to analyze the potentially life-threatening complications, such as the infection and migration of ePTFE grafts. METHODS: A total of 1264 liver transplantations (LTs) were performed for 1097 adult and 167 pediatric liver failure cases. In total, 1169 living and 95 cadaveric liver transplantation procedures were performed between 2011 and 2021. Right liver transplantation was performed in 1016 cases, including 1002 living donors and 14 cadaveric split right livers. Cadaveric LT was performed in 81 cases. RESULTS: For 1002 right living liver grafts, 905 vascular grafts were used during the backtable for anterior sector outflow venoplasty. The most commonly drained segments were 5 and 8 (472 cases); there were isolated (5 or 8) and multiple drained segments. Vascular graft migration was described in 7 of 905 (0.77%) patients. CONCLUSIONS: Although complication rates regarding ePTFE grafts are low, there are serious life-threatening causes of morbidity and mortality. We recommend cushioning the vascular graft with the omentum, which is effective in preventing graft migration.