Techniques of Exposure, Hilar Dissection, and Parenchymal Division in Hepatic Surgery

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1 Techniques of Exposure, Hilar Dissection, and Parenchymal Division in Hepatic Surgery William C. Chapman, MD, J. Kelly Wright, MD, Paul E. Wise, MD, and C. Wright Pinson, MD, MBA A number of methods for hepatic parenchymal transection facilitate ligation and division of hepatic vessels and biliary ducts in the plane of resection. Each represents a tool available to the liver surgeon, depending on training, experience, and personal preference. Although each method may have slight advantages in specific circumstances, experienced liver surgeons can usually successfully complete the parenchymal transection using various techniques. SURGICAL TECHNIQUE Exposure Proper exposure is crucial to the safety, ease, and efficiency of any operative procedure. This is no less true for hepatobiliary procedures because of the size and location of the liver and its proximity to major vascular structures. Surgeons have developed numerous abdominal and thoracic incisions to provide adequate access to the entire surface of the liver. In addi- tion, by using self-retaining retractor systems, the surgeon can obtain and maintain adequate exposure without depending on fatigable and nonstationary assistants. Performing complete dissection of the liver's ligamentous attachments can then provide even better exposure by achieving increased mobility of the organ and the surrounding viscera. From the Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN. Address reprint requests to C. Wright Pinson, M.D., M.B.A., F.A.C.S, Department of Surgery, Division of Hepatobiliary Surge D, and Liver Transplantation, Oxtord House, Suite 801, Vanderbilt University Medical Center, Nashville, TN ~-753. Copyright 2002, Elsevier Science (USA). All rig)its reserved X/02/ /0 doi: /otgn Operative Techniques in General Surgery, Vol 4, No 1 (March), 2002: pp

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Exposure, Hilar Dissection, and Parenchymal Division ] 5 extension ;tension Thoracic exter Subcos f~ :ii!!!!i!i!!!~ii~ 84 2 The surgeon can choose from a number of incisions based on the planned procedure.

The upper midline incision has been favored by most surgeons for traumatic liver injuries 4 and by some surgeons for elective cases on the biliary tract and left lobe of the liver.

3 Exposure, Hilar Dissection, and Parenchymal Division ] 5 extension ;tension Thoracic exter Subcos f~ :ii!!!!i!i!!!~ii~ 84 2 The surgeon can choose from a number of incisions based on the planned procedure. Little literature has been dedicated to the choice of incision when performing hepatobiliary procedures.l'2"3 Thus, most surgeons' preferences are based on their training. The upper midline incision has been favored by most surgeons for traumatic liver injuries 4 and by some surgeons for elective cases on the biliary tract and left lobe of the liver. This incision provides limited access to the right side of the liver, may provide limited exposure in obese patients or those with a short distance between the xiphoid and the umbilicus, and has a significant incidence of ventral herniation postoperatively. ~ Paramedian, Kocher, and interneural right upper quadrant incisions have also been popular for some biliary procedures, but they have only limited usefulness because of the limited exposure of the liver that they afford. The bilateral subcostal incision is the most popular incision among hepatobiliary surgeons. 5'6 This incision allows for exposure of the supra-, retro-, and infrahepatic vena cava, excellent exposure of the porta hepatis, and room for complete mobilization of the liver if necessary. Beginning any right upper quadrant procedure with an 8 to 10-cm incision approximately 3-4 cm (two fingerbreadths) inferior to the right costal margin allows for quick and easy assessment of the upper abdomen for the presence of metastases, the extent of local pathology, resectability, and any anomalous anatomy. The incision can then be extended to the right and left subcostal regions as needed to provide improved exposure. Alternatively, laparoscopy may allow a quick, minimally invasive assessment of peritoneal metastases and can be combined with laparoscopic ultrasonography to provide more detail as to the number and location of hepatic tumors and their resectability.

, 16 Chapman et al Rectus sheath 2 (continued) A perpendicular midline extension to the xiphoid also improves mobilization of the thoracic and anterior abdominal walls, especially in patients with

4 , 16 Chapman et al Rectus sheath 2 (continued) A perpendicular midline extension to the xiphoid also improves mobilization of the thoracic and anterior abdominal walls, especially in patients with narrow costal angles. Excision of the xiphoid may prove useful (B). A thoracic extension of the right subcostal incision into the sixth or seventh intercostal space provides excellent exposure of the right suprahepatic and posterior liver but increases morbidity from postoperative pulmonary complications. 3,r We have found that appropriate use of the bilateral subcostal incisions with the midline extension and adequate retraction makes the thoracic extension unnecessary. 8 Some authors have also suggested turning the midline xiphoid extension into a full sternotomy to further increase suprahepatic exposure, 9 but this is seldom necessary unless the heart or supradiaphragmatic vena cava must be exposed. Once the initial celiotomy is complete, the ligamentum teres hepatis (round ligament) within the falciform ligament can be ligated and divided. This allows for complete opening of the wound and placement of the surgeon's choice of self-retaining retractor. Surgical assistants with hand-held retractors are not always available in all operating facilities in sufficient numbers (two or three may be needed), are fatigable, and may find it difficult to remain steady. In addition, the number of assistants needed to retract often restricts the surgeon at an overcrowded operating table. For these reasons, we encourage the use of a self-retaining retraction system. Different retractor systems are available, each with its individual advantages and disadvantages ,12

Exposure, Hilar Dissection, and Parenchymal Division 17 3 We have chosen the split-ring Bookwaher self-retaining retractor because of its ease of assembly and adjustment and have found it quite

5 Exposure, Hilar Dissection, and Parenchymal Division 17 3 We have chosen the split-ring Bookwaher self-retaining retractor because of its ease of assembly and adjustment and have found it quite effective in providing adequate traction and countertraction when performing hepatobiliary procedures. 8 To use this system, a table post with a 30 to 45-degree extension bar is fixed over the drapes to the right siderail of the table at the patient's nipple line. A rod is suspended from this apparatus to hold the segmented ring, which is centered over the liver and tilted at 45 degrees.

This is performed with a Balfour blade with a tilting ratchet in the upper midline along with three or more right-angle blades

6 18 Chapman et al A 4 The tilt in the ring allows for elevated cephalad retraction of the thorax along with caudal retraction of the other viscera. This is performed with a Balfour blade with a tilting ratchet in the upper midline along with three or more right-angle blades (depending on the incision size) on the costal margins to elevate the thorax and flatten the diaphragm. This is usually sufficient to provide access to the diaphragm and suprahepatic cava when caudal retraction on the liver is applied (A).

$Exposure, Hilar Dissection, and Parenchymal Division 19 Falciform ligament divided '\. 3.,.84, J i /- J! Portal triad r < 3 9 iii'., h'>- ""... ~Jf B =!$

7 Exposure, Hilar Dissection, and Parenchymal Division 19 Falciform ligament divided '\. 3.,.84, J i /- J! Portal triad r < 3 9 iii'., h'>- ""... ~Jf B =! 4 (continued) Malleable retractors placed on the inferior portion of the ring can be used to retract the stomach and duodenum to the left and the hepatic flexure of the colon caudally and to the right out of the operative field, providing excellent exposure of the porta hepatis (B).

20 Chapman et al / Falciform ligament m / Right riangular ligament A Bare area (A, B) Once the retractor is in place, the liver can be further mobilized with division of the ligamentous attachments

8 20 Chapman et al / Falciform ligament m / Right riangular ligament A Bare area (A, B) Once the retractor is in place, the liver can be further mobilized with division of the ligamentous attachments superiorly and posteriorly (Shown here from above and looking caudally). These suspensory ligaments, including the left and right triangular ligaments and the anterior and posterior coronary ligaments, form a triangular or diamond-shaped area along the posterior aspect of the liver that corresponds to the bare area of the liver and contains the retrohepatic inferior vena cava and hepatic veins.

$Right triangular ligament \ Portal triad B Posterior coronary$

9 Exposure, Hilar Dissection, and Parenchymal Division 21 IVC & hepatic veins Anterior coronary ligament Left triangular ligament., Falciform ligament Tissue corresponding to bare area of liver Right triangular ligament \ Portal triad B Posterior coronary ligament (continued)

22 Chapman et al Right hepatic vein Adrenal ve Adrenal gla 6 Careful division of these ligaments allows for elevation and rotation of the liver to provide access to the posterior right lobe of

Easy visualization and access to these structures provides a safe means of achieving sufficient vascular control before any resection.

10 22 Chapman et al Right hepatic vein Adrenal ve Adrenal gla 6 Careful division of these ligaments allows for elevation and rotation of the liver to provide access to the posterior right lobe of the liver, the retrohepatic cava, the right adrenal gland, and the right adrenal vein. Easy visualization and access to these structures provides a safe means of achieving sufficient vascular control before any resection. Access to and control of lesser hepatic veins emptying into the retrohepatic interior verla cava can be achieved. But hepatic rotation must be carefully performed, not only because the liver can be damaged with compression against any of the sharp retractor blades, but also because the liver might fracture, especially in patients with a friable or fatty liver.

laparoscopic liver procedures than in those performed in an open fashion. Again, the process begins with proper positioning, depending on the area of liver in focus.

11 Exposure, Hilar Dissection, and Parenchymal Division 23 7 Laparoscopy is increasingly used in hepatic resections of segments II- VI. 13'14 The subject and controversies of laparoscopic-assisted liver resections are discussed in detail in other articles in this issue, but obtaining adequate exposure is no less important in laparoscopic liver procedures than in those performed in an open fashion. Again, the process begins with proper positioning, depending on the area of liver in focus. For resections of segments 11, III, IVa, and V, the patient is placed supine with the legs separated so that the surgeon may stand between the legs (A). For resections of segment VI, the patient is best placed in the left lateral decubitus position (B). Twenty degrees of reverse Trendelenburg position can improve the exposure for laparoscopic resections by causing the free abdominal viscera to mobilize toward the pelvis. Exposure is further augmented with excision of the falciform and left triangular ligaments to the inferior vena cava for resections of segments II-IVa. Partial excision of the right triangular and posterior coronary ligaments facilitates the resection of segments V or VI.

24 Chapman et al Hilar Dissection Extrahepatic dissection and control of the porta hepatis vessels and bile ducts will facilitate major hepatic resections by limiting bleeding and ensuring that the

12 24 Chapman et al Hilar Dissection Extrahepatic dissection and control of the porta hepatis vessels and bile ducts will facilitate major hepatic resections by limiting bleeding and ensuring that the remaining liver is fully vascularized and has ade- quate biliary drainage. These major resections include lobectomies, extended lobectomies, and those liver resections of lesions situated in close apposition to hilar structures. 8 A full understanding of the relational anatomy of the structures in the hepatoduodenal ligament and hepatic hilum is imperative for safe liver resection. In general, the bile duct occupies the anterior right porta hepatis. At the inferior liver edge is a confluence of a transversely oriented left hepatic duct and a more axially oriented right hepatic duct, which descends as the common hepatic duct (CHD) to join the cystic duct at the inferior border of the triangle of Calot and become the common bile duct (CBD). The proper hepatic artery generally approaches the liver in the left anterior porta hepatis and branches into right and left hepatic arteries in the hepatic hilum. The right hepatic artery usually passes posterior to the CHD (85%) before entering the liver. The portal vein lies in the posterior porta hepatis, and its primary bifurcation is at the inferior edge of segment IV. 15

13 Exposure, Hilar Dissection, and Parenchymal Division 25 Left Replaced righl artery artery a~ Right artery.~ry artery 9 A significant variability exists in the arterial and biliary anatomy that needs to be anticipated and defined during dissection of the porta hepatis. A replaced right hepatic artery may arise from the superior mesenteric artery and ascend in the right posterior porta behind the CHD and CBD in 20% of patients. With similar frequency, a replaced left hepatic artery may arise from the left gastric artery and cross the gastrohepatic ligament to enter the left liver outside the porta hepatis. Wide variation in the locations of sectoral bile ducts and their confluences may be seen; for example, major sectoral ducts of the right liver may join the left hepatic duct peripheral to the primary bifurcation or may descend in the porta to join the CHD or CBD distally. 16'17

26 Chapman et al I-I Principal plane 10 Further variability of the anatomy of the porta hepatis can arise if the liver has undergone sectoral or lobar atrophy and/or hypertrophy.

14 26 Chapman et al I-I Principal plane 10 Further variability of the anatomy of the porta hepatis can arise if the liver has undergone sectoral or lobar atrophy and/or hypertrophy. Rotational distortion of the relational anatomy of the hepatoduodenal ligament can hinder exposure of the hepatic hilum. as (Shown here as left-sided hypertrophy) In patients with adhesions and scarring from previous surgery in the porta hepatis, dissection of the hepatoduodenal ligament can be tedious. Careful division of the adhesions between the hepatic flexure of the colon and the liver, mobilization of the duodenum, and intermittent palpation of the region of the porta hepatis to identify hepatic artery pulses can facilitate approaching the hepatoduodenal ligament from the right in anticipation of exposing the CBD as an initial landmark.

Exposure, Hilar Dissection, and Parenchymal Division 27 Gall Hepatic artery ~ry Portal vein Bile duct 1 1 Hilar dissection for liver resection generally begins with cholecystectomy and exposure of

Further incision across the peritoneum of the porta hepatis allows for progressive exposure and isolation of the primary branches of the hepatic artery and hepatic duct at the hilum of the liver.

15 Exposure, Hilar Dissection, and Parenchymal Division 27 Gall Hepatic artery ~ry Portal vein Bile duct 1 1 Hilar dissection for liver resection generally begins with cholecystectomy and exposure of the triangle of Calot to facilitate early identification of the CHD-CBD junction. Further incision across the peritoneum of the porta hepatis allows for progressive exposure and isolation of the primary branches of the hepatic artery and hepatic duct at the hilum of the liver. At times, exposure of the hilar structures is improved by the incision of Glisson's capsule and elevation of segment IV (quadrate lobe). This dissection within the hilar plate can be carried out peripherally to gain control of segmental vascular and bilary branches as necessary for the anticipated parenchymal resection. Lobar or sectoral divisions of the portal triads, enveloped in a sheath of fibrous tissue originating from Glisson's capsule, can be defined during parencymal dissection and ligated en masse. ~9 Exposure and control of portal vein branches may be easier after bile duct and hepatic artery branch ligation and division. Additionally, portal vein isolation is facilitated by full mobilization of the liver and rotation of the liver to the left to better expose the right posterior aspect of the porta hepatis.

16 28 Chapman et al 12 Occasionally, liver resection is part of the management of a proximal bile duct tumor. Because of the close proximity of the hilar biliary tumor and the hepatic artery, the portal vein, and their branches, exposure of these vascular structures can be difficult. Circumferential dissection and division of the CBD distally allows for the anterior reflection of the CBD and CHD with adjacent neural and lymphatic tissues to skeletonize the hepatic artery and portal vein cephalad towards the hilum of the liver. 19

17 Exposure, Hilar Dissection, and Parenchymal Division 29 artery Portal vein 13 Alternatives to extensive hilar dissection for liver resection include extrahepatic occlusion of the hepatoduodenal ligament (Pringle maneuver) (A) and total vascular isolation (B).

30 Chapman et al Parenchymal Division A 14 After abdominal exploration and exposure of the liver and hilar dissection, the final phase of liver resection is completed with parenchymal division.

Because of the extensive vascular and bile duct network within the liver, the goal of parenchymal division is to expediently dissect and ligate hepatic vessels and bile ducts in the plane of

18 30 Chapman et al Parenchymal Division A 14 After abdominal exploration and exposure of the liver and hilar dissection, the final phase of liver resection is completed with parenchymal division. There are a number of techniques that have been developed to facilitate this portion of the procedure. Because of the extensive vascular and bile duct network within the liver, the goal of parenchymal division is to expediently dissect and ligate hepatic vessels and bile ducts in the plane of transection with minimal blood loss. 21 Portal venous tributaries are enveloped by Glisson's capsule, making them somewhat resistant to traumatic injury during the parenchymal transection. In contrast, hepatic venous branches may be thin walled and can be more easily avulsed during manipulation. The specific techniques used to dissect hepatic tissue away from vessels and bile ducts depend on the surgeon's preference and experience and by available technology within the surgeon's hospital setting. Temporary hepatic inflow occlusion (Pringle clamping) or complete vascular isolation are other techniques that may be used selectively to lessen blood loss during parenchymal division. 22'23 (A) Finger fracture (digitoclasia) parenchymal division has been the most widely used and is perhaps the simplest technique for parenchymal division in liver resection. 24 This technique is performed by initially incising the liver capsule along the planned resection plane, usually with electrocautery. After the liver capsule has been incised, the dissection is initiated with a blunt instrument (e.g., scissor tip or blunt clamp) by working through the parenchymal tissue. Vessels and bile ducts can be individually identified, encircled, and either suture ligated or divided with surgical clips. Many surgeons prefer to suture ligate ducts and larger vessels on the remnant liver side of the division and use surgical clips only on the specimen side, because clips may become dislodged during liver manipulation as the resection proceeds. Finger fracture techniques can also be combined with other methods of parenchymal division. The advantages of the finger fracture dissection technique are its simplicity and speed. This technique does not require sophisticated instrumentation that may be unavailable in some operative centers. The disadvantage of the finger fracture technique is the potential decrease in operative precision. Some authors have reported an increased blood loss using finger fracture compared with other methods, including ultrasonic dissection 25 (see below). However, one of the only reported randomized, prospective controlled trials comparing finger fracture dissection with ultrasonic dissection found no differences in operative blood loss, and the authors claimed that operative precisionwas actually improved with the finger fracture technique. 24

19 Exposure, Hilar Dissection, and Parenchymal Division (continued) (B) The ultrasonic aspirator is a popular method among many liver surgeons for parenchymal transection. This device uses an ultrasonic dissector to lyse hepatic parenchyma while preserving the integrity of vascular and biliary structures within the substance of the liver. This technique is intended to allow precise visualization and dissection of portal venous and hepatic venous branches, which can then be individually ligated and divided. Available systems can incorporate electrocautery as a component in the ultrasonic dissection, facilitating division of small vessels and bile ducts during liver transection. Disadvantages of these systems include the relatively high system purchase cost ($60,000-$100,000) and the cost of disposables required on a per case basis ($500- $1,000). Moreover, parenchymal transection using ultrasonic dissection is usually slower than finger fracture transection or the use of other mechanical devices. Surgical staplers have been used during open and laparoscopic liver resections. 26 Vascular staplers

32 Chapman et al REFERENCES 1. Bluestone L, Freed JS, Szuchmacher PH: The interneural incision for biliary tract operations. Surg Gynecol Obstet 147:21-24, 1978 2.

20 32 Chapman et al REFERENCES 1. Bluestone L, Freed JS, Szuchmacher PH: The interneural incision for biliary tract operations. Surg Gynecol Obstet 147:21-24, Thierry B, Morel P, Huber O, et al: Combined midline-transverse surgical approach for severe blunt injuries to the right liver. J Trauma 48: , Sato H, Sugawara Y, Yamasaki S, et al: Thoracoabdominal approaches versus inverted T incision for posterior segmentectomy in hepatocellular carcinoma. Hepatogastroenterology 47: , Feliciano DV: Surgery for liver trauma, Surg Clin North Am 69: , Huguet C, Addario-Chieco P, Gavelli A, et al: Technique of hepatic vascular exclusion for extensive liver resection. Am J Surg 163: , Meyers WC, Callery MP, Scaffer BK, et al: Staging, resection, and ablation of liver tumors, in Townsend CM (ed): Sabiston Textbook of Surgery, ed 16 Philadelphia: WB Saunders, 2001, p Foster JH: Liver resection techniques. Surg Clin North Am 69: , Pinson CW, Drougas JG, Lalikos JI: Optimal exposure for hepatobiliary operations using the Bookwalter retractor. Am Surg 61: , Jones RS: Atlas of Liver and Bjliary Surgery. Chicago, IL, Year Book, 1990, pp Stieber AC: Hepatic transplantation with the aid of the iron intern retractor. AmJ Surg 160: , Ong G, Nakayama F: New abdominal retractor for exposure of subphrenic region. Surg Gynecol Obstet 166:75-76, Dorton HE: New self-retaining retractor holder to facilitate surgical exposure. AmJ Surg 141: , Descottes B, Lachachi F, Sodji M, et al: Early experience with laparoscopic approach for solid liver tumors: Initial 16 cases. Ann Surg 232: , Cherqui D, Husson E, Hammound R, et ah Laparoscopic liver resections: a feasibility study in 30 patients. Ann Surg 232: , HealeyJE: A Synopsis of Clinical Anatomy. Philadelphia, PA WB Saunders, 1969, p Henderson, JM, Rikkers LE: Atlas of liver surgery, in Bell RH, Rikkers LF, Mulholland MW (eds): Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven, 1996, pp Skandalakis LJ, Colborn GL, Gray SW, et al: Surgical Anatomy of the Liver and Extrahepatic Biliary Tract. In Nyhus LM, Baker RJ: Mastery of Surgery, ed 2 Boston, MA, Little, Brown 1992, pp Blumgart LH: Hilar and intrahepatic bilary enteric anastomosis. Surg Clin North Am 74: , Pinson CW, Rossi RL: Extended right hepatic lobectomy, left hepatic lobectomy and skeletonization resection for proximal bile duct cancer. WorldJ Surg 12:52-59, Launois B,Jamieson GG: The importance of Glisson's capsule and its sheaths in the intrahepatic approach to resection of the liver. Surg Gynecol Obstet 174:7-10, Rees M, Plant G, Wells J, et ah One hundred and fifty hepatic resections: Evolution of technique towards bloodless surgery. BrJ Surg 83: , Belghitti J, Noun R, Malafosse R., et al: Continuous versus intermittent portal triad clamping for liver resection: a controlled study. Ann Surg 229: , Elias D. Lasser P, Debaene B, et al: Intermittent vascular exclusion of the liver (without vena cava clamping) during major hepatectomy. BrJ Surg: 82: , Takayama T, Makuuchi M, Kubota K, et al: Randomized comparison of ultrasonic vs. clamp transection of the liver. Arch Surg 136: , Fan ST, Lai ES, Lo CM, et al: Hepatectomy with an ultrasonic dissector for hepatocellular carcinoma. BrJ Surg 83: , Fong Y, Blumgart LH: Useful stapling techniques in liver surgery. J Am Coll Surg 185:93-100, 1997

Accessory Glands of Digestive System

Accessory Glands of Digestive System The liver The liver is soft and pliable and occupies the upper part of the abdominal cavity just beneath the diaphragm. The greater part of the liver is situated under