Fig. 11.1
J-shaped laparotomy. The incision starts from the xiphoid process on the midline to approximately 3–4 cm above the umbilicus. Then, it curves laterally towards the right hypocondrium until it reaches to the costal arch, at the level of the ninth intercostal space
Fig. 11.2
Liver handling after a J-shaped laparotomy. This incision allows the surgeon’s left hand to be positioned behind the liver at the posterior aspect of the defined dissection plane. Furthermore, it allows controlling the backflow bleeding by hanging the liver
Fig. 11.3
Vertical view of the hepato-caval confluence achieved by means of the removal of the xiphoid process
Fig. 11.4
Lateral view of the hepato-caval confluence with the surgeon seated: this perspective facilitates the mobilization of the right liver from the inferior vena cava (IVC). Tumor (T)
When the tumor is located in the para-caval portion of segment 1 or anyway at the hepato-caval confluence, and control of the hepatic veins at this level does not seem fully achievable with the abdominal incision only due to patient characteristics and/or the tumor features (position, relations and size), two solutions are possible, both featured by representing an extension of the J-shaped laparotomy, and both having the aim of extending the working space for the surgeon, especially at the mid–late phases of the dissection and in general when the major veins are approached.
A J-shaped thoraco-phreno-laparotomy has the peculiarity of allowing the operator himself to have more space for left-hand positioning and the related liver handling (Fig. 11.5), and moreover opening a better view of the hepato-caval plane, which becomes in line with the visual plane of the operator (Fig. 11.6) [24], this being particularly useful for affording conservative resection of large tumor located in segment 1 (Fig. 11.7) [25]. It is worth stressing the fact that the need for opening the chest may not be evident during mobilization of the liver, but generally it appears crucial during the dissection, and more often at the end of it when the specimen is going to be detached from the hepatic veins, and more space for handling, particularly with the left hand, could be needed. Therefore, paradoxically, chest-opening is a maneuver more frequently carried out by expert surgeons rather than young fellows, since it is a decision taken taking advantage moreover of the background experience which leads the surgeon to foresee the potential difficulties of the resection, and to shift to a thoraco-phreno-laparotomic approach without hesitation.
Fig. 11.5
J-shaped thoraco-phreno-laparotomy. The incision is a standard J-shaped laparotomy which continues along the ninth intercostal space up to mid-axillary line on the skin and the posterior axillary on the intercostal space. In this way, the space for the surgeon’s left hand is increased, with a better control of the hepato-caval confluence
Fig. 11.6
Lateral view of the hepato-caval confluence after a J-shaped thoraco-phreno-laparotomy. The space for the surgeon’s left hand is increased with a better view and control of the hepato-caval confluence. Right lung (L); inferior vena cava (IVC)
Fig. 11.7
J-shaped thoraco-phreno-laparotomy for a large tumor located in segment 1. The liver and the tumor (T) have been completely mobilized from the inferior vena cava (IVC)
A median extension to the lower abdomen is selected (Fig. 11.8), particularly in the event of existing median incision: this access facilitates the caudal tilting of the liver once mobilized, and like the previous incision a larger space for positioning the left hand and then for handling the liver. However, this access is not provided by a surgeon’s visual plane being perpendicular to the hepato-caval space, and is probably linked to a higher risk of wound hernias.
Fig. 11.8
Schematic representation of a J-shaped laparotomy (or thoraco-phreno-laparotomy in yellow) with a median extension to the lower abdomen
IOUS Intraoperative Staging
In the case of CLM, the increment of the detection power of IOUS is still relevant. Indeed, in these patients the detection of any tiny nodule undiscovered preoperatively becomes crucial for attempting a reduction of the still high postoperative early recurrence rate [26]. Between 10 and 40% of patients who are carriers of colon cancer have not palpable CLM [27, 28]; as a consequence of that, IOUS exploration of the liver remains crucial, and contrast-enhanced intraoperative ultrasound (CE-IOUS) seems able to enhance its role in this sense. In a maximized parenchymal-sparing perspective, the relevance of an accurate staging is obvious for avoiding missing any tiny lesion, and otherwise resulting in a resection which would be radical but is in fact an R2 operation.
CE-IOUS in these conditions seems useful in a particular setting of patients carrying multiple CLM: those without a bright liver (steatotic) at IOUS [29], and presenting isoechoic CLM [30] (Fig. 11.9).
Fig. 11.9
Contrast-enhanced intraoperative ultrasound (CE-IOUS on the right) which is better revealing a isoechoic colorectal liver metastasis (T) compared with unenhanced IOUS (left)
New perspectives can be obtained by using liver-specific contrast agents, which allow prolonged exploration. In a preliminary experience CE-IOUS only showed new lesions in 2 out of 8 patients [31]. More recent studies have shown that the prolonged persistence of the black-hole effect may help also in detecting intraoperatively those metastatic foci which disappear after chemotherapy [32].
Mobilization
For right-sided segmentectomies or subsegmentectomies or sectionectomies, the bare area is dissected and the right hemiliver is mobilized till the surgeon’s left hand is positioned behind the hemiliver, sustaining it, and is comfortably positioned over the posterior aspect of the drawn dissection plane (Fig. 11.10). This mobilization should be extensive enough to allow allocation of the surgeon’s hand, minimizing the risk during the traction maneuvers of damaging the adjacent structures, and particularly any short hepatic vein which should be preventivly divided whenever at the edge of the dissection area: in the unfortunate event, their damaging could be the source of conspicuous bleeding from the inferior vena cava (IVC), which could even be massive because recognized late since it occurs back to the liver, and could be source of vessel fractures extended to the caval wall, meanwhile the surgeon is concentrated on dissecting the liver.
Fig. 11.10
Definition of the resection area. a The surgeon’s left-hand fingertip and the probe act simultaneously to draw the optimal dissection plane to be followed. b The corresponding IOUS image in which the yellow dashed line indicates the ideal dissection plane that runs from the echoic shadow generated by the electrocautery interposed between the liver surface and the probe (EC) to the surgeon’s fingertip (F); tumor (T)
Therefore, a slight mobilization of the right hemiliver just dividing the triangular ligament and partially or completely the bare area will be accomplished for lesions located in segments 5, 6, 7 inferior and 8 ventral. Conversely, the right side of the retrohepatic IVC is reached for lesions located in the segments 7 and 8 dorsal. If the lesion is close to the hepatocaval confluence (last 4 cm), but not in contact with the hepatic veins, the retro-hepatic caval ligament is not divided, and only the space between the right hepatic vein (RHV) and the middle hepatic vein (MHV) is dissected allowing for finger-tip insertion and eventual compression. The caval confluence of the RHV is recognized following the trajectory of the right inferior phrenic vein, which flows near the RHV at this level and which is a constant landmark (Fig. 11.11) [33].
Fig. 11.11
Lateral view of the hepato-caval confluence after a J-shaped laparotomy. The right inferior phrenic vein (RIPV) represents a constant landmark for the caval confluence of the right hepatic vein (RHV) into the inferior vena cava (IVC)
If the lesion is still right-sided but in contact with an hepatic vein at its caval confluence (Fig. 11.12), or is involving the para-caval portion of the segment 1 (Fig. 11.13), liver mobilization includes division of the retro-hepatic caval ligament and exposure of the retro-hepatic IVC until the area to be resected is under control of the surgeon’s left hand (surgeon’s finger tip being placed over the most distal portion of the planned dissection plane). This detachment proceeds unless control is obtained, even though this means reaching the complete detachment from the IVC (Fig. 11.14): in this case, once the mobilization of the segment 1 is complete, and carried out through a right-sided approach, the left-hand fingertips are positioned at the edge between the segment 2 and 1 where the Arantius’ ligament runs, somehow hooking the caudate lobe (Fig. 11.15).
Fig. 11.12
IOUS image that shows a tumor (T) in contact with the right hepatic vein (RHV) at its confluence into the inferior vena cava (IVC). Middle hepatic vein (MHV); portal branch to the right anterior section (P5–8)
Fig. 11.13
IOUS image showing a tumor (T) involving the para-caval portion of the segment 1; middle hepatic vein (MHV); inferior vena cava (IVC)
Fig. 11.14
Complete detachment of the liver from the inferior vena cava (IVC). The fossa where the IVC was laying is shown
Fig. 11.15
The surgeon’s left-hand fingertips are positioned at the edge between segments 2 and 1 where the Arantius’ ligament runs, hooking the Spigelian lobe (SL)
For segment 2 and 3 segmentectomies or subsegmentectomies, the left triangular ligament and the left coronary ligament are divided, and the left lobe is handled with the surgeon’s left hand.
For lesions located at the segment 4 superior at the hepato-caval junction, the mobilization combines the one described for lesions at the segments 7 inferior and 8 ventral and for those in the left lobe. For these lesions, once a relationship with the main trunk of the MHV is established, particular attention should be paid to the fact that MHV generally features a vertical confluence into the IVC (Fig. 11.16), which makes its length shorter than the others, and moreover, its central position makes its compression more difficult; for these reasons, the injury of this vein during the dissection could be source of massive bleeding, and therefore a preventive check of the control of the vein flow by finger compression, or vein encirclement itself, have always to be considered.
Fig. 11.16
IOUS image showing the perpendicular, and straight confluence of the middle hepatic vein (MHV) into the inferior vena cava (IVC)
A particular trick which deserves to be mentioned is the use of IOUS to help mobilization once there are adhesions which may mask important structures to be recognized and preserved such as the hepatic hilum, the IVC, and the hepatic veins: just positioning the probe to check the position of these structures in relation to the dissection area (the surgeon’s finger tips positioned in there would be helpful), and the distance between the latter and the structures themselves, helps to avoid them being damaged, with the severe consequences related with that.
Tumor–Vessel Detachment
The glissonian pedicle may be spared when in contact with an encapsulated hepatocellular carcinoma (HCC) or a CLM, with integrity of the vessel wall appreciable at IOUS without any sign of bile duct dilation (Fig. 11.17). In the presence of bile duct dilation, tumor thrombus, invasion of the vessel wall, and for CLM, contact wider than half of the pedicle circumference, the pedicle must be divided (Fig. 11.18). In these conditions, extension of the hepatectomy is required for complete tumor clearance.
Fig. 11.17
IOUS image showing a CLM (T) in contact with the portal branch to the right anterior section (P5–8) without signs of infiltration (integrity of the vessel wall and no signs of bile duct dilation). The glissonian pedicle may be spared
Fig. 11.18
In the presence of bile duct dilation (BD), the pedicle must be divided
The hepatic vein may be spared when in contact with an encapsulated HCC with integrity of the vessel wall appreciable at IOUS (Fig. 11.19). Initially for the CLM, its contact was considered an indication for hepatic vein resection; more recently sparing of the hepatic vein is always attempted when the contact extension is less than two-thirds of the vein circumference at IOUS (Fig. 11.20).
Fig. 11.19
a IOUS image showing an encapsulated HCC (T) in contact with the middle hepatic vein (MHV) and the right hepatic vein (RHV). b In this case, the hepatic veins could be spared
Fig. 11.20
a IOUS image showing a CLM (T) in contact with the right hepatic vein (RHV) at its confluence into the inferior vena cava (IVC). b In this case, the hepatic vein is spared
Flow Analyses
In the presence of tumor thrombus, invasion of the vessel wall, and contact wider than two-thirds of the vein circumference in CLM, the hepatic vein must be divided (Fig. 11.21). In these conditions, extension of the hepatectomy is not compulsorily considered, even if the hepatic vein is invaded at its caval confluence (the last 4 cm). Indeed, an extension of the resection to the liver parenchyma theoretically drained by the hepatic vein to be resected is considered only if one of the following US signs is missing:
Presence of accessory hepatic veins at IOUS as an inferior right hepatic vein (IRHV) (Fig. 11.22) [34] in the presence of an invasion at the caval confluence of the right hepatic vein.
Color-flow IOUS (CF-IOUS) showing hepatopetal blood flow in the feeding portal branch, once the hepatic vein to be resected is clamped [35] by means of encirclement, or more simply by vein compression at its extrahepatic route using a fingertip [36]
Fig. 11.21
a IOUS image showing a CLM (T) infiltrating (red arrows) the right hepatic vein (RHV). b In this case, the hepatic vein is resected
Fig. 11.22
IOUS image showing an inferior right hepatic vein (IRHV). This vein typically runs behind the right portal branch (RPV). Portal branch to the right anterior section (P5–8); portal branch to the right posterior section (P6–7); inferior vena cava (IVC)
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