Application value of cystic plate approach for extrahepatic right hepatic pedicle dissection in minimally invasive anatomic liver resection / 中华消化外科杂志

Objective:To investigate the application value of cystic plate approach (CPA) for extrahepatic right hepatic pedicle dissection in minimally invasive anatomical hepatectomy (MIALR).Methods:The retrospective cohort study was conducted. The clinicopathological data of 42 patients with primary liver cancer who underwent laparoscopic right hemi-hepatectomy in Nanfang Hospital of Southern Medical University from August 2020 to August 2022 were collected. There were 36 males and 6 females, aged (55±13)years. Of the 42 patients, 25 cases undergoing CPA for extrahepatic right hepatic pedicle dissection were divided into the CPA group, and 17 cases undergoing traditional approach for extrahepatic right hepatic pedicle dissection were divided into the traditional approach group. Observation indicators: (1) surgical situations; (2) postoperative situations. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( IQR), and comparison between groups was conducted using the Mann?Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi?square test or Fisher exact probability. Comparison of ordinal data was conducted using the non‐parameter rank sum test. Results:(1) Surgical situations. All patients in the two groups underwent laparoscopic right hemi-hepatectomy successfully, with the surgical margin as negative. The operative time, volume of intraoperative blood loss, time of dissection of the targeted hepatic pedicle, cases undergoing dissection of the trunk of right anterior hepatic pedicle and its operation time, cases undergoing dissection of the trunk of right posterior hepatic pedicle and its operation time, cases with hepatic pedicle injury, cases with hepatic tissue injury, cases with dissection space as large and small were 150.00(130.00)minutes, 100.00(100.00)mL, 472.00(201.00)seconds, 10 and 366.00(94.75)seconds, 9 and 564.00(138.50)seconds, 2, 2, 25, 0 in patients of the CPA group, versus 140.00(113.00)minutes, 100.00(125.00)mL, 670.00(107.00)seconds, 8 and 663.00(136.00)seconds, 7 and 783.00(189.00)seconds, 8, 5, 2, 19 in patients of the traditional approach group. There were significant differences in the time of dissection of the targeted hepatic pedicle, time of dissection of the trunk of right anterior hepatic pedicle, time of dissection of the trunk of right posterior hepatic pedicle, hepatic tissue injury, dissection space between the two groups ( Z=-4.809, -3.254, -3.188, χ2=6.493, 34.314, P<0.05) and there was no significant difference in the operation time, volume of intraoperative blood loss, dissection of the trunk of right anterior hepatic pedicle, dissection of the trunk of right posterior hepatic pedicle, hepatic tissue injury between the two groups ( Z=-0.282, -0.412, χ2=0.095, 0.002, 1.976, P>0.05). (2) Postoperative situations. There was no patient undergoing postoperative hemorrhage in both of the two groups. The alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin (TBil) and prothrombin time (PT) at postoperative day 3, cases with postoperative biliary fistula, pathological type of tumor (hepatocellular carcinoma, intrahepatic cholangiocarcinoma) were 68.00(48.50)U/L, 52.00(35.50)U/L, 28.30(12.35)mmol/L, 12.40(2.40)seconds, 2, 21, 4 in patients of the CPA group. The above indicators were 58.00(25.00)U/L, 41.00(19.50)U/L, 26.80(14.25)mmol/L, 12.50(2.95)seconds, 5, 15, 2 in patients of the traditional approach group. There was no significant difference in the ALT, AST, TBil, PT at postoperative day 3, cases with postoperative biliary fistula between the two groups ( Z=-1.218, -1.488, -0.205, -0.320, χ2=1.976, P>0.05), and there was no significant difference in the pathological type of tumor between the two groups ( P>0.05). Conclusion:Application of CPA for extrahepatic right hepatic pedicle dissection in MIALR is safe and feasible.

Application value of cystic plate approach for extrahepatic right hepatic pedicle dissection in minimally invasive anatomic liver resection / 中华消化外科杂志

Objective:To investigate the application value of cystic plate approach (CPA) for extrahepatic right hepatic pedicle dissection in minimally invasive anatomical hepatectomy (MIALR).Methods:The retrospective cohort study was conducted. The clinicopathological data of 42 patients with primary liver cancer who underwent laparoscopic right hemi-hepatectomy in Nanfang Hospital of Southern Medical University from August 2020 to August 2022 were collected. There were 36 males and 6 females, aged (55±13)years. Of the 42 patients, 25 cases undergoing CPA for extrahepatic right hepatic pedicle dissection were divided into the CPA group, and 17 cases undergoing traditional approach for extrahepatic right hepatic pedicle dissection were divided into the traditional approach group. Observation indicators: (1) surgical situations; (2) postoperative situations. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( IQR), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data was conducted using the non‐parameter rank sum test. Results:(1) Surgical situations. All patients in the two groups underwent laparos-copic right hemi-hepatectomy successfully, with the surgical margin as negative. The operation time, volume of intraoperative blood loss, time of dissection of the targeted hepatic pedicle, cases under-going dissection of the trunk of right anterior hepatic pedicle and its operation time, cases under-going dissection of the trunk of right posterior hepatic pedicle and its operation time, cases with hepatic pedicle injury, cases with hepatic tissue injury, cases with dissection space as large and small were 150.00(130.00)minutes, 100.00(100.00)mL, 472.00(201.00)seconds, 10 and 366.00(94.75)seconds, 9 and 564.00(138.50)seconds, 2, 2, 25, 0 in patients of the CPA group, versus 140.00(113.00)minutes, 100.00(125.00)mL, 670.00(107.00)seconds, 8 and 663.00(136.00)seconds, 7 and 783.00(189.00)seconds, 8, 5, 2, 19 in patients of the traditional approach group. There were significant differences in the time of dissection of the targeted hepatic pedicle, time of dissection of the trunk of right anterior hepatic pedicle, time of dissection of the trunk of right posterior hepatic pedicle, hepatic pedicle injury, dissection space between the two groups ( Z=-4.809, -3.254, -3.188, χ2=6.493, 34.314, P<0.05) and there was no significant difference in the operation time, volume of intraoperative blood loss, dissection of the trunk of right anterior hepatic pedicle, dissection of the trunk of right posterior hepatic pedicle, hepatic tissue injury between the two groups ( Z=-0.282, -0.412, χ2=0.095, 0.002, 1.976, P>0.05). (2) Postoperative situations. There was no patient under-going postoperative hemorrhage in both of the two groups. The alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin (TBil) and prothrombin time (PT) at postoperative day 3, cases with postoperative biliary fistula, pathological type of tumor (hepatocellular carcinoma, intrahepatic cholangiocarcinoma) were 68.00(48.50)U/L, 52.00(35.50)U/L, 28.30(12.35)mmol/L, 12.40(2.40)seconds, 2, 21, 4 in patients of the CPA group. The above indicators were 58.00(25.00)U/L, 41.00(19.50)U/L, 26.80(14.25)mmol/L, 12.50(2.95)seconds, 5, 15, 2 in patients of the traditional approach group. There was no significant difference in the ALT, AST, TBil, PT at postoperative day 3, postoperative biliary fistula between the two groups ( Z=-1.218, -1.488, -0.205, -0.320, χ2=1.976, P>0.05), and there was no significant difference in the pathological type of tumor between the two groups ( P>0.05). Conclusion:Application of CPA for extrahepatic right hepatic pedicle dissection in MIALR is safe and feasible.

Application value of extra-glissonian pedicle transection approach guided by arantius' ligament in laparoscopic left hemihepatectomy / 中华消化外科杂志

Objective To explore the application value of the extra-glissonian pedicle transection approach guided by arantius' ligament in laparoscopic left hemihepatectomy.Methods The retrospective cohort study was conducted.The clinical data of 57 patients who underwent laparoscopic left hemihepatectomy in the First Affiliated Hospital of Fujian Medical University from January 2015 to January 2018 were collected.There were 18 males and 39 females,aged from 29 to 75 years,with an average age of 57 years.Of the 57 patients,22 undergoing the laparoscopic left hemihepatectomy with extra-glissonian pedicle transection approach guided by arantius' ligament and 35 undergoing laparoscopic left hemihepatectomy with regular intra-glissonian pedicle transection approach were allocated into the extra-glissonian transection group and intra-glissonian transection group,respectively.Observation indicators:(1) intraoperative situations and postoperative short-term outcomes;(2) postoperative complications;(3) follow-up.Patients were followed up by outpatient examination and telephone interview to investigate postoperative recurrence of diseases up to June 2018.Measurement data with normal distribution were represented as Mean±SD and comparison between groups was analyzed using the t test.Count data were described as absolute number or percentage and comparison between groups was analyzed using the chi-square test.Results (1) Intraoperative situations and postoperative short-term outcomes:the operation time,dissection time of left hepatic pedicle,volume of intraoperative blood loss were (123± 37) minutes,(14± 5) minutes,(337± 169) mL in the extra-glissonian transection group and (148± 27) minutes,(22± 3) minutes,(495±203) mL in the intra-glissonian transection group,respectively,showing statistically significant differences between the two groups (t =2.992,7.733,3.045,P＜0.05).Cases with intraoperative blood transfusion,time of gastrointestinal recovery,time for postoperative drainage-tube removal,duration of postoperative hospital stay were 1,(1.8±0.9)days,(3.2±0.9)days,(8.2± 1.7)days in the extra-glissonian transection group and 4,(2.0± 0.8)days,(3.6±0.8)days,(10.0±4.0)days in the intra-glissonian transection group,respectively,showing no statistically significant difference between the two groups (x2 =0.171,t=1.304,1.857,1.622,P＞0.05).There was no uncontrolled hemorrhage or air embolism in the two groups.(2) Postoperative complications:3 patients had complications of Clavien-Dindo classification Ⅰ in the extra-glissonian transection group including 1 of pulmonary infection,1 of abdominal infection,1 of incisional infection and 7 had complications in the intraglissonian transection group including 2 of pulmonary infection,2 of liver sectional effusion,1 of subphrenic abscess,1 of biliary leakage,1 of incisional infection,showing no statistically significant difference between the two groups (x2=0.066,P＞0.05).Patients with postoperative complications were cured and discharged after symptomatic treatment.There was no perioperative death in the two groups.(3) Follow-up:57 patients were followed up for 5-41 months,with a median time of 23 months.Two and 1 patients had tumor recurrence and hepatolithiasis recurrence in the intra-glissonian transection group,without recurrence of hepatic hemangioma or cholangiocarcinoma.Five patients had tumor recurrence in the intra-glissonian transection group,without recurrence of hepatic hemangioma,hepatolithiasis or cholangiocarcinoma.The disease recurrence rate was 13.6％ (3/22) and 14.3％(5/35) in the extra-glissonian transection group and intra-glissonian transection group,respectively,showing no statistically significant difference between the two groups (x2 =0.104,P＞0.05).Conclusions Extraglissonian pedicle transection approach guided by arantius' ligament in laparoscopic left hemihepatectomy is feasible and effective,which can control hepatic blood inflow of left liver,simplify the surgery procedure and shorten dissection time of left pedicle,in order to save operation time and reduce volume of intraoperative blood loss.

Pure laparoscopic right hemihepatectomy for hepatocellular carcinoma via the anterior approach / 中华肝胆外科杂志

Objective To study the feasibility and safety of pure laparoscopic right hemihepatectomy for hepatocellular carcinoma via the anterior approach.Methods The data of five patients with hepatocellular carcinoma who underwent pure laparoscopic right hemihepatectomy at the First People's Hospital of Foshan between December 2013 and December 2016 were retrospectively analyzed.Patients'operation time,blood loss,blood transfusion rate,surgical margins,hospital stay,complication and short term outcomes were reviewed.Results All the five patients completed pure laparoscopic right hemihepatectomy without conversion to open surgery.The average (range) operation time was 6.0 (5 ～ 8) h.The average blood loss was 340 (110 ～ 600) ml.No patient received blood transfusion.The average surgical margin was 2.4 (1 ～4.5) cm.The average postoperative hospital stay was 7 (4 ～ 15) d.The average follow-up was 22 (2 ～38) months.Three patients experienced postoperative complications,which included ascites,pleural effusion,and ascites accompanied by biliary leakage,respectively.The last patient recovered well from drainage.No liver failure,cancer recurrence or death was noted.Conclusions This study demonstrated that pure laparoscopic right hemihepatotectomy via the anterior approach is a minimally invasive procedure which has the advantage of fast postoperative recovery.It was feasible and safe to treat hepatocellular carcinoma with favorable short-term outcomes.

Clinical efficacy analysis on the precise hepatic pedicle dissection in anatomical hepatic segmentectomy / 局解手术学杂志

Objective To compare the efficacy and safety of precise hepatic pedicle anatomic hepatectomy and the irregular hepatecto-my method, and to analyze the clinical application value of precise hepatic pedicle dissection. Methods The clinical data of 120 patients with hepatocellular carcinoma treated in our hospital from Mar. 2009 to Mar. 2013 were analyzed retrospectively, and they were divided into the experimental group and the control group according to the patients’ clinical characteristics and their needs of treatment. The experimental group were given precise hepatic pedicle dissection, while the control group were given irregular liver excision. The effect, complications and recurrence rate of the two methods were compared. Results The operation time, the volume of blood during operation, hospitalization time and the cost of hospitalization of the experimental group were were less than those of the control group with statistically significant difference between the two groups (P<0. 05). The incidence of complications in the experimental group was 10. 0%, recurrence rate was 13. 3%;whereas in the control group, the incidence rate was 33. 3%, the recurrence rate was 35%, it is of significant differences between the two groups (P<0. 05). The aspartate aminotransferase and alanine aminotransferase levels of the experimental group were significantly lower than those of the control group with a statistically significant difference (P<0. 05). Conclusion The precise hepatic pedicle dissection is of significant efficacy, low complication and relapse rate, and it is of certain clinical application value.

Multiple anatomical variations of the hepatic pedicle: case report and clinical application / Múltiples variaciones anatómicas del pedículo hepático: reporte de caso y aplicación clínica

The knowledge in detail of the anatomy of the hepatic pedicle is critical when operating it and its surroundings. The presence of anatomic variations is higher at the arterial component level than at the bile component level or venous component level, which in the 90% of the cases it appears as the classic description. The presented case in this work implies a very low frequency of appearance. For this reason, the surgeon must be alert at the moment of making a decision so as to avoid injuries that may put the patient´s life at risk.

El conocimiento en detalle de la anatomía del pedículo hepático es fundamental al momento de intervenir quirúrgicamente sobre el mismo y su vecindad. La presencia de variaciones anatómicas es mayor a nivel del componente arterial, luego biliar y finalmente venoso, el cual en el 90% de los casos se dispone de acuerdo con la descripción clásica. El caso presentado en este trabajo supone una muy baja frecuencia de aparición, siendo precisamente estas disposiciones poco habituales las que obligan al cirujano a mantenerse alerta en el momento de actuar para evitar injurias que puedan comprometer la vida del paciente.

The use of the right hepatic pedicle to guide classification of liver neoplasms on medical imaging and precise liver resection / 中华肝胆外科杂志

Objective To explore the use of the right hepatic pedicle to guide classification of liver neoplasms on medical imaging and the type of liver resection.Methods From January 2009 to December 2012,32 patients with a single liver neoplasm surrounding the right hepatic pedicle,including 17 patients with primary liver cancer and 15 patients with cavernous hemangioma of liver,were recruited into this study in our hospital.Using the position of the neoplasm in relation to the right hepatic pedicle on CT or MRI,these liver neoplasms were divided into 4 types:type A neoplasms which infiltrated or surrounded the right hepatic pedicle; type B neoplasms which were in the front of the right hepatic pedicle; type C neoplasms which were at the back of the right hepatic pedicle,and type D neoplasms which were between the two branches of the right hepatic pedicle.Before surgery,a simulated plan was designed on the different hepatic vascular inflow obstruction and types of hepatectomy based on the classification in medical imaging.Results The locations of the liver neoplasm were completely in line with the preoperative imaging classification.Boththe vascular flow obstruction and the types of hepatectomy correlated with the preoperative surgery simulation planning.Five patients with type A neoplasms underwent right hemihepatectomy or extended right hepatectomy; 8 with type B tumors underwent right anterior sectionectomy or mesohepatectomy; 9 with type C neoplasms underwent segment Ⅴ,Ⅵ resection; 10 with type D tumors underwent right anterior or right posterior sectionectomy.Pringle maneuver,total hepatic blood inflow obstruction and selective right hepatic blood inflow obstruction were applied according to the operation and the regional anatomical structures.All operations were smoothly carried out with an average operation time of 145 min.The average blood loss was 320 ml and 18 patients required intraoperative blood transfusion with an average blood transfusion amount of 460 ml.Postoperative complications included bile leakage (n =3),right pleural effusion (n =2) and hemorrhage (n =1).They all responded to conservative treatment.Conclusion This classification using preoperative medical imaging of the right hepatic pedical could provide important information for liver resection,and it is helpful for formulating more refined operation scheme.

Precise hepatic pedicle dissection in anatomical hepatic segmentectomy / 中华肝胆外科杂志

Objective To review the important points in the preoperative assessment and the surgical technique in precise hepatic pedicle dissection in anatomical hepatic segmentectomy.Methods 104 patients who underwent anatomical hepatic segmentectomy were divided into two groups according to the different surgical approaches adopted in a prospective and non-randomized manner:the precise hepatic pedicle dissection group (the precise group,n=44) and the conventional hepatectomy group (the conventional group,n=60).The perioperative and follow-up data were analyzed.Patients who had primary liver cancer,including hepatocellular carcinoma and intrahepatic cholangiocellular carcinoma,were analyzed separately.Results (1) There was no perioperative death in the two groups.There was no significant differences in blood loss and transfusion between the 2 groups of patients (P=0.069,0.208; t=1.844,1.266).There was a significantly higher rate of vascular inflow occlusion (P=0.001).There were significantly longer periods of vascular inflow occlusion and operative time (P=0.001,0.001; t=3.849,3.574) in the precise group.There was no significant difference in postoperative complications (P=0.988) and the duration of postoperative hospital stay (P=0.509;t=0.662) between the two groups.(2) In patients with primary liver cancer,there were no significant differences between the precise group (n=29) and the conventional group (n=41) in tumor margin positivity,vascular invasion and pathological staging (P=0.985,0.630,0.769).(3) All patients were followed up for two years.When compared with the conventional group,the disease-free survival (P=0.012),overall survival (P =0.006),and median survival (16.5 ± 4.5mo vs.7.8 ± 3.8mo)were significantly longer in the precise group.Conclusion Precise hepatic pedicle dissection had the same safety and efficacy as conventional method in partial hepatectomy.For primary liver cancer,precise hepatic pedicle dissection had better survival compared to the conventional method when the surgical margin was negative.

Aspectos morfológicos, morfométricos e ultraestruturais do baço de ratos após o clampeamento total do pedículo hepático / Morphologic, morphometric, and ultrastructural aspects of the spleen of rats after hepatic pedicle total clamping

Avaliaram-se as alterações morfológicas, morfométricas e ultraestruturais que ocorreram no baço devido à isquemia produzida pelo clampeamento total do pedículo hepático. Para tanto, foram utilizados 40 ratos machos, distribuídos em quatro grupos de 10 animais. O grupo-controle (C) não foi submetido à isquemia, e os grupos tratados (E1, E2e E3) foram submetidos ao clampeamento por 10, 20 e 30 minutos, respectivamente. Fragmentos do baço foram retirados e analisados histologicamente pela microscopia de luz (hematoxilina-eosina, ferrocianeto-férrico) e pela microscopia eletrônica de transmissão. Os resultados demonstraram que 10 minutos de clampeamento do pedículo hepático são suficientes para apresentar sinais de congestão esplênica e 20 e 30 minutos promovem intensa digestão de hemácias pelos macrófagos, com presença de grânulos de ferro (hemossiderina) no parênquima esplênico.

The macro and microscopic alterations that occurred in the spleen during an ischemia produced by the hepatic pedicle total clamping were studied. Forty male rats were distributed in four groups of 10 animals each. The control group (C) was not submitted to ischemia and the treated groups (E1, E2, and E3) were submitted to the clamping during 10, 20, and 30 minutes, respectively. Spleen fragments were collected and histologically analyzed by the light microscopy (eosin-hematoxilin and ferric ferrocyanide) and by the transmission electron microscopy. The results showed that 10 minutes of hepatic pedicle total clamping was enough produce signs of splenic congestion and 20 and 30 minutes promoted intense red bood cels digestion by the macrophages with the presence of iron granules (hemosiderin) in the splenic parenchyma.

The role of intermittent hepatic pedicle clamping on oxygen-derived free radical generation in the rat liver / 한국간담췌외과학회지

BACKGROUND/AIMS: The tolerance of the liver to ischemia during intermittent hepatic pedicle clamping was compared with that during continuous hepatic pedicle clamping, and intermittent hepatic pedicle clamping was thought to more tolerable to ischemia/reperfusion injury. The mechanisms underlying this were unknown. We examined the relationship between ischemia/reperfusion injury and the production of oxygen-derived free radicals using spin resonance spectrometry. METHODS: Adult male Sprague-Dawley rats were subjected to either continuous or intermittent hepatic pedicle clamping. Alpha-(4-pyridyl 1-oxide)-N-tert-butylnitrone was administered to rats as a spin trap agent. Continuous clamping (15, 30, or 60 minutes) or intermittent clamping(four cycles of 15-minutes ischemia and 5 or 15 minutes of reperfusion) of hepatic pedicle was carried out. After reperfusion, blood samples were obtained and measuring liver enzyme to evaluate hepatic injury. Hepatic tissue blood flow was measured using a color Doppler blood flowmeter. RESULTS: When there was a longer period of hepatic pedicle occlusion, increased oxygen-derived free radical generation was detected after reperfusion. There was no significant increase in oxygen-derived free radical production or liver enzymes leakage when the duration of ischemia was 15 minutes. Oxygen-derived free radical generation and liver enzyme leakage were significantly less in intermittent pedicle clamping than in continuous clamping for 60 minutes. CONCLUSION: According this results, there is a oxygen-derived free radicals and liver damage in less in intermittent pedicle clamping than continuous clamping although many oxygen-derived free radicals are produced.

Application of combined hemihepatic infow and hepatic veins occlusion in major hepatectomy / 中国普通外科杂志

Objective To evaluate the effect of application of combined hemihepatic inflow and hepatic veins occlusion in major liver resection.Methods The clinical data of 46 cases of large hepatic carcinoma who underwent liver resection were surveyed retrospectively.The hepatic pedicle of affected side and hepatic veins were dissected and controlled initially,then hepatectomy was performed under the condition of vascular exclusion of the affected side of liver.Results All the 46 cases suffered from hepatocellular carcinoma.The average size of the tumors was 8.3 cm(6-15 cm) in diameter.One main hepatic vein was invaded by tumor in 20 cases and 2 main hepatic veins were invaded by tumor in 14 cases.Among the 46 hepatectomies,right hemihepatectomy was performed in 16,right posterior lobe hepatectomy in 14,and left hemihepatectomy in 16 cases.The mean occlusion time of the hemihepatic pedicle was 30 min(10-45 min),and occlusion time of the hepatic veins was 20 min(10-30 min).The average blood loss was 540 ml(300-1 500 mL).Postoperative complications occurred in 14 cases,and all recovered after treatment.There was no mortality in this series.Conclusions Combined hemihepatic inflow and hepatic veins occlusion in major hepatectomy is a safe,effective and practical vascular exclusion method which can effectively reduce the blood loss and the incidence of the liver function failure.