A next-generation preoperative simulation and a new anatomical resection of the liver based on hybrid concept of portal perfusion and venous drainage / Шинэ санаа Шинэ нээлт

ABSTRACT

Background: Recent technical innovation enhances progresses in liver surgery.Now, for example, a preoperative 3D-simulation of the liver is indispensable forliver surgery. Detailed 3D-image revealed that portal perfusion area in cranial sideof anterior segment sometimes surrounded superior right hepatic vein (SRHV). Insuch patients with HCC, SRHV should be resected for systematic resection.The aim of this presentation is to introduce various kinds of progresses inpreoperative simulation and propose a new hepatectomy based on a hybridconcept of portal perfusion of anterior segment and hepatic venous drainage areaof SRHV.A next generation simulation1) One-stop shopping of 3D-simulation of the liver We newly developed3D-simulation using a software of SYNAPSE VINCENT Ver. 3.1 (Fujifilm Medical,Tokyo, Japan), in which biliary system and hepatic vasculature are simultaneouslyreconstructed in one dynamic MD-CT. This technique can avoid incorrectpositional relationship when separately depicted DIC–CT or MRCP is fused on3D-image by MD-CT, as well as unnecessary radiation exposure. Recently, weapplied 3D-printer to a preoperative simulation of hepatic resection to betterunderstand the 3D-anatomy2) Assessment of partial functional reserve We have reported new methods toestimate regional hepatic functional reserve using hepatocyte-phase of EOB-MRI(J Gastroenterol 2012), (and fusion image of 3D-CT and asialoscintigraphy using99m-Tc galactosyl human albumin). The method of EOB-MRI utilized characterof hepatocyte-uptake of EOB through membrane transporters on hepatocytes.Fusion of both acialoscintigram of hepatic functional reserve and 3D-simulationby the above-mentioned software also well determines regional liver functionalreserve. Those techniques provided accurate estimation of partial functionalvolume, and help surgeons’ decision making for resection volume of the liver.A new anatomical resection SRHV-involvement was observed in 17 out of 66patients (26%). The large IRHV (more than 5 mm in diameter) was found in 16 outof 66 patients (24%). In patients with SRHV-involvement, the incidence of a largeIRHV (8 of 17 48%) was significantly higher, compared to that in those withoutSRHV-involvement (8 of 49 16%).The procedures are as follows 1) encircling of anterior Glissonian pedicle, SRHVand inferior right hepatic vein (IRHV), 2) confirmation of demarcation line ofanterior segment by occluding Glissonian pedicle and demarcation (congested)line by clamping proper hepatic artery and SRHV, and 3) IRHV-preserved completeresection of portal perfusion area plus drainage area of SRHV, combined withSRHV resection.Two patients having a large IRHV and HCC near the root of SRHV underwenta IRHV-preserved hepatectomy combined with SRHV resection (S8 + SRHVdrainagearea in 1 and anterior segment + SRHV-drainage area in 1). PostoperativeCT scan revealed complete resection of drainage area of SRHV and no congestionin the remnant posterior segment after hepatectomy due to excellent drainagethrough a large IR.Conclusions: Various advancements, such as preoperative 3D-simulationincluding partial functional reserve estimation and 3D-printer, enabled surgeonsto perform hepatic resection easily and safely.In such HCC patients having a large IRHV, our new hepatectomy based on ahybrid concept of portal perfusion of anterior segment and venous drainagearea of SRHV, combined with SRHV resection, is a promising option from theviewpoint of systematic resection (curability) and functional reserve of the futureremnant liver in selected patients.