Case and patient history

The patient was a 58 year old female diagnosed with a tumor in her liver. Dr. McGilvray at the Toronto General Hospital performed a left hepatectomy on the patient. The tumor, along with segments II, III and IV of the liver were successfully removed while the patient was under general anesthesia. The procedure was completed within 2 hours and 48 minutes on January 31st 2013. A description of the operation based on observations during the surgical procedure and literature review will be investigated in the following paragraphs. Intraoperative techniques Position of the patient Patient was placed in a supine position. For this case, no warming gel pad was needed. Sterile preparation extended up to the clavicles superiorly, to the pubis inferiorly and to the posterior axillary lines laterally (Mazziotti, and Cacallari, 1997)

Intraoperative techniques

A midline laparotomy incision was performed to gain access to the abdominal cavity. A midline laparotomy incision allows a larger surgical window than other incision techniques (ie. subcostal incision) performed for a left hepatectomy (Fan and Chang, 2002). The surgical window was held in place with a bilateral hinged 11.0’’x 8 .5’’ x 11.0’’ bilateral crossbar with two 3.5 ‘’x 3.0’’ Kelly.

Mobilization of the liver

To achieve adequate exposure of the liver to the surgeon, the liver had to be mobilized (Fan and Chang, 2002). To mobilize the left hemiliver, the peritoneal attachments of the liver were selectively cut by the electrocautery. The falciform ligament was divided to mobilize the liver from the abdominal wall and to expose the anterior aspect of the vena cava. The groove between the middle and right hepatic vein was dissected. The left coronary ligament was divided to separate the liver from the diaphragm. The gastrohepatic ligament was cut with the incision made close to the margin of the liver. The middle and left hepatic vein confluence was dissected out and encircled with umbilical tape.

Vascular inflow and outflow control via portal dissection

Once the liver was mobilized, portal dissection was performed. A standard cholecystectomy was completed. The cystic artery was tied and the left bile duct was cut. A peritoneal incision over the left aspect of the porta was performed. Vascular inflow (hepatic artery and portal vein) had to be controlled in preparation for the transection to be performed (Mazziotti, and Cacallari, 1997). To reduce flow of blood into the left side of the liver prior to the transection, the left hepataic artery, S4 artery, and left portal vein were sutured and ligated with a 2-0 silk. Portal vein was dissected near the insertion of the ligamentum venosum to ensure continued blood flow to the caudate lobe, which was left in place. The bile duct was divided outside the liver. Right and left liver lobes were pushed with hands during the transection. Normally, prior to the hydrojet dissection, vascular outflow would be controlled by clamping and dividing the common trunk of hepatic veins (Mazziotti, and Cacallari, 1997). However, in this case the veins were not divided until after the transection was completed to prevent the liver from becoming congested and to allow for decompression of the lobe (Mazziotti, and Cacallari, 1997).

Parenchymal transection

The liver was split into right and left lobes along the plane demarcated by Cantlie’s line. The plane of parenchymal transection ( Cantlie’s line ) began at the vascular demarcation in the fossa of the gallbladder and extended to the inferior vena cava, above the biliary plate (Fan and Chang, 2002). Cantlie’s line ensures that there is no damage to the portal structures in the right lobe liver remnant (Mazziotti, and Cacallari, 1997). The demarcation line is drawn using the electrocautery, and the liver is divided with the use of a hydrojet dissector. The use of a hydrojet dissector was favorable because it exposed the blood vessels prior to division (Aragon, and Solomon, 2012). During implementation of the hydrojet dissection, individual intrahepatic vessels are exposed (Porrett et al. 2008). To reduce the incidence of bleeding and biliary leaks from the cut hepatic surface, several precautions are taken during the transection. To seal small vessels from bleeding, electrocautery was employed as the transection progressed. For larger vessels, small and medium sized metallic clips were applied with clipping pliers. Special care was given to not injure the area of the biliary plate. Division of the hepatic veins occurred at the end of the transection. The left hepatic vein was stapled using an endo GIA. Operation was concluded by closing the incision. A size 0 suture was used for closing the fascia layer and a size 4-0 suture was used for closing the skin.

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Aragon, R.J., Solomon, N.L, (2012) Techniques of hepatic resection. Journal of Gastrointestinal Oncology. 3(1), 28-40

Christoph E. Broelsh. (1993) Altlas of liver surgery. (31-45). New York: Churchill Livingstone. Fan M.H, Chang, A.E (2002) Resection of liver tumors: technical aspects. Surgical oncology. 10, 139-152.

Mazziotti, A., Cacallari A., (1997) Techniques in Liver Surgery. (pp.33-46). London:Cambridge University Press.

Porrett PM, Olthoff KM. Hepatectomy. In: Kanchwala S, Paulson EC, Roses R, Morris JM, editors. (2008) Gowned and gloved surgery: introduction to common procedures. (pp. 102-13). Philadelphia: Saunders

Zollinger, R.M., (1988) Atlas of Surgical Operations. 6th ed. (214-220). New York: Macmillan Publishing Company.