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Segment oriented liver resections

Segment oriented liver resections

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  • Este de obicei indicată pentru tumori cu această localizare. Alte indicaţii sunt tumorile cu extensie la acest nivel sau neoplasmul de căi biliare. Segmentectomia I este extrem de dificilă. Necesită de regulă EVT.
  • Morbiditate: 2 Mortalitate: nulă Complicatii Abces cavitate restanta 1 Hemoperitoneu 1 – operat
  • Fratila CHC, Martalogu Meta din leiomiosarcom, Pascu CHC si CH, Popa metastaza sarcom, Stanga CHH
  • Morbiditate, mortalitate: nule
  • Burduja, Ficu, Geadau, Gherghines, Licu, Mihai, Tapurica , Titioaca
  • Burduja, Ficu, Geadau, Gherghines, Licu, Mihai, Tapurica, Titioaca Morbiditate, mortalitate: nule
  • Soare Ion are caseta video
  • Hemangiomul de anul asta facut de Doina
  • Poleac, Rusu, Sendrescu HNF, CHC, Hemangiom (cu ligatura de v. hepatica dreapta)
  • Morbiditate: 1 Mortalitate: 0
  • Denumită şi lobectomia stâmgă Este una dintre cele mai frecvente rezecţii hepatice. Este o rezecţie facilă datorită demarcaţiei atât pe faţa diafragmatică a ficatului prin lig. Falciform, cât şi pe faţa viscerală prin fisura ombilicală.
  • Morbiditate: 3 - tromboflebita 1, litiaza coledociana restanta, evisceratie blocata Mortalitate: nulă
  • Inntroducere film
  • Morbiditate : 5 Mortalitate : nulă Complicatii Hematom interhepatofrenic 1 – operat Abces subfrenic drept 3 Pleurezie bazala 1 - punctie
  • Copaci Constanta, Baltes, Knizel, Lemac, Popa Ecaterina
  • Morbiditate, mortalitate: nule
  • RM, b, 47 ani
  • Bejan, Bostan, Botel, Ciuperca, Glavan, Graur, Luncasu, Minica, Petrescu
  • Bejan, Bostan, Botel, Ciuperca, Glavan, Graur, Luncasu, Minica, Petrescu Morbiditate: 2 Mortalitate: nulă Complicatii Abces subfrenic 2
  • VI, b , 15 a ni Complicatie Abces subfrenic 1
  • GR, f, 58 ani
  • Micu Valerica (Chist hepatic tapetat cu epiteliu), Pur n ichi (Meta mamar) Morbiditate, mortalitate nule Subsegmentul IVb este cunoscut sub numele de lob pătrat. Are ca indicaţie particulară de rezecţie în tumorile Klatskin pentru a expune bifurcaţia canalelor biliare.
  • hemoragie postoperatorie la nivelul tranşei hepatice 20 ( 4 %) colecţii subfrenice 17 ( 3 %) insuficienţă hepatică acută 19 ( 4 %) coleperitoneu 3 ( 0,6 %) hemoragie digestivă superioară 5 ( 1 %) peritonită (ascită infectată, postcolectomie) 3 ( 0,6 %) fistula biliară 11 ( 2 %) Abces subfrenic 1 icter mecanic 1 ( 0,2 %) hemoperitoneu de diverse cauze 2 ( 0,4 %) ocluzie intestinală 3 ( 0,6 %) complicaţii pulmonare 26 ( 5 %) tromboflebită membre inferioare 3 ( 0,6 %)

15 15 Presentation Transcript

  • SEGMENT ORIENTED LIVER RESECTIONS I. Popescu CENTER OF GENERAL SURGERY AND LIVER TRANSPLANTATION FUNDENI CLINICAL INSTITUTE BUCHAREST
    • Nowadays liver resections are standardized operations whose mortality has decreased substantially in the last 25 years. *
    • An improved understanding of hepatic anatomy, early diagnosis of hepatic tumors , advances in operative technique, availability of spiral computerized tomography and magnetic resonance with 3-D reconstruction and intraoperative ultrasound have led to the ability to undertake resections based on the segmental anatomy of the liver.
    • * Ong & Lee – Br J Surg 1975; 62, 421: 17.6% (125 patients)
    • Iwatsuki & Starzl – Surg Clin N Am 1989; 69, 315: 3.2% (411 patients)
    • Myagawa & Makuuchi – Am J Surg 1995;169, 589: 2.3% (172 patients)
  •  
  • 1954 CLAUDE COUINAUD
  • TYPES OF SEGMENT ORIENTED LIVER RESECTIONS
    • Segmentectom y
      • I  VIII
    • Bisegmentectomi es
      • II, III
      • V, VIII
      • VI, VII
      • IVb, V
      • V, VI
    Segment oriented liver resections have been promoted especially by French and Asian authors. * * Castaing D, GArden OJ, Bismuth H. – Ann Surg 1989; 210: 20-23 Lui W et al. – Arch Surg 1995; 130: 1090-1097 Hasegawa H, Yamasaki S, Makuuchi M – J Chir Paris 1991; 128: 343-350
    • Trisegmentectomi es
      • IV, V, VIII
      • IVb, V, VI
    • Subsegmentectomi es
      • IVa, IVb
  • INDICA TIONS FOR SEGMENT ORIENTED LIVER RESECTIONS
      • patients with benign lesions for whom a major hepatectomy is not justified
      • cirrhotic patients with a limited hepatic reserve
      • patients with multiple lesions who otherwise need extended hepat e c tomy or are unresectable
      • patients with liver metastasis who may develop hepatic recurrences and need iterative hepatectomy
    • resection margins ( at least 1 cm)
    • liver parenchyma preserved as much as possible
    • minimized blood loss and haemodynamic stability
    • avoiding complications due to damage of the pedicles of remnant liver
    OPERATION OBJECTIVES
  • 1.01.1995 - 1 . 03 .200 3 569 hepatectomi es 552 patients 30 5 anatomical hepatectomies 137 segment oriented resections
  • 13 7 segment oriented liver resections 11 9 non-cirrhotic patients 18 cirrhotic patients
  • SURGICAL TECHNIQUE
    • Inci sion
    • Liver mobilization
    • Vascular approach
          • i ntra parenchymal
          • extrahepatic
    • Maneuvers for bleeding control: Pringle ’s
    • maneuvers , total vascular exclusion
    • Techniques of liver parenchyma transection:
    • ultrasonic scalpel, CUSA, jet cutter,
    • mic rowaves
    • Techniques of haemostasis on the raw
    • surface: Surgicel, Tachocomb, Tissue glue,
    • argon
  • Segmentectomi es
  • Segment I 8 cases
  • Hemangiom a
  • Segment I – 8 cases
    • Indications
    • Benign lesions 5
    • Hemangiom a 4 cirrhosis 1
    • Budd-Chiari syndrome 1
    • Malignant lesions 3
    • Klatskin tumor 1
    • Metastasis colorectal cancer 2
  • Segment I I – 1 case Metasta sis from colonic cancer
  • Segment III
  • Segment III – 5 ca ses Hepatocellular carcinoma associated with cirrhosis
    • Indications
    • Benign lesions 1
    • Hydatid cyst 1
    • Malignant lesions 4
    • Hepatocellular carcinoma 2 1 cirrhosis
    • Metasta sis leiom y osarcom a 1
    • Metasta sis sarcom a 1
    Segment III – 5 ca ses
  • Segment IV
  • Segment V 8 ca ses Hepatic adenoma
  • Segment V- 8 ca ses Indications Benign lesions 3 Inflammatory tumor 1 Focal nodular hyperplasia 1 Hepatic adenoma 1 Malignant lesions 5 Hepatocellular carcinoma 2 1 ci rrhosis Metasta sis from colon cancer 2 Metasta sis from breast cancer 1
  • Segment VI 1 case
    • Liver metastasis from colonic cancer
  • Segment V II - 1 case Hemangioma
  • Segment VIII - 3 ca ses FNH
    • Indications
    • Benign lesions 2
    • Focal nodular hyperplasia 1
    • Hemangiom a 1
    • Malignant lesions 1
    • Hepatocellular carcinoma 1
    Segment VIII 3 ca ses
  • Bisegmentectomi es
  • Left lateral sectorectomy (II, III) Intraparenchymal vascular approach
  • Extrahepatic vascular approach HCC with cirrhosis Left lateral sectorectomy (II, III)
    • Indications
    • Benign lesions 3 6
    • Hemangiom a 11 1 cirrhosis
    • Hydatid cyst 10
    • Hepatic abscess 5
    • Focal nodular hyperplasia 3
    • Inflammatory tumor 2 1 cirrhosis
    • Caroli’s disease 2
    • Liver trauma 2
    • Giant serous cyst 1
    • Malignant lesions 23
    • Hepatocellular carcinoma 11 8 cirrhosis
    • Cholangiocarcinoma 4 1 cirrhosis
    • Metastasis from colorectal cancer 6 1 cirrhosis
    • pancreatic cancer 1
    • ovarian cancer 1
    • Procurement for living-related liver transplantation 5
    Left lateral sectorectomy (II, III) 64 cases
  • Laparoscopic resection – 1 ca se Liver metastasis from breast cancer Left lateral sectorectomy
  • Harvesting of segments II-III from a living donor for a pediatric liver transplantation
  • Right lateral sectorectomy (VI, VII) 23 cases
    • Indications
    • Benign lesions 13
    • Hemangiom a 6
    • Adenom a 2
    • Hepatic abscess 3
    • Inflammatory tumor 2
    • Malignant lesions 10
    • Hepatocellular carcinoma 5 - 2 cirrhosis
    • Cholangiocarcinoma 1 - 1 cir rhosis
    • M etastasis from digestive cancer 1
    • from testicle cancer 1
    • from lung cancer 1
    • from adrenal carcinoma 1
    Right lateral sectorectomy (VI, VII) 23 ca ses
  • Bisegmentectom y IVb, V 5 ca ses Gallbladder cancer sta ge II
  • Indica tions B enign lesions 2 Hemangiom a 1 Hamartom a 1 Mal ign ant lesions 3 Gallbladder cancer 3 Bisegmentectom y IVb, V – 5 ca ses
  • Right medial sectorectomy (V, VIII) 1 case Inflammatory tumor
  • Bisegmentectom y V, VI – 9 ca ses Liver m etasta sis from colonic cancer S IV S VIII S IV S VIII
  • Bisegmentectom y V, VI – 9 ca ses
    • Indica tions
    • B enign lesions 6
    • Hemangiom a 5
    • H epatic abscess 1
    • M align ant lesions 3
    • H epatoce l lular carcinoma 1
    • Metasta sis from colorectal cancer 2
  • Trisegmentectomi es
  • I nflam m ator y tumor with central necrosis located in segment s IV, V, VIII Total hepatic volume 1752,2 cm 3 Tumor volume 292 cm 3 3-D RECONSTRUCTION C entral hepatectomy 3 ca ses 2 inflammatory tumors 1 metastasis from colonic cancer
  •  
  •  
  • Transverse hepatectomy (IVb, V, VI) Gallbladder cancer Sta ge IVa 3 cases 2 gallbladder cancer 1 metasta sis breast cancer
  • Sub segmentectom ies
  • Segment IV b – 2 cases 1 non-parasitic cyst 1 metastasis from breast cancer IVb IVb IVb IVb
    • subphrenic ab s ces s 8
    • hemoperitoneum 1
    • hematoma on the transection surface 1
    • remnant common bile duct stone 1
    • wound dehiscen ce 1
    • pulmonary complications 2
    • lower extremities thromb ophlebitis 4
    MORBIDITY - 10% ( 1 4/ 137 )
  • Morbidity 10% Mortality 0 Morbidity , mortality 0-7,6% Hemming A.W. – Am J Surg 1993; 165: 621-624 0 1 3 CH 0 0 3 TH 0 2 9 V, VI 0 0 5 IVb,V 0 0 1 RMS 0 5 23 RLS 0 3 64 LLS 0 0 1 II 0 1 3 VIII 0 0 1 VII 0 0 1 VI 0 0 8 V 0 0 2 IVb 0 0 5 III 0 2 8 I Deaths Complications Total Resection type
  • Conclusions
    • Segmental oriented liver resections are indicated for
        • patients with benign lesions
        • cirrhotic patients
        • patients with multiple hepatic lesions
        • patients with liver metastasis
    • Preoperative computerized tomography
    • ( if possible 3-D) and intraoperative ultrasound are mandatory.
    • Portal pedicle can be approached
        • intraparen chymal
        • extra hepatic
    • Intraoperat ive maneuvers for minimizing blood loss : Pringle ’s maneuver , total vascular exclusion
    • Postoperative morbidity and mortality are minimal.
    Conclusions
  • Segment oriented liver resections are well standardized operations, with a high level of difficulty but with proved benefits for the patient. Conclusion