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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

    1. 1. SEGMENT ORIENTED LIVER RESECTIONS I. Popescu CENTER OF GENERAL SURGERY AND LIVER TRANSPLANTATION FUNDENI CLINICAL INSTITUTE BUCHAREST
    2. 2. <ul><li>Nowadays liver resections are standardized operations whose mortality has decreased substantially in the last 25 years. * </li></ul><ul><li>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. </li></ul><ul><li>* Ong & Lee – Br J Surg 1975; 62, 421: 17.6% (125 patients) </li></ul><ul><li>Iwatsuki & Starzl – Surg Clin N Am 1989; 69, 315: 3.2% (411 patients) </li></ul><ul><li>Myagawa & Makuuchi – Am J Surg 1995;169, 589: 2.3% (172 patients) </li></ul>
    3. 4. 1954 CLAUDE COUINAUD
    4. 5. TYPES OF SEGMENT ORIENTED LIVER RESECTIONS <ul><li>Segmentectom y </li></ul><ul><ul><li>I  VIII </li></ul></ul><ul><li>Bisegmentectomi es </li></ul><ul><ul><li>II, III </li></ul></ul><ul><ul><li>V, VIII </li></ul></ul><ul><ul><li>VI, VII </li></ul></ul><ul><ul><li>IVb, V </li></ul></ul><ul><ul><li>V, VI </li></ul></ul>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 <ul><li>Trisegmentectomi es </li></ul><ul><ul><li>IV, V, VIII </li></ul></ul><ul><ul><li>IVb, V, VI </li></ul></ul><ul><li>Subsegmentectomi es </li></ul><ul><ul><li>IVa, IVb </li></ul></ul>
    5. 6. INDICA TIONS FOR SEGMENT ORIENTED LIVER RESECTIONS <ul><ul><li>patients with benign lesions for whom a major hepatectomy is not justified </li></ul></ul><ul><ul><li>cirrhotic patients with a limited hepatic reserve </li></ul></ul><ul><ul><li>patients with multiple lesions who otherwise need extended hepat e c tomy or are unresectable </li></ul></ul><ul><ul><li>patients with liver metastasis who may develop hepatic recurrences and need iterative hepatectomy </li></ul></ul>
    6. 7. <ul><li>resection margins ( at least 1 cm) </li></ul><ul><li>liver parenchyma preserved as much as possible </li></ul><ul><li>minimized blood loss and haemodynamic stability </li></ul><ul><li>avoiding complications due to damage of the pedicles of remnant liver </li></ul>OPERATION OBJECTIVES
    7. 8. 1.01.1995 - 1 . 03 .200 3 569 hepatectomi es 552 patients 30 5 anatomical hepatectomies 137 segment oriented resections
    8. 9. 13 7 segment oriented liver resections 11 9 non-cirrhotic patients 18 cirrhotic patients
    9. 10. SURGICAL TECHNIQUE <ul><li>Inci sion </li></ul><ul><li>Liver mobilization </li></ul><ul><li>Vascular approach </li></ul><ul><ul><ul><ul><li>i ntra parenchymal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>extrahepatic </li></ul></ul></ul></ul><ul><li>Maneuvers for bleeding control: Pringle ’s </li></ul><ul><li> maneuvers , total vascular exclusion </li></ul><ul><li>Techniques of liver parenchyma transection: </li></ul><ul><li>ultrasonic scalpel, CUSA, jet cutter, </li></ul><ul><li>mic rowaves </li></ul><ul><li>Techniques of haemostasis on the raw </li></ul><ul><li>surface: Surgicel, Tachocomb, Tissue glue, </li></ul><ul><li>argon </li></ul>
    10. 11. Segmentectomi es
    11. 12. Segment I 8 cases
    12. 13. Hemangiom a
    13. 14. Segment I – 8 cases <ul><li>Indications </li></ul><ul><li>Benign lesions 5 </li></ul><ul><li>Hemangiom a 4 cirrhosis 1 </li></ul><ul><li>Budd-Chiari syndrome 1 </li></ul><ul><li>Malignant lesions 3 </li></ul><ul><li>Klatskin tumor 1 </li></ul><ul><li>Metastasis colorectal cancer 2 </li></ul>
    14. 15. Segment I I – 1 case Metasta sis from colonic cancer
    15. 16. Segment III
    16. 17. Segment III – 5 ca ses Hepatocellular carcinoma associated with cirrhosis
    17. 18. <ul><li>Indications </li></ul><ul><li>Benign lesions 1 </li></ul><ul><li>Hydatid cyst 1 </li></ul><ul><li>Malignant lesions 4 </li></ul><ul><li>Hepatocellular carcinoma 2 1 cirrhosis </li></ul><ul><li>Metasta sis leiom y osarcom a 1 </li></ul><ul><li>Metasta sis sarcom a 1 </li></ul>Segment III – 5 ca ses
    18. 19. Segment IV
    19. 20. Segment V 8 ca ses Hepatic adenoma
    20. 21. 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
    21. 22. Segment VI 1 case <ul><li>Liver metastasis from colonic cancer </li></ul>
    22. 23. Segment V II - 1 case Hemangioma
    23. 24. Segment VIII - 3 ca ses FNH
    24. 25. <ul><li>Indications </li></ul><ul><li>Benign lesions 2 </li></ul><ul><li>Focal nodular hyperplasia 1 </li></ul><ul><li>Hemangiom a 1 </li></ul><ul><li>Malignant lesions 1 </li></ul><ul><li>Hepatocellular carcinoma 1 </li></ul>Segment VIII 3 ca ses
    25. 26. Bisegmentectomi es
    26. 27. Left lateral sectorectomy (II, III) Intraparenchymal vascular approach
    27. 28. Extrahepatic vascular approach HCC with cirrhosis Left lateral sectorectomy (II, III)
    28. 29. <ul><li>Indications </li></ul><ul><li>Benign lesions 3 6 </li></ul><ul><li>Hemangiom a 11 1 cirrhosis </li></ul><ul><li>Hydatid cyst 10 </li></ul><ul><li>Hepatic abscess 5 </li></ul><ul><li>Focal nodular hyperplasia 3 </li></ul><ul><li>Inflammatory tumor 2 1 cirrhosis </li></ul><ul><li>Caroli’s disease 2 </li></ul><ul><li>Liver trauma 2 </li></ul><ul><li>Giant serous cyst 1 </li></ul><ul><li>Malignant lesions 23 </li></ul><ul><li>Hepatocellular carcinoma 11 8 cirrhosis </li></ul><ul><li>Cholangiocarcinoma 4 1 cirrhosis </li></ul><ul><li>Metastasis from colorectal cancer 6 1 cirrhosis </li></ul><ul><li>pancreatic cancer 1 </li></ul><ul><li>ovarian cancer 1 </li></ul><ul><li>Procurement for living-related liver transplantation 5 </li></ul>Left lateral sectorectomy (II, III) 64 cases
    29. 30. Laparoscopic resection – 1 ca se Liver metastasis from breast cancer Left lateral sectorectomy
    30. 31. Harvesting of segments II-III from a living donor for a pediatric liver transplantation
    31. 32. Right lateral sectorectomy (VI, VII) 23 cases
    32. 33. <ul><li>Indications </li></ul><ul><li>Benign lesions 13 </li></ul><ul><li>Hemangiom a 6 </li></ul><ul><li>Adenom a 2 </li></ul><ul><li>Hepatic abscess 3 </li></ul><ul><li>Inflammatory tumor 2 </li></ul><ul><li>Malignant lesions 10 </li></ul><ul><li>Hepatocellular carcinoma 5 - 2 cirrhosis </li></ul><ul><li>Cholangiocarcinoma 1 - 1 cir rhosis </li></ul><ul><li>M etastasis from digestive cancer 1 </li></ul><ul><li> from testicle cancer 1 </li></ul><ul><li> from lung cancer 1 </li></ul><ul><li>from adrenal carcinoma 1 </li></ul>Right lateral sectorectomy (VI, VII) 23 ca ses
    33. 34. Bisegmentectom y IVb, V 5 ca ses Gallbladder cancer sta ge II
    34. 35. 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
    35. 36. Right medial sectorectomy (V, VIII) 1 case Inflammatory tumor
    36. 37. Bisegmentectom y V, VI – 9 ca ses Liver m etasta sis from colonic cancer S IV S VIII S IV S VIII
    37. 38. Bisegmentectom y V, VI – 9 ca ses <ul><li>Indica tions </li></ul><ul><li>B enign lesions 6 </li></ul><ul><li>Hemangiom a 5 </li></ul><ul><li>H epatic abscess 1 </li></ul><ul><li>M align ant lesions 3 </li></ul><ul><li>H epatoce l lular carcinoma 1 </li></ul><ul><li>Metasta sis from colorectal cancer 2 </li></ul>
    38. 39. Trisegmentectomi es
    39. 40. 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
    40. 43. Transverse hepatectomy (IVb, V, VI) Gallbladder cancer Sta ge IVa 3 cases 2 gallbladder cancer 1 metasta sis breast cancer
    41. 44. Sub segmentectom ies
    42. 45. Segment IV b – 2 cases 1 non-parasitic cyst 1 metastasis from breast cancer IVb IVb IVb IVb
    43. 46. <ul><li>subphrenic ab s ces s 8 </li></ul><ul><li>hemoperitoneum 1 </li></ul><ul><li>hematoma on the transection surface 1 </li></ul><ul><li>remnant common bile duct stone 1 </li></ul><ul><li>wound dehiscen ce 1 </li></ul><ul><li>pulmonary complications 2 </li></ul><ul><li>lower extremities thromb ophlebitis 4 </li></ul>MORBIDITY - 10% ( 1 4/ 137 )
    44. 47. 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
    45. 48. Conclusions <ul><li>Segmental oriented liver resections are indicated for </li></ul><ul><ul><ul><li>patients with benign lesions </li></ul></ul></ul><ul><ul><ul><li>cirrhotic patients </li></ul></ul></ul><ul><ul><ul><li>patients with multiple hepatic lesions </li></ul></ul></ul><ul><ul><ul><li>patients with liver metastasis </li></ul></ul></ul><ul><li>Preoperative computerized tomography </li></ul><ul><li>( if possible 3-D) and intraoperative ultrasound are mandatory. </li></ul>
    46. 49. <ul><li>Portal pedicle can be approached </li></ul><ul><ul><ul><li>intraparen chymal </li></ul></ul></ul><ul><ul><ul><li>extra hepatic </li></ul></ul></ul><ul><li>Intraoperat ive maneuvers for minimizing blood loss : Pringle ’s maneuver , total vascular exclusion </li></ul><ul><li>Postoperative morbidity and mortality are minimal. </li></ul>Conclusions
    47. 50. Segment oriented liver resections are well standardized operations, with a high level of difficulty but with proved benefits for the patient. Conclusion

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