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Surgical anatomy of Liver, Pancreas, Biliary tree and Principle of Liver resection.pptx
1. Relevant anatomy and physiology
of Liver, biliary duct and pancreas:
Principle of Liver resection
Dr. Olayinka L. Adewunmi
Division of General Surgery
UMTH Maiduguri
5th December, 2022
3. Introduction
• HPB surgery is a sub-specialty in General surgery
• Sound knowledge of the surgical anatomy and physiology is needed
to be able to carry out safe surgery
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15. Relevant Anatomy- Liver
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• Anatomy of the plate/sheath
system
• Cystic- A
• Hilar- B
• Umbilical- C
• Arantian
16. Relevant Anatomy-
Gallbladder and
extrahepatic biliary ducts
• Gallbladder on liver bed
(S4b and S5)
• Store/concentrate bile
• About 50mls volume
• Empty content through
the cystic ducts to the
CBD and duodenum
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24. Liver resection
• Major hepatectomy
• Minor hepatectomy
anatomic resection
non-anatomic resection
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25. Brisbane Terminology of Liver anatomy and
Resections (2000)
Anatomic term Couinaud Segments Surgical Resection
Right hemiliver/right liver 5-8 Right hepatectomy
Left hemiliver/left liver 2-4 Left hepatectomy
Right anterior section 5, 8 Right anterior sectionectomy
Right posterior section 6, 7 Right posterior sectionectomy
Left medial section 4 Left medial sectionectomy or
Resection of segment 4
Left lateral section 2, 3 Left lateral sectionectomy or
Bisectionectomy 2, 3
4, 5, 6, 7, 8 Right trisectionectomy or
Extended right hepatectomy
2, 3, 4, 5, 8 Left trisectionectomy or
Extended left hepatectomy
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27. Physiology- Bile ducts
• Secrete bile, needed for digestion of fat and fat-soluble vitamins
• Components of bile
water, bile salts, bilirubin, cholesterol, lecithin, electrolytes
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28. Physiology- Pancreas
• Endocrine and Exocrine functions
• Exocrine- secretes lipase, amylase, carboxypeptidase, pepsinogen
• Endocrine- secretes Insulin, glucagon, somatostatin, PP, etc.
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30. Introduction
• Surgery is the main stay in the treatment of solid tumors, including
liver tumors (primary or metastatic)
• Refinement in surgical techniques has increased survival following
liver resection in recent years.
• However, the most important factor influencing outcomes after liver
resection is the surgeon’s knowledge of the basic surgical principles of
the procedure
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31. Principles of Liver resection
• Principles of liver resection
• Pre-op
• Intra-op
• Post-op
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33. Pre-op considerations
• Imaging
• Helical CT scan with 3phase contrast (Liver protocol)
Lesion identification and relationship to vascular/portal pedicle
Define anatomy of the portal triad and look for aberrant
anatomy
• MRI
• Discussion with radiologist (hepatobiliary radiologist)
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34. Pre-op considerations
• Laboratory
• Liver function test, total protein
and albumin
• Clotting profile
• EUCr
• Risk assessment score:
• Child-Turcotte-Pugh score-child A
qualify for Liver resection
• MELD score <9
• Test of functional liver
remnant/reserve (FLR)
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35. Pre-op considerations
• MD Anderson Cancer Center (University of Texas)
• eTLV (in cm3) = -794.41 + 1,267.28 x BSA (in m2)
• Normal FLR: ≥20% in normal liver, ≥30% in hepatic injury and ≥40% in
cirrhotic/fibrotic liver
• If eFLR is low, then portal vein embolization of the side to be resected
is recommended. This will cause atrophy of the planned resected part
and compensatory hypertrophy of the normal side.
• Hypertrophy <5% is a predictor of post-op liver insufficiency and 90
days post-op mortality
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38. Intra-op
• Anaesthesia- GA
• Positioning
Patient- supine, hand
extended
Surgeon- right
Assistant- left
• Incisions
• Chevron, inverted T, J incision,
Kochers, Kehr, L incision, reverse L,
etc.
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39. Intra-op…
• Vascular control
Pringle technique- intermittent vs continuous
Total hepatic vascular control (inflow and outflow)
extra-hepatic control
intra-parenchyma control
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40. Intra-op…parenchyma transection
• Finger fracture
• Clamps/forceps (Kelly, Debakey,
etc.)
• Bovie electrocoagulation
• Harmonic scalpel
• Ligasure
• Tissuelink (saline-linked cautery)
• Sealing agents
• vascular staples
• CUSA- Cavitron UltraSonic
Aspirator
• Hydrojet/water jet dissector
• NB: none of the devices has
shown superior advantage over
the other.
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41. Intra-op…
• Prevention of haemorrhage
• 2 surgeon technique
• Intra-op USS
• Liver hanging maneuver
• Low CVP <5mmHg from
anaesthetist
• Drain vs no drain
• Post-op care
HDU/Wards
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42. Complications
• Haemorrhage
• Liver insufficiency/dysfunction
• Perihepatic fluid collections
• bile leak
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43. Conclusion
• Over several years, Liver resection surgery has evolved as a effective
and safe way to treat benign and malignant liver pathology
• Careful patient selection and surgeons knowledge of the basic
principles of liver resection are important determinant of outcomes.
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44. References
• Jarnagin R. Williams: Blumgart’s Surgery of the Liver, Biliary Tract and
Pancreas, 6th edition
• Keith L. Moore and Arthur F. Dalley: Clinically oriented anatomy, 5th
edition
• Keith Lillemoe and Williams R. Jarnagin: Mastery Techniques in
Surgery: Hepatobiliary and Pancreatic surgery, 4th series
• O. James Garden and Simon Peterson-Brown: Hepatobiliary and
pancreatic surgery, a companion to specialist surgical practice, 5th
edition.
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45. References
• Charles F. Brunicardi: Schwartz’s principles of Surgery, 10th edition
Chapters 31, 32 and 33
• Michael J Zinner and Stanley W Ashley: Maingot’s abdominal
operations, 12th edition. Sections VII, VIII and IX
• Norman, S. W., Christopher J.K.B., and P.Ronan O’ Connell (2008).
Bailey and Love principles and practice of Surgery, 25th edition,
chapter 61, 63 and 64.
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46. References
• Vauthey, J. N., Abdalla, E. K., Doherty, D. A., Gertsch, P.,
Fenstermacher, M. J., Loyer, E. M., Lerut, J., Materne, R., Wang, X.,
Encarnacion, A., Herron, D., Mathey, C., Ferrari, G., Charnsangavej, C.,
Do, K. A., & Denys, A. (2002). Body surface area and body weight
predict total liver volume in Western adults. Liver transplantation :
official publication of the American Association for the Study of Liver
Diseases and the International Liver Transplantation Society, 8(3),
233–240.
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47. THANK YOU FOR YOUR
ATTENTION
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