GENERAL SURGICAL

TECHNIQUE IN
HEPATECTOMY
DIRIGÉ PAR : DR KAING KIMSAN
PRESENTATEUR : DES KEAM PISETHSAPHEAREACH
 CONTENUE

• TYPE OF HEPATIC RESECTION

• PRINCIPLE OF HEPATECTOMY
• OPERATION’S KEYPOINT
 TYPE OF HEPATIC RESECTION

• MINOR ≤ 2
 BISEGMENTECTOMY
 SEGMENTECTOMY
 SUBSEGMENTECTOMY
 WEDGE RESECTION

• MAJOR ≥ 3
 TRISEGMENTECTOMY
 RIGHT OR LEFT HEPATECTOMY
 EXTENDED RIGHT OR LEFT HEPATECTOMY
 PRINCIPLE OF HEPATECTOMY

• COMPLETE RESECTION
• PARENCHYMAL-SPARING LIVER RESECTION
• TUMOR FREE MARGIN
INCISION
LAPAROSCOPIC PORTS PLACEMENT
 OPERATION’S KEYPOINT

• PEROPERATIVE BLEEDING  INFLOW AND OUTFLOW CONTROL

• POST OPERATIVE LIVER FAILURE  FUTURE REMNANT LIVER FAILURE
• POST OPERATIVE HEMORRHAGE AND BILE LEAK  HEMOSTASIS AND
BILOSTASIS
 OPERATION’S KEYPOINT

• PEROPERATIVE BLEEDING  INFLOW AND OUTFLOW CONTROL

• POST OPERATIVE LIVER FAILURE  FUTURE REMNANT LIVER FAILURE
• POST OPERATIVE HEMORRHAGE AND BILE LEAK  HEMOSTASIS AND
BILOSTASIS
CONTROL OF INFLOW AND OUTFLOW SYSTEM

• INFLOW OCCLUSION
 TOTAL INFLOW OCCLUSION (PRINGLE MANEUVER)
 SELECTIVE INFLOW OCCLUSION

• OUTFLOW OCCLUSION
 TOTAL VASCULAR EXCLUSION (TVE)
 SELECTIVE TOTAL VASCULAR EXCLUSION (STVE)
 SELECTIVE PARTIAL VASCULAR EXCLUSION (SPVE)
 PRINGLE MANEUVER

• PM IS A TECHNIQUE WHICH IS USED TO STOP BLOOD INFLOW TO THE LIVER IN

PURPOSE TO REDUCE PER-OPERATIVE BLOOD LOSE DURING LIVER
TRANSECTION.
• INTERMITTENT PM IS ISCHEMIA/REPERFUSION OF LIVER 15/5 MINS OR 10/5 MINS
REPEATEDLY UP TO 120MINUTES
• CONTINUOUS PM IS CONTINUOUS ISCHEMIA WITHOUT REPERFUSION FROM 60 TO
90 MINUTES
 SELECTIVE INFLOW OCCLUSION

• CLAMP THE RIGHT OR LEFT OF HEPATIC HILAR DEPENDS ON TUMOR ON LEFT OR

RIGHT OR SIDE OF HEMILIVER TO BE RESECTED.
TOTAL VASCULAR EXCLUSION (TVE)
SELECTIVE TOTAL VASCULAR EXCLUSION
(STVE)
SELECTIVE PARTIAL VASCULAR EXCLUSION
(SPVE)
 OPERATION’S KEYPOINT

• PEROPERATIVE BLEEDING  INFLOW AND OUTFLOW CONTROL

• POST OPERATIVE LIVER FAILURE  FUTURE REMNANT LIVER FAILURE
• POST OPERATIVE HEMORRHAGE AND BILE LEAK  HEMOSTASIS AND
BILOSTASIS
 FUTURE LIVER REMNANT

• CONSIDERATION OF THE
POSTOPERATIVE FUNCTION OF THE
FLR IS IMPORTANT FOR ALL PATIENTS
UNDERGOING A MAJOR
HEPATECTOMY.
FUTURE LIVER REMNANT
 PARENCHYMAL PRESERVING TECHNIQUE

• DECREASES THE RISK OF POSTOPERATIVE LIVER FAILURE

• MINIMIZES PHYSIOLOGY IMPACT OF LIVER RESECTION IN CIRRHOTIC AND
NONCIRRHOTIC
• MAXIMIZES THE PATIENT POPULATION ELIGIBLE FOR SURGERY
• DOES NOT COMPROMISE ONCOLOGIC OUTCOMES
• ALLOWS FOR SALVAGE OPERATION AND FOR PLANNED 2-STAGES OPERATION
 PORTAL VEIN EMBOLIZATION

• INDICATION IS CONSIDERED WHEN

FLR IS NOT LARGE ENOUGH FOR
HEPATECTOMY
• ABSOLUTE CONTRAINDICATION :
PORTAL HYPERTENSION AND
THROMBUS IPSILATERAL PV
• SURGERY 4-6 WEEKS AFTER PVE
PORTAL VEIN EMBOLIZATION
 ASSOCIATING LIVER PARTITION AND PORTAL
VEIN LIGATION FOR STAGED HEPATECTOMY
(ALPPS)
• MODIFIED 2 STAGES LIVER
RESECTION COMBINE RIGHT PORTAL
VEIN LIGATION AND IN SITU
SPLITTING OF THE LIVER.
 ASSOCIATING LIVER PARTITION AND PORTAL
VEIN LIGATION FOR STAGED HEPATECTOMY
(ALPPS)
• INDICATION :
 BILOBAR MESTASTASE CRLM
 PERIHILAR OR INTRAHEPATIC CHOLANGIOCARCINOMA
 RESCUE ALPPS AFTER FAIL PVE
ASSOCIATING LIVER PARTITION AND PORTAL
VEIN LIGATION FOR STAGED HEPATECTOMY
(ALPPS)
ASSOCIATING LIVER PARTITION AND PORTAL
VEIN LIGATION FOR STAGED HEPATECTOMY
(ALPPS)
 TECHINIQUE OF SUBSEGMENT/SEGMENT-
BASED LIVER RESECTION
• 5 METHODE :
 SURFACE ANATOMY OF THE LIVER
 SURFACE ANATOMY + IOUS
 ULTRASOUND-GUIDED PUNCTURE OF PORTAL VEIN BRANCH AND INJECTION OF DYE
 PRELIMINARY CONTROL OF THE VASCULAR PEDICLES OF THE SEGMENT TO BE
REMOVED
 SELECTIVE PORTAL VENOUS OCCLUSION USING A BALLOON CATHETER THROUGH A
BRANCH OF SUPERIOR MESENTERIC VEIN
 OPERATION’S KEYPOINT

• PEROPERATIVE BLEEDING  INFLOW AND OUTFLOW CONTROL

• POST OPERATIVE LIVER FAILURE  FUTURE REMNANT LIVER FAILURE
• POST OPERATIVE HEMORRHAGE AND BILE LEAK  HEMOSTASIS AND
BILOSTASIS
 CLASSIC HEPATIC PARENCHYMA
TRANSECTION
• THE FINGER FRACTURE TECHNIQUE
• CLAMP-CRUSH TECHNIQUE
• BIPOLAR DISSECTION
LIGATION OF CANALICULE
LIGATION OF PRINCIPLE VASCULAR
MODERN HEPATIC PARENCHYMA
TRANSECTION
MICKAEL LESURTEL & JACQUES BELGHITI HPB 2008; 10: 265-270
JAIN-YANG Guo et al. World J Gastroenteral 2014 July 14
MOBILIZATION OF LIVER
MOBILIZATION OF RIGHT LIVER
MOBILIZATION OF LEFT
HANGING MANEUVER