Resection of the Inferior Part of the Right Lobe Couinauds S5 S6 See DVD

Figure 7.42 shows the area of S5 + S6 resection. For this resection (Fig. 7.43a-c), the same procedure as that used for S5 resection is done first. After the dissection of the left side of area S5 is finished, liver dissection is done along the right segmental branch. This is followed by the procedure for an S6 resection.

Fig. 7.42. Couinaud's S5 plus S6

Middle segmental branch

Cut stumps of tertiary branches for lower part of middle segment

Fig. 7.43a-c. Procedure for resection of Couinaud's S5 plus S6. a First, middle segmental branch is temporarily clamped to confirm the intersegmental plane between middle and right segments. Several centimeters of liver parenchymal dissection is done from food side of the liver, reaching the main trunk of middle segmental branch

Middle segmental branch

Cut stumps of tertiary branches for lower part of middle segment

Fig. 7.43a-c. Procedure for resection of Couinaud's S5 plus S6. a First, middle segmental branch is temporarily clamped to confirm the intersegmental plane between middle and right segments. Several centimeters of liver parenchymal dissection is done from food side of the liver, reaching the main trunk of middle segmental branch a

Fig. 7.43b. After transecting some tertiary branches of middle segmental branch, liver parenchymal dissection along the right segmental branch must be done

Appendix: A History of Challenges Faced in Hepatic Surgery (2000 Cases of Hepatic Resection for HCC)

We carried out more than 2000 hepatic resections for hepatocellualr carcinoma (HCC) over a 30-year period at the Institute of Gastroenterology of Tokyo Women's Medical University, Tokyo, Japan

120 100 80 60 40 20 0

Number of hepatic resections for HCC and CCC (1968-2004)

Number of hepatic resections for HCC and CCC (1968-2004)

120 100 80 60 40 20 0

Glissonean pedicle transection

method (3 rd stage)

Controlled method I (2nd stage)

i .

'il

Finger fracture method (1st stage)

1

i

------n-------«Mill

1

1

1,

1,

1

1

1,

I

1

1,

1

1

1968 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

1968 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Fig. 1. At the first stage, the finger fracture method was used. At the second stage, the controlled method was introduced. In 1984, the Glissonean pedicle transec-tion method (the third stage) went into use. Since that time and continuing up to the present, this method has been used for all hepatic resections

2000 cases of hepatic resection for HCC Institute of Gastroenterology TWMU

Remaining liver function test 1

2000 cases of hepatic resection for HCC Institute of Gastroenterology TWMU

Remaining liver function test 1

New concept of liver segmentation

1986

Glissonean pedicle transection method

1984

Arterial and portal angio-echogram

1986

Hepatic resection via anterior approach

1984

Original instrument for hepatic resection

1986

Selective clamp of segmental pedicle

1986

IVC clamping during liver dissection

1990

Fig. 2. Many problems had to be solved in order to perform hepatic resection safely. During the past 40 years, we have developed ideas and devices to make the operation safer and easier to carry out

Estimating liver function remaining after hepatic resection

It is now believed that 70% of hepatic volume can be resected without impairing postoperative liver function. However, most HCC cases are complicated by chronic hepatitis or liver cirrhosis, and in those cases even a small volume of hepatic resection carries with it the risk of postoperative liver insufficiency. Therefore it is necessary to know the allowable range of hepatic resection on the basis of the degree of liver damage.

What amount of remaining liver function is necessary to prevent postoperative liver insufficiency?

To make this determination, the postoperative courses of patients who had undergone hepatic resection were studied. I concluded that in cases of chronic hepatitis or liver cirrhosis, 40% of ICGR15 (indocyanine green retention rate at 15 min) is necessary to prevent postoperative liver failure. But in cases of chronic hepatitis that are not so severe fibrosis, because of rapid liver regeneration, there is no problem even if the postoperative ICGR15 value is 50%.

Fig. 4. With this grid, which has two vertical axis (X and Y), remaining liver function can be determined by charting ICGR15. The ICGR15 value is plotted on the X vertical axis and is connected by a straight line to the 100% point on the Y vertical axis. The relation of resected liver volume and remaining liver function is shown by the ICGR15 value on the Y vertical axis

Relation between resection rate and changing rate of ICG (K) value

Relation between resection rate and changing rate of ICG (K) value

Fig. 3. I devised a method to determine the relation of the resected liver volume and the postoperative remaining liver function. I saw that the ratio of the resected liver volume is in direct proportion to the change in the ICGK (plasma clearance rate of indocyanine green) pre- and postoperatively in animal experiments

Takasaki K. et al: IntSurg 65: 309-313 1980

Fig. 3. I devised a method to determine the relation of the resected liver volume and the postoperative remaining liver function. I saw that the ratio of the resected liver volume is in direct proportion to the change in the ICGK (plasma clearance rate of indocyanine green) pre- and postoperatively in animal experiments

Fig. 4. With this grid, which has two vertical axis (X and Y), remaining liver function can be determined by charting ICGR15. The ICGR15 value is plotted on the X vertical axis and is connected by a straight line to the 100% point on the Y vertical axis. The relation of resected liver volume and remaining liver function is shown by the ICGR15 value on the Y vertical axis

Limits of allowable volume in hepatic resection

Limits of allowable volume in hepatic resection

ICGR15

50% Background 40% chronic hepatitis

Allowable volume of resection: 62%

20 40 60 S0 (%) (Volume of hepatic resection)

Fig. 5. Clinical case 1. The preoperative ICGR15 was 15%; the background condition of the liver was chronic hepatitis. In this case, remaining liver function had to be at least 50% of ICGR15 to prevent postoperative liver failure. The 15% point on the X vertical axis is connected with a straight blue line to the 100% point on the Y vertical axis. The intersection of this line and the 50% point of ICGR15 indicates the volume of hepatic resection (solid red vertical line). In this case, the allowable range of hepatic resection was 62%. The resection procedure therefore had to be controlled so as not to exceed a resected liver volume of 62%, in order to prevent postoperative liver failure

ICGR15

50% Background 40% chronic hepatitis

20 40 60 S0 (%) (Volume of hepatic resection)

Allowable volume of resection: 62%

Fig. 5. Clinical case 1. The preoperative ICGR15 was 15%; the background condition of the liver was chronic hepatitis. In this case, remaining liver function had to be at least 50% of ICGR15 to prevent postoperative liver failure. The 15% point on the X vertical axis is connected with a straight blue line to the 100% point on the Y vertical axis. The intersection of this line and the 50% point of ICGR15 indicates the volume of hepatic resection (solid red vertical line). In this case, the allowable range of hepatic resection was 62%. The resection procedure therefore had to be controlled so as not to exceed a resected liver volume of 62%, in order to prevent postoperative liver failure

Limits of allowable volume in hepatic resection (HCC case 2 with LC)

Limits of allowable volume in hepatic resection (HCC case 2 with LC)

Background liver cirrhosis

Allowable volume of resection: 23%

20 40 60 80 (%) (Volume of hepatic resection)

Fig. 6. Clinical case 2. Liver cirrhosis was a background complication in this case. Because regeneration after resection could not be expected, 40% of ICGR15 had to be preserved. The preoperative ICGR15 was 30%. That point on the X vertical axis is connected by a straight line (blue) to the 100% point on the Y vertical axis. The red line drawn vertically from the intersection of the blue line and the 40% point on the Y vertical axis indicate that the maximum allowable volume of hepatic resection is 23%. The resection procedure therefore had to be controlled so as not to exceed a resected liver volume of 23%

Background liver cirrhosis

Allowable volume of resection: 23%

20 40 60 80 (%) (Volume of hepatic resection)

Fig. 6. Clinical case 2. Liver cirrhosis was a background complication in this case. Because regeneration after resection could not be expected, 40% of ICGR15 had to be preserved. The preoperative ICGR15 was 30%. That point on the X vertical axis is connected by a straight line (blue) to the 100% point on the Y vertical axis. The red line drawn vertically from the intersection of the blue line and the 40% point on the Y vertical axis indicate that the maximum allowable volume of hepatic resection is 23%. The resection procedure therefore had to be controlled so as not to exceed a resected liver volume of 23%

2000 cases of hepatic resection for HCC Institute of Gastroenterology TWMU

Remaining liver function test 1978

New concept of liver segmentation

Remaining liver function test 1978

New concept of liver segmentation

1986

Fig. 7. In 1986, I proposed a new concept of liver segmentation based on the bifurcation patterns of Glisso-nean pedicles

1986

Fig. 9. The structure of the Glissonean pedicle tree inside the liver is shown schematically. The artery, portal vein, and bile duct are not visible, as they are sheathed within the fibroid bundle
Fig. 8. Removal of surrounding liver parenchyma from Glissonean pedicle branches using a Cavitron ultrasonic aspirator (CUSA) exposes the pedicle tree

New concept of liver segment (segment

based on Glissonean pedicle tree and cone unit)

(30 % r^TS .. ,.

■r

30 % .-A ■''■

k ■-■d 10

Right Segment

Fig. 10. The new concept of liver segmentation, based on the Glissonean pedicle tree. The three branches of the tree enter the right, middle, and left segments of the liver, each segment representing 30% of total liver volume, with the remaining 10% being taken up by the caudate area

Middle Segment Right Segment

Left Segment

Caudate Area

Relation between the segments and hepatic veins

Several tertiary branches branch out from each secondary branch inside the liver.

Several tertiary branches branch out from each secondary branch inside the liver.

Fig. 11. Relation between the liver segments and Fig. 12. The ramification pattern of tertiary branches hepatic veins. The middle hepatic vein (MHV) lies from secondary branches varies from patient to patient, between the left and middle segments; the right hepatic typically ranging from two to eight branches vein (RHV) between the middle and right segments

Cone unit

Cone unit

One tertiary branch feeds one cone

13 One tertiary branch feeds a cone-shaped area.

Figs. 13, 14. Each tertiary branch feeds one cone-shaped area, hereafter referred to as a cone unit

2000 cases of hepatic resection for HCC Institute of Gastroenterology

Remaining liver function test

1978H

New concept of liver segmentation

1986^

Glissonean pedicle transection method

1984

Arterial and portal angio-echogram

1986

Hepatic resection via anterior approach

1984

Original instrument for hepatic resection

1986

Selective clamp of segmental pedicle

1986

IVC clamping during liver dissection

1990

Figs. 15, 16. My new procedure for hepatic resection, the Glissonean pedicle transection method, was first performed in 1984

Left segment resection

Types of hepatic resection (divided into two types)

Segment resection

Resection of one or two segments, under transection of corresponding secondary branches of Glissonean pedicle.

" Cone-unit resection

Resection of one or several cone units, under transection of corresponding tertiary branches of Glissonean pedicle.

Fig. 17. There are two types of hepatic resection procedure: segment resection and cone unit resection

Figs. 18-25. Segment resection is performed by transecting a segmental branch at the hilus of the liver and resecting the area in which that that branch is distributed

Fig. 18. Schematic diagram of left segment resection, showing transection of the left segmental pedicle and dissection of liver parenchyma

Fig. 19. Schematic diagram of middle segment resection, showing transection of the middle segmental pedicle and dissection of liver parenchyma

Fig. 20. Schematic diagram of right segment resection, showing transection of the right segmental pedicle and dissection of liver parenchyma

Fig. 19. Schematic diagram of middle segment resection, showing transection of the middle segmental pedicle and dissection of liver parenchyma

Fig. 20. Schematic diagram of right segment resection, showing transection of the right segmental pedicle and dissection of liver parenchyma

Fig. 22. Intraoperative photograph of middle segment resection, with the ligature of the middle segmental branch indentified

Fig. 21. Intraoperative photograph showing preparation at the hepatic hilum for segmental resection. The right, middle, and left segmental branches are identified

Fig. 22. Intraoperative photograph of middle segment resection, with the ligature of the middle segmental branch indentified

Segmental resection under Glissonean pedicle transection method

Fig. 23. The borders of the middle segment are shown Fig. 24. Liver parenchymal dissection was done on by a change of color both demarcated lines

I Right Lobectomy

(Two segments resection)

Transection of two segmental branches

Fig. 26. For cone unit resection, transect one or more tertiary branches and resect the cone units that feed off those branches

Transection of two segmental branches

Fig. 25. In the case of a right lobectomy, both the right and middle segmental branches must be transected

Fig. 26. For cone unit resection, transect one or more tertiary branches and resect the cone units that feed off those branches

Fig. 27. Even in cases of small HCC, tumors sometimes grow and spread throughout the liver via the portal vein

Fig. 28. Schema of intrahepatic tumor metastasis via the portal vein

Cone unit resection

Fig. 29. Schema of cone unit resection

30

Cone unit resection

Fig. 29. Schema of cone unit resection

Figs. 30-32. Cone unit resection, with a cauliflower head as an illustrative model. Steps 1, 2, and 3 are illustrated

Fig. 33. Schema of cone units resection

Fig. 34. Following the transection of applicable tertiary branches, liver parenchyma is dissected along the liens indicated. Resected cone units specimen

Fig. 35. When dealing with small tumors, it is difficult to determine in which branch they lie. I developed the arterial and portal angio-echogram in 1986 to address this problem
Fig. 37. Echogram showing that the tumor (upper left) lies just outside the enhanced area. The punctured branch was confirmed to be a cancer-bearing portal branch

Fig. 36. CO2 is injected into the portal vein, which on an echogram enhances the area fed by the vein. Tumors, however, are not enhanced

Figs. 38, 39. In echograms, the intersegmental planes (arrows) are clearly shown after injection of CO2 gas into the middle segmental branch of portal vein. rHv, right hepatic vein; Tu, tumor

Figs. 38,39. Continued Fig. 40. For dealing with large tumors, in 1984 I devel oped the anterior approach for hepatic resection

Fig. 41. With large tumors, there is some risk of bleeding and intravascular dissemination of cancer cells at the time of hepatic mobilization. For this type of case, transection of liver parenchyma is done along a line (dotted line) from the anterior surface to the interior vena cava (IVC)

Fig. 42. Schematic illustration on hepatic resection via the anterior approach

Fig. 41. With large tumors, there is some risk of bleeding and intravascular dissemination of cancer cells at the time of hepatic mobilization. For this type of case, transection of liver parenchyma is done along a line (dotted line) from the anterior surface to the interior vena cava (IVC)

Fig. 42. Schematic illustration on hepatic resection via the anterior approach

44

Figs. 43-45. A clinical case of large HCC, which occupied the entire area of the right lobe and the medial area of the left segment. After transection of the Glissonean pedicles at the hepatic hilus, liver parenchyma is dissected from the ventral to the dorsal side. The IVC can be seen at the dorsal end of the cut surface

Figs. 43-45. Continued Fig. 46. The year 1986 saw the development of several original instruments for hepatic resection

Fig. 47. I devised 4 kinds of surgical instruments for my precedure
Fig. 49. Sono Surg (Olympus). By fitting an electric coagulation function to an ultrasonic histotripsy device, liver-cutting performance in cases of cirrhosis was improved

Fig. 48. Kent retractor. A costal arch is pulled up by hooks suspended from the arched bar, thus improving operative views

Fig. 50. Pringle forceps. These are used to gently interrupt blood flow in the porta hepatis

2000 cases of hepatic resection for HCC Institute of Gastroenterology TWMU

Remaining liver function test

1978

New concept of liver segmentation

1986

Glissonean pedicle transection method

1984

Arterial and portal angio-echogram

1986

Hepatic resection via anterior approach

1984

Original instrument for hepatic resection

1986

Selective clamp of segmental pedicle

1986 1

f IVC clamping during liver dissection

1990]

Fig. 51. Glisson forceps. Glisson forceps are used to Fig. 52. Control of bleeding during the operation can tape a Glissonean pedicle at the hepatic hilus be achieved by selective intermittent clamping of portal blood flow in cases of severe liver cirrhosis

Figs. 53, 54. At the time of middle segment resection, the middle segment Glissonean pedicle is first transected. During parenchyma dissection on the intersegmental plane between the middle and left segments, the left segmental branch of the Glissonean pedicle is temporarily clamped. After 10 min, the clamp is switched to the right segmental branch and parenchyma dissection on the intersegmental plane between the right and middle segments is performed

2000 cases of hepatic resection for HCC

Institute of Gastroenterology TWMU

Remaining liver function test

1978

New concept of liver segmentation

1986

Glissonean pedicle transection method

1984

Arterial and portal angio-echogram

1986

Hepatic resection via anterior approach

1984

Original instrument for hepatic resection

1986

Selective clamp of segmental pedicle

1986

IVC clamping during liver dissection

1990

Figs. 55-57. Clamping of the inferior vena cava at the food side of the liver reduces central venous pressure by almost 4 cm on average

Change of CVP by IVC clamp Before clamp After clamp

PSVC

8.8 cmHjO

PSVC

8.8 cmHjO

6.2 cmHjO 2.0 cmH2O

4.2 cmH2O1

6.2 cmHjO 2.0 cmH2O

4.2 cmH2O1

Figs. 55-57. Continued

Details of surgical procedures (1980-2004, n = 2083)

□ subsegmentectomy

□ 1 segmentectomy

□ 1.5 segmentectomy

□ 2 segmentectomy 2.5 segmentectomy

□ subsegmentectomy

□ 1 segmentectomy

□ 1.5 segmentectomy

□ 2 segmentectomy 2.5 segmentectomy

Fig. 58. Details of procedures of hepatic resection. 97% of the cases were complicated with liver cirrhosis or chronic hepatitis. 57% of the cases of resection were smaller than one segment resection

Fig. 59. Results after hepatic resection for HCC in recent cases. 63% of all operated patients were alive 5 years after operation and 44% of patients were alive after 10 years. In cases of simple nodular type (step 1), without regard to size, 5-year and 10-year survival rates are 76% and 54%, respectively. Even in cases of simple nodular extranodular growth type, 5-year and 10-year survival rates are 53% and 39%. These results are almost 20% better than those of other institutes. I believe that systematized hepatic resection must be a reasonable procedure for HCC treatment

Fig. 59. Results after hepatic resection for HCC in recent cases. 63% of all operated patients were alive 5 years after operation and 44% of patients were alive after 10 years. In cases of simple nodular type (step 1), without regard to size, 5-year and 10-year survival rates are 76% and 54%, respectively. Even in cases of simple nodular extranodular growth type, 5-year and 10-year survival rates are 53% and 39%. These results are almost 20% better than those of other institutes. I believe that systematized hepatic resection must be a reasonable procedure for HCC treatment

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