Introduction to left hemihepatectomy

Contents 1 Pinyin 2 English reference 3 Name of the procedure 4 Classification 5 ICD code 6 Overview 7 Indications 8 Pre-operative preparation 9 Anesthesia and *** 10 Surgical procedure 11 Post-operative management 12 Complications 1 Pinyin

zuǒ bàn gān qiē chú shù

2 English reference

left hemihepatectomy

3 Name of the procedure

Left hemihepatectomy

4 Classification

Pediatric surgery/liver surgery

5 ICD code

50.3

6 Overview

Left hemihepatectomy is more commonly used especially for hepatocellular carcinoma and intrahepatic stones in the left lobe. The limit of resection is about 0.5 cm to the left of the median fissure of the liver so as not to damage the middle hepatic vein, which runs in the middle of the median fissure and drains the middle two lobes of the liver. The liver is the largest substantial organ in the human body and is located in the upper right part of the abdominal cavity, below the diaphragm. Most of it is located in the right quaternary region, with only a small portion reaching beyond the median line to the epigastric and left quaternary regions. The liver consists of hepatic parenchyma and a series of ductal structures. The intrahepatic ducts include the hepatic artery, portal vein, biliary system, and a separate hepatic venous system. The first three are encased in a connective tissue sheath (Glisson's sheath) and are generally preceded by the bile ducts, centered by the hepatic artery, and followed by the portal vein, which travel companionably and enter and exit the liver parenchyma through the first hepatic hilum. The latter travels in the interlobar and intersegmental fissures and collects the hepatic return blood flow, which converges into three hepatic veins, left, center, and right, and flows into the inferior vena cava through the second hepatic valve. In addition, there are some scattered small hepatic veins called short hepatic veins that converge into the inferior vena cava directly after the liver, the number of which varies in size, with an average of about 14. If not handled carefully during hepatic resection, it can cause hemorrhage, so it is called the third hepatic portal.

Lobes and segments of the liver: according to the groove structure of the liver surface, it can be divided into four lobes: the left lobe, the right lobe, the square lobe, and the caudate lobe, but this is not compatible with the internal structure of the liver, and it can not be adapted to the needs of liver surgery. After the study of the internal piping system of the liver, it was found that the distribution of blood vessels and bile ducts in the liver has a certain segmentation, and there is a certain vascular supply and bile duct drainage in a certain area, as well as a certain venous drainage, which resulted in the new concept of liver lobes and segments.

From the liver corrosion specimen can be seen in the liver lobes, segments between the obvious fissures. The liver has three major fissures, namely, the median fissure, the left interlobar fissure and the right interlobar fissure; and there are two intersegmental fissures and a dorsal fissure. These fissures divide the liver into right and left hemihepatic, five lobes and six segments (Fig. 12.18.201).

Median fissure: an obliquely shaped main fissure. From the middle of the gallbladder fossa, it rests posteriorly and superiorly against the left margin of the inferior vena cava, dividing the liver into right and left halves. The middle hepatic vein passes through the plane of the median fissure.

Left interlobar fissure: a sagittal fissure. It is located on the left side of the median fissure, from the umbilical notch backward up to the left hepatic vein into the vena cava, in the diaphragmatic plane with the sickle ligament slightly to the left as the boundary, and in the dirty plane with the left longitudinal sulcus as the sign of the left half of the liver is divided into two lobes of the left inner and left outer. Inside the fissure there is an interlobular branch of the left hepatic vein passing through.

Right interlobar fissure: a nearly horizontal oblique fissure. It is located on the right side of the median fissure, from the intersection of the middle and outer 1/3 of the anterior border of the right side of the liver at the midpoint of the gallbladder notch to the right edge of the inferior vena cava posteriorly and superiorly, dividing the right half of the liver into the right anterior lobe and the right posterior lobe. The right hepatic vein passes within the fissure.

Left intersegmental fissure: located in the left outer lobe, nearly horizontal, from the left hepatic vein into the inferior vena cava, outward through the left edge of the liver at the junction of the middle and posterior 1/3 of the liver surface, the left outer lobe is divided into two segments, upper and lower. The left hepatic vein passes within the fissure.

Right intersegmental fissure: This fissure is located in the right posterior lobe, nearly transverse, from the right notch across the right posterior lobe to the midpoint of the right margin of the liver, dividing the right posterior lobe into upper and lower segments.

Dorsal fissure: This fissure is located in the middle of the posterior-superior margin of the liver, anterior to the caudate lobe, where the hepatic vein flows into the inferior vena cava, separating the caudate lobe from the other lobes of the liver.

The above clefts divide the liver into six segments, and the surgeon can perform right hemihepatectomy, left hemihepatectomy, right trilobar resection, left outer lobe resection, and various hepatic segmental resections according to the above divisions. If the right half of the liver and the left inner lobe are resected at one time, it is called right trilobectomy; if the left half of the liver and the right inner lobe are resected, it is called left trilobectomy; and if the left inner lobe and the right anterior lobe are resected, it is called middle hepatic lobectomy. Due to the different parts of the tumor invasion or trauma to a different range, in addition to the above rules of hepatectomy, there are still irregular hepatectomy, and in recent years is a rising trend, and gradually formed a "left rule right irregular" of **** knowledge.

In 1954, Couinaud divided the liver into 8 segments based on the anatomical distribution of the hepatic cleft and portal vein in the liver, which was gradually accepted. These eight liver segments are represented by Roman numerals and are: the caudate lobe as segment I, the left outer lobe as segments II and III, the left inner lobe as segment IV, the right anterior lobe as segments V and VIII, and the right posterior lobe as segments VI and VII (Fig. 12.18.202). Surgical resection of one of these segments is called segmental resection; simultaneous resection of two or more adjacent segments is combined segmental resection; simultaneous resection of two or more nonadjacent segments is skip-segmental resection; and resection of only part of one segment is subsegmental or subtotal segmental resection. In this way, hepatic segmental resection for early lesions limited to a certain segment can not only remove the lesion, but also preserve more normal liver tissue, which is beneficial to the recovery of the patient.

Left hemihepatectomy is the resection of the left outer lobe and left inner lobe, bounded by the median fissure (Figures 12.18.21, 12.18.22).

7 Indications

Left hemihepatectomy is indicated for:

1. Malignant tumors of the liver Hepatoblastomas are most common in children, and rhabdomyosarcomas are occasionally seen. Primary hepatocellular hepatocellular carcinoma can also be seen in older children and is usually present with cirrhosis. Metastatic tumors are commonly found in retroperitoneal neuroblastoma and nephroblastoma. Secondary tumors are indications for surgery only when the tumor is limited to a certain lobe and the primary tumor can be resected.

2. Benign tumors: hepatic hemangioma, hemangioendothelioma, rare teratoma.

3. Liver cysts Parasitic cysts are dominated by liver worms, and non-parasitic cysts are common in polycystic livers, and most are found in the right lobe of the liver. If the cysts are limited to a certain lobe and damage the liver severely, hepatectomy is appropriate.

4. Hepatic trauma Hepatic resection is indicated in cases of severe liver damage that cannot be repaired, or in cases of ruptured liver with impaired blood flow.

5. Confined inflammatory lesions that invade the liver more extensively and damage the liver tissue severely, and are ineffective after general treatment, such as chronic bacterial liver abscess, liver tuberculosis, chronic amebic liver abscess, and so on.

6. Intrahepatic choledocholithiasis Intrahepatic stones confined to one lobe, with severe lesions, resulting in lobe atrophy.

7. Biliary hemorrhage If the biliary bleeding is not stopping due to malignant tumor erosion, intrahepatic vascular rupture, or intrahepatic limited infection, hepatic resection of the bleeding is feasible and the cause of the bleeding is removed.

8 Preoperative preparation

1. Cardiac, pulmonary, renal, and hepatic functions should be examined comprehensively preoperatively to understand the child's systemic stress capacity and hepatic reserve capacity. In the medical history, attention should be paid to the presence of low back pain caused by metastasis of liver cancer, and in the physical examination, attention should be paid to the presence of lung metastasis, ascites and malignant disease, etc. In addition, necessary preoperative examinations should be made. In addition, necessary preoperative tests should be performed, such as liver function test, ultrasound or ct test, radioisotope scan and fetal alpha globulin test.

2. Preoperative high protein, high carbohydrate and high fiber diet. Actively improve anemia, increase the body's resistance in a short period of time, improve the coagulation mechanism, and reduce intestinal bacteria.

3. Trauma patients should be actively anti-shock, to correct the imbalance of hydroelectric acid and alkali.

4. From 2 days before the operation, oral neomycin 4-8g daily or metronidazole 0.2g 3 times a day, to prevent postoperative infection or hepatic coma.

5. Preoperative placement of gastric tube and urinary catheter.

6. According to the scope of hepatectomy, prepare fresh blood in discretion for intraoperative application.

9 Anesthesia and ***

Reasonable choice of anesthesia according to the mode of surgery, size and general condition of the patient. Commonly used tracheal intubation general anesthesia, its effect is true, can maximize to meet the needs of the operation, but also to facilitate intraoperative respiratory, circulatory management, improve the safety of surgery, especially for critically ill children. However, general anesthesia will increase the burden on the liver, coupled with the effect of the drug itself on the liver, which is unfavorable to children with existing liver damage. Therefore, the choice of general anesthesia plus continuous epidural block combined anesthesia method is gradually increasing, so that there is good muscle relaxation, but also reduces the anesthetic drugs, the systemic effect on the child is small, the effect is good.

For patients with poor hepatic function, it is appropriate to use continuous epidural anesthesia; for patients with fair hepatic function or the possibility of using a combined thoracic and abdominal incision during the operation, general anesthesia can be used with endotracheal intubation. It is estimated that if it is necessary to block the hepatic portal blood flow during the operation, intraperitoneal hypothermia can be performed according to the specific conditions during the operation.

Hypothermia anesthesia because of the obvious inhibition of liver function, so that the postoperative morbidity and mortality rate increased, and was eliminated.

*** : supine position

10 Surgical Procedure

1. Incision The common incision is a right subcostal oblique incision, which is extended to the right posteriorly or left subcostal margin if necessary, and can be used for any type of hepatic surgery without opening the chest. The straight incision has been abandoned.

The hepatic round ligament, left coronary ligament, left deltoid ligament, falciform ligament, hepatogastric ligament, and a portion of the right coronary ligament are incised, and the left liver is fully freed.

2. The hepato-duodenal ligament was incised and the hepatic artery, portal vein and bile ducts were dissected out. The left hepatic artery is first cut off by double ligation, and the Glisson sheath is incised at the transverse sulcus of the hepatic portal, and the lower edge of the left inner lobe of the liver is bluntly separated for 1 to 1.5 cm, so as to reveal the left hepatic duct and the left transverse portion of the portal vein, which is located in the anterior portion of the portal vein (Fig. 12.18.23).

3. The left branch of the portal vein and the left hepatic duct are divided with a curved vascular clamp and ligated and cut off respectively (Figure 12.18.24).

4. At the top of the liver, the liver tissue is incised along the left side of the apex of the falciform ligament, and the left hepatic vein is isolated and ligated, either directly with a large suture, or from within the liver parenchyma during liver dissection (Fig. 12.18.25). When dealing with the left hepatic vein, it should be noted that the left hepatic vein is often dried with the middle hepatic vein*** and enters the inferior vena cava after the merger of the two veins, and the posterior superior edge of the left hepatic vein often travels within the coronary ligament and is located on the superficial surface of the left outer lobe of the liver, which can directly enter the inferior vena cava, and should therefore be clearly differentiated when separating it, so as to prevent damage to the middle hepatic vein or the inferior vena cava.

5. Left hemihepatectomy The hepatic peritoneum is cut along the left side of the median fissure at 1 cm, and the hepatic tissues are separated bluntly with the handle of the knife or the finger, and the blood vessels and bile ducts are cut off and ligated by clamping. The middle hepatic vein is located in the median fissure, so do not injure it during dissection of the hepatic parenchyma, and do not ligate its trunk, but only its left branch (Figure 12.18.26).

When resecting to the vicinity of the second hepatic hilum, there are many short hepatic veins between the inferior vena cava and the hepatic tissue that are connected to the left segment of the caudate lobe, and they should be carefully ligated and cut off one by one during the operation. The hepatic section is covered with a tipped greater omentum and then fixed with interrupted sutures. In order to reduce bleeding, microwave knife and ultrasonic knife can be used to cut the liver, and blood seepage from the liver section can be compressed with warm saline gauze, argon gas knife can be used when possible, and medical bio-protein glue and hemostatic gauze can also be used to assist in hemostasis. The hepatic section is placed under the cigarette-roll drainage and latex tube drainage.

If the tumor in the left lobe of the liver is large, or if there is extensive adhesion at the hepatic portal, it is more difficult to reveal the hepatic portal. At this time, the ligaments of the liver can be freed and then the hepatic portal can be blocked at room temperature, and then the liver can be cut along the left side of the median fissure in a 1-cm place rapidly, and the left hepatic duct, the left branch of the portal vein and the left branch of the hepatic artery can be exposed and cut off by ligation in the liver. Hepatoportal blockage is generally not more than 20 min, and not more than 10 min when combined with cirrhosis, and the two blockages should be interrupted for 5 min.

11 Postoperative treatment

After left hemihepatectomy, the liver function is impaired to different degrees, and the degree of impairment varies according to the size of the hepatectomy, intraoperative blood loss, and the length of time of hepatic portal blockage, so the liver function impairment should be closely monitored in the postoperative period and supplemented in time. Therefore, after surgery, liver function should be closely monitored, adequate glucose, vitamin C, vitamin K and vitamin B should be supplemented in time, and blood should be transfused in case of anemia.

2. Adequate albumin, small amount of plasma or fresh whole blood should be supplemented within 2 weeks after surgery.

3. Apply broad-spectrum antibiotics to reduce intestinal bacteria and prevent incision and abdominal infection.

4. Postoperative intermittent oxygenation to increase the oxygen supply to the liver.

5. Avoid the application of drugs that damage the liver and drugs that are metabolized in the liver, such as morphine, barbiturates and hibernating drugs.

6. When there is suspicion of hepatic coma, increased blood ammonia or mental abnormality, and there is a sign of hepatic coma, immediately enter arginine or monosodium glutamate intravenously to prevent the occurrence of hepatic coma.

12 Complications

1. Intra-abdominal hemorrhage Mostly due to dislodgement of the knot ligating the blood vessels, or incomplete hemostasis of the liver section, or impaired coagulation mechanism. Postoperative application of hemostatic drugs, such as the occurrence of hemorrhagic shock, or drainage tube with a large amount of fresh blood outflow, in the case of active blood transfusion in a timely abdominal exploration to stop bleeding.

2. Upper gastrointestinal bleeding Stress ulcers can occur after liver surgery. It is characterized by bloody or coffee-colored gastric fluid in the gastric tube, and in severe cases, it can lead to accelerated heart rate and decreased blood pressure. Postoperative gastrointestinal decompression should be continued and H2 receptor antagonist should be applied. When bleeding is detected, antacids and hemostatic drugs can be injected into the gastric tube, and growth inhibitors can be applied if necessary. Those who are ineffective in non-surgical treatment of hemorrhage should be treated surgically.

3. Hepatic insufficiency The function of the remaining liver should be carefully evaluated preoperatively and intraoperatively, and postoperative treatment should be active in preserving the liver.

4. Abdominal infection After hepatic lobectomy, although the section has been hemostatic, but there will still be exudation, such as drainage is not smooth will be secondary to septic infection. It is characterized by high fever and even toxic shock. Treatment to systemic application of antibiotics, repeated ultrasound-guided puncture pus extraction and injection of antibiotics, as far as possible without surgical drainage.

5. Biliary fistula by the liver section of small bile duct leakage, bile duct ligation line detachment or intraoperative bile duct injury caused by undetected. Poor drainage can lead to peritonitis. Drainage is good, the formation of a fistula, generally can be self-healing.

6. Biliary peritonitis, such as liver trauma with a large bile duct ligation detachment or necrosis, bile leakage can occur and cause biliary peritonitis, which is a more serious complication. Therefore, the hepatic tissue should be made as little ischemic as possible during surgery, the hepatic duct ligation should be secure, and postoperative drainage should be adequate. Once bile leakage occurs, it should be adequately drained.