Hepato-Biliary-Pancreatic Surgery and Liver Transplantation: A Comprehensive Guide, with Video Clips

Preface
Contents
List of Videos
Part I: Operative Technique of Hepatectomy
1: Use of Intraoperative Ultrasonography
References
2: The Techniques and Instruments for Minimizing Bleeding During Parenchymal Dissection
2.1 Methods to Control Blood Flow
2.1.1 Inflow Control, Pringle Maneuver
2.1.2 Total Vascular Exclusion
2.2 Methods and Instruments for Parenchymal Transection
2.2.1 Clamp Crushing Method
2.2.2 Cavitron Ultrasonic Surgical Aspirator (CUSA)
2.2.3 Water Jet
2.2.4 Harmonic Scalpel
2.2.5 Ligasure
2.2.6 Tissue-Link
2.2.7 Habib
2.2.8 Stapler
References
3: The Safe Application of Hanging Maneuver
3.1 Liver Anatomy Based on Three Glisson’s Pedicles and Three Hepatic Veins
3.2 Hanging Maneuver
3.3 Surgical Techniques
3.4 Single Tape along the Anterior Surface of Retrohepatic IVC
3.5 Two Tapes along the Anterior Surface of Retrohepatic IVC
3.6 One Tape along the Ligamentum Venosum
3.7 One Tape along the Anterior Surface of the Retrohepatic IVC and Ligamentum Venosum
3.8 Other Types of Liver Resection by Hanging Maneuver
References
4: Left Hemihepatectomy
5: Right Hemihepatectomy
5.1 Position
5.2 Laparotomy
5.3 Mobilization of Right Liver and Identification of Right Hepatic Vein
5.4 Hepatic Hilum Manipulation
5.4.1 Hepatic Hilar Vessel Manipulation
5.4.2 Manipulation of Glisson Pedicle
5.5 Liver Resection
5.6 Drainage Tube Insertion, Closure
5.7 Bleeding Control, Bile Leakage Test and Fixation of Falciform Ligament
6: Central Bisectionectomy
6.1 Preoperative Preparation
6.2 Operative Procedures [3]
6.3 Postoperative Care
6.4 Conclusion
References
7: Left Lateral Sectionectomy
References
8: Right Anterior Sectionectomy
8.1 Introduction
8.2 Indications and Contraindications
8.3 Preoperative Evaluation
8.4 Surgical Technique
8.4.1 Open Surgery and Laparoscopy
8.5 Complications
8.5.1 Bleeding
8.5.2 Bile Leakage
8.5.3 Oncologic Safety
8.6 Conclusion
References
9: Right Posterior Sectionectomy
9.1 Indications
9.2 Technique
9.2.1 Incision
9.2.2 Cholecystectomy
9.2.3 Hepatic Hilum for Inflow Control
9.2.3.1 Individual Dissection
9.2.3.2 Glissonian Approach
9.2.4 Liver Mobilization
9.2.5 Parenchymal Division
9.2.6 Cut Surface and Drain
Reference
10: S4 Segmentectomy With or Without Resection of Ventral Area of Right Anterior Section
10.1 Surgical Procedures
10.1.1 Patient Position, Incision and Peritoneal Exploration
10.1.2 Mobilization of the Liver
10.1.3 Localization of the Tumor
10.1.4 Cholecystectomy
10.1.5 Hepatectomy
10.1.5.1 Left Resection Margin
10.1.5.2 Right Resection Margin
10.1.6 Hemostasis, Drainage, and Closure
10.2 Precautions for Surgery
10.2.1 Bleeding
10.2.2 Tips for Liver Parenchymal Transection
References
11: S5 & S6 Segmentectomy
11.1 Method
12: S7 & S8 Segmentectomy
12.1 Introduction
12.2 Indications and Contraindications
12.3 Preoperative Assessment and Designing the Liver Resection
12.4 Comprehending 3D Image and its Necessity in Planning the Surgery
12.5 Operative Technique
12.5.1 Laparotomy and Liver Mobilization
12.5.2 The Procedure of Anatomical Resection of Segments 7 and 8
12.5.2.1 Segmentectomy 8
12.5.2.2 Segmentectomy 7
References
13: Laparoscopic Left Hemihepatectomy
13.1 Definition
13.2 Indications
13.3 Preoperative Examination
13.4 Patient Position
13.5 Trocars Site
13.6 Pneumoperitoneum
13.7 Bleeding Control
13.8 Surgical Technique
13.8.1 Round Ligament Division
13.8.2 Cholecystectomy
13.8.3 Left Hilar Dissection and ICG (Indocyanine Green) Technique
13.8.4 Liver Mobilization
13.8.5 Liver Parenchymal Transection
13.8.6 Left Hilar Division
13.8.7 Left Hepatic Vein Division
13.8.8 Specimen Extraction
13.8.9 Check Resection Margin and Drain Tube Insertion
13.9 Summary
References
14: Laparoscopic Left Lateral Sectionectomy
14.1 Indication
14.2 The Patient’s Posture and the Position of the Operators
14.3 Locations of Trocars
14.4 Steps of Surgery
14.4.1 Mobilization of the Liver (Fig. 14.2)
14.4.2 Liver Traction (Fig. 14.3)
14.4.3 Liver Resection by Glissonean Approach
14.4.4 Drain Insertion and Extraction of the Surgical Specimen
15: Laparoscopic Right Hemihepatectomy
15.1 Indication
15.2 Patient Position and Trocar Placement
15.3 Operative Technique
Further Reading
Part II: Deceased Donor Liver Transplantation
16: Liver Procurement in a Deceased Donor
16.1 Procedures
References
17: Recipient Hepatectomy Without Venovenous Bypass
17.1 Liver Mobilization
17.2 Liver Removal
17.3 Anastomosis
18: Recipient Hepatectomy with Venovenous Bypass
18.1 Mobilization of the Recipient’s Liver
18.1.1 Patient Position and Incision
18.1.2 Division and Mobilization of the Recipient’s Liver
18.1.3 Division of the Hepatic Hilum
18.2 Installation of Veno-Venous Bypass
18.2.1 Installation Method
18.2.2 Removal Method
18.2.3 Pros and Cons of Veno-Venous Bypass
18.2.3.1 Pros
18.2.3.2 Cons
18.3 Total Hepatectomy
19: Implantation of the Deceased Donor Liver Graft
19.1 Anastomosis of IVC (Inferior Vena Cava)
19.2 Anastomosis of the Portal Vein
19.3 Reperfusion
19.4 Anastomosis of the Hepatic Artery
19.5 Bile Duct Anastomosis
19.6 Addendum
Part III: Living Donor Liver Transplantation
20: Donor Right or Extended Right Hemihepatectomy
20.1 Donor Selection
20.2 Graft Selection
20.3 Incision of Operation
20.4 Liver Biopsy and Liver Mobilization
20.5 Cholecystectomy and Dissection of the Hepatic Hilum
20.6 Intraoperative Ultrasound
20.7 Hepatic Parenchymal Resection
20.8 Resection of Hepatic Duct
20.9 Hanging Maneuver
20.10 Extraction of the Graft
References
21: Donor Left Hemihepatectomy
21.1 Incision and Exposure
21.2 Liver Mobilization
21.3 Placement of the Hanging Tape
21.4 Cholecystectomy
21.5 Hilar Dissection and Demarcation for Transection
21.6 Resection of the Liver Parenchyma
21.7 Resection of the Left Bile Duct
21.8 Resection of the Remaining Liver Parenchyma
21.9 Vessel Dissection and Liver Retrieval
21.10 Bench Operation
21.11 Pure Laparoscopic Donor Hepatectomy
22: Living Donor Liver Graft Back-Table Procedure
22.1 Hepatic Vein Reconstruction
22.1.1 Securing Blood Flow in the Anterior Section of the Modified Right Liver Graft
22.1.2 Middle Hepatic Vein Reconstruction of Extended Right Liver Graft
22.1.3 Reconstruction of Blood Flow in Left Liver Graft
22.1.4 Reconstruction of the Large Right Inferior Hepatic Vein
22.2 Portal Vein Reconstruction
22.2.1 Reconstruction Using the Recipient’s Portal Vein
22.2.2 Reconstruction Using Vein Graft Due to Short or Variation in the Recipient’s Portal Vein
22.3 Biliary Reconstruction
23: Middle Hepatic Vein Reconstruction of Right Liver Graft
23.1 Overview
23.2 Judgment on the Necessity of Reconstructing the Middle Hepatic Vein
23.3 Blood Vessels Used for Reconstruction
23.4 Technical Considerations for Reconstruction
23.5 Anastomosis Tips (See Video 23.1)
23.6 In the Case of Anastomosis of Right Hepatic Vein and Reconstructed Middle Hepatic Vein as a Single Orifice
23.7 Reconstructed Middle Hepatic Vein after Reperfusion
References
24: Recipient Total Hepatectomy
24.1 Introduction
24.2 Surgical Method
24.2.1 Incision
24.2.2 Mobilization of the Liver
24.3 Handling of the Hepatic Hilum
24.3.1 Classical Hilar Dissection Technique
24.3.2 High Hilar Dissection Technique (HHD)
24.3.3 Modified High Hilar Dissection Technique
24.3.3.1 Whole Flow Preserving HHD
24.3.3.2 Left Flow Preserving HHD
24.4 Portal Vein Thrombectomy
24.5 Coping with and Prevention of Bleeding during Surgery
24.6 Conclusion
References
25: Reconstruction of Hepatic Vein and Portal Vein
25.1 Reconstruction of Hepatic Vein
25.1.1 Back-Table Procedures
25.1.1.1 Modified Right Lobe Graft
25.1.1.2 Extended Right Lobe Graft
25.1.1.3 Left Lobe Graft
25.1.2 Recipient Operation
25.1.2.1 Modified Right Lobe Graft
25.1.2.2 Extended Right Lobe Graft
25.1.2.3 Left Lobe Graft
25.1.2.4 Dual Liver Graft
Two Left-Sided Liver Grafts
Right- and Left-Sided Liver Grafts
25.2 Reconstruction of Portal Vein
25.2.1 Right Lobe Graft
25.2.2 Left Lobe Graft
25.2.3 Dual Lobe Grafts
References
26: Hepatic Artery Anastomosis
26.1 Introduction
26.2 Graft Artery
26.3 Recipient Artery
26.4 Anastomosis Techniques
References
27: Biliary Reconstruction
27.1 Chapter Outline
27.2 Method
27.3 Conclusion
References
Part IV: Cholecystectomy
28: Laparoscopic Cholecystectomy (3–4 Ports Method)
28.1 Introduction
28.2 Preoperative Preparation
28.3 Anesthesia
28.4 Patient’s Posture and Arrangement of Equipment and Personnel
28.5 Surgical Techniques
28.6 Microlaparoscopic Cholecystectomy
References
29: Laparoscopic Single-Site Cholecystectomy (Single Port Method)
29.1 Surgical Procedures
29.2 Conclusion
References
30: Laparoscopic Surgery for Gallbladder Polyps and Early-Stage Gallbladder Cancer
30.1 Gallbladder Polyps and Early-Stage Gallbladder Cancer
30.1.1 Overview
30.1.2 Gallbladder Polyps
30.1.3 Early-Stage Gallbladder Cancer
30.2 Surgical Techniques
30.2.1 Laparoscopic Cholecystectomy
30.2.1.1 Positioning of Patients
30.2.1.2 Incision and Trocar Insertion
30.2.1.3 Surgical Sequence
30.2.2 Extended Cholecystectomy (Lymphadenectomy)
30.3 Conclusion
References
31: Extended Cholecystectomy (Wedge Resection)
31.1 Surgical Procedure
31.1.1 Kocherization
31.1.2 Dissection of Cystic Duct and Execution of Frozen Biopsy of Cyst Duct Margin
31.1.3 Regional Lymphadenectomy
31.1.4 Hepatic Resection
31.2 Laparoscopic-Extended Cholecystectomy in Gallbladder Cancer
References
32: Extended Cholecystectomy (Including Segment IVb and V Resection)
32.1 Operation
32.1.1 Patient’s Position and Diagnostic Laparoscopy (Fig. 32.1)
32.1.2 Incision
32.1.3 Examination of the Resection Margin of Cystic Duct
32.1.4 Kocher Maneuver and Lymph Node Dissection (Lymph Node Group #13a, 8, 12) (Fig. 32.2)
32.1.5 Liver Mobilization
32.1.6 Dissection of Glisson Pedicle (Right Glisson and Right Anterior Glisson Pedicle) for the Determination of Right Resection Line (Fig. 32.3)
32.1.7 Determination of Left and Superior Resection Lines (Fig. 32.4)
32.1.8 Management of Liver Cut Surface
Further Reading
Part V: Resection of Choledochal Cyst
33: Open Resection of Chledochal Cyst
33.1 Introduction
33.2 Diagnosis
33.3 Treatment Before Surgery
33.4 Treatment
33.5 Treatment of Choledochal Cysts Other Than Type I and IVb
33.6 Things to Know before Surgery
33.7 Surgical Technique
33.8 Results
References
Untitled
34: Laparoscopic and Robotic Excision of Choledochal Cyst
34.1 Introduction
34.2 Laparoscopic Excision of Choledochal Cyst
34.2.1 Operating Room Setup: Patient Position
34.2.2 Trocar Placement and Exposure
34.2.3 Dissection of Calot’s Triangle and Exposure of the Distal Margin of the Choledochal Cyst
34.2.4 Excision of the Choledochal Cysts
34.2.5 Roux-En-Y Reconstruction
34.2.6 Hepaticojejunostomy
34.2.7 Extracorporeal Jejunojejunostomy and Specimen Retrieval
34.2.8 Tips and Comments
34.2.9 Postoperative Management and Follow-Up of Patients
34.3 Robotic Excision of the Choledochal Cyst
34.3.1 Trocar Placement and Excision of the Choledochal Cyst via Laparoscopic Surgery
34.3.2 Robotic HJ Anastomosis
34.4 Short-Term and Long-Term Outcomes
34.5 Conclusion
References
Part VI: Hilar Cholangiocarcinoma
35: Extended Right Hepatectomy and Caudate Lobectomy
35.1 Indications
35.2 The Concept of Extended Right Hepatectomy
35.3 Preoperative Evaluation and Management
35.4 Intraoperative Management of Biliary Decompression Tubes
35.5 Operative Procedures
Part VII: Extrahepatic Bile Duct Cancer
36: Bile Duct Resection
36.1 Introduction
36.2 Preoperative Management and Evaluation
36.3 Operative Method
References
37: Pancreatico-duodenectomy
37.1 Position
37.2 Incision and Exposure
37.3 Mobilization of Pancreas Head and Duodenum
37.4 Tunneling of Pancreatic Neck
37.5 Division of Duodenum
37.6 Division of Pancreatic Neck
37.7 Division of Bile Duct and Regional Lymphadenectomy
37.8 Division of Jejunum
37.9 Dissection of Uncinate Process, Retroperitoneal Tissues, and Nerve Plexus
37.9.1 Dissection of Uncinate Process
37.9.2 Retroperitoneal Tissues
37.9.3 Dissection of Lymph Nodes and Nerve Plexus around SMA
37.10 Reconstruction
37.10.1 Pancreaticojejunostomy
37.10.2 Hepaticojejunostomy
37.10.3 Duodenojejunostomy
37.11 Insertion of Drain and Closure
38: Hepatopancreatoduodenectomy
38.1 Indications and Contraindications
38.2 Preoperative Evaluation and Design for Surgical Resection
38.3 Surgical Techniques
38.4 Risks and Pitfalls During Surgery
38.5 Conclusion
References
Part VIII: Operative Technique of Pancreatectomy
39: Pylorus-Preserving Pancreaticoduodenectomy
39.1 Surgical Techniques
39.1.1 Patient Position and Skin Incision
39.1.2 Kocher Maneuver
39.1.3 Pancreatic Approach
39.1.4 Duodenal Surgery
39.1.5 Dissection of Lesser Sac
39.1.6 Division of the Pancreas
39.1.7 Mobilization of the Ligament of Treitz and SMA Dissection
39.1.8 Reconstruction and Pancreaticojejunostomy
39.1.9 Hepaticojejunostomy and Duodenostomy
References
40: Radical Antegrade Modular Pancreatosplenectomy (RAMPS)
40.1 The Procedure
40.1.1 Skin Incision
40.1.2 Expose of Pancreas
40.1.3 Kocherization
40.1.4 Dividing Neck of the Pancreas
40.1.5 Ligation of Splenic Vessels and Dissection of Lymph Node
40.1.6 Determination of Posterior Plane of Dissection
40.1.7 Combined Resection of Other Organs
Reference
Further Reading
41: Spleen-Preserving Distal Pancreatectomy
41.1 Introduction
41.1.1 Terminology
41.1.2 Definition
41.1.3 Indications
41.2 Surgical Technique
41.2.1 Incision
41.2.2 Exposure of Pancreas and Confirmation of Pancreatic Tumor Location
41.2.3 Pancreatic Dissection
41.2.4 Management of the Pancreatic Remnant
41.2.5 Pancreatic Detachment from the Splenic Vein
41.3 The Surgical Field of View Is Evaluated before Completing the Surgery and Post-Operative Patient Care
References
42: Laparoscopic Pancreaticoduodenectomy
42.1 Historical Background
42.2 Surgical Management
References
43: Laparoscopic Distal Pancreatectomy
43.1 Introduction
43.2 Indications
43.3 Preoperative Factors
43.3.1 Patient Assessment
43.3.2 Tumor Assessment
43.3.3 Planning Operation
43.4 Operative Technique
43.4.1 Patient Posture
43.4.2 Trocar Placement
43.4.3 Access to Pancreas
43.4.4 Pancreatic Division
43.4.4.1 Endo-GIA Stapler
43.4.4.2 Ultrasonic Sheers
43.4.5 Vascular Control
43.4.5.1 Splenic Artery
43.4.5.2 Splenic Vein
43.4.5.3 Small Tributary Vessels
43.4.6 Surgical Design
43.4.6.1 50% > Distal Pancreatectomy: Modified Lasso Technique
43.4.6.2 70% Distal Pancreatectomy: “Subtotal (Extended)” Distal Pancreatosplenectomy
43.4.6.3 50% Distal Pancreatectomy
43.4.7 Spleen-Preserving Procedure
43.5 Methods to Prevent POPF after Distal Pancreatectomy
43.6 Intraoperative Peritoneal Drainage
43.7 Special Consideration
43.7.1 The Role of Spleen in Adult Patients
43.7.2 Application in Left-Sided Pancreatic Cancer
43.7.3 Role of Robotic Surgical System in Laparoscopic Distal Pancreatectomy
43.7.4 Robotic Single-Site plus ONE-Port Distal Pancreatectomy
References
Video Articles
44: Laparoscopic Central Pancreatectomy
44.1 Operative Procedure
44.1.1 Patient Position and Trocar Placement
44.1.2 Approach to the Pancreas
44.1.3 Dissection of the Pancreas and Exposure of the Superior Mesenteric Vein (SMV) and the Portal Vein (PV)
44.1.4 Proximal and Distal Pancreatic Division
44.1.5 Pancreatic Anastomosis
44.1.6 Drain Placement
45: Transduodenal Ampullectomy of Ampullary Adenoma
45.1 Introduction
45.2 Indications and Contraindications
45.3 Preoperative Evaluation
45.4 Surgical Procedures
45.4.1 Incision
45.4.2 Kocher Maneuver
45.4.3 Incision of the Duodenum
45.4.4 Excision of the AoV
45.4.5 Ductoplasty of the Bile and Pancreatic Ducts
45.4.6 Implantation of Common Duct into Duodenum
45.4.7 Closure of Duodenostomy
45.4.8 Drain Insertion and Abdominal Wall Closure
45.5 Conclusion
References
46: Essential Tips for Pancreatic and Duodenal Surgery: Vessel Resection
46.1 Combined Venous Resection
46.1.1 End-to-End Anastomosis
46.1.2 Interposition Grafting
46.1.2.1 Autogenous Vessels
46.1.2.2 Cadaveric Vessels
46.1.2.3 Xenogenic Graft, Bovine Pericardial Patch
46.1.2.4 Artificial Graft: Polytetrafluoroethylene (PTFE, Gore-Tex®) Grafts
46.2 Combined Arterial Resection
46.2.1 Proper Hepatic/Right Hepatic Arterial Resection
46.2.2 Distal Pancreatectomy with Celiac Axis Resection (DP-CAR, Appleby Operation)
46.2.3 Resection of Superior Mesenteric Artery
References
47: Essential Tips for Reconstruction After Pancreaticoduodenectomy
47.1 Pancreaticojejunostomy
47.1.1 Modified Blumgart Duct-to-Mucosa Technique
47.1.2 Conventional 2-Layer Duct-to-Mucosa Technique
47.2 External Drainage of Pancreatic Duct
47.2.1 Transjejunal External Drainage of Pancreatic Duct
47.2.1.1 Background
47.2.1.2 Surgical Technique
47.2.1.3 Post-Surgery Management
47.2.2 Transhepatic External Drainage of Pancreatic Duct
47.3 Pancreaticogastrostomy
47.3.1 Preparation of Pancreas
47.3.2 Preparation of Stomach
47.3.3 Pancreatic-Gastric Anastomosis
47.3.4 Pros and Cons of Pancreaticogastrostomy
References