Hepatobiliary Surgery - part 1 ppt

Chamberlain, MD, MPA, FACS Chief, Hepatobiliary Surgery and Pancreatic Surgery Program Director, General Surgery Beth Israel Medical Center Albert Einstein College of Medicine New York,

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Ronald S Chamberlain Leslie H Blumgart

a d e m e c u

Table of contents

1 Essential Hepatic and Biliary

Anatomy for the Surgeon

2 Imaging of the Liver, Bile

Ducts and Pancreas

3 Endoscopic and Percutaneous

8 Periampullary Cancer and

Distal Pancreatic Cancer

The Vademecum series includes subjects generally not covered in other handbook series, especially many technology-driven topics that reflect the increasing influence of technology in clinical medicine.

The name chosen for this comprehensive medical handbook series is Vademecum, a Latin word that roughly means “to carry along” In the Middle Ages, traveling clerics carried pocket-sized books, excerpts of the carefully transcribed canons, known as Vademecum In the 19th century a medical publisher

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10 The Surgical Approach to Colorectal Liver Metastases:

Non-Patient Evaluation, Selectionand Results

11 Surgical Techniques of OpenCholecystectomy

12 Laparoscopic Cholecystectomyand the Laparoscopic

Management of Common BileDuct Stones

13 Surgical Techniques forCompletion of a BilioentericBypass

(excerpt)

Ronald S Chamberlain, MD, MPA, FACS

Beth Israel Medical Center Albert Einstein College of Medicine

New York, New York

Leslie H Blumgart, MD, FACS, FRCS (Eng, Edin),

FRCPS (Glas)

Memorial-Sloan-Kettering Cancer Center

New York, New York

VADEMECUMHepatobiliary SurgeryLANDES BIOSCIENCEGeorgetown, Texas U.S.A.

Copyright ©2003 Landes Bioscience

All rights reserved

No part of this book may be reproduced or transmitted in any form or by anymeans, electronic or mechanical, including photocopy, recording, or anyinformation storage and retrieval system, without permission in writing from thepublisher

Printed in the U.S.A

Please address all inquiries to the Publisher:

Landes Bioscience, 810 S Church Street, Georgetown, Texas, U.S.A 78626Phone: 512/ 863 7762; FAX: 512/ 863 0081

ISBN: 1-57059-630-1

Library of Congress Cataloging-in-Publication Data

Hepatobiliary surgery / [edited by] Ronald S Chamberlain, Leslie H Blumgart.

p.; cm (Vademecum)

Includes bibliographical references and index.

Ronald S Chamberlain ISBN 1-57059-630-1

1 Liver Surgery Handbooks, manuals, etc 2 Biliary tract Surgery Handbooks, manuals, etc I Chamberlain, Ronald S II Blumgart, L H III Series.

[DNLM: 1 Liver Diseases surgery 2 Biliary Tract Diseases surgery 3 Digestive System Surgical Procedures WI 770 H52995 2001] RD546.H358 2001

617.5´56059 dc21

00-064876

While the authors, editors, sponsor and publisher believe that drug selection and dosage andthe specifications and usage of equipment and devices, as set forth in this book, are in accordwith current recommendations and practice at the time of publication, they make nowarranty, expressed or implied, with respect to material described in this book In view of theongoing research, equipment development, changes in governmental regulations and therapid accumulation of information relating to the biomedical sciences, the reader is urged tocarefully review and evaluate the information provided herein

The surgical care of patients is a full commitment As most of you will realize, accepting any additional commitments beyond clinical medicine is a burden that is borne by the family of the practicing surgeon This past year has been a tremendous bur- den on my family as several works came to fruition To Kim, the light and joy in my life — thank you, I love you To Courtney and Taylor, Daddy is so proud of both you You are all the sources

of my inspiration and contentment.

Ronald S Chamberlain

Dedication

Preface xiii

1 Essential Hepatic and Biliary Anatomy for the Surgeon 1

Ronald S Chamberlain and Leslie H Blumgart Introduction 1

The Liver 1

Parenchyma (The Liver Substance) 2

Hepatic Veins (OUTFLOW) 4

Hepatic Venous Anomalies 6

Hepatic Arteries (INFLOW) 6

The Biliary Tract 10

The Common Bile Duct 11

Gallbladder and Cystic Duct 12

Anomalous Biliary Drainage 16

Summary 17

2 Imaging of the Liver, Bile Ducts and Pancreas 20

Douglas R DeCorato, Lawrence H Schwartz Test Selection 21

Hepatic Lesions 23

3 Endoscopic and Percutaneous Management of Gallstones 34

Seth Richter and Robert C Kurtz Introduction 34

Endoscopic Retrograde Sphincterotomy 34

Bile Duct Stone Retrieval 35

Complications of Endoscopic Therapy 38

Percutaneous Stone Extraction 38

Specific Clinical Problems 39

The Era of Laparoscopic Cholecystectomy 40

4 Interventional Radiology in Hepatobiliary Surgery 42

Lynn A Brody and Karen T Brown Introduction 42

Diagnostic Procedures 42

Therapeutic and Palliative Procedures 49

5 Perioperative Care and Anesthesia Techniques 73

Mary Fischer, Enrico Ferri, Jose A Melendez Introduction 73

Preoperative Evaluation 73

Hepatic Evaluation 74

Intraoperative Management 74

Postoperative Care 76

6 Benign Tumors of the Liver: A Surgical Perspective 81

Ronald S Chamberlain Introduction 81

Evaluation 81

Benign Liver Tumors 85

Additional Liver Tumors 97

Conclusions 99

7 Hepatocellular Carcinoma 101

Bryan Clary Introduction 101

Etiology 101

Diagnosis and Pretreatment Planning 102

Treatment 104

Conclusion 110

8 Periampullary Cancer and Distal Pancreatic Cancer 111

Richard D Schulick Introduction 111

Pancreaticoduodenectomy for Periampullary Cancer 112

Distal Pancreatectomy for Distal Pancreatic Cancer 115

9 Hepatic Resection for Colorectal Liver Metastases: Surgical Indications and Outcomes 121

Ronald P DeMatteo, Yuman Fong Introduction 121

Epidemiology 121

Preoperative Evaluation 121

Physical Examination 122

Laboratory Tests 122

Imaging 122

Surgical Indications 123

Surgical Results 124

Survival 125

Prognostic Variables 126

Recurrent Hepatic Metastases 127

Conclusion 127

10 The Surgical Approach to Non-Colorectal Liver Metastases: Patient Evaluation, Selection and Results 129

Jonathan B Koea Introduction 129

Patient Selection 129

Preoperative Staging 132

Techniques of Resection 136

Nonoperative Techniques 137

Results 138

Conclusions 143

11 Surgical Techniques of Open Cholecystectomy 146

Ronald S Chamberlain Introduction 146

Clinical Presentation 146

Preoperative Studies 147

Perioperative Management 149

Operative Technique for Cholycystectomy 149

Surgical Technique 152

12 Laparoscopic Cholecystectomy and the Laparoscopic Management of Common Bile Duct Stones 156

Fredrick Brody Introduction 156

Indications 156

Laparoscopic Cholecystectomy 156

Laparoscopic Common Bile Duct Exploration 162

13 Surgical Techniques for Completion of a Bilioenteric Bypass 165

Pierre F Saldinger, Leslie H Blumgart Scope of the Problem 165

Anatomy 165

General Considerations 169

Incisions 171

Abdominal Exploration 172

Basic Anastomotic Technique 172

Alternative Anastomotic Techniques 173

Choledochojejunostomy or Hepaticojejunostomy 173

Ligamentum Teres (Round Ligament) Segment III Approach 177

Choledochoduodenostomy 179

14 Hilar Cholangiocarcinoma: Surgical Approach and Outcome 183

Ronald S Chamberlain, Leslie H Blumgart Etiology and Pathology 183

Preoperative Evaluation 185

Staging 186

Surgical Resection for Hilar Cholangiocarcinoma 187

Distal Bile Duct Tumors 187

Hilar Cholangiocarcinoma (HCCA) 188

Liver Transplantation 191

Palliative and Adjuvant Treatment for Cholangiocarcinoma 191

Intrahepatic Surgical Bilioenteric Bypass 191

Surgical Techniques 192

Laparoscopy 192

Exposure and Retraction 193

Palliative Approaches 197

Conclusion 199

15 Surgical Management of Gallbladder Cancer 201

Ronald P DeMatteo, Yuman Fong Introduction 201

Anatomical Considerations 201

Preoperative Evaluation 202

Clinical Presentations 202

Surgical Approach 205

Summary 207

16 Techniques of Hepatic Resection 208

Sharon Weber, William R Jarnagin, Leslie H Blumgart Introduction 208

Operative Technique 208

Right Hepatectomy 209

Extended Right Hepatectomy (Right Hepatic Lobectomy or Right Trisegmentectomy) 214

Left Hepatectomy 215

Left Lateral Segmentectomy (Left Lobectomy) 218

Extended Left Hepatectomy (Left Trisegmentectomy) 218

Caudate Lobe Resection (Segment I Resection) 222

Segmental Resection 224

Wedge Resections 225

Postoperative Care 226

17 Technique for Placement of the Hepatic Arterial Infusion Pump 227

N Joseph Espat Introduction 227

When Should HAIP Therapy Be Considered? 228

Preoperative Patient Evaluation 228

Surgical Technique for the HAIP Placement 229

Considerations for Patients with Variant Anatomy 231

Replaced Right Hepatic Artery (RRHA) 231

Replaced Left Hepatic Artery (RLHA) 232

Trifurcation of the Common Hepatic Artery (CHA) into RHA, LHA and GDA 232

Creation of the Subcutaneous Pump Pocket 232

Assessment of Hepatic Perfusion 235

Brief Comments on Technical Complications 235

Summary 237

18 Non-Resectional Hepatic Ablative Techniques:

Cryotherapy and Radiofrequency Ablation 238

Ronald S Chamberlain and Ronald Kaleya Introduction 238

Indications for Non-Resectional Ablative Therapies 238

Additional Indications and Contraindications 239

Cryotherapy 239

Radiofrequency Ablation 244

Results 249

Summary 253

19 Surgical Techniques in the Management of Hepatic Trauma or Emergencies 257

H Leon Pachter, Amber A Guth Introduction 257

History 257

Diagnosis of Blunt Hepatic Trauma 258

Diagnostic Tests 259

Nonoperative Management of Hepatic Injuries 261

Blunt Hepatic Injuries 261

Outcome of Nonoperative Management 262

Surgical Management of Complex Hepatic Injuries 263

Operative Management of the Injured Liver 263

Complications of Surgical Management 267

Outcome of Hepatic Trauma 269

20 Liver Transplantation 270

Patricia A Sheiner, Rosemarie Gagliardi, D Sukru Emre Indications 270

Possible Contraindications to Liver Transplantation 270

Organ Allocation 273

Medical Urgency 273

Timing of Transplantation 273

Preoperative Planning 274

Donor Selection 275

Intraoperative Considerations 276

The Standard Transplant Operation (Recipient) 277

Vascular Anastomoses 277

Bile Duct Anastomosis 278

Piggyback Technique 278

Bypass 278

Split Livers 279

Living Donors 280

Results 281

Index 283

Contributors

Ronald S Chamberlain, MD, MPA, FACS

Chief, Hepatobiliary Surgery and Pancreatic Surgery

Program Director, General Surgery Beth Israel Medical Center Albert Einstein College of Medicine New York, New York

Division of Interventional Radiology

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapter 4

Karen T Brown

Division of Interventional Radiology

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapter 4

Bryan Clary

Department of Surgery

Duke University Medical Center

Durham, North Carolina

Chapter 7

Douglas R DeCorato

Department of Radiology

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapter 2

Ronald P DeMatteoDepartment of SurgeryMemorial Sloan-Kettering Cancer CenterNew York, New York

Chapters 9, 15

Sukru EmreMiller Transplantation InstituteMount Sinai Medical CenterNew York, New York

Chapter 20

N Joseph EspatDepartment of SurgeryUniversity of Illinois at ChicagoChicago, Illinois

Chapter 17

Enrico FerriDepartment of AnesthesiologyMemorial Sloan-Kettering Cancer CenterNew York, New York

Chapter 5

Mary FischerDepartment of AnesthesiologyMemorial Sloan-Kettering Cancer CenterNew York, New York

Chapter 5

Yuman Fong

Department of Surgery

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapters 9, 15

Amber A Guth

New York University School of Medicine

Surgical ICU

Bellevue Hospital Center

New York, New York

Chapter 19

Rosemarie Gagliardi

Miller Transplantation Institute

Mount Sinai Medical Center

New York, New York

Chapter 20

William R Jarnagin

Department of Surgery

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapter 16

Ronald N Kaleya

Department of Surgery

Montefiore Medical Center

Bronx, New York

Chapter 18

Jonathan B Koea

Hepatobiliary Service

Department of Surgery

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapter 10

Robert C Kurtz

Gastroenterology

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapter 3

Jose A Melendez

Department of Anesthesiology

Memorial Sloan-Kettering Cancer Center

New York, New York

Chapter 5

H Leon PachterDepartment of SurgeryNew York University School of MedicineDirector, Division of Shock and TraumaBellevue Hospital Center

New York, New York

Chapter 19

Seth RichterDepartment of GastroenterologyMemorial Sloan-Kettering Cancer CenterNew York, New York

Chapter 3

Pierre F SaldingerDanbury HospitalDanbury, Connecticut

Chapter 13

Patricia A SheinerMiller Transplantation InstituteMount Sinai Medical CenterNew York, New York

Chapter 20

Richard D SchulickDepartment of Surgery and OncologyThe Johns Hopkins HospitalBaltimore, Maryland

Chapter 8

Lawrence H SchwartzDepartment of RadiologyMemorial Sloan-Kettering Cancer CenterNew York, New York

Chapter 2

Sharon WeberHepatobiliary ServiceDepartment of SurgeryMemorial Sloan-Kettering Cancer CenterNew York, New York

Chapter 16

Hepatobiliary Surgery is a technical manual and not a textbook Although

some chapters are robust in their discussion of anatomic and physiologic detail, others are written in a purely “how to” style At its core, the book is written as a reference and guidebook for practicing surgeons, gastroenter- ologists, and interventional radiologists with an interest in hepatobiliary dis- eases However, we believe it will also be of great value to medical students

on surgery clerkships, general surgery residents, and surgical oncology lows as they pursue excellence in their education and training.

fel-Mastery of hepatobiliary surgery requires one to not only be an plished surgical craftsman, but also a competent internist, knowledgeable gastroenterology collaborator, and skilled interpreter of radiologic images.

accom-No one medical discipline has a patent on knowledge and opinion, and most complex hepatobiliary problems are best managed by securing the opin- ion of experts in all disciplines before embarking on a treatment plan This book attempts to parallel that dialogue by collating the expertise, experience and opinion of all of these disciplines and distilling it down into one vol- ume Please note, this book is not gospel about how unique patients should

be managed, nor does it claim to present the only way in which various operative procedures and interventions can be performed Rather, this book presents a strategy that works for us and can hopefully be utilized to enhance your practice and the care of your patients.

Ronald S Chamberlain

This book represents a group project There are many people whose efforts

we acknowledge here and many others whose names we may fail to mention but to whom we remain grateful We acknowledge …

Our contributing authors, whose generosity in compiling, collating and writing up their experience has made this effort possible.

The committed editorial, organizational, and proofreading expertise vided by Judy Lampron Judy’s tremendous energy and tireless efforts in communicating and cajoling contributors, devoting hours to late night and weekend manuscript review sessions, and providing constant support made

pro-it all possible.

Maria Reyes whose professionalism and expertise in the editorial process have contributed greatly to the successful and timely completion of this work Tireless efforts from Kim Mitchell, Cynthia Dworaczyk, and Ron Landes from Landes Bioscience have made this all possible.

Ronald S Chamberlain Leslie H Blumgart

surgi-The importance of a precise knowledge of parenchymal structure, blood supply,lymphatic drainage, and variant anatomy on outcome is perhaps nowhere moreapparent then in hepatobiliary surgery Though the liver was historically an areawhere few brave men dared to tread, and even fewer returned a second time, recentadvances in anesthetic technique and perioperative care now permit hepatic surgery

to be performed with low morbidity and mortality in both academic and nity hospitals That said, surgeons are duly cautioned to inventory their own skillsand knowledge before venturing forward into the right upper quadrant This chap-ter will review functional biliary and hepatic anatomy necessary for the conduct ofsafe and successful hepatic operations

commu-The Liver

Surface Anatomy

The liver is situated primarily in the right upper quadrant, and usually benefitsfrom complete protection by the lower ribs Most of the liver substance resides onthe right side, although it is not uncommon for the left lateral segment to arch overthe spleen The superior surface of the liver is molded to and abuts the undersurface

of the diaphragm on both the right and left sides During normal inspiration, theliver may rise as high as the 4th or 5th intercostal space on the right

The liver itself is completely invested with a peritoneal layer except on the rior surface where it reflects onto the undersurface of the diaphragm to form theright and left triangular ligaments The liver is attached to the diaphragm and ante-rior abdominal wall by three separate ligamentous attachments, namely the falci-form, round, and right and left triangular ligaments (Figure 1.1) The falciformligament, which is situated on the anterior surface of the liver, arises from the ante-

poste-2 Heptobiliary Surgery

1

rior leaflets of the right and left triangular ligaments and terminates inferiorly wherethe ligamentum teres enters the umbilical fissure The gallbladder is normally at-tached to the undersurface of the right lobe and directed towards the umbilicalfissure At the base of the gallbladder fossa, is the hilar transverse fissure throughwhich the main portal structures to the right lobe course Additional importantlandmarks on the posterior liver surface include a deep vertical groove in which theinferior vena cava is situated and a large bare area (i.e no peritoneal coating) that isnormally in contact with the right hemidiaphragm and right adrenal gland The leftlateral segment of the liver arches over the caudate lobe that is situated to the left ofthe vena cava The caudate lobe is demarcated on the left by a fissure containing theligamentum venosum (a remnant of the umbilical vein) Additional left-sided im-portant surface features include the gastrohepatic omentum located between the leftlateral segment and the stomach The gastrohepatic omentum may contain replaced

or accessory hepatic arteries Finally, there is usually a thick fibrous band that ops the vena cava high on the right side and runs posteriorly towards the lumbarvertebrae This band, which is sometimes referred to as the vena caval ligament,must be divided to allow proper visualization of the suprahepatic cava and righthepatic veins

envel-Parenchyma (The Liver Substance)

The liver is comprised of two main lobes, a large right lobe and a smaller leftlobe Although the falciform ligament is often thought to divide the liver into a

Fig 1.1 Surface anatomy of the liver (A) Anterior surface, (B) inferior surface of theliver viewed in vivo, and (C) inferior view of the liver, viewed ex vivo Reprinted withpermission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH,Fong Y and WH Jarnigan (Eds.) W.B Saunders, London, UK (2000)