【Laparoscopy in Gallbladder Surgery】Left hepatectomy

Left hepatectomy is more commonly used, especially for liver cancer and intrahepatic stones in the left lobe. The resection limit is about 0.5 cm to the left of the median hepatic fissure, so as not to damage the middle hepatic vein that runs in the median fissure and confluences the two middle hepatic lobes.

Indications

1. Hepatic cholangiocarcinoma, hepatocellular carcinoma, hilar cholangiocarcinoma, metastatic liver cancer and other tumors involving the left hemi-liver and left caudate lobe (S2-S4, S1).

2. The general condition is good, without obvious organic diseases of heart, lung, kidney and other vital organs.

3. Liver function Child-Pugh grade A; or Child-Pugh grade B liver function recovered to Child-Pugh grade A after short-term treatment.

4. Liver function reserve test showed that ICG excretion test was less than 20%, and serum total bilirubin was less than 17.1 μmol/L.

Preoperative preparation

1. The risk of postoperative hepatic insufficiency caused by excessive liver resection during left hemihepatectomy is small, but for hilar cholangiocarcinoma that may block the hilar bile duct, PTCD drainage is required first to reduce jaundice. It is also possible that an extended left hepatectomy may be required because of violation of the right bile duct.

2. It is necessary to carefully confirm the resection path through imaging examination before operation, and understand whether there are anatomical variations in blood vessels and bile ducts, so as to completely protect the right hepatic vein and bile duct system during the operation, and avoid damage to the right liver function due to unclear identification during the operation.

3. For patients with metastatic cancer, it is necessary to fully evaluate the primary lesion and liver metastases, and formulate an appropriate surgical strategy.

4. Breathing training, nutrition management, skin preparation, blood preparation.

Surgical procedure

1. Position supine.

2. The incision is generally a midline incision on the upper abdomen. If necessary, it can be extended to the upper left to cut off the xiphoid process and costal arch cartilage. A downward oblique incision on the right costal margin can also be used. A combined thoracoabdominal incision is rarely required.

3. Separation of the left hemi-liver Before removing the liver, first separate the connective tissue and ligaments attached to the left hemi-liver. The round ligament of the liver was cut and ligated first, and the liver was gently pulled down with the stump on the liver side, and the falciform ligament was cut along the anterior abdominal wall. The liver is pushed back and down to better expose the coronary ligament, cut, and the left triangular ligament dorsal to the diaphragm is ligated and cut. Then, cut off the hepatogastric ligament and incise the hepatoduodenal ligament (be careful not to damage the liver pedicle), and the left hemi-liver is separated.

4. Handle the hepatic portal vessel of the first hepatic hilum. After separating the liver, pull the liver upward with a large retractor to expose the first hepatic hilum. Sometimes to prevent bleeding during lobe resection. A gauze strip or catheter can be inserted into the liver pedicle vessel first to control the blood flow. There are two commonly used methods to deal with the hepatic portal vessels:

(1) Extrathecal ligation: the left hepatic duct, left hepatic artery, and left portal vein branch are ligated outside the Glisson sheath. First, blunt dissection was made along the left trunk of Glisson's sheath 0.5cm above and 0.5cm below and penetrated into the liver parenchyma about 1cm. Do not tear the blood vessels running in the sheath during dissection. After the separation is clear, two veins are ligated with a thick silk thread about 2cm to the left of the main portal vein bifurcation; it may not be cut temporarily, and after the parenchyma of the left liver lobe is completely severed, verify whether the ligated left trunk is correct. Then, it was cut between the two knots, the left liver was removed, and the stump of the vessel trunk was sutured.

(2) Separate ligation within the sheath: When the hepatic portal vessel runs abnormally, the Glisson sheath needs to be separated, and the left hepatic duct, left hepatic artery, and left branch of the portal vein should be ligated separately. The left hepatic duct and left hepatic artery need to be cut off first, while the portal vein should not be cut off temporarily, as a sign for resection of the liver lobe in the future.

5. Treat the left hepatic vein of the second hepatic portal. After the first hepatic portal is processed, pull the liver downward to expose the second hepatic portal. At this time, it is necessary to distinguish the anatomical relationship between the left hepatic vein and the middle hepatic vein. Sometimes the middle hepatic vein and the left hepatic vein flow into the inferior vena cava separately; sometimes the middle hepatic vein first flows into the left hepatic vein and then flows into the inferior vena cava. It should also be noted that the left hepatic vein is short in the extrahepatic part, and it is often necessary to cut the liver capsule to distinguish it. Use the back of a knife to slowly separate the bifurcation of the left hepatic vein and the middle hepatic vein, retain the middle hepatic vein, and use a blunt thick round needle to guide a thick silk thread through the liver parenchyma, ligate the left hepatic vein, cut off, and separate the second hepatic porta.

6. Cut off the left hemi-liver and incise the liver capsule at 0.5 cm along the left edge of the middle hepatic vein, use the back of a knife to bluntly separate the liver parenchyma, and cut off the encountered left hepatic vessels one by one with curved hemostatic forceps ,ligation. Do not injure the trunk of the middle hepatic vein during this procedure. Then blunt dissection from the visceral anterior edge of the liver to the liver parenchyma, and finally cut off the left branch of the portal vein and completely cut off the left hemi-liver. The blood vessels and hepatic ducts of the liver section should be ligated or sutured one by one with thin silk thread, and the bleeding can be stopped by applying pressure with hot saline gauze.

7. Omentum covers the liver section. Since the falciform ligament of the liver has been removed in the left hemihepatectomy, the liver section needs to be sutured intermittently with silk thread and then covered with lesser omentum or greater omentum suture, which not only prevents intestinal adhesion, but also prevents intestinal adhesion. Helps stop bleeding. If there is still bleeding, mattress suture should be used at the wound edge to stop the bleeding. After checking that there is no bleeding or bile leakage, a cigarette drainage or double-lumen tube drainage was placed in the left hemihepatic fossa and the omentum foramen, and then the abdominal wall was sutured layer by layer.

Postoperative monitoring and management

After the operation, the amount and nature of the drainage should be closely observed to know whether there is active bleeding and bile leakage. When there is a small amount of bile leakage and bleeding after operation, no special treatment is required as long as the drainage is smooth. When the drainage volume is large, attention should be paid to water, electrolyte disturbance and acid-base imbalance. If cholangioenterostomy is performed for hilar cholangiocarcinoma, the nature and amount of drainage should be closely observed.

It is recommended to check the liver function once on the 1st, 3rd, and 5th day after the operation, observe the changes of liver function dynamically, and deal with it in time if there are any abnormal indicators.

If obstructive jaundice occurs, it is necessary to check whether there is left hepatic duct injury or stenosis. If there is extrahepatic bile duct dilatation, early PTCD drainage can be performed to ensure good liver function and gain opportunities for later treatment.

Formulate a reasonable infusion plan, detect the amount of pleural effusion and ascites, pay attention to the balance of inflow and outflow, and use plasma and diuretics when necessary. At the same time, patients often have liver virus infection and continue to treat underlying diseases.