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SEGMENT ORIENTED LIVER RESECTIONS I. Popescu CENTER OF GENERAL SURGERY AND LIVER TRANSPLANTATION FUNDENI CLINICAL INSTITUTE BUCHAREST

Nowadays liver resections are standardized operations whose mortality has decreased substantially in the last 25 years. * An improved understanding of hepatic anatomy, early diagnosis of hepatic tumors , advances in operative technique, availability of spiral computerized tomography and magnetic resonance with 3-D reconstruction and intraoperative ultrasound have led to the ability to undertake resections based on the segmental anatomy of the liver. * Ong & Lee – Br J Surg 1975; 62, 421: 17.6% (125 patients) Iwatsuki & Starzl – Surg Clin N Am 1989; 69, 315: 3.2% (411 patients) Myagawa & Makuuchi – Am J Surg 1995;169, 589: 2.3% (172 patients)

TYPES OF SEGMENT ORIENTED LIVER RESECTIONS Segmentectom y I  VIII Bisegmentectomi es II, III V, VIII VI, VII IVb, V V, VI Segment oriented liver resections have been promoted especially by French and Asian authors. * * Castaing D, GArden OJ, Bismuth H. – Ann Surg 1989; 210: 20-23 Lui W et al. – Arch Surg 1995; 130: 1090-1097 Hasegawa H, Yamasaki S, Makuuchi M – J Chir Paris 1991; 128: 343-350 Trisegmentectomi es IV, V, VIII IVb, V, VI Subsegmentectomi es IVa, IVb

INDICA TIONS FOR SEGMENT ORIENTED LIVER RESECTIONS patients with benign lesions for whom a major hepatectomy is not justified cirrhotic patients with a limited hepatic reserve patients with multiple lesions who otherwise need extended hepat e c tomy or are unresectable patients with liver metastasis who may develop hepatic recurrences and need iterative hepatectomy

resection margins ( at least 1 cm) liver parenchyma preserved as much as possible minimized blood loss and haemodynamic stability avoiding complications due to damage of the pedicles of remnant liver OPERATION OBJECTIVES

1.01.1995 - 1 . 03 .200 3 569 hepatectomi es 552 patients 30 5 anatomical hepatectomies 137 segment oriented resections

13 7 segment oriented liver resections 11 9 non-cirrhotic patients 18 cirrhotic patients

SURGICAL TECHNIQUE Inci sion Liver mobilization Vascular approach i ntra parenchymal extrahepatic Maneuvers for bleeding control: Pringle ’s maneuvers , total vascular exclusion Techniques of liver parenchyma transection: ultrasonic scalpel, CUSA, jet cutter, mic rowaves Techniques of haemostasis on the raw surface: Surgicel, Tachocomb, Tissue glue, argon

Segment I – 8 cases Indications Benign lesions 5 Hemangiom a 4 cirrhosis 1 Budd-Chiari syndrome 1 Malignant lesions 3 Klatskin tumor 1 Metastasis colorectal cancer 2

Segment I I – 1 case Metasta sis from colonic cancer

Segment III – 5 ca ses Hepatocellular carcinoma associated with cirrhosis

Indications Benign lesions 1 Hydatid cyst 1 Malignant lesions 4 Hepatocellular carcinoma 2 1 cirrhosis Metasta sis leiom y osarcom a 1 Metasta sis sarcom a 1 Segment III – 5 ca ses

Segment V 8 ca ses Hepatic adenoma

Segment V- 8 ca ses Indications Benign lesions 3 Inflammatory tumor 1 Focal nodular hyperplasia 1 Hepatic adenoma 1 Malignant lesions 5 Hepatocellular carcinoma 2 1 ci rrhosis Metasta sis from colon cancer 2 Metasta sis from breast cancer 1

Segment VI 1 case Liver metastasis from colonic cancer

Segment V II - 1 case Hemangioma

Indications Benign lesions 2 Focal nodular hyperplasia 1 Hemangiom a 1 Malignant lesions 1 Hepatocellular carcinoma 1 Segment VIII 3 ca ses

Left lateral sectorectomy (II, III) Intraparenchymal vascular approach

Extrahepatic vascular approach HCC with cirrhosis Left lateral sectorectomy (II, III)

Indications Benign lesions 3 6 Hemangiom a 11 1 cirrhosis Hydatid cyst 10 Hepatic abscess 5 Focal nodular hyperplasia 3 Inflammatory tumor 2 1 cirrhosis Caroli’s disease 2 Liver trauma 2 Giant serous cyst 1 Malignant lesions 23 Hepatocellular carcinoma 11 8 cirrhosis Cholangiocarcinoma 4 1 cirrhosis Metastasis from colorectal cancer 6 1 cirrhosis pancreatic cancer 1 ovarian cancer 1 Procurement for living-related liver transplantation 5 Left lateral sectorectomy (II, III) 64 cases

Laparoscopic resection – 1 ca se Liver metastasis from breast cancer Left lateral sectorectomy

Harvesting of segments II-III from a living donor for a pediatric liver transplantation

Right lateral sectorectomy (VI, VII) 23 cases

Indications Benign lesions 13 Hemangiom a 6 Adenom a 2 Hepatic abscess 3 Inflammatory tumor 2 Malignant lesions 10 Hepatocellular carcinoma 5 - 2 cirrhosis Cholangiocarcinoma 1 - 1 cir rhosis M etastasis from digestive cancer 1 from testicle cancer 1 from lung cancer 1 from adrenal carcinoma 1 Right lateral sectorectomy (VI, VII) 23 ca ses

Bisegmentectom y IVb, V 5 ca ses Gallbladder cancer sta ge II

Indica tions B enign lesions 2 Hemangiom a 1 Hamartom a 1 Mal ign ant lesions 3 Gallbladder cancer 3 Bisegmentectom y IVb, V – 5 ca ses

Right medial sectorectomy (V, VIII) 1 case Inflammatory tumor

Bisegmentectom y V, VI – 9 ca ses Liver m etasta sis from colonic cancer S IV S VIII S IV S VIII

Bisegmentectom y V, VI – 9 ca ses Indica tions B enign lesions 6 Hemangiom a 5 H epatic abscess 1 M align ant lesions 3 H epatoce l lular carcinoma 1 Metasta sis from colorectal cancer 2

I nflam m ator y tumor with central necrosis located in segment s IV, V, VIII Total hepatic volume 1752,2 cm 3 Tumor volume 292 cm 3 3-D RECONSTRUCTION C entral hepatectomy 3 ca ses 2 inflammatory tumors 1 metastasis from colonic cancer

Transverse hepatectomy (IVb, V, VI) Gallbladder cancer Sta ge IVa 3 cases 2 gallbladder cancer 1 metasta sis breast cancer

Segment IV b – 2 cases 1 non-parasitic cyst 1 metastasis from breast cancer IVb IVb IVb IVb

subphrenic ab s ces s 8 hemoperitoneum 1 hematoma on the transection surface 1 remnant common bile duct stone 1 wound dehiscen ce 1 pulmonary complications 2 lower extremities thromb ophlebitis 4 MORBIDITY - 10% ( 1 4/ 137 )

Morbidity 10% Mortality 0 Morbidity , mortality 0-7,6% Hemming A.W. – Am J Surg 1993; 165: 621-624 0 1 3 CH 0 0 3 TH 0 2 9 V, VI 0 0 5 IVb,V 0 0 1 RMS 0 5 23 RLS 0 3 64 LLS 0 0 1 II 0 1 3 VIII 0 0 1 VII 0 0 1 VI 0 0 8 V 0 0 2 IVb 0 0 5 III 0 2 8 I Deaths Complications Total Resection type

Conclusions Segmental oriented liver resections are indicated for patients with benign lesions cirrhotic patients patients with multiple hepatic lesions patients with liver metastasis Preoperative computerized tomography ( if possible 3-D) and intraoperative ultrasound are mandatory.

Portal pedicle can be approached intraparen chymal extra hepatic Intraoperat ive maneuvers for minimizing blood loss : Pringle ’s maneuver , total vascular exclusion Postoperative morbidity and mortality are minimal. Conclusions

Segment oriented liver resections are well standardized operations, with a high level of difficulty but with proved benefits for the patient. Conclusion

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