Transcript Diapositive 1

Right hepatectomy and liver
parenchyma
AF Bouras, CHRU de Lille
ACHBT Junior, Rouen 2012
Parenchyma, technique and
datas…
• No realy specifical datas about RH and
parenchyma type…
• Kind of patchwork …
*Cirrhosis also was
found to be
independently
associated withhernia
development; but
because of a lack of
data in 15% of the cases
regarding this variable,
it could not accurately
be included in the final
multivariate model.
Bouras, J Visc Surg 2012
What happens
often…
Intervention is correctly planned (parenchymal
disease is diagnosed preoperatively…
What happens
sometimes…
Peroperative discovery of cirrhosis, major
steatosis or post CT liver…What to do ?
What happens
sometimes…
Peroperative discovery of cirrhosis, major
steatosis or post CT liver…What to do ?
« Nature is a good girl ! »
What happens
sometimes…
Peroperative discovery of cirrhosis, major
steatosis or post CT liver…What to do ?
What happens
sometimes…
Peroperative discovery of cirrhosis, major
steatosis or post CT liver…What to do ?
Right hepatectomy is dangerous
Sparing parenchymal Policy
Torzilli, Surg Endosc 2004
Go back and
Fight another day
Livraghi,
Ann Surg 2006
Farges, Ann Surg 2003
• PP
PRT comparing 36 IP to 37 PC, 47% steatosis > 30%
IP is associated with lower blood loss
and shorter transection time
BUT…
but IP may be preferable in younger patients (eg, _65 years
of age) with an expected inflow occlusion less than 75
minutes and in absence of severe steatosis. IC may be
selected in older patients or in those with severe steatosis.
Steatosis >= 30%
HPB Oct 2012
Cirrhosis and PT clamping
Others types of PT clamping in
cirrhosis ?
• IVC Clamping
Interests ?
Iatrogenic tumor rupture,
and spillage of cancer cells
into the systemic circulation
Anterior approach
prolonged ischemia of the liver
remnant from rotation of the
hepatoduodenal ligament
excessive bleeding
caused by avulsion of the
hepatic vein and caval
branches
Interests ?
Iatrogenic tumor rupture,
and spillage of cancer cells
into the systemic circulation
Anterior approach
prolonged ischemia of the liver
remnant from rotation of the
hepatoduodenal ligament
excessive bleeding
caused by avulsion of the
hepatic vein and caval
branches
Hanging maneuver
Bleeding from the caudate hepatic
branches can be substantial and difficult
to stop, especially inpatients with liver
cirrhosis and portal hypertension
Liu, Ann Surg 2006
Feasability
Silver Clips
It is especially important
that this be done in patients
with cirrhosis, whose
typically small hepatic veins
produce high pressure that
can lead to venous backflow,
and often major hemorrhage
Haberal, Transpl Proc 2001
©rush clamping vs Ligasure
9 vs 10 patients with cirrhosis
61 vs 61 cirrhotic patients, controled study
Other transection
methods
• No data for stapler device transection on
cirrhosis or steatosis
• Datas about Ultracision ® and injuried liver
????
Raw cut surface
Drainage
VS
Remaining question, messages ?
• Technical details for transection
• Trans cystic drainage
• Clamp it soon, whatever parenchymal injury is
!!!
Thank you