RU2464941C1 - Method of left-sided hemihepatectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for left-sided hemihepatectomy. Mobilisation of left lobe of liver is performed by dissection of falciform, triangular and coronary ligaments. Pre-caval space is tunneled directly along anterior wall of hepatic part of inferior vena cava: 4 cm long track, directed downwards and outwards at angle 30° with respect to left hepatic vein, directed from lateral semicircle of said vein to lateral semicircle of inferior vena cava, more distally than the place of confluence of middle hepatic vein. Mikulicz clamp branches are introduced into made track in closed state, brought apart with fixation of holder between them. Branches are removed out of created track pulling with them holder, which is used to perform traction of liver on 3 cm upwards, which results in exposure of hepatic part of inferior vena cava and small veins, which are ligated successively. After that, liver parenchyma is cut and left hepatic vein is ligated near the place of confluence.

EFFECT: method makes it possible to reduce blood loss, reduce trauma.

1 ex, 3 dwg

Description

The invention relates to medicine, namely to surgery.

To date, there has been an increase in a variety of, including oncological, lesions of the liver. In these situations, a left-sided liver resection is often required. In modern surgery, questions of the technique of surgical interventions on the liver remain open, especially with diseases of its left lobe. Despite the arsenal of numerous ways to perform left-sided liver resections, the rates of intraoperative complications and mortality in these patients remain high. This fact dictates the need to improve the techniques for executing left-sided liver resection. The prototype of the method, the authors propose a method of left-sided liver resection. The operation begins with the mobilization of the right half of the liver. For this, the liver is taken down and to the left, while the right triangular and coronary ligaments are pulled apart. The next step in the operation is the intersection of the hepatic-renal ligament. The liver is lifted up, and the kidney is pushed back. The extraperitoneal part of the liver is dull. The inferior vena cava is isolated and provisional ligatures are placed under it. Then they proceed to the main stage of the operation - the isolation and dressing of the glisson elements in the gates of the liver. The liver is carefully, but far enough moved into the pleural cavity. At the same time, the elements of the liver gate become more accessible. With hemihepatectomy, a separate ligation of the vessels and the hepatic duct is usually possible. The peritoneum above the gate of the liver is dissected in the transverse direction. For proper orientation, first the common bile and hepatic ducts should be distinguished. The common bile duct is isolated from all sides, a thin rubber tube is circled around it and pulled forward and outward. Then they proceed to the most critical part of this stage of the operation - the isolation and ligation of the left trunk of the portal vein. The vessels are pinched and observe the color change of the liver. When the gates are closed, they resort to the aforementioned Gans technique: after dissection of the portal plate, the lobes of the liver are stretched in the opposite direction. It is better to abstain from extracapsular excretion of the leg and stitching it through the liver tissue, since different variants of vascular discharge are better recognized when they are separately ligated. The most common options include trifurcation, proximal displacement of the right lateral vein and transposition from right to left of the right paramedian vein. After ligation and intersection of the vessels of the left half, the liver is moved up and to the left, as a result of which the inferior vena cava becomes visible. The peritoneum covering it is dissected. Short hepatic veins entering the liver tissue bandage and cross. Isolation and ligation of the left superior hepatic vein refers to the difficult moments of the operation, since the extrahepatic part of the vein is short, and the vessel is wide and the ligature can easily slip off of it. The dorsal, middle and lower left hepatic veins are also ligated. Then the dissection of the liver along the middle gap. For this, it is necessary to separate the gall bladder. In the middle of the fossa of the gallbladder, the liver is dissected to a shallow depth, then the fissure is opened in a blunt way (using the scalpel handle) to the bifurcation of the sagittal vein. The branches going to her from the removed part are bandaged. Following along the sagittal vein, the separation of liver tissue along the fissure continues, and the sagittal vein remains in the thickness of the remaining part of the liver. Approaching the back surface of the liver, it is necessary to navigate so as not to damage the inferior vena cava; cut off the liver should be above the right edge of the inferior vena cava. The last stage of the operation is the closure of a liver wound. Usually, a large omentum is used for this, as well as the gall bladder, if it remains unremoved. Sew diaphragm. Rubber drains are inserted: one to the liver stump, the second to the pleural cavity through an additional puncture in the ninth to tenth intercostal space in the mid axillary line. The wound of the chest and abdominal wall is sutured in layers (Yu.M. Dederer. M .: Medicine, 1975., 200 pp. 52-56.).

The disadvantages of the method are:

1. Technical complexity in execution;

2. Injury;

3. Promotes the formation of a number of intraoperative complications. The authors propose their own method of right-sided hemihepatectomy. After performing operative access to the liver, its left lobe is mobilized by crossing the sickle, right triangular and coronary ligaments. The portal vein of the liver, the common hepatic artery and the common bile duct are mobilized and taken to the holders. Then proceed to the preparation of the hepatic veins (region Gilius II), flowing into the suprahepatic section of the inferior vena cava. At the same time, the trunks of the left and middle hepatic veins are isolated throughout. Then, in a blunt way, tunneling of the precavicular space is carried out directly along the front wall of the hepatic department of the inferior vena cava. Tunneling is performed as follows: with the second finger of the right hand, in the precancerous space, a 4 cm long stroke is made, directed from top to bottom and outward at an angle of 30 ° with respect to the left hepatic vein, which runs from the lateral semicircle of this vein to the lateral semicircle of the hepatic section of the inferior vena cava distal to the confluence of the middle hepatic vein. Thus, a message is formed between the lateral semicircle of the left hepatic vein and the outer edge of the hepatic department of the inferior vena cava. Then, the jaws of Mikulich's clamp in closed condition are guided into the created tunnel. The jaws of the clamp are parted, a holder is fixed between them (gauze braid or rubber tube), after which the jaws of the clamp are removed from the created stroke by pulling the holder behind them. Using this holder, traction of the liver is carried out 3 cm upwards, which leads to exposure of the hepatic region of the inferior vena cava, as well as small veins, including veins of the first segment of the liver. Then, ligation of the small inflowing into the hepatic department of the inferior vena cava to the left hepatic vein is carried out sequentially. Then hepatic parenchyma is cut along the border of the lobes, ligating the intrahepatic veins of segments V and VIII. After that, the left hepatic vein is ligated at the confluence. Thus, the left-sided hemihepatectomy is completed (Figs. 1-3).

The technical result of the proposed method is the implementation of left-sided hemihepatectomy.

The method proposed by the authors, in our opinion, has the following advantages:

1. Does not require special high-tech equipment;

2. Low invasiveness of this method;

3. Reduces intraoperative blood loss;

4. Reduces the duration of the operation;

5. Helps to reduce a variety of complications, including iatrogenic;

6. Reduces the patient’s hospital stay.

The authors operated on 13 people using the method described above.

Clinical example: case history No. 3457 - 2009. Patient AF, 53 years old, was admitted to the clinic with a diagnosis of cecum cancer with a single metastasis in the II segment of the right lobe of the liver. Performed left-sided hemicolectomy according to the above method. The postoperative period is smooth. The patient was discharged 21 days after surgery. Receives chemotherapy treatment. Control after 12 months - almost complete regeneration of the left lobe of the liver in the same volume, no tumor recurrence.

Claims (1)

A method of left-sided hemihepatectomy, including mobilizing its left lobe by intersecting the crescent, triangular and coronary ligaments, preparing the hepatic veins flowing into the inferior vena cava and isolating the left and middle hepatic veins along the trunks, tunneling the precaval space directly along the anterior wall of the hepatic inferior vena cava which is carried out: with the second finger of the right hand in the precancerous space make a 4 cm long course, directed from top to bottom and outward at an angle of 30 ° relative to to the left hepatic vein, directed from the lateral semicircle of this vein to the lateral semicircle of the inferior vena cava, distal to the inflow of the middle hepatic vein, into which the jaws of the Mikulich clamp are inserted in the closed position, they are opened and the holder is fixed between them, after which the branches are removed from the created of the course, extending a holder behind it, with the help of which traction of the liver is carried out 3 cm up, which leads to exposure of the hepatic department of the inferior vena cava and small veins, which are ligated sequentially, further carried cut liver parenchyma and ligated at the confluence of the left hepatic vein.

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