Ratti Francesca, Cipriani Federica, Catena Marco, Paganelli Michele, Aldrighetti Luca
Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
Surg Endosc. 2017 Feb;31(2):949. doi: 10.1007/s00464-016-5015-6. Epub 2016 Jun 20.
Due to technical challenges and reduced pool of candidates, laparoscopic major hepatectomies remain relatively limited: In particular, right hepatectomy is technically more challenging than left since it requires liver mobilization, dissection of inferior vena cava (IVC) and hepatocaval confluence (HepCC), and section of right hepatic vein (RHV).
Among 53 laparoscopic right hepatectomies (San Raffaele Hospital; 2013-2015), the approach to HepCC was standardized by three techniques: (1) primary approach to IVC and RHV with complete mobilization of right hemiliver; (2) anterior approach with hanging maneuver without liver mobilization (partial anterior approach-PAA); and (3) anterior approach without hanging maneuver without liver mobilization of right hemiliver (total anterior approach-TAA). The technique was defined preoperatively based on tumor size/position, IVC/RHV compression, and HepCC dislodgement. Type of parenchyma and risk of lesion rupture were also evaluated.
Primary approach to IVC and RHV Before liver transection and after liver mobilization, IVC dissection is performed, and RHV is isolated and suspended on a vessel loop. RHV is sectioned after parenchymal transection.
no compression by tumor of IVC/RHV, no HepCC dislodgement, soft parenchyma, no risk of lesion rupture. PAA IVC and HepCC are dissected free before transection, without previous liver mobilization; a tape is positioned in front of the anterior aspect of IVC, to perform the hanging maneuver. RHV section is performed after parenchymal transection.
huge masses without compression of IVC/RHV, no HepCC dislodgement, liver stiffness, risk of lesion/parenchyma rupture. TAA Both IVC and RHV dissections are performed at the end of parenchymal transection, without previous mobilization of right lobe.
huge masses with compression of IVC/RHV, HepCC dislodgement.
Different approaches are available for HepCC dissection during laparoscopic right hepatectomy: Liver parenchyma characteristics, tumor size, and relationship with HepCC should be considered in surgical planning, to achieve satisfactory outcomes.
由于技术挑战和候选者数量减少，腹腔镜下的大型肝切除术仍然相对有限：特别是右肝切除术在技术上比左肝切除术更具挑战性，因为它需要游离肝脏、解剖下腔静脉（IVC）和肝腔静脉汇合处（HepCC），以及切断右肝静脉（RHV）。
在53例腹腔镜右肝切除术（圣拉斐尔医院；2013 - 2015年）中，通过三种技术对HepCC的处理方法进行了标准化：（1）对IVC和RHV的初次处理方法，同时完全游离右半肝；（2）前入路并采用悬吊手法且不游离肝脏（部分前入路 - PAA）；（3）前入路且不采用悬吊手法且不游离右半肝（完全前入路 - TAA）。该技术在术前根据肿瘤大小/位置、IVC/RHV受压情况以及HepCC移位情况来确定。还评估了肝实质类型和病变破裂风险。
对IVC和RHV的初次处理方法 在肝实质离断前和肝脏游离后，进行IVC解剖，分离RHV并将其悬吊于血管环上。在肝实质离断后切断RHV。
IVC/RHV无肿瘤压迫，HepCC无移位，肝实质柔软，病变无破裂风险。PAA 在离断前游离IVC和HepCC，无需预先游离肝脏；在IVC前方放置一条带子以进行悬吊手法。在肝实质离断后切断RHV。
巨大肿块但IVC/RHV无压迫，HepCC无移位，肝脏硬度大，病变/肝实质有破裂风险。TAA 在肝实质离断结束时进行IVC和RHV的解剖，无需预先游离右叶。
巨大肿块且IVC/RHV有压迫，HepCC有移位。
在腹腔镜右肝切除术中，对于HepCC解剖有不同的方法可供选择：在手术规划中应考虑肝实质特征、肿瘤大小以及与HepCC的关系，以获得满意的结果。
