Li Yan, Zhang Anlan, Tian Zhongchuan, Ma Jie, Li Ming, Zhou Baoyong
Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Department of Hepatobiliary Surgery, Zhongxian People's Hospital, Chongqing Medical University, Chongqing, China.
Ann Surg Oncol. 2025 Jan;32(1):424-425. doi: 10.1245/s10434-024-16342-1. Epub 2024 Oct 10.
Robotic vascular resection and reconstruction is a challenging procedure. Portal vein arterialization (PVA) can offer an efficient solution in those cases in which the hepatic artery cannot be reconstructed.1.Can J Surg 64:e173-e182;2.The Paul Brousse Hospital Experience. HPB (Oxford) 16:723-738;3.J Am Coll Surg 207:e1-6; PVA increases oxygen supply to the remaining part of the liver, promotes liver regeneration, and prevents liver failure.Majlesara A, Golriz M, Ramouz A, et al. Portal vein arterialization as a salvage method in advanced hepatopancreatobiliary surgery. Br J Surg. 2024;111. In this multimedia article, we describe a patient who was treated with PVA for a robotic hepatic artery injury during robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy (Rob-Larmorth).5.Ann Surg Oncol 31:5636-5637 METHODS: A 52-year-old male patient was admitted with epigastric pain. Further imaging showed intrahepatic cholangiocarcinoma involving the root of the right anterior branch of the portal vein. Following multidisciplinary consultation, surgical resection was recommended as the primary approach. The robotic technique was chosen in this operation, with preoperative anticipation of needing Rob-Larmorth. Unfortunately, the left hepatic artery sustained unintended damage during skeletonization of the duodenal ligaments. Anastomosis could not be performed due to severe damage to the distal end intima. We utilized PVA technology to anastomose the hepatic artery to the portal vein. Finally, Rob-Larmorth and PVA were successfully performed.
The surgery took 490 min and the estimated blood loss was approximately 300 mL. No blood transfusion was performed. Postoperatively, the patient recovered smoothly without liver failure, although percutaneous drainage was required due to bile leakage. Pathological examination revealed moderately to poorly differentiated bile duct cell carcinoma (T2N0M0, stage II). No recurrence was observed during the 12-month follow-up.
PVA can be an effective solution when no other revascularization options are available. Implementing PVA as a bridging procedure increases oxygen delivery to the remnant liver, facilitating regeneration and reducing the risk of liver failure. The development of arterial collaterals is a significant concern for individuals undergoing PVA. Complications reported after PVA include early shunt thrombosis, portal hypertension, and a notable 90-day mortality rate.1.Can J Surg 64:e173-e182 However, Majlesara and colleagues found no evidence of postoperative liver damage associated with PVA. They also reported low morbidity rates and no associated mortality for both one- and two-stage embolization of the arterioportal shunt.Majlesara A, Golriz M, Ramouz A, et al. Portal vein arterialization as a salvage method in advanced hepatopancreatobiliary surgery. Br J Surg. 2024;111.
PVA can offer an effective solution when hepatic artery reconstruction is not feasible.
机器人血管切除与重建是一项具有挑战性的手术。门静脉动脉化（PVA）可为肝动脉无法重建的病例提供有效的解决方案。1.《加拿大外科杂志》64:e173 - e182；2.保罗·布罗斯医院经验。《HPB（牛津）》16:723 - 738；3.《美国外科医师学会杂志》207:e1 - 6；PVA可增加肝脏剩余部分的氧气供应，促进肝脏再生，并预防肝衰竭。马杰莱萨拉A、戈尔里兹M、拉穆兹A等。门静脉动脉化作为晚期肝胆胰外科手术的挽救方法。《英国外科杂志》。2024；111。在这篇多媒体文章中，我们描述了一名在机器人左肝优先前入路根治性模块化原位右半肝切除术（Rob - Larmorth）期间因机器人肝动脉损伤接受PVA治疗的患者。5.《外科肿瘤学杂志》31:5636 - 5637 方法：一名52岁男性患者因上腹部疼痛入院。进一步影像学检查显示肝内胆管癌累及门静脉右前支根部。经过多学科会诊，建议手术切除作为主要治疗方法。该手术选择了机器人技术，术前预计需要进行Rob - Larmorth。不幸的是，在十二指肠韧带骨骼化过程中，左肝动脉意外受损。由于远端内膜严重受损，无法进行吻合。我们利用PVA技术将肝动脉与门静脉进行吻合。最终，成功实施了Rob - Larmorth和PVA。
手术耗时490分钟，估计失血量约300毫升。未进行输血。术后，患者恢复顺利，未发生肝衰竭，尽管因胆漏需要进行经皮引流。病理检查显示为中分化至低分化胆管细胞癌（T2N0M0，II期）。在12个月的随访期间未观察到复发。
当没有其他血管重建选择时，PVA可能是一种有效的解决方案。将PVA作为一种桥接手术可增加向残余肝脏的氧气输送，促进再生并降低肝衰竭风险。动脉侧支循环的形成是接受PVA患者的一个重要问题。PVA后报告的并发症包括早期分流血栓形成、门静脉高压以及显著的90天死亡率。1.《加拿大外科杂志》64:e173 - e182 然而，马杰莱萨拉及其同事未发现与PVA相关的术后肝损伤证据。他们还报告了动脉门静脉分流一期和二期栓塞的低发病率且无相关死亡率。马杰莱萨拉A、戈尔里兹M、拉穆兹A等。门静脉动脉化作为晚期肝胆胰外科手术的挽救方法。《英国外科杂志》。2024；111。
当肝动脉重建不可行时，PVA可提供有效的解决方案。
