Resection of tumors at the bifurcation of the left and right hepatic duct requires one of the most difficult operations. The surgical procedure requires not only a portal lymphadenectomy and bile duct resection, but almost always a liver resection. The goals of this operation are: (1) resection of the primary tumor, (2) resection of the lymphatic drainage of the liver and (3) reestablishment of biliary continuity.
Indications ■ Primary malignancies (e.g., intrahepatic cholangiocarcinoma involving the hepatic hilus, hilar cholangiocarcinoma, gallbladder carcinoma involving the hepatic hilus, diffuse carcinoma of the extrahepatic bile duct)
■ Benign diseases (e. g., primary sclerosing cholangitis, inflammatory pseudotumor)
■ Traumatic lesion at the hepatic hilus
Biliary carcinoma with distant organ metastasis (liver, lung, bone, peritoneum)
Uncontrollable severe cholangitis with or without sepsis
Poor liver reserve with prolonged cholestasis
Severe coagulopathy despite vitamin K administration
Relative Contraindication ■ Locally advanced cholangiocarcinoma with bilateral hepatic arterial encasement
Preoperative Investigation and Preparation for the Procedure
History: Biliary surgery
Clinical evaluation: Jaundice, cholangitis, nutritional status
Laboratory tests: Bilirubin, alkaline phosphatase, ALT, AST, albumin, coagulation parameters (prothrombin time, platelets), indocyanin green test, tumor markers carbohydrate antigen 19-9 (CA19-9) and car-cinoembryonic antigen (CEA)
Radiology: Ultrasonography, cholangiography (PTC, ERCP, MRCP), 3D CT
(angiography), CT volumetry
Endoscopy: Peroral cholangioscopy, percutaneous transhepatic cholangioscopy.
The above procedures should be performed to make a differential diagnosis or to define the intraductal spread of cancer by taking a biopsy.
What we should not do
A metallic stent should not be used in resectable biliary carcinoma.
Preparation Prior to Surgery
■ Antibiotics sensitive to bile culture
■ Percutaneous transhepatic biliary drainage (endoscopic biliary drainage is not advisable)
■ Portal vein embolization for major hepatectomy
■ Internal biliary drainage or bile replacement through a nasogastric tube for patients with external biliary drainage
Incision, division of round and falciform ligament (see Sect. 1, chapters "Positioning and Accesses" and "Retractors and Principles of Exposure").
Exposure and exploration: installation of the retractor (see Sect. 1, chapter "Retractors and Principles of Exposure") and inspection of possible peritoneal metastasis.
Percutaneous transhepatic biliary drainage (PTBD) catheters are moved to the operative field to maintain intraoperative biliary drainage.
Ultrasound to evaluate location of the tumor in relation to vascular structures (portal vein, hepatic artery, hepatic vein).
Careful inspection of vascular variation.
STEP 2 Regional lymph node and connective tissue dissection
Lymph nodes in the hepatoduodenal ligament (No. 12), along the common hepatic (No. 8) and celiac arteries (No. 9) and retropancreatic nodes (No. 13), should be dissected (A) while placing a vessel loop around the common, proper, right, middle and left hepatic arteries and common bile duct (B).
Nerve plexuses around the hepatic artery should be dissected. Confirmation of vascular variation.
STEP 3 Distal bile duct resection
The Kocher maneuver is performed to mobilize the duodenum and allow dissection of the distal bile duct. The distal bile duct is dissected down to the head of the pancreas and divided above the pancreas. The resection margin must be examined by frozen section.
In some cases this procedure should be advanced more distally to detach the bile duct from the pancreatic tissue and resect the duct in the pancreas with a free margin.
STEP 4 Skeletonization of the upper part of the hepatoduodenal ligament
The transected distal bile duct is pulled up and the distal portion of the hepatic artery and portal bifurcation exposed (A). After dividing the caudate lobe branches of the portal vein (A), the right and left portal veins are encircled by a vessel loop (B).
Left Hepatic Resection
Once the arterial anatomy and possible arterial variation are clearly identified, the left and middle hepatic arteries (and cystic artery) or right hepatic artery are divided at the origin (see Figure B of STEP 4). The remaining left hepatic artery is skeletonized more distally to encircle the right anterior and posterior branches at the right extremity of the hilar plate or the middle and left hepatic artery at Rex's recess.
The left portal vein is divided and ligated distally to the bifurcation. An alternative is to use a small vascular clamp on the proximal side and oversew the venous stump with a running suture of 5-0 Prolene.
STEP 7 Mobilization of the caudate lobe with division of the short hepatic veins
In case of left side hepatectomy, the short hepatic veins are divided in the same manner from the left caudal side to the right cranial side. Finally the distal end of the canal of Arantius is ligated and divided at the confluence of the left hepatic vein or the vena cava.
STEP 8 Exposure and transection of the left hepatic vein
In case of a left hepatectomy, the left hepatic vein is not transected before liver dissection. A vessel loop is placed around the common trunk of the left and middle hepatic vein. In case of a left trisectionectomy, the common trunk of the left and middle hepatic veins is transected before the liver.
STEP 9 Demarcation and incision of the liver capsule
In case of a left hepatectomy with caudate lobe resection, dorsal demarcation appears between the caudate process and segment 7 after complete devascularization of the caudate lobe.
STEP 10 Division of the draining veins of the pericaval segment
In case of a total caudate lobe resection, draining veins of the pericaval segment (segment 9) are identified behind the middle hepatic vein and carefully divided. Liver transection is continued until the left hepatic vein is reached, divided and closed at its confluence of the middle hepatic vein. The right intrahepatic bile duct is identified behind the middle hepatic vein, and the posterior wall is carefully detached from the right anterior branch of the hepatic artery, which runs in the connective tissues between the bile duct and the portal vein. Two stay sutures are placed caudally and cranially and the bile duct is incised from the caudal edge where the anterior branch or the bile duct of segment 5 is opened.
STEP 11 Intrahepatic bile duct resection
Further extension of the incision opens the segmental or subsegmental bile ducts of segment 8 (B8, B8a, B8bc) and the right posterior duct. The surgical field after removal of the left lobe and caudate lobe is shown.
STEP 12 Extended lymph node dissection
After removing the hemiliver and the caudate lobe, para-aortic node dissection is carried out from the level of the ligamentum crus to the origin of the inferior mesenteric artery. The lymph nodes behind the left renal vein are carefully dissected by taping the left renal vein and the right renal artery. Right celiac ganglionectomy is also performed during this procedure.
STEP 13 Biliary reconstructions
Before bilioenteric anastomosis, hepaticoplasty should be performed with 5-0 PDS sutures to minimize the number of anastomoses (A).
A Roux-en-Y jejunal loop is lifted through the shortest route: the retrocolic and retrogastric route. A jejunostomy tube is also introduced from the proximal edge of the jejunal limb before hepaticojejunostomy (B).
The posterior wall is first anastomosed with 4-0 PDS sutures and a biliary drainage tube is placed in each anastomosis. Finally the anterior wall is anastomosed. See chapter on biliary anastomosis.
STEP 14 Drainage after reconstruction
After completing hemostasis in the surgical field, closed drains are placed in the foramen of Winslow, the pericaval space along the aorta and along the cut surface of the liver. Biliary drainage catheters and a jejunostomy tube are fixed on the skin, and the abdomen is closed. Although some groups do not use biliary stents, externally drained bile is mixed with elemental diet and ingested through the jejunostomy tube from the second postoperative day.
Right Hepatic Resection
Once the arterial anatomy and possible arterial variations are clearly identified, the right hepatic artery is divided at its origin. The remaining right hepatic artery is skeletonized more distally to encircle the right anterior and posterior branches at the right extremity of the hilar plate or the middle and left hepatic artery at Rex's recess. The figure demonstrates a right predominant lesion and ligation of the right portal vein and segment 4 veins that is necessary. Also illustrated is the ligated right hepatic artery.
STEP 6 Mobilization of the right hepatic lobe and caudate lobe with division of the short hepatic veins
The right liver is mobilized and the entire short hepatic veins are divided between ties on the caval side and clips on the liver side from the right caudal side to the left cranial side.
STEP 7 Exposure and transection of the right hepatic vein
A vessel loop is placed around the right hepatic vein, and vascular clamps are placed on the caval side and the liver side. The transection can be performed between the clamps. The caval side is secured by a running 4-0 Prolene suture and the other side with a 3-0 silk suture. An alternative technique is to transect the right hepatic vein with a vascular stapler (see the chapter on right hemihepatectomy).
A stay suture is placed at the inferior margin of the ischemic side of the liver, and the liver capsule is incised with monopolar diathermy or bipolar scissors along the demarcation. At this point, central venous pressure (CVP) should be maintained below 3 cm H2O.
In case of a right hepatectomy with caudate lobectomy, a transection line on the visceral surface of the liver is turned transversely from the Cantlie line about 1 cm above the hilar plate to maintain a surgical margin and reach to the right edge of Rex's recess.
STEP 9 Transection of the liver
The liver dissection is started from the inferior margin under intermittent occlusion of the hepatic artery and the portal vein. The dissection is continued cranially and posteriorly, preserving the middle hepatic vein.
STEP 10 Intrahepatic bile duct resection
The left intrahepatic bile duct is identified at the right edge of Rex's recess. Two stay sutures are placed ventrally and dorsally (A), the left hepatic duct is transected perpendicularly, and the right liver, caudate lobe and extrahepatic bile duct are removed (B). At the ventral edge of the resected margin of the left hepatic duct, the bile duct of segment 4 is opened followed by the segments 2 and 3 dorsally.
Extended lymph node dissection is performed as above.
A Roux-en-Y jejunal loop is lifted through the shortest route: the retrocolic route. A jejunostomy tube is also introduced from the proximal edge of the jejunal limb before hepaticojejunostomy.
■ Postoperative surveillance in an intensive or intermediate care unit
■ Liver function test (bilirubin, ALT, AST, albumin), coagulation parameters, hemoglobin, red blood cell (RBC), withe blood cell (WBC), CRP
■ Color Doppler ultrasound to estimate the blood flow of the portal vein and hepatic artery
Local Postoperative Complications
- (Pleural effusion)
- Wound infection
- Bile leak from hepaticojejunostomy or raw surface of the liver
- Subphrenic or subhepatic abscess
- Intra-abdominal bleeding
- Liver failure
- Portal vein thrombosis
- Anastomotic stricture
- Chronic liver failure
Check the intraoperative external biliary drainage to prevent unexpected biliary congestion from which septic complications may develop. Suture the large short hepatic veins or caudate lobe veins in detaching the caudate lobe from the vena cava.
Check the CVP in the monitor before liver transection. If the CVP is higher than 3 cm H2O, do not start to transect the liver.
The hepatic vein on the liver side should be closed by a running suture to prevent bleeding during the handling of the liver.
Stay sutures should be placed before dividing the intrahepatic bile duct, otherwise the small segmental duct will slip away and be hidden by the liver parenchyma.
The lymphatic vessels should be tied in a para-aortic lymph node dissection to prevent postoperative massive lymphorrhea.
■ Tissue diagnosis is not a prerequisite for surgical resection of suspected cholangio-carcinoma - clinical presentation and radiographic appearance is enough.
■ ERCP and peroral cholangioscopy are avoided for high bile duct obstruction since these are unlikely to define the problems or palliate obstruction, and can lead to cholangitis.
■ Percutaneous drainage is not always necessary prior to surgery. The patients who will benefit from preoperative drainage are those who (1) have cholangitis, (2) have renal dysfunction, (3) have possible vascular invasion on the side that will be the remnant liver after resection or (4) should undergo portal vein embolization.
■ In mobilizing the candidate lobe for a patient who will be subjected to a left lobectomy and caudate resection, it is usually safest to mobilize the caudate from the right to the left. Only in the thinnest patients is it safe to perform the mobilization from the left.
■ Some surgeons believe that caudate resection is an essential part of every resection for hilar cholangiocarcinoma, while others believe that resecting this portion of the liver is indicated only when the caudate lobe is directly involved by tumor.
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