Surgical Techniques for HCC Resection

The operative approach to the tumor mass is dictated, to some degree, by the results of the intraoperative ultra-sonography (IOUS). After completely mobilizing the liver, we routinely use IOUS to determine the size of the tumor and its relation to adjacent vascular and biliary structures. The tumor's proximity to vascular and biliary structures, the size of the mass, and the degree of underlying liver disease dictate, to some degree, the amount of liver to be resected. In performing the actual resection, several different parenchymal dissection techniques are available, none of which have been shown in randomized trials to be superior with regard to blood loss. Currently, we use the ultrasonic aspirator in association with the argon beam. Major resections are usually performed following one or several anatomic fissures of the liver, sparing intraparenchymal division of large vessels and intrahepatic bile ducts, thereby minimizing the risk of incurring the two most common operative complications: blood loss and bile leaks.

Techniques of vascular control are also critical in minimizing blood loss. Vascular control can range from total vascular exclusion (TVE) with control of the hepatic pedicle and vena cava above and below the liver to the Pringle maneuver, in which only hepatic inflow is occluded. We use the Pringle maneuver as the vascular control technique of choice for most major hepatic resections. When performing the maneuver, one must be cognizant of the total time that hepatic inflow is occluded. Although the upper limit to inflow occlusion has been reported to be up to 200 minutes, we apply the Pringle maneuver by intermittently occluding the hepatic artery and portal vein for 15-minute periods separated by 5 minutes of restored flow. Although TVE can be useful in cavohepatic junctional tumors, we believe it is, in general, unnecessary. In addition, roughly 14% of patients will be unable to hemodynamically tolerate TVE, and it may lead to an actual increase in blood loss and complications when used by surgeons inexperienced in the technique. For this reason, we favor the selective use of venovenous bypass instead of TVE when cavohepatic resection is anticipated.

Abdominal drainage, which once was considered mandatory, is now used selectively. Several studies have shown that the routine use of drains is unnecessary and may lead to an overall increase in the rate of infection. For these reasons, routine abdominal drainage is unnecessary and should be employed only on an individual basis. We currently use drains after thoracoabdominal incisions, biliary reconstructions, and extended resections.

Constipation Prescription

Constipation Prescription

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