Shu You Peng Hepatic Caudate Lobe Resection Shu You Peng Hepatic Caudate Lobe Resection With 370 figures, mostly in color Author Prof. Shu You Peng Second Affiliated Hospital Sir Run Run Shaw Hospital Zhejiang University Hangzhou 310009, China E-mail: [email protected] ISBN 978-7-308-06598-6 Zhejiang University Press , Hangzhou Additional material to this book can be downloaded from http://extras.springer.com. ISBN 978-3-642-05104-3 e-ISBN 978-3-642-05105-0 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009936648 © Zhejiang University Press, Hangzhou and Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Cover design: Frido Steinen-Broo, EStudio Calamar, Spain Printed on acid-free paper Springer is a part of Springer Science+Business Media (www.springer.com) Dedication This book is dedicated to my sisters, Dr. Lillian S.C. Pang, MD, PhD, FRCPath; Dr. Shuyi Peng, MD; Madam Shutuo Peng, MA; and my brothers, Dr. Shugan Peng, MD; Shujue Peng, MD. Without their consistent encouragement and support, I would not have undertaken my study of liver diseases and surgical career. This book is also dedicated to all my patients whose desire for life and living well is what makes this entire effort meaningful and worthwhile. Foreword 1 The segment(cid:3)I is the most secret segment of the liver. It is the deepest segment between the hilum and the inferior vena cava, independent from the right liver (segments(cid:3)V to VIII according to Couinaud’s classification) and the left liver (segments II to IV). It is by itself a single liver, receiving its portal branches from the main left and the main right portal branches, and its hepatic branches arriving independently and directly into the inferior vena cava all along its retrohepatic part. Prof. Peng uses the term “porta hepatis” not only for the hepatic hilum but according to the Chinese anatomy to each of all of the three groups of vessels encircling the segment I: (1) the portal branches at the hilum, (2) the main hepatic veins, and (3) the small hepatic veins going directly to the vena cava. This terminology is not usual in the western anatomy and might surprise some readers. But I agree that this gives a good image of the proximity and the complexity of the network of these veins—plus the arteries—which encircles this segment. This is to say that the approach of segment I is the most difficult of all the segments of the liver and as a consequence, its surgical extirpation. In the usual description of the hepatectomy of segment I, precisely segmen- tectomy I, this segment is removed in association with other segments: usually segments II and III. It is right to say that removal of the left lobe (II and III) opens the left border of the inferior vena cava and makes easier the approach and the ligation of the small hepatic veins at the anterior face of the vena cava. Also the hepatectomy of segments II, III and IV associated to segment I, is even easier for avoiding dissecting the parenchyma between segments I and IV. Of course we are loosing in term of economy of liver parenchyma and in several circumstances as in the surgery of cirrhotic liver or of colorectal liver metastases, it is important to VIII Foreword 1 save the maximum amount of liver parenchyma. In this book, Prof. Peng describes with clarity and precision the segmentectomy I alone by several approaches, I must say all of them: anterior, left, right or combined approaches. The description of these techniques is a real demonstration of the use of the anatomical lines of division of the liver which is an important objective—above all in the center of the liver—to avoid opening or ligating large vessels with the two harmful consequences: bleeding and devascularisation. Prof. Peng uses to achieve the resection a tool that he created himself: the Peng’s Multifunction Operative Dissector (PMOD). This is a marvelous instrument to obtain a precise and bloodless line of section associating section, aspiration of the parenchyma allowing to discover the vessels and at the same time doing the hemostasis by coagulation of the small vessels. I assisted personally Prof. Peng in his Institution in Hangzhou and I used also myself the Peng’s instrument. I am convinced of the efficiency of this instrument: in addition it is very cheap and easy to use even in a non-specialized surgical unit. The numerous pictures illustrating the smallest steps of each technique show clearly how to perform all types of resection of segment I. The videos associated to the book make even easier the understanding of the techniques and show also the efficiency of the Peng’s tool. This book, describing the most delicate hepatectomy in the center of the liver, will make easy the performance of the other hepatectomies of the left liver and right liver. It is a perfect introduction to the liver surgery. It is like doing the Bechamel sauce: if you know it, all recipes will be easy. Henri Bismuth Professor of Surgery Member of the Académie Française de Chirurgie Founding President of the European Surgical Association Honorary Member of the American College of Surgeons Honorary Member of the American Surgical Association Director of the Hepatobiliary Institute 25th August 2009 Foreword 2 In spite of the rapid development in liver surgery in the past several decades, the caudate lobe has still been considered as a “no-man’s land” until very recently. In the 1960s, liver resection was a prohibitive and highly risky endeavor, carried out by a few pioneer surgeons, with inconsistent and often- disappointing results. The field of liver surgery has since grown at a spectacular rate, and has now evolved into well-planned and safe procedures. This change has mainly been brought about by the innovative advances made by surgeons based on the better understanding of liver anatomy and physiology, appreciation of liver regeneration, and improvements in the control of haemorrhage due at least partly to modern technology. The progress of diagnostic radiology allows detection of small and asymptomatic lesions. In parallel, the rapid development of liver transplantation from the end of the 1980s has greatly enhanced the experience of surgeons and anaesthetists which enabled the boundaries of liver surgery to be extended. What was previously considered as technically impossible has now become possible. Liver surgery which was defined as ‘extreme’ in view of the extent or the complexity of the procedure has now been adopted as routine and carried out in many centers. The caudate lobe is the dorsal portion of the liver lying posteriorly and embracing the retrohepatic inferior vena cava in a semi-circumferential fashion. The caudate lobe lies between the major vascular structures with the inferior vena cava posteriorly, the portal triad inferiorly, and the hepatic venous confluence superiorly. There is a series of short hepatic veins which drain blood directly from the caudate lobe into the retrohepatic inferior vena cava. Thus, the caudate lobe is surrounded by important and potentially dangerous structures deep in the center of the liver. The X Foreword 2 unique anatomical position makes caudate lobe resection, especially isolated caudate lobe resection, technically challenging. The caudate lobe consists of three parts: the Spiegel lobe, the paracaval portion and the caudate process. In the majority of cases, the three parts receive different blood supply making partial caudate lobectomy a possibility. When resection of the caudate lobe is required for tumor clearance, the operation may be an isolated caudate lobe resection or a caudate lobe resection combined with a major hepatectomy, e.g. right or left hepatectomy. Thus, caudate lobectomy can be classified into four types: isolated complete caudate lobectomy, combined complete caudate lobectomy, isolated partial caudate lobectomy and combined partial caudate lobectomy. Although caudate lobectomy has been performed combined with resection of other portions of the liver, isolated complete caudate lobectomy was not reported until in 1990 by Lerut et al. (Surg Gynaecol Obstet 1990, 171: 160-162). There have not been too many publications since this important landmark paper, especially on the technique used in isolated caudate lobectomy, probably because of the small size of the caudate lobe making resectable lesions still confined to the caudate lobe uncommon. This book describes the surgical approaches used by Prof. Peng in caudate lobectomy: the right-sided approach, the left-sided approach, the combined right- and left-sided approach, the anterior approach, and the retrograde approach. These approaches and surgical techniques are being presented in a clear and succinct manner, illustrated with many operative photographs and diagrams to allow the readers to follow the operation in a step-by-step manner, meanwhile giving detailed accounts of the indications, possible complications, their prevention and treatment. This book has been written by a very experienced HPB surgeon whom I am sure even the mature and expert liver surgeons have much to learn from. A particular feature of this book is the inclusion of a DVD-ROM showing the key steps used in the different approaches to caudate lobectomy. It is always a joy for me to watch Prof. Peng, either directly in his operating theatre or indirectly through these video clips, in using his Peng’s Multifunction Operative Dissector (PMOD) to dissect and to transect the liver. Prof. Peng always makes difficult operations to look easy to carry out! Hopefully, by showing the operations carried out by a master of surgery, the readers can learn more out of this monograph. It is a great honour for me to be invited by Prof. Peng to write this Preface to introduce this book conceived and completed by him. I have known Prof. Peng for about twenty years, and he has always been my admired friend and respected colleague. Prof. Peng has been well-known in China to be a scholar, a pioneer in many fields of surgery and a highly skillful surgeon. Prof. Peng has emerged as an important surgical leader in China and I hope he will continue to keep at the forefront with important contributions to make to the surgical community in the future. Foreword 2 XI The publishing of this remarkable book, I am sure will become an important landmark in Prof. Peng’s distinguished surgical career. This book is a ‘must’ for all liver surgeons who are interested to improve their knowledge and skills in complicated liver surgery. Wan Yee Lau MD, FRCS (Edin, Engl, Glas), FACS, Hon FRACS Academician of the Chinese Academy of Sciences Professor of Surgery The Chinese University of Hong Kong 13th August 2009