V m Ronald S. Chamberlain Leslie H. Blumgart a d e m e c u V a d e m e c u m Table of contents 1. Essential Hepatic and Biliary Anatomy for the Surgeon 2. Imaging of the Liver, Bile Ducts and Pancreas 3. Endoscopic and Percutaneous Management of Gallstones 4. Interventional Radiology in Hepatobiliary Surgery 5. Perioperative Care and Anesthesia Techniques 6. Benign Tumors of the Liver: A Surgical Perspective 7. Hepatocellular Carcinoma 8. Periampullary Cancer and Distal Pancreatic Cancer The Vademecum series includes subjects generally not covered in other handbook series, especially many technology-driven topics that reflect the increasing influence of technology in clinical medicine. The name chosen for this comprehensive medical handbook series is Vademecum, a Latin word that roughly means “to carry along”. In the Middle Ages, traveling clerics carried pocket-sized books, excerpts of the carefully transcribed canons, known as Vademecum. In the 19th century a medical publisher in Germany, Samuel Karger, called a series of portable medical books Vademecum. The Landes Bioscience Vademecum books are intended to be used both in the training of physicians and the care of patients, by medical students, medical house staff and practicing physicians. We hope you will find them a valuable resource. All titles available at www.landesbioscience.com LANDES BIOSCIENCE ISBN 1- 57059- 630- 1 9 781570 596308 LANDES BIOSCIENCE Hepatobiliary Surgery 9. Hepatic Resection for Colorectal Liver Metastases: Surgical Indications and Outcomes 10. The Surgical Approach to Non- Colorectal Liver Metastases: Patient Evaluation, Selection and Results 11. Surgical Techniques of Open Cholecystectomy 12. Laparoscopic Cholecystectomy and the Laparoscopic Management of Common Bile Duct Stones 13. Surgical Techniques for Completion of a Bilioenteric Bypass (excerpt) Ronald S. Chamberlain, MD, MPA, FACS Beth Israel Medical Center Albert Einstein College of Medicine New York, New York Leslie H. Blumgart, MD, FACS, FRCS (Eng, Edin), FRCPS (Glas) Memorial-Sloan-Kettering Cancer Center New York, New York Hepatobiliary Surgery G EORGETOWN , T EXAS U.S.A. vademecum L A N D E S B I O S C I E N C E VADEMECUM Hepatobiliary Surgery LANDES BIOSCIENCE Georgetown, Texas U.S.A. Copyright ©2003 Landes Bioscience All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Printed in the U.S.A. Please address all inquiries to the Publisher: Landes Bioscience, 810 S. Church Street, Georgetown, Texas, U.S.A. 78626 Phone: 512/ 863 7762; FAX: 512/ 863 0081 ISBN: 1-57059-630-1 Library of Congress Cataloging-in-Publication Data Hepatobiliary surgery / [edited by] Ronald S. Chamberlain, Leslie H. Blumgart. p.; cm. (Vademecum) Includes bibliographical references and index. Ronald S. Chamberlain ISBN 1-57059-630-1 1. Liver Surgery Handbooks, manuals, etc. 2. Biliary tract Surgery Handbooks, manuals, etc. I. Chamberlain, Ronald S. II. Blumgart, L. H. III. Series. [DNLM: 1. Liver Diseases surgery. 2. Biliary Tract Diseases surgery. 3. Digestive System Surgical Procedures. WI 770 H52995 2001] RD546.H358 2001 617.5´56059 dc21 00-064876 While the authors, editors, sponsor and publisher believe that drug selection and dosage and the specifications and usage of equipment and devices, as set forth in this book, are in accord with current recommendations and practice at the time of publication, they make no warranty, expressed or implied, with respect to material described in this book. In view of the ongoing research, equipment development, changes in governmental regulations and the rapid accumulation of information relating to the biomedical sciences, the reader is urged to carefully review and evaluate the information provided herein. The surgical care of patients is a full commitment. As most of you will realize, accepting any additional commitments beyond clinical medicine is a burden that is borne by the family of the practicing surgeon. This past year has been a tremendous bur- den on my family as several works came to fruition. To Kim, the light and joy in my life — thank you, I love you. To Courtney and Taylor, Daddy is so proud of both you. You are all the sources of my inspiration and contentment. Ronald S. Chamberlain Dedication Contents Preface xiii 1. Essential Hepatic and Biliary Anatomy for the Surgeon 1 Ronald S. Chamberlain and Leslie H. Blumgart Introduction 1 The Liver 1 Parenchyma (The Liver Substance) 2 Hepatic Veins (OUTFLOW) 4 Hepatic Venous Anomalies 6 Hepatic Arteries (INFLOW) 6 The Biliary Tract 10 The Common Bile Duct 11 Gallbladder and Cystic Duct 12 Anomalous Biliary Drainage 16 Summary 17 2. Imaging of the Liver, Bile Ducts and Pancreas 20 Douglas R. DeCorato, Lawrence H. Schwartz Test Selection 21 Hepatic Lesions 23 3. Endoscopic and Percutaneous Management of Gallstones 34 Seth Richter and Robert C. Kurtz Introduction 34 Endoscopic Retrograde Sphincterotomy 34 Bile Duct Stone Retrieval 35 Complications of Endoscopic Therapy 38 Percutaneous Stone Extraction 38 Specific Clinical Problems 39 The Era of Laparoscopic Cholecystectomy 40 4. Interventional Radiology in Hepatobiliary Surgery 42 Lynn A. Brody and Karen T. Brown Introduction 42 Diagnostic Procedures 42 Therapeutic and Palliative Procedures 49 5. Perioperative Care and Anesthesia Techniques 73 Mary Fischer, Enrico Ferri, Jose A. Melendez Introduction 73 Preoperative Evaluation 73 Hepatic Evaluation 74 Intraoperative Management 74 Postoperative Care 76 6. Benign Tumors of the Liver: A Surgical Perspective 81 Ronald S. Chamberlain Introduction 81 Evaluation 81 Benign Liver Tumors 85 Additional Liver Tumors 97 Conclusions 99 7. Hepatocellular Carcinoma 101 Bryan Clary Introduction 101 Etiology 101 Diagnosis and Pretreatment Planning 102 Tr eatment 104 Conclusion 110 8. Periampullary Cancer and Distal Pancreatic Cancer 111 Richard D. Schulick Introduction 111 Pancreaticoduodenectomy for Periampullary Cancer 112 Distal Pancreatectomy for Distal Pancreatic Cancer 115 9. Hepatic Resection for Colorectal Liver Metastases: Surgical Indications and Outcomes 121 Ronald P. DeMatteo, Yuman Fong Introduction 121 Epidemiology 121 Preoperative Evaluation 121 Physical Examination 122 Laboratory Tests 122 Imaging 122 Surgical Indications 123 Surgical Results 124 Survival 125 Prognostic Variables 126 Recurrent Hepatic Metastases 127 Conclusion 127 10. The Surgical Approach to Non-Colorectal Liver Metastases: Patient Evaluation, Selection and Results 129 Jonathan B. Koea Introduction 129 Patient Selection 129 Preoperative Staging 132 Techniques of Resection 136 Nonoperative Techniques 137 Results 138 Conclusions 143 11. Surgical Techniques of Open Cholecystectomy 146 Ronald S. Chamberlain Introduction 146 Clinical Presentation 146 Preoperative Studies 147 Perioperative Management 149 Operative Technique for Cholycystectomy 149 Surgical Technique 152 12. Laparoscopic Cholecystectomy and the Laparoscopic Management of Common Bile Duct Stones 156 Fredrick Brody Introduction 156 Indications 156 Laparoscopic Cholecystectomy 156 Laparoscopic Common Bile Duct Exploration 162 13. Surgical Techniques for Completion of a Bilioenteric Bypass 165 Pierre F. Saldinger, Leslie H. Blumgart Scope of the Problem 165 Anatomy 165 General Considerations 169 Incisions 171 Abdominal Exploration 172 Basic Anastomotic Technique 172 Alternative Anastomotic Techniques 173 Choledochojejunostomy or Hepaticojejunostomy 173 Ligamentum Teres (Round Ligament) Segment III Approach 177 Choledochoduodenostomy 179 14. Hilar Cholangiocarcinoma: Surgical Approach and Outcome 183 Ronald S. Chamberlain, Leslie H. Blumgart Etiology and Pathology 183 Preoperative Evaluation 185 Staging 186 Surgical Resection for Hilar Cholangiocarcinoma 187 Distal Bile Duct Tumors 187 Hilar Cholangiocarcinoma (HCCA) 188 Liver Transplantation 191 Palliative and Adjuvant Treatment for Cholangiocarcinoma 191 Intrahepatic Surgical Bilioenteric Bypass 191 Surgical Techniques 192 Laparoscopy 192 Exposure and Retraction 193 Palliative Approaches 197 Conclusion 199 15. Surgical Management of Gallbladder Cancer 201 Ronald P. DeMatteo, Yuman Fong Introduction 201 Anatomical Considerations 201 Preoperative Evaluation 202 Clinical Presentations 202 Surgical Approach 205 Summary 207 16. Techniques of Hepatic Resection 208 Sharon Weber, William R. Jarnagin, Leslie H. Blumgart Introduction 208 Operative Technique 208 Right Hepatectomy 209 Extended Right Hepatectomy (Right Hepatic Lobectomy or Right Trisegmentectomy) 214 Left Hepatectomy 215 Left Lateral Segmentectomy (Left Lobectomy) 218 Extended Left Hepatectomy (Left Trisegmentectomy) 218 Caudate Lobe Resection (Segment I Resection) 222 Segmental Resection 224 Wedge Resections 225 Postoperative Care 226 17. Technique for Placement of the Hepatic Arterial Infusion Pump 227 N. Joseph Espat Introduction 227 When Should HAIP Therapy Be Considered? 228 Preoperative Patient Evaluation 228 Surgical Technique for the HAIP Placement 229 Considerations for Patients with Variant Anatomy 231 Replaced Right Hepatic Artery (RRHA) 231 Replaced Left Hepatic Artery (RLHA) 232 Trifurcation of the Common Hepatic Artery (CHA) into RHA, LHA and GDA 232 Creation of the Subcutaneous Pump Pocket 232 Assessment of Hepatic Perfusion 235 Brief Comments on Technical Complications 235 Summary 237 18. Non-Resectional Hepatic Ablative Techniques: Cryotherapy and Radiofrequency Ablation 238 Ronald S. Chamberlain and Ronald Kaleya Introduction 238 Indications for Non-Resectional Ablative Therapies 238 Additional Indications and Contraindications 239 Cryotherapy 239 Radiofrequency Ablation 244 Results 249 Summary 253 19. Surgical Techniques in the Management of Hepatic Trauma or Emergencies 257 H. Leon Pachter, Amber A. Guth Introduction 257 History 257 Diagnosis of Blunt Hepatic Trauma 258 Diagnostic Tests 259 Nonoperative Management of Hepatic Injuries 261 Blunt Hepatic Injuries 261 Outcome of Nonoperative Management 262 Surgical Management of Complex Hepatic Injuries 263 Operative Management of the Injured Liver 263 Complications of Surgical Management 267 Outcome of Hepatic Trauma 269 20. Liver Transplantation 270 Patricia A. Sheiner, Rosemarie Gagliardi, D. Sukru Emre Indications 270 Possible Contraindications to Liver Transplantation 270 Organ Allocation 273 Medical Urgency 273 Timing of Transplantation 273 Preoperative Planning 274 Donor Selection 275 Intraoperative Considerations 276 The Standard Transplant Operation (Recipient) 277 Vascular Anastomoses 277 Bile Duct Anastomosis 278 Piggyback Technique 278 Bypass 278 Split Livers 279 Living Donors 280 Results 281 Index 283 Editors Contributors Ronald S. Chamberlain, MD, MPA, FACS Chief, Hepatobiliary Surgery and Pancreatic Surgery Program Director, General Surgery Beth Israel Medical Center Albert Einstein College of Medicine New York, New York Chapters 1, 6, 11, 14, 18 Leslie H. Blumgart, MD, FACS, FRCS (Eng, Edin), FRCPS (Glas) Chief, Hepatobiliary Service Enid A. Haupt Chair in Surgery Memorial Sloan-Kettering Cancer Center, New York Chapters 1, 13, 14, 16 Fredrick Brody Department of Surgery Cleveland Clinic Foundation Cleveland, Ohio Chapter 12 Lynn A. Brody Division of Interventional Radiology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 4 Karen T. Brown Division of Interventional Radiology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 4 Bryan Clary Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 7 Douglas R. DeCorato Department of Radiology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 2 Ronald P. DeMatteo Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Chapters 9, 15 Sukru Emre Miller Transplantation Institute Mount Sinai Medical Center New York, New York Chapter 20 N. Joseph Espat Department of Surgery University of Illinois at Chicago Chicago, Illinois Chapter 17 Enrico Ferri Department of Anesthesiology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 5 Mary Fischer Department of Anesthesiology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 5 [...]... Ronald N Kaleya Department of Surgery Montefiore Medical Center Bronx, New York Chapter 18 Richard D Schulick Department of Surgery and Oncology The Johns Hopkins Hospital Baltimore, Maryland Chapter 8 Jonathan B Koea Hepatobiliary Service Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Chapter 10 Lawrence H Schwartz Department of Radiology Memorial Sloan-Kettering Cancer... Robert C Kurtz Gastroenterology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 3 Jose A Melendez Department of Anesthesiology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 5 Sharon Weber Hepatobiliary Service Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Chapter 16 Preface Hepatobiliary Surgery is a technical manual and not a textbook... Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Chapters 9, 15 Amber A Guth New York University School of Medicine Surgical ICU Bellevue Hospital Center New York, New York Chapter 19 H Leon Pachter Department of Surgery New York University School of Medicine Director, Division of Shock and Trauma Bellevue Hospital Center New York, New York Chapter 19 Seth Richter Department... attachments, namely the falciform, round, and right and left triangular ligaments (Figure 1. 1) The falciform ligament, which is situated on the anterior surface of the liver, arises from the anteHepatobiliary Surgery, edited by Ronald S Chamberlain and Leslie H Blumgart ©2003 Landes Bioscience 2 Heptobiliary Surgery 1 Fig 1. 1 Surface anatomy of the liver (A) Anterior surface, (B) inferior surface of the liver... student of the game Selected Readings 1 2 3 Cameron J L In discussion of Hanks J B, Meyers W C, Filston H C et al Surgical resection for benign and malignant liver disease Annals of Surgery 19 80 19 1:58 4-5 92 Couninaud C 19 57 Le Foi Etudes anatomogiques et chirurgicales Masson, Paris Hahn L and LH Blumgart Surgical and radiologic anatomy of the liver and biliary tree In Surgery of the Liver and Biliary Tract... Fig 1. 11) The right hepatic duct emerges from the liver at the base of Segment V just to right of the caudate process This duct drains Segments V, VI, VII, and VIII and originates at the junction of the right posterior (Segments VI and VII), and anterior (Segments V and VIII) sectoral ducts The right posterior sectoral duct follows an Essential Hepatic and Biliary Anatomy for the Surgeon 15 1 Fig 1. 10... permission from: Surgery of the Liver and Biliary Tract (3rd Edition), Blumgart LH, Fong Y (Eds.) W.B Saunders, London, UK (2000) 1 12 Heptobiliary Surgery 1 Fig 1. 8 Portal pedicles This cutaway view of the right and left portal pedicles demonstrates the course of the right and left portal veins, hepatic ducts, and hepatic arteries as they enter the hepatic parenchyma Reprinted with permission from: Surgery. .. sectoral duct follows a horizontal course, the right anterior sectoral duct runs almost vertical within Segment V, and receives branches from both Segment V (inferior) and VIII (superior) 16 Heptobiliary Surgery 1 Fig 1. 11 Left portal vein pedicle The union of the Segment IV, II, and III portal veins within the umbilical fissure forms the left portal vein A separate Segment I portal vein also enters the... Gastroenterology Memorial Sloan-Kettering Cancer Center New York, New York Chapter 3 Rosemarie Gagliardi Miller Transplantation Institute Mount Sinai Medical Center New York, New York Chapter 20 Pierre F Saldinger Danbury Hospital Danbury, Connecticut Chapter 13 William R Jarnagin Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Chapter 16 Patricia A Sheiner Miller Transplantation... gastroenterologists, and interventional radiologists with an interest in hepatobiliary diseases However, we believe it will also be of great value to medical students on surgery clerkships, general surgery residents, and surgical oncology fellows as they pursue excellence in their education and training Mastery of hepatobiliary surgery requires one to not only be an accomplished surgical craftsman, . Bioscience, 810 S. Church Street, Georgetown, Texas, U.S.A. 78626 Phone: 512 / 863 7762; FAX: 512 / 863 00 81 ISBN: 1- 5 705 9-6 3 0 -1 Library of Congress Cataloging-in-Publication Data Hepatobiliary surgery. Fong Introduction 12 1 Epidemiology 12 1 Preoperative Evaluation 12 1 Physical Examination 12 2 Laboratory Tests 12 2 Imaging 12 2 Surgical Indications 12 3 Surgical Results 12 4 Survival 12 5 Prognostic Variables 12 6 Recurrent. 10 1 Etiology 10 1 Diagnosis and Pretreatment Planning 10 2 Tr eatment 10 4 Conclusion 11 0 8. Periampullary Cancer and Distal Pancreatic Cancer 11 1 Richard D. Schulick Introduction 11 1 Pancreaticoduodenectomy