Fascial Plates Of Liver Hilus

Safe hepatic resection depends on a clear understanding of the hepatic anatomy. Although hepatic regenerative capacity and metabolic reserve permit many types of resections, resection based on preservation of residual anatomic integrity best reduces the operative risk and optimizes function. Couinaud's1 ' description of hepatic anatomy highlights the anatomic features of the liver relevant to resection and in adults provides anatomic terminology that is clinically useful.

The hilar plate is the extension of a vasobiliary sheath that is particularly relevant to hepatic resection ( Fig. 22-1 ). The vasobiliary sheath represents a fusion of the endoabdominal fascia around the bile ducts, portal vein, and hepatic artery at the porta hepatis. These fibrous sheaths invest the components of the pedicles from the portal vein bifurcation to the sinusoids. By contrast, the hepatic veins lack an endoabdominal fascial component, and, consequently, they are more fragile than their portal counterparts. The density of the vasculobiliary sheaths

Figure 22-1 The fascial plates of the liver hilus, which represent a fusion of endoabdominal fascia around the portal structures. The fascial plate at the liver base is formed by three plates—cystic, hilar, and umbilical—which fuse with ill-defined boundaries. (The numbers refer to the hepatic segments.) By permission of the Mayo Foundation.

Hilar Plate Liver

Figure 22-2 The standard subcostal incision extending to the anterior axillary lines bilaterally. By permission of the Mayo Foundation.

Hilar plate

Figure 22-2 The standard subcostal incision extending to the anterior axillary lines bilaterally. By permission of the Mayo Foundation.

Figure 22-3 A, Mobilization of the liver is initiated by dividing the falciform ligament. B, Division of the falciform ligament is extended to the hepatic veins posteriorly. C, The liver is rotated medially to divide the right coronary and triangular ligaments, exposing the bare area of the liver. D, Complete division of the right coronary and triangular ligaments exposes the right lateral aspect of the inferior vena cava (IVC). Multiple short hepatic veins are visible after complete exposure. By permission of the Mayo Foundation.

Hilus The Liver

Figure 22-4 Parenchymal transection of the liver. The hepatic parenchyma is transected in the standard fashion with compression of the parenchyma manually along both sides of the planned transection plane. the parenchyma may be divided with an ultrasonic aspirator (as shown here) or by other methods. Vessels and bile ducts along the devascularized side or specimen side of the liver are clipped. The vessel and bile duct along the opposite side (the patient's side) of the liver are suture ligated for permanent and secure closure and to avoid artifact on postresection liver imaging. By permission of the Mayo Foundation.

Hepatic Hilus

Figure 22-5 Exposure of the hepatic hilus for vascular control before major hepatic resection. Cholecystectomy facilitates exposure of the major vessels of the liver at its hilus. The peritoneum along the right lateral aspect of the hepatoduodenal ligament is incised, and the bile duct is retracted medially and superiorly using a vein retractor. The major portal vessels can then be identified. By permission of the Mayo Foundation.

Figure 22-6 Vascular and biliary control before left hepatectomy is best obtained through the gastrohepatic omentum along the left lateral aspect of the hepatoduodenal ligament. Initially, the left hepatic artery is ligated at its origin. A, The left main artery enters the liver just below the falciform ligament. B, The left main portal vein, which courses toward the left shoulder, is transected with a vascular stapler. C, Finally, the left main bile duct is transected and ligated. a = artery, L = left, v = vein. By permission of the Mayo Foundation.

Figure 22-7 Exposure of the right hepatic artery and right main portal vein branch is best obtained through the right lateral aspect of the hepatoduodenal ligament. The bile duct is retracted medially and superiorly with a vein retractor. A, The right main hepatic artery is identified and divided between clamps. B, The right main portal vein branch is exposed and transected with a vascular stapler. C, After clear identification, the right main bile duct is divided. a = artery, R = right, v = vein. By permission of the Mayo Foundation.

Figure 22-8 After completion of hilar ligation of the major lobar hepatic vessels, the interface between the vascularized and devascularized portions of the liver is evident. The planned transection plane is marked with cautery immediately adjacent to the devascularized portion of the liver. By permission of the Mayo Foundation.

electrocautery

Figure 22-9 Transection of the right main hepatic vein. Access to the right main hepatic vein extrahepatically can best be achieved only after full mobilization of the right lobe. Frequently, a thick band of tissue extends from the caudate lobe to segment VII, just inferior to the right hepatic vein. Complete division of the retrocaval ligament is required for adequate extrahepatic exposure of the main right hepatic vein in its junction with the inferior vena cava. Inf = inferior, R = right. By permission of the Mayo Foundation.

Figure 22-10 Parenchymal transection is continued throughout the liver with vascular biliary structures ligated as necessary. The surgeon's orientation for appropriate parenchymal transsection can be maintained by using the index finger as a guide. IVC = inferior vena cava, v = vein. By permission of the Mayo Foundation.

TABLE 22-1 -- Clinicopathologic Factors Adversely Associated With Survival in Patients Who Underwent Hepatic Resection for Metastatic Colorectal Cancer

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