Fusion of the planes of the liver: an anatomic entity merging the midplane and the left intersectional plane

Application and clinical effects in lung bullae resection of CT 3-dimensional reconstruction

BACKGROUND

To investigate the value and clinical effect of computed tomography (CT) 3-dimensional reconstruction technology in lung bullae resection.

METHODS

Ninety-eight patients who underwent thoracoscopic surgical resection of lung bullae in our hospital from February 2019 to February 2023 were selected and divided into 2 groups according to the principle of voluntary participation in the clinical trial, of which 43 cases underwent preoperative spiral CT for thin-layer enhancement or planar CT scanning of lung bullae (control group), and 43 cases were imaged with MimicsMedical 21 software for 3-dimensional reconstruction to develop a surgical plan (observation group). To compare the surgery-related indexes, postoperative complications, pain, and analgesic use between the 2 groups, we measured serum creatine phosphokinase and myoglobin levels.

RESULTS

The amount of surgical bleeding, drainage volume, hospital stay, and postoperative visual analog scale score of the research group were lower than those of the control group (P < .05), and the duration of analgesic medication was shorter than that of the control group (P < .05), and the levels of serum creatine phosphokinase and myoglobin were lower than those of the control group at 1 and 3 days postoperatively, and the differences were statistically significant (P < .05).

CONCLUSION

Preoperative CT 3-dimensional reconstruction technique can clearly show the anatomical structures around the lung bullae and has its application value for precise lung bullae.

A comprehensive study and extensive review of morphological variations of liver with new insights

PURPOSE

Liver is divided into four anatomical lobes presenting minor fissures and invisible major fissures. The prevalence of Accessory Fissures in liver ranges widely from 6 to 94%. The morphometric analysis of individual lobes is also scarce in literature. There have been instances where the surgeon has experienced some of these variations as a surprise during surgery as the existing data on the surface variations of liver is still contradictory. A sound knowledge of these variations would aid the surgeons and radiologists to circumvent the misdiagnosis and complications during surgeries.

METHODS

The study was conducted in 93 cadaveric livers. Minor liver fissures, Accessory fissures and lobes were noted and measured. The livers were classified according to the Netter's classification. The morphology of caudate and quadrate lobes was studied. Any other variations in the appearance of groove for Inferior vena cava, gall bladder and its fossa were also studied. The results are tabulated.

RESULTS

The study revealed several variations in the morphological features of liver. Accessory fissures were noted in 51.61% of livers, distributed on various liver surfaces. Accessory lobes were noted in 27.9%. Pons hepatis was present in 22.5%. Gall bladder variations that were noted include the Hartmann's pouch (n = 14; 15.05%) and the Phrygian cap (n = 2; 2.15%). 65.6% livers (n = 61) had the sulcus of the caudate process or fissure of Gans or Rouviere sulcus which is a normal fissure present in majority of normal healthy livers.

CONCLUSION

The current study provides a complete understanding and a thorough knowledge of surface morphological variations in liver. We hope that this will be greatly helpful for surgeons and radiologists to avoid possible errors in interpretations, to plan appropriately and assist during liver surgeries and to do radiological interventions.

Hepatic volume profiles in potential living liver donors with anomalous right-sided ligamentum teres

PURPOSE

In living liver donors with rare anatomical anomaly of right-sided ligamentum teres (RSLT), right or left hemiliver procurement is commonly contraindicated. The purpose of this study was to evaluate the hepatic volume profiles in potential donors with RSLT using semi-automated CT volumetry (CTV).

METHODS

Among 5535 potential donor candidates in our institution between April 2003 and May 2019, 23 cases of RSLT (0.4%) were included. Proportional liver volumes were measured using semi-automated CTV and compared with those of manual volumetry and intraoperative graft weights (seven surgical cases).

RESULTS

The mean percentage volume of the right posterior section was significantly larger than that of the left hemiliver (38.5 ± 8.4% vs. 23.3 ± 5.7%, P < 0.001). Particularly in independent right lateral type, the mean percentage volume of the right posterior section was about two times larger to that of the left hemiliver (41.5% ± 6.5% vs. 21.9% ± 4.4%, P < 0.001), whereas the volume proportions of these two parts were similar between the two parts in bifurcation and trifurcation types (P = 0.810 and 0.979, respectively). Semi-automated CTV of corresponding whole liver, right posterior section, right anterior section, and left hemiliver showed strong correlations with manual CTV (r = 0.989-0.998; P < 0.001). For the seven surgical cases, the graft weights estimated by semi-automated CTV showed a significant correlation with intraoperative graft weights (r = 0.972; P < 0.001).

CONCLUSION

In independent right lateral type of RSLT, the right posterior section tends to be significantly larger than left hemiliver, and may be an alternative option for graft in potential living liver donors with this rare anatomical anomaly.

True left-sided gallbladder: A case report and comparison with the literature for the different techniques of laparoscopic cholecystectomy for such anomalies

•

True LSG is a rare anomaly that may present with right-sided abdominal symptoms and may be missed by preoperative imaging.

•

Though right-sided ports are feasible in LSG, modifications to surgical technique may be done for safe dissection.

•

Meticulous dissection of the gallbladder border is necessary to avoid injury to surrounding tissues.

Introduction

True left-sided gallbladder (LSG) is a rare finding that may present with symptoms similar to those of a normally positioned gallbladder. Moreover, it may be missed by preoperative imaging studies such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), or endoscopic ultrasound. True left-sided gallbladder is a surgical challenge and surgical technique may need to be modified for the completion of laparoscopic cholecystectomy.

Presentation of case

In this case report, we present a case of true left-sided gallbladder that produced right-sided abdominal symptoms. Ultrasound of the abdomen failed to show the left-sided position of the gallbladder. MRI showed the gallbladder located to the left of the ligamentum teres underneath segment III of the liver. Intraoperatively, the gallbladder was grasped and retracted to the right under the falciform ligament and it was removed using classical right-sided ports with no modification to the technique. No complications were encountered intraoperatively or postoperatively.

Discussion

True LSG is a rare anomaly that may present with right-sided symptoms like normally positioned gallbladder. It may be missed in preoperative imaging studies and can be discovered only intraoperatively. Modification of laparoscopic ports, change in patient’s position and/or surgeon’s position, or conversion to open cholecystectomy may be needed for safe removal of the gallbladder.

Conclusion

Classical technique of laparoscopic cholecystectomy is feasible for left-sided gallbladder. However, if the anatomy is not clear, modifications of the surgical technique may be necessary for the safe dissection of the gallbladder.

Implications of Left-sided Gallbladder in the Emergency Setting: Retrospective Review and Top Tips for Safe Laparoscopic Cholecystectomy

BACKGROUND

Left-sided gallbladder without situs viscerum inversus (LSG-woSVI) is a rare congenital anomaly. Clinical features and routine presurgical imaging could miss the anomalous position, thereby producing complications during surgery. Laparoscopic cholecystectomy can be performed safely, but the risk of bile duct injury (BDI) is greater than in cholecystectomy of the orthotopic gallbladder. We present a retrospective review of all scientific literature for diagnosed cases of LSG-woSVI undergoing cholecystectomy from 1996 to 2014. Our objectives were to outline empirical top tips for a safe cholecystectomy in incidentally diagnosed LSG-woSVI.

METHODS

We carried a comprehensive search of PubMed using medical subject headings "left-sided gallbladder," "right-sided ligamentum teres" "situs viscerun inversus," "preoperative diagnoses," "cholecystectomy," and "bile duct injury." We considered a classification of the LSG-woSVI in 2 groups: True LSG-woSVI and LSG-woSVI in patients with right-sided ligamentum teres.

RESULTS

Our retrospective review revealed 55 cases of LSG-woSVI. The mean age was 51 years ±17 SD, male/female ratio was 2:1, clinical presentation was pain in the right upper abdominal quadrant in 75.5%, preoperative diagnosis was reached in 16.3%, True LSG was diagnosed in 83%, acute cholecystitis was found in 50%, laparoscopic cholecystectomy was performed in 79.6%, fundus-first dissection technique was used in 16.7%, intraoperative cholangiography was performed in 39.1%, and BDI occurred in 7.3% of the reported cases.

CONCLUSIONS

Increased awareness of the anatomic aberrations in LSG-woSVI associated with improved preoperative diagnosis and a good knowledge about safe surgical techniques for cholecystectomy could indubitably reduce the incidence of BDI.

Major hepatectomy using the glissonean approach in cases of right umbilical portion

Right umbilical portion (RUP) is a rare congenital anomaly associated with anomalous ramifications of the hepatic vessels and biliary system. As such, major hepatectomy requires a careful approach. We describe the usefulness of the Glissonean approach in two patients with vessel anomalies, such as RUP. The first patient underwent a right anterior sectionectomy for intrahepatic cholangiocarcinoma. We encircled several Glissonean pedicles that entered the right anterior section along the right side of the RUP. We temporarily clamped each pedicle, confirmed the demarcation area, and finally cut them. The operation was performed safely and was successful. The second patient underwent a left trisectionectomy for perihilar cholangiocarcinoma. We secured the right posterior Glissonean pedicle. The vessels in the pedicle were preserved, and the other vessels and contents were resected. Identifying the vessels for preservation facilitated the safe lymphadenectomy and dissection of the vessels to be resected. We successfully performed the operation.

Portal Vein Embolization as an Oncosurgical Strategy Prior to Major Hepatic Resection: Anatomic, Surgical, and Technical Considerations

Preoperative portal vein embolization (PVE) is used to extend the indications for major hepatic resection, and it has become the standard of care for selected patients with hepatic malignancies treated at major hepatobiliary centers. To date, various techniques with different embolic materials have been used with similar results in the degree of liver hypertrophy. Regardless of the specific strategy used, both surgeons and interventional radiologists must be familiar with each other's techniques to be able to create the optimal plan for each individual patient. Knowledge of the segmental anatomy of the liver is paramount to fully understand the liver segments that need to be embolized and resected. Understanding the portal vein anatomy and the branching variations, along with the techniques used to transect the portal vein during hepatic resection, is important because these variables can affect the PVE procedure and the eventual surgical resection. Comprehension of the advantages and disadvantages of approaches to the portal venous system and the various embolic materials used for PVE is essential to best tailor the procedures for each patient and to avoid complications. Before PVE, meticulous assessment of the portal vein branching anatomy is performed with cross-sectional imaging, and embolization strategies are developed based on the patient's anatomy. The PVE procedure consists of several technical steps, and knowledge of these technical tips, potential complications, and how to avoid the complications in each step is of great importance for safe and successful PVE and ultimately successful hepatectomy. Because PVE is used as an adjunct to planned hepatic resection, priority must always be placed on safety, without compromising the integrity of the future liver remnant, and close collaboration between interventional radiologists and hepatobiliary surgeons is essential to achieve successful outcomes.

Surgical implications of a left-sided gallbladder

BACKGROUND

A left-sided gallbladder in a normally positioned liver is considered to be a very uncommon anomaly. Laparoscopic cholecystectomy can be performed safely, but bile duct injury is not unusual. It is associated with anomalous intrahepatic portal and biliary systems which impacts any form of partial hepatectomy.

METHODS

We performed a retrospective review of patients with left-sided gallbladder who were managed by the hepatobiliary surgeons at our institution since 1996.

RESULTS

Nineteen patients with left-sided gallbladder underwent a hepatobiliary procedure. Of the 13 patients with gallstones, only 1 was diagnosed before cholecystectomy. Nine operations were completed laparoscopically, whereas 4 required an open procedure. Two patients were referred with bile duct injuries. There was 1 liver resection for a colorectal metastasis. Left-sided gallbladders in 3 deceased organ donors resulted in major implications in the performance of liver transplantation.

CONCLUSIONS

Left-sided gallbladders are probably more common than generally believed but are rarely diagnosed before cholecystectomy. Associated bile duct injury appears to be not infrequent. Because of the aberrant vasculobiliary anatomy, any form of liver resection requires careful planning.

Vascular architecture in anomalous right-sided ligamentum teres: three-dimensional analyses in 35 patients

BACKGROUND

Right-sided ligamentum teres (RSLT) is a congenital anomaly that is sometimes encountered during hepatobiliary surgeries. However, a valid protocol for describing the segmental anatomy of livers with RSLT has not been established, and confusions or anatomic misunderstandings have been a major problem.

METHODS

The vascular architecture and morphological characteristics were investigated in 35 livers with RSLT using three-dimensional (3D) simulations.

RESULTS

Couinaud's four sectors and three hepatic veins were clearly distinguished in the liver with RSLT using 3D simulations. The ligamentum teres was connected with the right paramedian portal pedicle, and the long axis of the cystic fossa was always observed on the left of the ligamentum teres in all 35 livers. However, when the main portal scissura was visualized using 3D simulation, the gallbladder was always located on the border of either side of the hemilivers, and the malposition of the gallbladder was not confirmed.

CONCLUSIONS

Although the right-sided components of the livers are well developed as a result of the right-dominant distribution of the feeding vessels in livers with RSLT, the basic segmental structure defined by the four sectors and the three hepatic veins are as well preserved as those in the typical liver anatomy.

Abnormalities of the gallbladder, clinical effects

The aim of this review of the literature was to present and discuss the anatomical and embryological basis of congenital abnormalities of the gallbladder, based on a case of volvulus. In the rare cases of ectopic gallbladder, diagnosis of a biliary disease could be difficult. In such cases surgery can also be dangerous, especially when it is associated with abnormalities of the intra-hepatic biliary and vascular tree. This study, based on the embryology of the extra hepatic bile duct, focused on the most frequent gallbladder abnormalities to keep them in mind.

Fusion of the midplane with the left intersectional plane: a liver anatomical variation revisited with multidetector-row CT

This article updates the description of an anatomical variation of the liver, in which the gallbladder is adjacent to the ligamentum teres, that was described until now as "right-sided ligamentum teres and right umbilical portion of the portal vein". A study of eight patients showing this anatomical variation has led to a new archetypal anatomical description of the hepatic and portal veins, using multidetector-row computed tomography (MDCT) with three-dimensional (3D) volume-rendering (VR) reconstructions. While 2D axial imaging gave the same information, MDCT imaging with VR reconstructions provided a clear 3D visualization of this anatomical variation. Typical features can be described as follows: (1) juxtaposition of the ligamentum teres and the gallbladder; (2) typical portal vein branching with a right posterior branch, a left posterior branch and a main medial branch that terminates in the ligamentum teres; (3) two main hepatic veins and a hypotrophied medial hepatic vein. We think, based on the direct comparison of anatomical findings and knowledge of chronological embryological development, that this abnormality results from the defective development of the central part of the liver and not from the persistence of the right rather than the left umbilical vein. Because of the presence of only one medial plane, containing both the gallbladder and the ligamentum teres, we propose renaming it "fusion of hepatic planes".