Anatomic resection of segment VIII of liver for hepatocellular carcinoma in cirrhotic patients based on an intrahepatic Glissonian approach

Comprehensive evaluation of the ramification patterns of hepatic vascular anatomy based on three-dimensional visualization technology

The liver segmentation method proposed by Couinaud is widely accepted by surgeons because of its convenience and practicality. However, this conventional eight-segment classification does not reflect realistic details of the liver and thus requires further adjustments to promote improvements in surgical strategies. This study aimed to explore the ramification patterns of the hepatic vasculature comprehensively. A total of 197 eligible patients meeting the study criteria were enrolled for three-dimensional reconstruction analysis. In the left hemiliver, the portal vein bifurcated into P2 and umbilical portion (UP) in 172 (98.3%) patients. The P4b of 103 patients (103/172, 59.9%) whose P4b branched from the right horn of the left portal vein (LPV) diverged from the main trunk of the UP. In the right paramedian sector (RPMS), the entire portal trunk directly bifurcates into P8vent and P8dor. Simple branching of P5 off the trunk of the RPMS was observed in 78 patients (78/130, 60%). The anterior fissure vein (AFV) was identified in 86 (86/148, 58.1%) patients. V8d entered the right hepatic vein (RHV) in all the patients. In 75.3% (113/150) of all the patients, V5d joined the RHV. In the right lateral sector (RLS), more than half (71/133, 53.4%) of the patients had an arch-like type. We summarize different patterns of liver vascular branches, providing a valuable reference for clinical surgery and liver transplantation. Cranio-caudal segmentation is more common than ventral-dorsal segmentation. The AFV can be regarded as a reliable anatomical landmark for subsegmentation in segment 8. In addition, the absence of AFV was associated with the P8 pattern.

Robotic anatomical resection for hepatocellular carcinoma located within segment 7 using the Glissonean approach

Worldwide use of robotic-assisted hepatectomy has increased dramatically over the past two decades. The role of robotic liver surgery is still controversial, especially with respect to its long-term oncological outcomes in treating early-stage hepatocellular carcinoma (HCC). The Glissonean approach is a fundamental technique for anatomical resection using open and laparoscopic liver surgery. To our knowledge, there have been few reports on purely robotic anatomical segmentectomy 7 for HCC using the Glissonean approach have been described. The present study describes the technical details and surgical outcomes of totally robotic segmentectomy 7 using the Glissonean approach. Fourteen patients with HCC limited to segment 7 underwent segmentectomy 7 from January 2019 through April 2023 in our hospital. The surgical techniques, peri-operative, and oncological outcomes were analyzed. Purely robotic anatomical segmentectomy 7 using the Glissonean approach was safe and feasible with the technology described herein in all of the 14 patients. The peri-operative and oncological outcomes were better and/or comparable with those of other similar hepatic resections using open approach and/or laparoscopic approach. The median follow-up time was 18 months. Intrahepatic recurrence occurred in 2 (14.3%) patient within one year following surgery. The 3-year overall survival rate was 81%. Although technically challenging, the purely robotic segmentectomy 7 could be performed safely and simultaneously with oncological radicality using the Glissonean approach.

Laparoscopic and open minor liver resection for hepatocellular carcinoma with clinically significant portal hypertension: a multicenter study using inverse probability weighting approach

BACKGROUND

Liver resection offers substantial advantages over open liver resection (OLR) for patients with hepatocellular carcinoma (HCC) in terms of reduced intraoperative blood loss and morbidity. However, there is limited evidence comparing the indications and perioperative outcomes with the open versus laparoscopic approach for resection. This study aimed to compare postoperative outcomes between patients undergoing laparoscopic liver resection (LLR) and OLR for HCC with clinically significant portal hypertension (CSPH).

METHODS

A total of 316 HCC patients with CSPH (the presence of gastroesophageal varices or platelet count < 100,000/ml and spleen diameter > 12 cm) undergoing minor liver resection at eight centers were included in this study. To adjust for confounding factors between the LLR and OLR groups, an inverse probability weighting method analysis was performed.

RESULTS

Overall, 193 patients underwent LLR and 123 underwent OLR. After weighting, LLR was associated with a lower volume of intraoperative blood loss and the incidence of postoperative complications (including pulmonary complications, incisional surgical site infection, and paralytic ileus) compared to the OLR group. The 3-, 5-, and 7-year postoperative recurrence-free survival rates were 39%, 26%, and 22% in the LLR group and 49%, 18%, and 18% in the OLR group, respectively (p = 0.18). And, the 3-, 5-, and 7-year postoperative overall survival rates were 71%, 56%, and 44% in the LLR group and 76%, 51%, 44% in the OLR group, respectively (p = 0.87).

CONCLUSIONS

LLR for HCC patients with CSPH is clinically advantageous by lowering the volume of intraoperative blood loss and incidence of postoperative complications, thereby offering feasible long-term survival.

Minimally Invasive Anatomic Liver Resection for Hepatocellular Carcinoma Using the Extrahepatic Glissonian Approach: Surgical Techniques and Comparison of Outcomes with the Open Approach and between the Laparoscopic and Robotic Approaches

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

Glissonean approach for hepatic inflow control in minimally invasive anatomic liver resection: A systematic review

BACKGROUND

The Glissonean approach has been widely validated for both open and minimally invasive anatomic liver resection (MIALR). However, the possible advantages compared to the conventional hilar approach are still under debate. The aim of this systematic review was to evaluate the application of the Glissonean approach in MIALR.

METHODS

A systematic review of the literature was conducted on PubMed and Ichushi databases. Articles written in English or Japanese were included. From 2,390 English manuscripts evaluated by title and abstract, 43 were included. Additionally, 23 out of 463 Japanese manuscripts were selected. Duplicates were removed, including the most recent manuscript.

RESULTS

The Glissonean approach is reported for both major and minor MIALR. The 1st, 2nd and 3rd order divisions of both right and left portal pedicles can be reached following defined anatomical landmarks. Compared to the conventional hilar approach, the Glissonean approach is associated with shorter operative time, lower blood loss, and better peri-operative outcomes.

CONCLUSIONS

Glissonean approach is safe and feasible for MIALR with several reported advantages compared to the conventional hilar approach. Clear knowledge of Laennec's capsule anatomy is necessary and serves as a guide for the dissection. However, the best surgical approach to be performed depends on surgeon experience and patients' characteristics. Standardization of the Glissonean approach for MIALR is important.

Impact of laparoscopic parenchyma-sparing resection of lesions in the right posterosuperior liver segments on surgical outcomes: A multicenter study based on propensity score analysis

BACKGROUND

Laparoscopic liver resection for hepatic lesions is increasingly performed worldwide. However, parenchyma-sparing laparoscopic liver resection for hepatic lesions in the right posterosuperior segments is very technically demanding. This study aimed to compare postoperative outcomes between patients undergoing laparoscopic liver resection and open liver resection for hepatic lesions in the right posterosuperior segments.

METHODS

In total, 617 patients who underwent liver resection of hepatic lesions in the right posterosuperior segments (segment Ⅶ or Ⅷ) at 8 centers were included in this study. We lessened the impact of confounders through propensity score matching, inverse probability weighting, and double/debiased machine learning estimations.

RESULTS

After matching and weighting, the imbalance between the 2 groups significantly decreased. Compared with open liver resection, laparoscopic liver resection was associated with a lower volume of intraoperative blood loss and incidence of postoperative complications in the matched and weighted cohorts. After surgery, the incidence of pulmonary complication and cardiac disease was lower in the laparoscopic liver resection group than in the open liver resection group in both the matched and weighted cohorts. The odds ratios of laparoscopic liver resection for postoperative complications in the matched and weighted cohorts were 0.49 (95% confidence interval, 0.29-0.83) and 0.40 (95% confidence interval, 0.25%-0.64%), respectively. The double/debiased machine learning risk difference estimator for postoperative complications of laparoscopic liver resection was -19.8% (95% confidence interval, -26.8% to -13.4%).

CONCLUSION

Parenchyma-sparing laparoscopic liver resection for hepatic lesions in the right posterosuperior segments had clinical benefits, including lower volume of intraoperative blood loss and incidence of postoperative complications.

Re-evaluation of the Couinaud classification for segmental anatomy of the right liver, with particular attention to the relevance of cranio-caudal boundaries

BACKGROUND

Although the Couinaud classification of liver segments has been challenged by several studies, whether the cranio-caudal boundaries can be delineated in the right liver has not yet been assessed. This study scrutinized the third-order branching pattern of the portal vein in the right liver with attention to the validity of cranio-caudal segmentation.

METHODS

Three-dimensional reconstruction of the portal vein and hepatic vein, using non-contrast-enhanced magnetic resonance imaging was performed in 50 healthy participants.

RESULTS

In the right paramedian sector, the portal vein ramified into 2 thick P8s (P8vent and P8dor) in all the participants. Additional thick P8s that ran laterally and/or medially (P8lat and/or P8med) were observed in 18 (32%) participants. In contrast, multiple thin P5s, ranging in number from 2 to 6 (median, 4), branched from the right paramedian trunk, the right portal trunk, and/or even from P8s. In the right lateral sector, an arch-like type in which multiple P6s ramified from a single thick P7 was observed in 26 (52%) participants. A bifurcation type composed of a single P7 and a single P6 was observed in 23 (46%) participants, and a trifurcation type was observed in 1 participant.

CONCLUSION

No clear cranio-caudal intersegmental plane could be delineated in the right liver in most of the participants. The resection of a whole Couinaud segment in the right liver should not be regarded as a systematic, anatomic resection from an oncologic viewpoint. In contrast, detailed information on the third-order portal vein ramification pattern is likely to be helpful when performing smaller anatomic resections.

Anatomy of the Right Anterior Sector of the Liver and Its Clinical Implications in Surgery

BACKGROUND

Surgery remains the gold standard both for delimited hepatocellular carcinoma by selective anatomic liver segentectomy and for colorectal liver metastases by parenchymal sparing liver resection. Right anterior sector (RAS) (segments V-VIII; Couinaud) is the largest and most difficult sector to operate on. A better knowledge of its segmentation could prevent postoperative remnant liver ischemia and its impacts on patient's survival.

METHODS

A literature search was conducted in PubMed for papers on anatomy and surgery of the right anterior sector.

RESULTS

Segmentation of the RAS depended of the anatomic variations of the third-order portal branches. Cranio-caudal segmentation was the most commonly found (50-53%), followed by ventro-dorsal (23-26%), trifurcation (13-20%), and quadrifurcation types (5-11%). Ventral and dorsal partial or total subsegmentectomy seemed accessible in 47 to 50% of patients, including bifurcation, trifurcation, and quadrifurcation types, and could spare up to 22% of the total liver volume. The RAS hepatic vein was present in 85-100% of the patients and could be used as a landmark between RAS dorsal and ventral part in 63% of patients. Reported overall morbidity rate of RAS subsegmentectomy ranged from 33 to 59% among studies with a postoperative major complication rate (Clavien-Dindo ≥ III) ranging around 18% and a biliary leakage rate from 16 to 21%. In-hospital reported mortality rate was low (0-3%), and results were comparable to "classic" liver resections. RAS subsegmentectomy remains a complex procedure; median operating time ranged from 253 to 520 min and median intraoperative blood loss reached 1255 ml.

CONCLUSION

Better knowledge of RAS anatomy could allow for parenchymal preservation by using subsegmentectomy of the RAS, selective or as a part of a major hepatectomy.

Axis of serotonin -pERK-YAP in liver regeneration

BACKGROUND AND AIM

Serotonin and YAP exhibit a vital role in regulating cell proliferation and wound-healing response. The aim of the study was to investigate whether 5-HT could promote liver regeneration by activating YAP.

METHODS

PH models were established by WT and TPH1-/- mice. ELISA, RT-PCR, western blot, immunohistochemistry, flow cytometry and MTT assay were used to assess the level of 5-HT and YAP and proliferation after PH.

RESULTS

We found that 5-HT level was lower in the serum and liver of TPH1-/- mice. After PH, TPH1-/- mice, lacking in 5-HT, demonstrated worse regenerative ability and suffered more severe liver injury. Additionally, YAP expression was also lower in TPH1-/- mice. Moreover, we found that YAP expression was prominent within the first three days following PH. Similarly, 5-HT could promote cell proliferation by upregulating YAP expression in L-O2 cells. As predicted, using YAP-siRNA sharply reduced the proliferative capacity mediated by 5-HT. Further study also indicated that ERK participated in the regulation of YAP induced by 5-HT. By using an ERK inhibitor, the YAP expression and cell proliferation induced by 5-HT were both suppressed. Although YAP-siRNA was used to block YAP expression, pERK and ERK expression were not affected. Taken together, these data showed that 5-HT contributed to liver regeneration by regulating YAP expression, which at least in part, was by activation of pERK.

CONCLUSION

A role of the 5-HT-pERK-YAP axis in liver regeneration emerged from our study and might be a potential target to promote regeneration and injury repair.

A new fluorescence imaging technique for visualizing hepatobiliary structures using sodium fluorescein: result of a preclinical study in a rat model

BACKGROUND

Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue light fluorescence imaging to cholangiography and liver mapping during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue light fluorescence for cholangiography and liver mapping in a rat model.

METHODS

Sodium fluorescein solution (1 mL to each individual) were administered intravenously to 20 male Sprague-Dawley rats (6 weeks old, 200-250 g), after laparotomy. Whole abdominal organs were observed under blue light (at a wavelength of 440-490 nm) emitted from a commercialized LED curing light.

RESULTS

Immediately after the tracer solution was administered into the circulatory system of the rat, it was possible to visualize the location of the kidneys and the bile duct under blue light emitted from the light source. The liver was vaguely stained green by the tracer, while the ureters were not. After establishing biliary retention via duct clamping in the left lateral segment of the liver, the green color of the segment became distinct by the tracer, which showed vague coloration following release of the clamp.

CONCLUSION

We established the preclinical basis for using blue light fluorescence cholangiography and liver mapping in this study. The clinical feasibility of these techniques during laparoscopic cholecystectomy and hepatectomy remained to be demonstrated.

Pharmacological inhibition of TRPV4 channel suppresses malignant biological behavior of hepatocellular carcinoma via modulation of ERK signaling pathway

TRPV4 (transient receptor potential vanilloid 4), a member of the TRP superfamily, has been reported to correlate with several different forms of cancers. However, the role of TRPV4 in human hepatocellular carcinoma (HCC) remains unclear. The present study demonstrated that elevated expression of TRPV4 was shown in HCC tumor tissues when compared with paired non-tumoral livers both in protein and mRNA levels. Furthermore, the enhanced expression of TRPV4 was highly associated with histological grade (P = 0.036) and the number of tumors (P = 0.045). Pharmacological inhibition of TRPV4 channels in HCC cells with the specific antagonist HC-067047 suppressed cell proliferation, induced apoptosis and decreased the migration capability by attenuating the epithelial-mesenchymal transition (EMT) process in vitro. The p-ERK expression was apparently repressed after treatment with the TRPV4 antagonist, further blockade of the ERK pathway with U0126 could significantly aggravate HCC cells apoptosis. In NOD-SCID mouse xenograft models, intraperitoneal injection of HC-067047 could obviously suppress tumor growth and induce apoptosis in vivo. Together, our studies showed that the antitumor effects caused by TRPV4 channel inhibition in HCC cell lines might be attributed to the suppression of EMT process and inactivation of p-ERK which induced subsequent cell apoptosis. Thus, pharmacological inhibition of TRPV4 channel may be an option for HCC treatment.

Updates and Critical Insights on Glissonian Approach in Liver Surgery

Recent advances in surgical techniques have broadened the indications of surgical management of liver malignancies. Intraoperative bleeding is one of the known predictors of postoperative outcomes following liver surgery, signifying the importance of vascular control during liver resection. Furthermore, preservation of future liver remnant plays a critical role in prevention of post-hepatectomy liver failure as one of the main causes of postoperative morbidity and mortality. Glissonian approach liver resection offers an effective method for vascular inflow control while protecting future liver remnant from ischemia-reperfusion injury. Several studies have demonstrated the feasibility of Glisson's pedicle resection technique in modern liver surgery with an acceptable safety profile. Moreover, with increasing popularity of minimally invasive surgery, laparoscopic liver resection via Glissonian approach has been shown to be superior to standard laparoscopic hepatectomy. Herein, we systematically review the role of Glissonian approach hepatectomy in current practice of liver surgery, highlighting its advantages and disadvantaged over other methods of vascular control.

Impact of Glissonean pedicle approach for centrally located hepatocellular carcinoma in mongolia

Approaches to surgical resection of centrally located HCC remain controversial. Traditionally, hemi- or extended hepatectomy is suggested. However, it carries a high risk of postoperative complications in patients with cirrhosis. An alternative approach is Glissonean pedicle transection method. This study was conducted to assess the surgical and survival outcomes associated with central liver resection using the Glissonean pedicle transection. Sixty-nine patients with centrally located HCC were studied retrospectively. They were divided into conventional approach group with hemi- or extended hepatectomy, and Glissonean approach group with multisegmental central liver resection using the Glissonean pedicle transection. Glissonean pedicle transection method has comparable or superior surgical and survival outcomes to conventional hemi- or extended hepatectomy with regard to intraoperative bleeding, complications, hospital stay, and postoperative mortality and survival outcomes in patients with centrally located HCC. The 1-, 3-, and 5-year overall survival rates of the conventional approach group were 74%, 64%, and 55% respectively. For the Glissonean approach group, the 1 and 3-year overall survival rates were 86% and 61%, respectively. Glissonean pedicle transection method is a safe and effective surgical procedure in patients with centrally located HCC.

Laparoscopic Transabdominal With Transdiaphragmatic Access Improves Resection of Difficult Posterosuperior Liver Lesions

OBJECTIVE

We describe the technical details and evaluate the safety, feasibility, and usefulness of a combined lateral and abdominal (CLA) approach for laparoscopic resection of liver segments 7 and 8.

BACKGROUND

Laparoscopic resection of lesions in the posterosuperior area of segments 7 and 8 is technically challenging, and currently there is no standardized laparoscopic approach.

METHODS

Through review of a prospectively maintained database, we identified 44 patients who underwent laparoscopic resection of lesions in segment 7 or 8. Twenty-five patients required the CLA approach because their lesions were more posterosuperior and intraparenchymal; 19 patients underwent resection with a regular abdominal-only approach of more accessible anteroinferior lesions. We reviewed operative details and video footage of these operations and compared the outcomes of the 2 groups.

RESULTS

In the group treated with the CLA approach, deep location was more frequent (88% vs 42%; P = 0.035), median tumor diameter was larger (24.5 mm vs 15 mm; P = 0.114), and the median weight of the excised parenchyma was greater (56.5 g vs 23 g; P = 0.093). Median operative time was longer in the CLA approach group (217.5 minutes vs 165 minutes; P = 0.046), but blood loss, rate of conversion to open surgery, surgical margin status, morbidity, and mortality were similar between the 2 groups.

CONCLUSIONS

The CLA approach permits safe laparoscopic resection of lesions in the posterosuperior area of segments 7 and 8, allowing surgeons to overcome the difficulties of limited visualization and access to the target lesions.

Isolated Caudate Lobe Resection for Huge Hepatocellular Carcinoma (10 cm or greater in diameter)

Isolated caudate lobectomy for huge hepatocellular carcinoma (HCC) (10 cm or greater in diameter) is a technically demanding surgical procedure that entails the surgeon's experience and precise anatomical knowledge of the liver. We describe our clinical experiences and evaluate the results of partial or total isolated caudate lobectomy for HCC larger than 10 cm in the caudate lobe. En bloc excisions combined with adjacent hepatic parenchyma (as part of extended hepatectomies) were excluded. Twenty-seven patients were included in the study (24 male, three3 female). Median age was 43 years (range, 18 to 81 years). All primary diagnoses were HCC. Twenty-one patients had surgical margins lesser than 1 cm. Tumor embolus within the main trunk of the portal vein was found in five patients by intraoperative ultrasound. Median operative time was 288 minutes (range, 160 to 310 minutes), and estimated intraoperative blood loss was 2260 mL (range, 200 to 7000 mL). Median blood transfusion was 1460 mL (range, 0 to 7200 mL). Postoperative morbidity rate was 44.4 per cent. There were no postoperative deaths. Overall survival rates at 1, 3, and 5 years were 80.2, 52.1, and 27.1 per cent, respectively. Nineteen patients (70.4%) had tumor recurrence as of the last follow-up. The recurrence lesion was treated in most of these patients. Isolated caudate lobectomy for huge HCC is a technically demanding but safe procedure, although the procedure is sometimes extremely difficult.

Anatomy and surgical relevance of Rouviere's sulcus

Rouviere's sulcus (RS) (i.e., incisura hepatis dextra, Gans incisura) represents an important anatomical landmark. The aim of the study was to determine the frequency of the RS, its description, its location, its relations to the right portal pedicle and to the plane of the common bile duct, and the evaluation of the surgical relevance of the obtained data. Forty macroscopically healthy and undamaged livers were removed during autopsies from cadavers of both sexes. The RS was present in 82% of the cases and in these the open RS was identified in 70% of the livers. The fused type was observed in 12% of the cases; 18% of the livers had no sulcus. The mean length of the open type RS was 28 ± 2 mm (range 24-32 mm) and its mean depth was 6 ± 2 mm (range 4-8 mm). The right posterior sectional pedicle was found in the RS in 70% of the cases. In 5% of the livers, we also dissected a branch of the anterior sectional pedicle. Inside 25% of the RS, we found the vein of segment 6. The RS identification may avoid bile duct injury during laparoscopic cholecystectomy and enables elective vascular control during the right liver resection.

Inferior Right Hepatic Vein: A Useful Anatomic Variation for Isolated Resection of Segment VIII

Anatomical resection of segment VIII (SVIII) is one of the most difficult hepatectomies to perform. Although it is the best choice of surgical treatment for tumors located at SVIII, its feasibility can be compromised when the right hepatic vein (RHV) must be resected en bloc with SVIII. Herein we describe a case of a cirrhotic patient that was submitted to segmentectomy VIII in bloc with the main trunk of the RHV, due to hepatocellular carcinoma. The resection could only be performed because a well developed inferior right hepatic vein (IRHV) was present. Anatomical variations of the liver vascularization should be used by liver surgeons to improve surgical results.

Surgical resection for small hepatocellular carcinoma in cirrhosis: the Eastern experience

Detection of small Hepatocarcinoma (HCC) by screening of high-risk populations is important to increase the percentage of patients suitable for curative treatment, which would lead to prolongation of the mean survival of patients with HCC. It should be remembered that small HCC is not always necessarily equivalent to early HCC as defined histologically. With recent advances in diagnostic imaging modalities, including contrast-enhanced ultrasonography and magnetic resonance imaging with liver-specific contrast enhancement, accurate differential diagnosis of early HCCs from dysplastic nodules has become possible. Because a certain proportion of small HCCs is known to show microscopic vascular invasion, surgical resection would be the treatment of first choice. To minimize potential microscopic invasion, anatomic resection and/or resection with a wide margin should be performed, while preserving liver function to the maximum extent possible. Surgical resection, however, cannot prevent multicentric occurrence of HCC, which remains a major issue precluding curative treatment of HCC.

Resection of segment VIII for hepatocellular carcinoma

Background

Anatomical resection of segment VIII (SVIII) is technically demanding. Only two small studies have published short-term outcomes. The aim of the present study was to evaluate short- and long-term outcomes after anatomical resection involving SVIII for hepatocellular carcinoma (HCC), and to compare long-term outcomes with those after non-anatomical resection of SVIII.

Methods

Outcomes after anatomical resection of SVIII or its subsegments for HCC were compared with those in patients who underwent primary non-anatomical resection of SVIII during the same period.

Results

A total of 154 patients underwent anatomical resection involving SVIII and 122 had non-anatomical resection. In patients undergoing anatomical resection, the preoperative indocyanine green retention rate at 15 min ranged from 2·9 to 32·2 (median 13·6) per cent, and was 10 per cent or more in 109 patients (70·8 per cent). Median duration of operation and blood loss were 378 min and 705 ml respectively. There were no postoperative deaths, but major adverse events occurred in ten patients (6·5 per cent). The cumulative 5-year recurrence-free and overall survival rates were 28·5 and 79·6 per cent, which were significantly better than rates of 19·4 and 64·8 per cent respectively after non-anatomical resection (P = 0·036 and P &lt; 0·001).

Conclusion

Complete resection of SVIII or its subsegments can be performed safely and the long-term outcomes seem acceptable. This can be a curative procedure for HCC, especially in patients with limited liver function reserve, in whom right hepatectomy or right paramedian sectorectomy might otherwise be needed.

Total or partial anatomical resection of segment 8 using the ultrasound-guided finger compression technique

BACKGROUND

A new surgical technique to define intra-operatively segmental and subsegmental areas of the liver using ultrasound-guided bimanual liver compression has been recently described. However, this technique does not allow disclosure of the subsegmental ventral (S8v) and dorsal (S8d) portions of segment 8 (S8). Another technique that overcomes these limitations is described.

METHODS

Six patients with hepatoma, cirrhosis and no evidence of portal vein thrombosis were submitted to the procedure. Demarcation of the resection area was achieved using ultrasound-guided finger compression of the S8 subsegmental portal branches (P8v and P8d).

RESULTS

The procedure was feasible in all patients and demarcation was always obtained within 1 min of bimanual ultrasound-guided compression. In one patient, the entire S8 was resected. In the remaining five patients, the dorsal (four patients) or the ventral (one patient) portion was removed, respectively. There was no mortality or morbidity and no blood transfusions were administered.

CONCLUSIONS

Disclosure of the subsegmental portions of S8 using the ultrasound-guided compression technique was feasible, safe and effective, and represents the completion of the ultrasound-guided compression technique for performing segmental and subsegmental anatomical resection of the liver.