Cellular intermingling between adrenal gland and liver: an infrequent cause of incomplete resection at right adrenalectomy

Predictive factors and radiological findings of adrenohepatic adhesion during laparoscopic adrenalectomy

Purpose

This retrospective study aimed to identify predictive factors and imaging features of adrenohepatic adhesion found during laparoscopic right adrenalectomy.

Materials and Methods

Altogether, 77 patients underwent laparoscopic right adrenalectomy between January 2005 and December 2018. Adrenohepatic adhesion was defined as strict adhesion that required either partial adrenalectomy with coagulation of residual tissue or partial hepatectomy to accomplish complete resection. We assessed their surgical video records to determine if adrenohepatic adhesion was present. Age, sex, body mass index, tumor size, tumor diagnosis and radiological findings (attachment between the liver and the adrenal gland, diameters of the right and left adrenal veins and its ratio) were evaluated as preoperative variables.

Results

Adrenohepatic adhesion was present in 11 of the 77 patients (14.3%). Age, sex, and body mass index were not statistically significant factors. Tumor size was significantly small in adhesion group (14.2 mm vs. 25.9 mm, p=0.02). Attachment to the liver and adrenal gland was frequently seen regardless of the adhesion. The mean right/left adrenal veins diameters ratio was significantly lower in the adhesion group (0.8 vs. 1.1, p=0.01). Multivariate logistic regression analysis demonstrated the right/left adrenal veins diameters ratio was the only significant predictor of adhesion. The sensitivity, specificity, negative predictive value and positive predictive value were 0.82, 0.76, 0.43, and 0.95 respectively when the optimal cutoff value for the ratio was 0.9 (area under the curve, 0.75; 95% confidence interval, 0.60–0.90).

Conclusions

The right/left adrenal veins diameters ratio was possible predictor of adrenohepatic adhesion.

Verification of inferior right hepatic vein-conserving segments 7 to 8 resection of the liver

This study aims to investigate the safety of inferior right hepatic vein (IRHV)-conserving surgery by comparing the surgical data and postoperative complications between IRHV-conserving segments 7 to 8 (S7 to S8) resection and conventional right hemihepatectomy (RH). Five patients who underwent IRHV-conserving S7 to S8 segmentectomy between 2007 and 2011 (IRHV group) and 25 liver cancer patients who underwent RH without biliary tract reconstruction during the same period (RH group) were investigated. The surgical data, postoperative complications, and duration of hospital stay were compared. The IRHV and RH groups included 2 (40%) and 13 (52%) hepatocellular carcinoma patients, respectively. There were no significant differences in liver function before surgery between the groups. The presence of the IRHV did not adversely affect the processing of the short hepatic vein or frontal dissection of the inferior vena cava. The operative time was shorter (median, 366 minutes versus 501 minutes; P = 0.0001), the postoperative bilirubin level was lower (12 mg/dL versus 1.8 mg/dL; P = 0.037), and the duration of hospital stay was shorter (10 days versus 14 days; P = 0.002) in the IRHV group. No significant differences were noted in the intraoperative blood loss, postoperative transaminase levels, or the incidence of severe complications (Clavien grade IIIb or higher) between the groups. IRHV-conserving resection of the liver is a safe surgical procedure that is useful in preventing postoperative elevation of bilirubin level and in shortening the duration of hospital stay.

Retraction-Related Acute Liver Failure after Urological Laparoscopic Surgery

Liver retraction is necessary for optimal exposure during laparoscopic right renal surgery. We described a patient who developed fulminant liver failure as a result of liver retractor-induced excessive ischemic changes in the right lobe of the liver. A 37-year-old male underwent a right side laparoscopic pyeloplasty for ureteropelvic junction obstruction. At the beginning of the operation, a small snake retractor was placed through a 5-mm port under direct vision. The liver was lifted in the appropriate direction to optimize exposure by using the laparoscope holder. The operation was prolonged. However, we achieved significant improvements in the efficiency of liver retraction using the holder. On the first postoperative day, the patient's serum levels of GOT, GPT and LDH had remarkably increased. A computerized tomogram confirmed the presence of excessive ischemic changes of the right lobe of the liver. Our method which used a laparoscope holder device for liver retraction maintained a better surgical field. However, neglecting to make minor adjustments to the positioning of the retractor can cause significant pressure on the liver parenchyma in a single area. As surgical procedures increase in complexity, the surgeon should keep these potential side effects in mind and shift the retraction point at regular intervals. In this report, we discussed various types of retractor-related liver injuries and their management, and highlighted the importance of intermittent release of retraction during prolonged surgery.