Fundamentals of Laparoscopic Surgery Ashley H. Surgical Procedures to Resect and Replace the. Esophagus . Leslie H. Blumgart Chair in Surgery. Graeme J Poston and Leslie H Blumgart. The success of any surgical intervention on the liver and bile ducts is totally dependent on a thorough working . DOWNLOAD Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2- Volume Set, 6e By William R Jarnagin MD [PDF EBOOK EPUB KINDLE]. Book Media.
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Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set. Book • 6th Edition • Edited by: Index. Pages II Download PDF. caite.info - Ebook download as PDF File .pdf), Text File .txt) or read book Graeme J Poston and Leslie H Blumgart 2 Surgical anatomy of the pancreas. ([PDF]) Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set By - William R Jarnagin Full Ebook MEET YOUR FAVORITE.
The junction of the two main right biliary ducts usually occurs immediately above the right branch of the portal vein. Gastroenterol Clin Biol One example is atherosclerotic stenosis of the coeliac axis. Try a Free Sample. This segment comprises two anatomically and functionally distinct portions. This procedure usually requires the preliminary division of the bridge of liver tissue which runs between the inferior parts of segments III and IV. B right anterior sectorectomy.
Chapter 51B: Perihilar cholangiocarcinoma with emphasis on presurgical management. Interventional techniques in hilar and intrahepatic biliary strictures. Congenital disorders of the pancreas: Surgical considerations. Definition and classification of pancreatitis.
Etiology, pathogenesis, and diagnostic assessment of acute pancreatitis. Management of acute pancreatitis and complications. Etiology, pathogenesis, and diagnosis of chronic pancreatitis. Management of chronic pancreatitis: Conservative, endoscopic, and surgical.
Pancreatic and periampullary tumors: Classification and pathologic features. Cystic neoplasms of the pancreas: Epidemiology, clinical features, assessment, and management. Pancreatic cancer: Clinical aspects, assessment, and management. Duodenal adenocarcinoma. Pancreas as a site of metastatic cancer.
Pancreatic neuroendocrine tumors: Classification, clinical picture, diagnosis, and therapy. Techniques of pancreatic resection: Pancreaticoduodenectomy, distal pancreatectomy, segmental pancreatectomy, total pancreatectomy, and transduodenal resection of the papilla of vater. Minimally invasive pancreatic resectional techniques.
Chemotherapy and radiotherapy for pancreatic cancer: Adjuvant, neoadjuvant and palliative. Palliative treatment of pancreatic and periampullary tumors. Chronic hepatitis: Epidemiology, clinical features, and management.
Hepatic steatosis, steatohepatitis, and chemotherapy-related liver injury. Pyogenic liver abscess. Amebiasis and other parasitic infections.
Hydatid disease of the liver. Simple cysts and polycystic liver disease: Clinical and radiographic features, surgical and nonsurgical management.
Cirrhosis and portal hypertension: Pathologic aspects. Nonhepatic surgery in the cirrhotic patient. Portal hypertension in children. Management of liver failure. Support of the failing liver. Management of ascites in cirrhosis and portal hypertension.
Medical management of bleeding varices: Primary and secondary prophylaxis of bleeding. Portal hypertensive bleeding: Acute management.
Operative devascularization. The place of portosystemic shunting. Technique of portosystemic shunting: Portocaval, distal splenorenal, mesocaval. Transjugular intrahepatic portosystemic shunting: Indications and technique. Budd-Chiari syndrome and veno-occlusive disease. Tumors of the liver: Chapter 90A: Benign liver lesions. Chapter 90B: Cystic hepatobiliary neoplasia.
Hepatocellular carcinoma. Hepatic metastasis from colorectal cancer. Hepatic metastasis from neuroendocrine cancers. Noncolorectal nonneuroendocrine metastases.
Hepatic tumors in childhood. Chapter 96A: Hepatic artery embolization and chemoembolization of liver tumors. Chapter 96B: Radioembolization for liver tumors. External beam radiotherapy for liver tumors. Chapter 98A: Ablative treatment of liver tumors: Chapter 98B: Dancygier H. Traverse LW.
Rosmurgy AS II. Rowinski W. Variability of the arterial system of the human pancreas. Cancer Study of surgical anatomy of duodenum preserving resection of the head of the pancreas. Endoscopic pancreatocholangiography 1. Taylor TV. Clin Anat Carr-Locke DL. Anatomy of the pancreas—emphasis on blood-supply and lymphatic drainage. Kausagi T. The hepatic. Natterman C. Goldschmidt AJW.
Fowler CL. J Pediatr Surg Surgical management of hepatobiliary and pancreatic disorders 44 Spiral CT ERCP and endoscopic ultrasound Laparoscopy with peritoneal cytology and laparoscopic ultrasound. Jeacock J. Carey LC. Contemp Surg Retrograde cholangiopancreatography. Int J Pancreatol Kobayashi S. The pancreas. Smanio T. Pancreas divisum. Current surgical therapy. Bockman DE. Cremer M et al. Histology and fine structure. Endosonography in chronic pancreatitis—a comparison between endoscopic retrograde pancreatography and endoscopic ultrasonography.
Surgical anatomy of the pancreas. Results of surgical treatment of necrotizing pancreatitis. Kuroda A. Retroperitoneal and peritoneal drainage and lavage in the treatment of severe necrotizing pancreatitis. Diehl SJ. Hollander LF. Tumor staging with laparoscopy and laparoscopic ultrasonography. Pain relieving procedures in chronic pancreatitis.
Vesentini S et al. Kobayashi I. Rosch T. Braig C. Williams and Wilkins. Bittner R et al. Acute pancreatitis: Tytgat GN. Preoperative staging and assessment of resectability of pancreatic cancer. Garden OJ. Improved survival in 45 patients with pancreatic abscess. Pancreatic cancer: Radiology Gain T et al. Greig JD.
The pancreatic neurotomy on the head of the pancreas for relief of pain due to chronic pancreatitis: Japanese classification of pancreatic carcinoma: The pattern of lymph node involvement in carcinoma of the head of the pancreas.
Sobin LH. Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography. John TG. Nagakawa T. Japan Research Society. Ueno K et al.
Laparoscopy with laparoscopic ultrasonography in the TNM staging of pancreatic carcinoma. Wright A. Jin G. Surgical anatomy of the pancreas 45 segmentation. Surg Radiol Anat Ampullopancreatic carcinoma: Allan PL et al.
Carcinoma of the pancreatic head and periampullary region. Wittenberg J. Phoa SS et al. Sadick M et al. Tio TL. Cikot RJ et al.
Wakabayashi T. Yashioko H. Whittekind CH. Waltman AC. Surgical diseases of the pancreas. New York: Springer Wiley.
Pederzoli P. Bassi C. A histologic study of surgical findings in patients undergoing extensive surgical dissections. TNM classification of malignant tumours. Comparison of laparoscopic US and contrastenhanced spiral CT in the staging of potentially resectable tumors of the pancreatic head region.
Lehmann KJ. Surgical indications and techniques in necrotising pancreatitis. VanDelden OM. Raven Press. Laugner B. Krautzberger W. The principal portal venous supply. The ligamentum venosum runs along the anterior border of the caudate. The pioneering work of Couinaud 1 provided a much clearer understanding of hepatic anatomy and allowed a safer.
The caudate lobe is not infrequently involved in primary and secondary malignancies. While rarely Figure 3. As hepatic surgery has advanced. Anatomy Landmarks The caudate lobe segment I is that portion of hepatic parenchyma situated posterior to the hilum and anterior to the inferior vena cava IVC 2 Fig. Caudate lobectomy 47 performed as an isolated procedure. The posterior aspect of segment IV and the medial surface of segment VII mark the rightward extent of the caudate.
A thorough understanding of the caudate lobe anatomy is necessary for safe resection. The caudate segment I. The main portal venous supply from the LPV and the caudate veins draining into the inferior vena cava are clearly shown. In many respects. A plane from the origin of the right posterior sectoral portal vein p. The middle hepatic vein is adjacent to the right portion of the caudate. PV to the confluence of the right hepatic vein RHV and inferior vena cava approximates the right border of the caudate right.
The posterior edge of the caudate on the left has a fibrous component that attaches to the crus of the diaphragm and extends posteriorly behind the vena cava to join segment VII Fig. The paracaval portion of the caudate lies anterior to the IVC and extends cephalad to the roots of the major hepatic veins. The ligamentum venosum. The caudate process is located between the main right Glissonian pedicle and the IVC and fuses with segment VI of the right lobe 3 — 5 Fig.
Surgical management of hepatobiliary and pancreatic disorders 48 Figure 3. The rightward extent of the caudate is variable. The ligamentous attachment. Its anterior border is formed by the left portal vein.
The extent of the caudate from the hilum to the insertion of the hepatic veins is clearly shown. A plane passing from the origin of the right posterior sectoral portal vein to the confluence of the right hepatic vein RHV and IVC serves as a useful approximation of the right border 2 Fig. The caudate lobe is bounded posteriorly. It is important that the left branch be identified and preserved during conventional left hepatectomy i. The principal portal venous branch to the caudate arises from the left portal vein small arrow.
The ligamentous attachment extending from the caudate to the inferior vena cava IVC and segment VII is indicated large arrowhead. Caudate lobectomy 49 Figure 3. A much smaller branch drains the right caudate and caudate process via the right posterior sectoral duct. From a practical standpoint. The most common pattern is one branch from the main left hepatic artery and a second. Three branches may be seen in up to one-third of patients.
B-D The counterclockwise rotation of the liver as it enlarges. Branches draining into the back of the vena cava may be encountered if there is a significant retrocaval caudate process. Although often considered a left-sided structure. Surgical management of hepatobiliary and pancreatic disorders 50 Hepatic venous drainage The caudate lobe is the only hepatic segment that does not drain into one of the main hepatic veins. Consideration of its embryogenesis may Figure 3.
The left umbilical vein L Umb V carries placental blood to the left portal vein. The hepatic venous drainage of the caudate is accomplished by a variable number of short venous branches that enter directly into the anterior and left aspect of the vena cava 2. Caudate lobectomy 51 umbilical fissure and empties into the left portal vein Fig.
Maintaining a low CVP greatly facilitates mobilization of the liver off the vena cava and control of the retrohepatic vena caval branches.
The central venous pressure CVP is carefully controlled and not allowed to rise above 5 mmHg until the parenchymal transection is completed. The liver is mobilized sufficiently to allow intraoperative ultrasound. A short segment of resected vein may be amenable to primary repair or may require autogenous graft. The authors make liberal use of vascular staplers for major pedicle and hepatic venous structures.
Caudate lobectomy may be undertaken as an isolated procedure or. The lesser omentum is incised and the caudate is inspected and palpated. Surgical approaches Surgical approaches to the caudate are critically dependent on the size and location of the tumor s and the type of associated resection. General principles The techniques of liver resection favored by the authors have been previously published and are described elsewhere in this book.
The extrahepatic portion of the ductus venosus and its mesentery progressively shorten. With hepatic enlargement and counterclockwise rotation. The ductus venosus obliterates shortly after birth and persists as the ligamentum venosum 7 Fig. Because of their location.
Parenchymal transection is accomplished with a Kelly clamp to expose ducts and vessels. Preoperative imaging often cannot distinguish tumor invasion from compression.
On the other hand. The ductus venosus is suspended within the dorsal mesentery of the liver. The caudate may be approached from the left or the right. As described above. Cholecystectomy may improve access to the base of segment IV and should be considered. The right sided branches must also be identified and controlled 2. Surgical management of hepatobiliary and pancreatic disorders 52 occluded vena cava can often be resected without the need for reconstruction.
During this phase of the dissection. The left lobe of the liver is mobilized and retracted upwards. The principal branches.
If parenchyma is found to completely encircle the IVC. A substantial tumor will often render the caudate stiff and difficult to manipulate. The IVC is indicated by the large arrow. Figure 3. Caudate lobectomy 53 be elevated and the hepatic venous branches safely controlled with clips or ligatures Fig. The ligamentous or parenchymal attachments to segment VII can also be divided working from the right Fig. As the dissection progresses.
A venous branch draining directly into the IVC is prepared for ligation and division. The ligamentous attachments and the portal venous inflow have been divided. The right lobe is rotated upwards and to the left. The posteriorly draining hepatic veins can be controlled and divided from the left or right. Complete or nearly complete mobilization of the caudate can often be achieved in this manner.
Surgical management of hepatobiliary and pancreatic disorders 54 Figure 3. The possibility of vigorous bleeding from a posterior tear in the middle hepatic vein makes this part of the procedure particularly hazardous. An alternative approach has been described.
The falciform ligament is divided to the level of the suprahepatic vena cava. The hilar plate should be lowered and. In the latter case. When caudate resection is combined with right or left hepatectomy.
Total vascular isolation for caudate resection has also been described. A large retrohepatic vena caval branch is prepared for ligation and division arrow. The diaphragmatic attachments have been divided. This transhepatic approach allows the transection of the remaining caudate parenchyma under direct vision of the middle hepatic vein. A clamp is passed between the inferior vena cava and the fibrous ligament arrow.
Surgical management of hepatobiliary and pancreatic disorders 56 the left aspect of the caudate Figure 3. As an alternative approach. The retrohepatic veins coursing from the right lobe into the IVC should also be divided. Careful dissection in this area. With the left liver and caudate completely prepared.
In this circumstance. It may be necessary to divide the duct at the level of the right anterior and posterior sectoral hepatic ducts. The left hepatic vein may be divided during the hilar dissection or during parenchymal transection. If extrahepatic control of the hepatic veins is not feasible. The left portal vein and hepatic artery are exposed within the porta hepatis and divided at a point proximal to the principal caudate branches.
The posteriorly draining caudate veins are then exposed and divided. Adding caudate lobectomy requires exposing and mobilizing the caudate. The bile duct margins should be sent for frozen section histology to ensure complete tumor clearance. It is essential to avoid narrowing the biliary confluence when the left hepatic duct stump is oversewn. Tumors situated high in the liver. Caudate lobectomy 57 exposed as described above.
The liver tissue is then divided along the principal resection plane. Once adequately exposed. Complete removal required an extended right hepatectomy and caudate lobectomy en bloc. The gallbladder should be removed and the hilar plate lowered. Ligatures left on the divided cystic duct and right hepatic artery Figure 3. The tumor extended very near to the insertion of the middle and right hepatic veins. Caudate resection with right hepatectomy Caudate resection is somewhat easier to perform in conjunction with right hepatectomy.
This is especially true when the bifurcation is high. The right hepatic artery and right portal vein are exposed within the porta hepatis.
It is usually helpful to first isolate and divide the right hepatic artery. In situations where the extrahepatic bile duct is not sacrificed. Surgical management of hepatobiliary and pancreatic disorders 58 Figure 3. The liver is now fully mobilized off the vena cava by dividing the accessory hepatic veins.
Dissection of the left portal vein at the base of the umbilical fissure exposes the. Caudate lobectomy 59 can be used to retract the common bile duct and hepatic artery upwards and to the left.
In approximately one half of patients. A clamp has been passed around the common trunk of the middle and left hepatic veins white arrow.
The falciform ligament should be divided to the level of the suprahepatic vena cava. With the inflow to the right lobe controlled. Continued cephalad dissection will usually reveal the portal venous bifurcation. Continued dissection from below and at the Figure 3. The left liver is now retracted upwards and to the right. The right adrenal may be adherent to the undersurface of the liver. It is often possible to extend this dissection across the anterior surface of the vena cava and control some or all of the caudate veins.
This branch should be divided early in the dissection to avoid inadvertent injury and to allow better exposure of the right portal vein. With the liver retracted upwards and to the left. A small posterolateral branch to the right portion of the caudate is usually encountered Fig. The right lobe must be liberated from all of its diaphragmatic and retroperitoneal attachments.
A sling has been placed around the portal triad. The procedure is carried out as described above. It should be noted that the right hepatic duct need not be divided during the hilar dissection.
The main right pedicle is exposed white arrow and is prepared for ligation and division. Note the close proximity of the middle hepatic vein black arrow. It is safer and easier to control the right duct by dividing and oversewing the main right portal pedicle. It is usually a straightforward matter to extend this resection to include most or all of segment IV as an extended right hepatectomy. When necessary. The hepatic parenchyma may be divided just to the right of the middle hepatic vein.
Since This can be done without fear of causing venous congestion of segment IV. Surgical management of hepatobiliary and pancreatic disorders 60 lobe is completed. Any remaining caudate veins are divided. When this procedure is performed for hilar cholangiocarcinoma. Two studies have documented narrow resection margins and early recurrences in patients undergoing isolated caudate resection for hepatocellular carcinoma and metastatic tumors. While some authors have reported a greater incidence of complications associated with caudate resection.
Table 3. Caudate lobectomy 61 however. The numbers in parentheses indicate the frequency of caudate resection as a percentage of all hepatic resections Author Number Diagnoses Cholangiocarcinoma 45 Procedures En bloc complete caudate resection 42 Isolated complete caudate resection 3 Nimura et al. In one of the largest series of partial hepatectomy for hepatocellular carcinoma. Some authors have suggested that isolated caudate resection for metastatic tumors or hepatocellular carcinoma may not provide adequate tumor clearance.
The addition of caudate lobectomy does not significantly increase the morbidity above that expected for major hepatectomy. Nimura et al. The results of several large series of resections for hilar cholangiocarcinoma. In properly selected patients. While some lesions may be excised with an isolated caudate lobectomy.. Surgical management of hepatobiliary and pancreatic disorders 62 Partial caudate resection 7 Bartlett et al.
The cumulated evidence supports the efficacy of isolated complete caudate lobectomy for small or medium sized tumors.
The surgical approach to caudate resection is critically dependent on the size and location of the. Tumors involving the right hepatic duct. Elias D. Fong Y. Sugimachi K. Kosuge T et al. Characteristics of hepatocellular carcinoma originating in the caudate lobe.
Lawson TL. Complete resection of the caudate lobe of the liver: Yanaga K. Mankarios H. Etude anatomiques et chirugicales. Shimada M. Sano K. Lerut J. Surgical approach to segment I for malignant tumors of the liver. Acta Hepatol Jpn Shriver C. One hundred consecutive hepatic resections: Taketomi A.
Cunningham JD. Analysis of biliary drainage in the caudate lobe of the liver: Stapleton GN. Gruwez JA. Marx WL. An isolated caudate lobectomy by the transhepatic approach for hepatocellular carcinoma in cirrhotic liver.
Useful stapling techniques in liver surgery. Cavallari A eds. Lasser PH. Mazziotti A. Surgery Caudate lobectomy 63 tumor. Maieda T. Anatomy of the caudate lobe with special reference to portal vein and bile duct. Caudate lobe of the liver: Stewart ET. J Am Coll Surg The surgeon should be completely comfortable with the relevant anatomy and the common variations.
Blood supply of the right and left hepatic ducts. AJR Jiang Y. Yamamoto J. Matsumata T. Kumon M. Dodds WJ. Surgical anatomy of the hepatic hilum with special reference to the caudate lobe. Desruennes E. Furukawa H. Hepatology Greenwich Medical Media. Taylor AJ. Bartlett D. Takayama T. Resection of the caudate lobe of the liver. Erickson SJ. Melendez J. Techniques in liver surgery. Hickman R. Benjamin IS. Yamanoi A et al. Lancet Hu RH. Improvements in survival by aggressive resections of hilar cholangiocarcinoma.
Surgical strategies for carcinoma of the hepatic duct confluence. Shionoya S. Hochwald SN. Hilar cholangiocarcinoma: Tung TT. Jarnagin WR.
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