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Surgical anatomy of Liver, Pancreas, Biliary tree and Principle of Liver resection.pptx

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Olayinka Lukman Adewunmi

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Relevant anatomy and physiology of Liver, biliary duct and pancreas: Principle of Liver resection Dr. Olayinka L. Adewunmi Division of General Surgery UMTH Maiduguri 5th December, 2022
Outline Introduction Surgical anatomy Aberrant anatomy Surgical physiology Principles of Liver resection Pre-op, intra-op and post-op Complications Conclusions References 12/5/2022 principles of liver resection 2
Introduction HPB surgery is a sub-specialty in General surgery Sound knowledge of the surgical anatomy and physiology is needed to be able to carry out safe surgery 12/5/2022 principles of liver resection 3
Relevant Anatomy- Liver GROSS ANATOMY Largest solid organ 2.5% of total body weight Largest the regenerative potential Glisson's capsule 4
Relevant Anatomy- Liver 5
Relevant Anatomy- Liver 12/5/2022 principles of liver resection 6
Relevant Anatomy- Liver Ligaments of the liver Falciform ligament Round ligament Coronary ligament Triangular ligament 12/5/2022 principles of liver resection 7
Relevant Anatomy of the vascular & portal pedicle Primary division- lobal division Secondary division- sectional division Tertiary division- segmental division 12/5/2022 principles of liver resection 8
Relevant Anatomy- Liver Prevailing anatomy of the hepatic artery- 75% of patients 12/5/2022 principles of liver resection 9
Relevant Anatomy- Liver Aberrant anatomy- 25% of patients 12/5/2022 principles of liver resection 10
Relevant Anatomy- Liver Prevailing anatomy of the bile duct- 80% of patients. 12/5/2022 principles of liver resection 11
Relevant Anatomy- Liver Aberrant anatomy of the bile duct 12/5/2022 principles of liver resection 12
Relevant Anatomy- Liver Prevailing anatomy of the intra-hepatic portal vein 12/5/2022 principles of liver resection 13
Relevant Anatomy- Liver Portal vein anatomy Right Middle Left 12/5/2022 principles of liver resection 14
Relevant Anatomy- Liver 12/5/2022 principles of liver resection 15 Anatomy of the plate/sheath system Cystic- A Hilar- B Umbilical- C Arantian
Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Gallbladder on liver bed (S4b and S5) Store/concentrate bile About 50mls volume Empty content through the cystic ducts to the CBD and duodenum 12/5/2022 principles of liver resection 16
Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Anomaly of cystic duct insertion into the CHD 12/5/2022 principles of liver resection 17
Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Anomaly of cystic artery origin and gallbladder supply 12/5/2022 principles of liver resection 18
Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Aberrant anatomy of the Gallbladder 12/5/2022 principles of liver resection 19
Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Blood supply to the CHD and CBD 12/5/2022 principles of liver resection 20
Relevant Anatomy- Pancreas GROSS ANATOMY Fleshy organ Exocrine function Endocrine Unforgiving organ 12/5/2022 principles of liver resection 21
Relevant Anatomy- Pancreas 12/5/2022 principles of liver resection 22
Relevant Anatomy- Pancreas 12/5/2022 principles of liver resection 23
Liver resection Major hepatectomy Minor hepatectomy anatomic resection non-anatomic resection 12/5/2022 principles of liver resection 24
Brisbane Terminology of Liver anatomy and Resections (2000) Anatomic term Couinaud Segments Surgical Resection Right hemiliver/right liver 5-8 Right hepatectomy Left hemiliver/left liver 2-4 Left hepatectomy Right anterior section 5, 8 Right anterior sectionectomy Right posterior section 6, 7 Right posterior sectionectomy Left medial section 4 Left medial sectionectomy or Resection of segment 4 Left lateral section 2, 3 Left lateral sectionectomy or Bisectionectomy 2, 3 4, 5, 6, 7, 8 Right trisectionectomy or Extended right hepatectomy 2, 3, 4, 5, 8 Left trisectionectomy or Extended left hepatectomy 12/5/2022 principles of liver resection 25
Physiology- Liver Metabolism Storage Excretion Synthesis 12/5/2022 principles of liver resection 26
Physiology- Bile ducts Secrete bile, needed for digestion of fat and fat-soluble vitamins Components of bile water, bile salts, bilirubin, cholesterol, lecithin, electrolytes 12/5/2022 principles of liver resection 27
Physiology- Pancreas Endocrine and Exocrine functions Exocrine- secretes lipase, amylase, carboxypeptidase, pepsinogen Endocrine- secretes Insulin, glucagon, somatostatin, PP, etc. 12/5/2022 principles of liver resection 28
Principles of Liver resection 12/5/2022 principles of liver resection 29
Introduction Surgery is the main stay in the treatment of solid tumors, including liver tumors (primary or metastatic) Refinement in surgical techniques has increased survival following liver resection in recent years. However, the most important factor influencing outcomes after liver resection is the surgeons knowledge of the basic surgical principles of the procedure 12/5/2022 principles of liver resection 30
Principles of Liver resection Principles of liver resection Pre-op Intra-op Post-op 12/5/2022 principles of liver resection 31
Pre-op considerations History Examination Investigations Laboratory Imaging Risk assessment Optimization 12/5/2022 principles of liver resection 32
Pre-op considerations Imaging Helical CT scan with 3phase contrast (Liver protocol) Lesion identification and relationship to vascular/portal pedicle Define anatomy of the portal triad and look for aberrant anatomy MRI Discussion with radiologist (hepatobiliary radiologist) 12/5/2022 principles of liver resection 33
Pre-op considerations Laboratory Liver function test, total protein and albumin Clotting profile EUCr Risk assessment score: Child-Turcotte-Pugh score-child A qualify for Liver resection MELD score <9 Test of functional liver remnant/reserve (FLR) 12/5/2022 principles of liver resection 34
Pre-op considerations MD Anderson Cancer Center (University of Texas) eTLV (in cm3) = -794.41 + 1,267.28 x BSA (in m2) Normal FLR: 20% in normal liver, 30% in hepatic injury and 40% in cirrhotic/fibrotic liver If eFLR is low, then portal vein embolization of the side to be resected is recommended. This will cause atrophy of the planned resected part and compensatory hypertrophy of the normal side. Hypertrophy <5% is a predictor of post-op liver insufficiency and 90 days post-op mortality 12/5/2022 principles of liver resection 35
Pre-op considerationsOptimization Correct clotting anomaly Correct anaemia Fluid and electrolyte correction Prophylaxis: antibiotics, DVT, stress ulcer 12/5/2022 principles of liver resection 36
Pre-op considerations Equipment Retractor- Thompsons Parenchyma dissector Intra-op USS (optional but encouraged) 12/5/2022 principles of liver resection 37
Intra-op Anaesthesia- GA Positioning Patient- supine, hand extended Surgeon- right Assistant- left Incisions Chevron, inverted T, J incision, Kochers, Kehr, L incision, reverse L, etc. 12/5/2022 principles of liver resection 38
Intra-op Vascular control Pringle technique- intermittent vs continuous Total hepatic vascular control (inflow and outflow) extra-hepatic control intra-parenchyma control 12/5/2022 principles of liver resection 39
Intra-opparenchyma transection Finger fracture Clamps/forceps (Kelly, Debakey, etc.) Bovie electrocoagulation Harmonic scalpel Ligasure Tissuelink (saline-linked cautery) Sealing agents vascular staples CUSA- Cavitron UltraSonic Aspirator Hydrojet/water jet dissector NB: none of the devices has shown superior advantage over the other. 12/5/2022 principles of liver resection 40
Intra-op Prevention of haemorrhage 2 surgeon technique Intra-op USS Liver hanging maneuver Low CVP <5mmHg from anaesthetist Drain vs no drain Post-op care HDU/Wards 12/5/2022 principles of liver resection 41
Complications Haemorrhage Liver insufficiency/dysfunction Perihepatic fluid collections bile leak 12/5/2022 principles of liver resection 42
Conclusion Over several years, Liver resection surgery has evolved as a effective and safe way to treat benign and malignant liver pathology Careful patient selection and surgeons knowledge of the basic principles of liver resection are important determinant of outcomes. 12/5/2022 principles of liver resection 43
References Jarnagin R. Williams: Blumgarts Surgery of the Liver, Biliary Tract and Pancreas, 6th edition Keith L. Moore and Arthur F. Dalley: Clinically oriented anatomy, 5th edition Keith Lillemoe and Williams R. Jarnagin: Mastery Techniques in Surgery: Hepatobiliary and Pancreatic surgery, 4th series O. James Garden and Simon Peterson-Brown: Hepatobiliary and pancreatic surgery, a companion to specialist surgical practice, 5th edition. 12/5/2022 principles of liver resection 44
References Charles F. Brunicardi: Schwartzs principles of Surgery, 10th edition Chapters 31, 32 and 33 Michael J Zinner and Stanley W Ashley: Maingots abdominal operations, 12th edition. Sections VII, VIII and IX Norman, S. W., Christopher J.K.B., and P.Ronan O Connell (2008). Bailey and Love principles and practice of Surgery, 25th edition, chapter 61, 63 and 64. 12/5/2022 principles of liver resection 45
References Vauthey, J. N., Abdalla, E. K., Doherty, D. A., Gertsch, P., Fenstermacher, M. J., Loyer, E. M., Lerut, J., Materne, R., Wang, X., Encarnacion, A., Herron, D., Mathey, C., Ferrari, G., Charnsangavej, C., Do, K. A., & Denys, A. (2002). Body surface area and body weight predict total liver volume in Western adults. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 8(3), 233240. 12/5/2022 principles of liver resection 46
THANK YOU FOR YOUR ATTENTION 12/5/2022 principles of liver resection 47

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Surgical anatomy of Liver, Pancreas, Biliary tree and Principle of Liver resection.pptx

  • 1. Relevant anatomy and physiology of Liver, biliary duct and pancreas: Principle of Liver resection Dr. Olayinka L. Adewunmi Division of General Surgery UMTH Maiduguri 5th December, 2022
  • 2. Outline Introduction Surgical anatomy Aberrant anatomy Surgical physiology Principles of Liver resection Pre-op, intra-op and post-op Complications Conclusions References 12/5/2022 principles of liver resection 2
  • 3. Introduction HPB surgery is a sub-specialty in General surgery Sound knowledge of the surgical anatomy and physiology is needed to be able to carry out safe surgery 12/5/2022 principles of liver resection 3
  • 4. Relevant Anatomy- Liver GROSS ANATOMY Largest solid organ 2.5% of total body weight Largest the regenerative potential Glisson's capsule 4
  • 6. Relevant Anatomy- Liver 12/5/2022 principles of liver resection 6
  • 7. Relevant Anatomy- Liver Ligaments of the liver Falciform ligament Round ligament Coronary ligament Triangular ligament 12/5/2022 principles of liver resection 7
  • 8. Relevant Anatomy of the vascular & portal pedicle Primary division- lobal division Secondary division- sectional division Tertiary division- segmental division 12/5/2022 principles of liver resection 8
  • 9. Relevant Anatomy- Liver Prevailing anatomy of the hepatic artery- 75% of patients 12/5/2022 principles of liver resection 9
  • 10. Relevant Anatomy- Liver Aberrant anatomy- 25% of patients 12/5/2022 principles of liver resection 10
  • 11. Relevant Anatomy- Liver Prevailing anatomy of the bile duct- 80% of patients. 12/5/2022 principles of liver resection 11
  • 12. Relevant Anatomy- Liver Aberrant anatomy of the bile duct 12/5/2022 principles of liver resection 12
  • 13. Relevant Anatomy- Liver Prevailing anatomy of the intra-hepatic portal vein 12/5/2022 principles of liver resection 13
  • 14. Relevant Anatomy- Liver Portal vein anatomy Right Middle Left 12/5/2022 principles of liver resection 14
  • 15. Relevant Anatomy- Liver 12/5/2022 principles of liver resection 15 Anatomy of the plate/sheath system Cystic- A Hilar- B Umbilical- C Arantian
  • 16. Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Gallbladder on liver bed (S4b and S5) Store/concentrate bile About 50mls volume Empty content through the cystic ducts to the CBD and duodenum 12/5/2022 principles of liver resection 16
  • 17. Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Anomaly of cystic duct insertion into the CHD 12/5/2022 principles of liver resection 17
  • 18. Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Anomaly of cystic artery origin and gallbladder supply 12/5/2022 principles of liver resection 18
  • 19. Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Aberrant anatomy of the Gallbladder 12/5/2022 principles of liver resection 19
  • 20. Relevant Anatomy- Gallbladder and extrahepatic biliary ducts Blood supply to the CHD and CBD 12/5/2022 principles of liver resection 20
  • 21. Relevant Anatomy- Pancreas GROSS ANATOMY Fleshy organ Exocrine function Endocrine Unforgiving organ 12/5/2022 principles of liver resection 21
  • 22. Relevant Anatomy- Pancreas 12/5/2022 principles of liver resection 22
  • 23. Relevant Anatomy- Pancreas 12/5/2022 principles of liver resection 23
  • 24. Liver resection Major hepatectomy Minor hepatectomy anatomic resection non-anatomic resection 12/5/2022 principles of liver resection 24
  • 25. Brisbane Terminology of Liver anatomy and Resections (2000) Anatomic term Couinaud Segments Surgical Resection Right hemiliver/right liver 5-8 Right hepatectomy Left hemiliver/left liver 2-4 Left hepatectomy Right anterior section 5, 8 Right anterior sectionectomy Right posterior section 6, 7 Right posterior sectionectomy Left medial section 4 Left medial sectionectomy or Resection of segment 4 Left lateral section 2, 3 Left lateral sectionectomy or Bisectionectomy 2, 3 4, 5, 6, 7, 8 Right trisectionectomy or Extended right hepatectomy 2, 3, 4, 5, 8 Left trisectionectomy or Extended left hepatectomy 12/5/2022 principles of liver resection 25
  • 26. Physiology- Liver Metabolism Storage Excretion Synthesis 12/5/2022 principles of liver resection 26
  • 27. Physiology- Bile ducts Secrete bile, needed for digestion of fat and fat-soluble vitamins Components of bile water, bile salts, bilirubin, cholesterol, lecithin, electrolytes 12/5/2022 principles of liver resection 27
  • 28. Physiology- Pancreas Endocrine and Exocrine functions Exocrine- secretes lipase, amylase, carboxypeptidase, pepsinogen Endocrine- secretes Insulin, glucagon, somatostatin, PP, etc. 12/5/2022 principles of liver resection 28
  • 29. Principles of Liver resection 12/5/2022 principles of liver resection 29
  • 30. Introduction Surgery is the main stay in the treatment of solid tumors, including liver tumors (primary or metastatic) Refinement in surgical techniques has increased survival following liver resection in recent years. However, the most important factor influencing outcomes after liver resection is the surgeons knowledge of the basic surgical principles of the procedure 12/5/2022 principles of liver resection 30
  • 31. Principles of Liver resection Principles of liver resection Pre-op Intra-op Post-op 12/5/2022 principles of liver resection 31
  • 32. Pre-op considerations History Examination Investigations Laboratory Imaging Risk assessment Optimization 12/5/2022 principles of liver resection 32
  • 33. Pre-op considerations Imaging Helical CT scan with 3phase contrast (Liver protocol) Lesion identification and relationship to vascular/portal pedicle Define anatomy of the portal triad and look for aberrant anatomy MRI Discussion with radiologist (hepatobiliary radiologist) 12/5/2022 principles of liver resection 33
  • 34. Pre-op considerations Laboratory Liver function test, total protein and albumin Clotting profile EUCr Risk assessment score: Child-Turcotte-Pugh score-child A qualify for Liver resection MELD score <9 Test of functional liver remnant/reserve (FLR) 12/5/2022 principles of liver resection 34
  • 35. Pre-op considerations MD Anderson Cancer Center (University of Texas) eTLV (in cm3) = -794.41 + 1,267.28 x BSA (in m2) Normal FLR: 20% in normal liver, 30% in hepatic injury and 40% in cirrhotic/fibrotic liver If eFLR is low, then portal vein embolization of the side to be resected is recommended. This will cause atrophy of the planned resected part and compensatory hypertrophy of the normal side. Hypertrophy <5% is a predictor of post-op liver insufficiency and 90 days post-op mortality 12/5/2022 principles of liver resection 35
  • 36. Pre-op considerationsOptimization Correct clotting anomaly Correct anaemia Fluid and electrolyte correction Prophylaxis: antibiotics, DVT, stress ulcer 12/5/2022 principles of liver resection 36
  • 37. Pre-op considerations Equipment Retractor- Thompsons Parenchyma dissector Intra-op USS (optional but encouraged) 12/5/2022 principles of liver resection 37
  • 38. Intra-op Anaesthesia- GA Positioning Patient- supine, hand extended Surgeon- right Assistant- left Incisions Chevron, inverted T, J incision, Kochers, Kehr, L incision, reverse L, etc. 12/5/2022 principles of liver resection 38
  • 39. Intra-op Vascular control Pringle technique- intermittent vs continuous Total hepatic vascular control (inflow and outflow) extra-hepatic control intra-parenchyma control 12/5/2022 principles of liver resection 39
  • 40. Intra-opparenchyma transection Finger fracture Clamps/forceps (Kelly, Debakey, etc.) Bovie electrocoagulation Harmonic scalpel Ligasure Tissuelink (saline-linked cautery) Sealing agents vascular staples CUSA- Cavitron UltraSonic Aspirator Hydrojet/water jet dissector NB: none of the devices has shown superior advantage over the other. 12/5/2022 principles of liver resection 40
  • 41. Intra-op Prevention of haemorrhage 2 surgeon technique Intra-op USS Liver hanging maneuver Low CVP <5mmHg from anaesthetist Drain vs no drain Post-op care HDU/Wards 12/5/2022 principles of liver resection 41
  • 42. Complications Haemorrhage Liver insufficiency/dysfunction Perihepatic fluid collections bile leak 12/5/2022 principles of liver resection 42
  • 43. Conclusion Over several years, Liver resection surgery has evolved as a effective and safe way to treat benign and malignant liver pathology Careful patient selection and surgeons knowledge of the basic principles of liver resection are important determinant of outcomes. 12/5/2022 principles of liver resection 43
  • 44. References Jarnagin R. Williams: Blumgarts Surgery of the Liver, Biliary Tract and Pancreas, 6th edition Keith L. Moore and Arthur F. Dalley: Clinically oriented anatomy, 5th edition Keith Lillemoe and Williams R. Jarnagin: Mastery Techniques in Surgery: Hepatobiliary and Pancreatic surgery, 4th series O. James Garden and Simon Peterson-Brown: Hepatobiliary and pancreatic surgery, a companion to specialist surgical practice, 5th edition. 12/5/2022 principles of liver resection 44
  • 45. References Charles F. Brunicardi: Schwartzs principles of Surgery, 10th edition Chapters 31, 32 and 33 Michael J Zinner and Stanley W Ashley: Maingots abdominal operations, 12th edition. Sections VII, VIII and IX Norman, S. W., Christopher J.K.B., and P.Ronan O Connell (2008). Bailey and Love principles and practice of Surgery, 25th edition, chapter 61, 63 and 64. 12/5/2022 principles of liver resection 45
  • 46. References Vauthey, J. N., Abdalla, E. K., Doherty, D. A., Gertsch, P., Fenstermacher, M. J., Loyer, E. M., Lerut, J., Materne, R., Wang, X., Encarnacion, A., Herron, D., Mathey, C., Ferrari, G., Charnsangavej, C., Do, K. A., & Denys, A. (2002). Body surface area and body weight predict total liver volume in Western adults. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 8(3), 233240. 12/5/2022 principles of liver resection 46
  • 47. THANK YOU FOR YOUR ATTENTION 12/5/2022 principles of liver resection 47