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1、1,Isolated caudate lobe resection for hepatic tumor: surgical approaches and perioperative outcomes,Yi Wang(王义，肝外二科主任）,etc. Eastern Hepatobiliary Surgery Hospital, Shanghai. The American Journal of Surgery. Impact Factor：2.36 哈尔滨医科大学 朱开彬,2,Anatomy,Caudate lobe of the liver is relatively inaccessible
2、 because of its deep location and lying among the hepatic veins, the IVC and the hilar structures.,3,It divided into 3 portions: the left Spiegel lobe (SL), the right caudate process (CP), and the paracaval portion (PP). SL was the protuberant portion of liver located to the left of the inferior ven
3、a cava and below the lesser omentum.,4,The CP is a tongue-like projection between the IVC and the adjacent portal vein. The PP is the portion of the liver in front of the IVC, between the SL and the right lobe, adjacent to the middle hepatic vein ventrally.,5,6,Venous drainage occurs along its poste
4、rior aspect directly into the IVC through multiple small branches of variable size and location.,7,Biliary drainage includes small tributaries to the right, but is predominantly through the left hepatic duct. Arterial flow is variable, but is mainly through a solitary branch from the main left hepat
5、ic artery and a second smaller branch from the right posterior sectorial artery.,8,In this study, we reviewed our experience with ICLRs for caudate tumors in different portions of the lobe to examine the operative indications, to explore the surgical techniques, and to assess the perioperative outco
6、mes.,9,Patients and Methods,46 patients with hepatic tumor originating in and conning to caudate lobe who underwent ICLR between December 1996 and October 2008. An associated caudate lobectomy were excluded.,10,Surgical approaches,Three approaches were used, including the left-sided, right-sided, an
7、d anterior transhepatic approaches, for 4 types of ICLR in this series.,11,ligament to mobilize the lateral segment of the liver and turn it to the right, the lesser omentum was excised to explore the caudate lobe .,Isolated resection of the SL: The left-sided approach was used . After dissection of
8、 the left corneal and the triangular,12,13,The ligament of IVC was then dissected.,14,All the short hepatic veins were ligated and dissected, proceeding from the left side to the right side and caudocranially, to free the SL from the IVC.,15,At the base of the umbilical ssure of the liver, the cauda
9、te vessels from the left portal vein and left hepatic artery were dissected and the liver tissue was transected between the CP, the PP, and the SL, until removal of the SL.,16,Isolated resection of the CP： The right-sided approach was used. Following extensive mobilization, the right lobe of the liv
10、er was turn over toward the left .,17,the short hepatic veins were ligated and dissected serially between the caudate lobe and the IVC, proceeding from the CP toward the cranial direction and extending over the anterior surface of the IVC.,18,The portal branches to the caudate lobewere ligated and d
11、issected, and the liver tissue was then transected from the right border of the CP to the root of theright hepatic vein,19,Isolated resection of the PP. An anterior transhepatic approach was used, the key of this approach to success was making the dissection plane wide enough to approach the deeply
12、situated tumor from the raw surface.,20,With the aid of intraoperative ultrasound, parenchymal transection started from segment IV, along the left or right side of the MHV according to the tumor size and its relations with the vessel, to expose the anterior surface of the PP.,21,The PP was then deta
13、ched from the hilar plate by ligating and dividing the ascending paracaval portal branches. By turning the left edge of the PP ventrally and to the right, the anterior surface of the IVC was exposed and the short hepatic veins were dissected.,22,A) MRI showed a HCC (T) originating in the paracaval p
14、ortion of caudate lobe. F) Two months after the operation, CT showed a residue space at the site of paracaval portion (arrowhead) and there was no recurrence in the liver.,23,(C) Circling the superhepatic IVC (arrow) and the MHV (arrowhead) for implementation of total hepatic vascular isolation. (D)
15、 By splitting the overlying liver parenchyma, the tumor (T) was reached, and the subsequent resection of the tumor was performed under THVI. (E) Following isolated resection of paracaval portion, the split liver was oversewn without any sign of congestion,24,Total ICLR: If the hepatic tumor involved
16、 SL and PP with or without CP, a total ICLR was indicated. We alternated between the left- and right-sided approaches, not the anterior transhepatic approach used by many authors ,because less destructive to the main liver and shortened the vascular control time .,25,liver transection could commence from the right between the CP and the right lobe, the right portal branch, and then turn to the left between the base of segment IV and the SL, the PP, along the back of MHV toward the right directi
