Mobilisation of the liver

Mobilisation of the liver

Incision A roof top incision is performed 2–3 /uni00A0 cm below the costal margin ( Figure 69.19 ) with a vertical extension (Mercedes-Benz) if required. Fixed retraction under the ribs provides adequate access and thoracoabdominal incisions are no longer required. If doubt exists about operability a small right subcostal inci sion is used initially , and a thorough examination performed, including the caudate lobe. Intraoperative ultrasonography (IUS) is the standard of care for hepatobiliary surgery and is used with bimanual palpation to assess the e xtent of the tumour(s). IUS detects only an additional 10% compared with palpation alone. The hepatic pedicle Hilar dissection Having determined that tumour does not directly involve the hilar structures a standard cholecystectomy is performed. The CBD is identified in the free edge of the lesser omen tum, facilitated by following the cystic duct to its junction, dissected free and slung. The tissue in the right free border The Mercedes-Benz sign takes its name from the insignia displayed on the bonnet of a Mercedes-Benz car. of the hepatoduodenal ligament is dissected and removed by ligation and division to avoid lymphatic leaks and the portal vein identified and slung. Developing the plane anterior to the vein allows the bile duct and artery to be mobilised forwards and the bifurcation of the vein to be identified (the branch to the side to be retained must be clearly identified). At this point anterior tissue (the hilar plate) should be freed from the base of the liver, lowering the structures that bifurcate. The artery - and duct are separated at the bifurcation and slung just below it. The vascular anatomy is then confirmed, and the possibility of a replaced right hepatic artery arising from the superior mesenteric artery and lying posterior to the bile duct (25% of people) and an accessory left hepatic artery from the left gastric artery in the lesser omentum (25% of people) considered. Hilar arterial and biliary anatomy in the hepatoduodenal ligament and at the hilum is so variable that careful dissection is required even if the pattern appears to be one of the recognised variants. A standard approach is important in the event of unexpected intraoperative findings. The approach to the hilum - allows di ff erent conditions and pathologies to be approached with confidence, including formal resections (metastases and primary liver tumours), hilar cholangiocarcinoma, bile duct injuries and penetrating trauma.

Figure 69.19 Access for liver surgery. Rooftop incision with optional vertical extension.