PREOPERATIVE DIAGNOSIS: Liver cancer.
POSTOPERATIVE DIAGNOSIS: Liver cancer.
OPERATIONS PERFORMED:
1. Right trisegmentectomy.
2. Roux-en-Y jejunojejunostomy.
3. Roux-en-Y hepaticojejunostomy.
4. Extensive lysis of adhesions.
5. Repair of umbilical hernia, nonincarcerated, primary repair.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal tube anesthesia.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 150 mL.
DRAINS: One JP drain to bulb suction.
SPECIMENS OBTAINED:
1. Distal bile duct.
2. Distal cystic duct.
3. Right trisegmentectomy.
INTRAOPERATIVE FROZEN MARGINS:
1. Cystic duct negative for malignancy.
2. Bile duct negative for malignancy.
3. Cut surface of the liver negative for malignancy.
4. Primary tumor consistent with cholangiocarcinoma or hepatocellular carcinoma.
DESCRIPTION OF OPERATION: The patient was placed supine on the operating table. After adequate IV access and IV sedation, the patient was intubated and anesthetized. Central venous cannulation and arterial cannulation were performed by Anesthesiology. A Foley catheter was placed by the nursing staff. The abdomen was prepped with Betadine solution, including the chest, and draped with sterile linen and sterile drapes. A right subcostal incision was created and taken down through the peritoneum with electrocautery. One hand was placed intraperitoneally and the surfaces were palpated. The peritoneum had no evidence of carcinomatosis. There were no other masses below the liver or within the mesentery. The mass within the liver was palpable. With no evidence of disease outside the liver between the CAT scan as well as palpation and exploration, the incision was carried to a bi-subcostal incision with midline extension. The falciform ligament was taken down between 0 silk ties. The next 50 minutes were then used to carefully take down adhesions between the small bowel, the omentum, the colon and the liver. The bowel structures and omentum were adherent to the gallbladder, which was invaded by cancer and the surface edge of the liver all the way down to the right triangular ligament. Many of these adhesions were taken down between 2-0 silk ligatures for hemostasis.
With the liver now freed up, the membranous portion of the falciform ligament was taken down with electrocautery to the hepatic veins. The porta hepatis was now explored. The right, middle, and left hepatic arteries were circumferentially dissected and vessel loops were placed. The portal vein was skeletonized and carried up to the bifurcation. The left portal vein was identified and a vessel loop was placed for control. The common bile duct was circumferentially dissected and was transected near the head of the pancreas. The distal margin of the bile duct was sent for frozen pathology. The cystic duct took off from the bile duct very low, just above where the common bile duct was transected. This was transected and also sent for distal margins and both came back negative.
The right lobe of the liver was now mobilized, taking down the triangular ligament and its attachments to the retroperitoneum. The peritoneum over the vena cava was taken down with blunt dissection and electrocautery. Four tributaries directly from the liver into the vena cava were taken down between ligatures and divided. Each one was oversewn at the vena cava with a 3-0 silk pop-off suture. The right lobe had two hepatic veins. Each one was circumferentially dissected and an umbilical tape was placed for control. Each one was then occluded and divided with endoreticulating vascular stapler. The right hepatic artery was divided between silk ties. The portal vein was divided right at the bifurcation and the proximal portion ligated as well as suture ligated with 3-0 silk ligatures. The right portal vein had been previously embolized.
The bile duct was palpated and its landmarks were identified. The hilum of the liver was now elevated and the bile duct to the right lobe was identified and circumferentially dissected, ligated, and divided. With all vascular structures and the biliary system now disconnected from the right lobe of the liver, the palpable tumor was identified and its margins were located. The margin between segment IV and the left lobe was found to be approximately 2 cm from the palpable mass. The Habib RFA dissector was now used to precoagulate the surface the liver from the right hepatic vein all the way to the porta hepatis, staying well away from the porta hepatis so as not to transmit heat to the biliary and vascular structures. After precoagulation, the liver tissue was then cut with scissors, transecting down to the major vascular structures. After the major vascular structures were divided, endoreticulating vascular staplers were used to occlude and divide the biliary and vascular structures in the remaining hepatic substance. The specimen was removed and sent to pathology for frozen evaluation. All frozen slides came back negative for malignancy. The cut surface of the liver was Argon beam coagulated at the areas that had any amounts of bleeding. Most were all dry. Around the bile duct, going to the left lobe, as well as the left hepatic artery, there was a small amount of oozing blood. FloSeal hemostatic gelatin matrix was then placed with Nu-Knit for persistent hemostasis.
Evaluation of the bile duct found that it was cut just below the takeoff between the anterior and posterior portions. A small tributary had been cut away from the anterior portion 2 cm away from the main orifice. This was oversewn with a 5-0 Maxon suture in interrupted style. The vena cava was evaluated and found with all ties to be intact. The retroperitoneum was Argon beam coagulated for hemostasis. The retracting system was now rearranged. The small bowel was followed from the ligament of Treitz to the ileocecal valve and no pathology was identified. Fifty centimeters from the ligament of Treitz, the bowel was brought in a retrocolic fashion anterior to the pylorus up into the hilum of the liver. This provided enough length for hepaticojejunostomy. The bowel was now brought down below the colon and divided with a 3.5 mm endoreticulating stapler. The mesentery was taken down past the second arcade branch. The branches were ligated and divided.
The proximal portion of the Roux was now anastomosed in a side-to-side fashion to the distal jejunum in a two-layer fashion with 3-0 silk Lembert sutures and 3-0 Maxon running suture, full thickness. The distal divided jejunum was now brought up retrocolic through the previous tunnel and placed up in the hilum. An enterotomy was created 1 cm from the staple line in an antimesenteric fashion. The left bile duct was now anastomosed to the jejunum in a mucosa-mucosa technique with 5-0 Maxon interrupted full thickness sutures. The rent in the mesentery of the colon was tacked to the bowel to prevent herniation and to close the defect with individual 3-0 silk simple sutures. The rent in the mesentery below the colon for the jejunojejunostomy was closed with 3-0 interrupted silks as well. The abdomen was irrigated with sterile saline and antibiotic solution and aspirated dry. The cut surface of the liver was completely dry.
A 12 French flat JP drain was brought through a separate stab incision and placed within the resection bed. The hepaticojejunostomy and the repaired bile duct were covered with CoSeal fibrin glue. The abdomen was closed in a one-layer fashion with #1 PDS suture. The midline extension was closed in interrupted fashion with figure-of-eight and the bi-subcostal incisions were closed with running looped PDS. An On-Q pain pump was now placed with two limbs superior and subperitoneal to the wound. The catheters had been placed prior to closure. Each catheter was then prefilled with 0.5% Marcaine without epinephrine. The skin was reapproximated with sterile staples. The drain was attached to the skin with a drain stitch of 2-0 silk. The patient tolerated the procedure well and was hemodynamically stable throughout the case. He was taken to the recovery room in awake and stable condition.
