Techniques of Liver Surgery Vinay Kumaran
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1Techniques of LIVER SURGERY2
3Techniques of LIVER SURGERY
Vinay Kumaran MBBS MS MCh Consultant and Head HPB Surgery and Liver Transplant Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute Mumbai, Maharashtra, India Foreword Samiran Nundy
4
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Techniques of Liver Surgery
First Edition: 2016
9789385891564
Printed at
5Dedicated to
First and foremost, our patients. We learn from them as we treat them and sometimes their quiet courage in the face of daunting odds is the best reason to battle the disease.
Our students who help us operate, look after the patients, ask us questions, make us read, make us better and sometimes teach us more than we manage to teach them.
Our colleagues from other departments. Surgery is a team sport. The surgeon may be the most visible member of the team but he can do nothing without the Anesthetist, the Radiologist, the Intensivist, the Gastroenterologist, the Pathologist, the Microbiologist, the Oncologist, the Radiation Oncologist and so on. I cannot off-hand think of a department of the hospital that we have not had to call on for help at some time
You, the surgeon, who has picked up this book. To think about liver surgery is a slippery slope to fascination with the organ. You are hooked. Welcome to the fold.6
7CONTRIBUTORS 9FOREWORD
During selection interviews for the very large numbers of candidates who now want to take up gastrointestinal surgery, I often ask them in which particular aspect of the specialty are they interested. Most say hepatopancreaticobiliary (HPB) surgery and of this ‘sub-sub’ specialty what they aspire to be are great liver and liver transplant surgeons. This is because of the amazing metamorphosis of operations on the liver from being rare, rather clumsy procedures accompanied by massive losses of blood, postoperative infections, bile leaks and multiorgan failure culminating in a 30% mortality rate to clean, precise and anatomically exact operations which, in many major centers even in this country, carry mortality rates of less than 5%. Only a short while ago, a diagnosis of hepatocellular and gallbladder carcinoma was a death sentence because most were thought to be inoperable and, even if excised, had little chance of cure. Now, we have reached a situation where liver resections done for these tumors as well as cholangiocarcinomas and colorectal metastases have not only become safe but also followed by good long-term outcomes.
The reasons behind the improvement are many and include the careful choice of subjects before operation using sophisticated tests of liver function and accurate delineation of hepatic vascular and biliary anatomy through advanced imaging, doing anatomical rather than nonanatomical procedures, employing newer methods to divide the parenchyma, careful anesthetic monitoring and management and noninvasive ways of dealing with postoperative complications.
Of course, the most glamorous aspect of all surgeries is now liver transplantation. It saves young lives, is accompanied by regular media coverage but (except for a few states in the South where some deceased donor transplants are done), we have been left with performing one of the most difficult procedures in surgery which is living donor transplantation. Yet, remarkably, in spite of their complexity, most of these operations are done in India now than anywhere else in the world and the results from our leading institutions match the best worldwide.
This book has been written to guide the aspiring surgeons through all the important aspects of liver surgery—its indications, technique, etc., and it carries instructions on how to operate for primary tumors in the liver as well as metastases. It ends with, inevitably, four authoritative chapters on liver transplantation.
It is a book that is also especially relevant to India and other countries in the developing world because it deals with problems that are faced by surgeons in resource poor countries who have to make the best out of the facilities they have.
Finally, I must declare a conflicting interest. All the authors of these chapters, I am proud to say, have been colleagues or students of mine and it is wonderful that they have succeeded in producing such a useful ‘how to do it’ book on such a difficult subject. The result of their efforts is a publication that should be read by all surgeons who plan to perform liver operations.
So, I have great pleasure in congratulating Vinay Kumaran and his colleagues, for their efforts in producing a book which will be of use to general and gastrointestinal surgeons in this country as well as abroad for a long time to come.
Samiran Nundy
Dean
Sir Ganga Ram Institute for
Postgraduate Medical Education and Research
New Delhi, India10
11PREFACE
I was approached in November 2011 to write a book on liver surgery by Ms Shaila Prashar from M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India. Our idea was to write a book for surgeons interested in liver surgery. This is not a textbook to be used to prepare for examinations. The idea is not to try and cover all the theory behind the various diseases of the liver which require surgery but to provide practical advice to those who intend to operate on the liver.
It was too extensive a project for one author. I asked colleagues who perform such operations regularly to write about different aspects of liver surgery. To a large extent, it is a series of “how I do it” articles. Some background is provided but no attempt has been made to describe all the possible ways a particular operation can be done. Instead, the idea was to provide a relatively detailed description of the author's preferred method of performing a particular operation or part of an operation.
In a book about techniques, we decided not to have a chapter on indications for liver transplant. The discussion would have been predominantly medical. We assume that any one reading about the technique of liver transplantation is familiar with the indications and timing of the same.
This book contains the first detailed description of the “W technique”. A safe and reproducible technique for performing the hepatic artery anastomosis in living donor liver transplantation.
Some of the cases depicted in the illustrations are intended to show what is possible in the hands of experienced HPB and liver transplant surgeons. There is a learning curve and the surgeon making initial forays into surgery of the liver should not take on complex vascular resections in the early years of their exploration of the field.
We hoped to complete the project in 6 months but it ended up taking more than 4 years as we added material, changed authors for chapters and edited and revised the text.
At the end, we hope we have produced a book which will be of practical use to the surgeon with an interest in hepatobiliary surgery and the technical aspects of liver transplantation.
Vinay Kumaran12
13ACKNOWLEDGMENTS
I thank all the contributing authors. They are all busy surgeons and they took time out from their busy schedules to write the chapters in this book. There is much in this book which comes from having performed the same operation again and again in scores of patients with differing levels of complexity. Small points which may not be found in conventional textbooks, but which can make the difference between smoothly progressing to the next step or getting into major problems.
I thank Dr Samiran Nundy, for writing the foreword for this book. He has been a mentor and an inspiration to us. He has been a constant source of encouragement, not only in the development of this book but also in our professional growth.
I am also thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for publishing this book. Mr Sarfraz Hassan initiated the project and it was subsequently followed up by Mr Nitin Huria, Ms Shaila Prashar, Mr Cheenu Sharma and Ms Shivangi Pramanik. Shaila and Shivangi did the bulk of the work.14
15ABBREVIATIONS CBD
– Common bile duct
CD
– Cystic duct
CVP
– Central venous pressure
D-D
– Duct to duct anastomosis
DDLT
– Deceased donor liver transplantation
FHF
– Fulminant hepatic failure
GIA (stapler)
– Gastrointestinal anastomosis
GRWR
– Graft to recipient weight ratio
HA
– Hepatic artery
HAP
– Hepatic artery proper
HCC
– Hepatocellular carcinoma
HJ
– Hepaticojejunostomy
HTK
– Histidine-tryptophan-ketoglutarate
IHV
– Inferior hepatic vein
IVC
– Inferior vena cava
JJ
– Jejunojejunostomy
LDLT
– Living donor liver transplantation
LHA
– Left hepatic artery
LHV
– Left hepatic vein
LLG
– Left lobe graft
LPV
– Left portal vein
MHV
– Middle hepatic vein
MPV
– Main portal vein
PSC
– Primary sclerosing cholangitis
PV
– Portal vein
RAPV
– Right anterior portal vein
RHA
– Right hepatic artery
RHV
– Right hepatic vein
RLG
– Right lobe graft
RPPV
– Right posterior portal vein
RPV
– Right portal vein
SFS
– Small for size
SMV
– Superior mesenteric vein
TACE
– Transarterial chemoembolization