Right hepatectomy with extra-hepatic vascular division prior to transection: intention-to-treat analysis of a standardized policy

Abstract

Background: Right hepatectomy (RH) is the most common type of major hepatectomy and can be achieved without portal triad clamping (PTC) in non‐cirrhotic liver. The present study reviews our standardized policy of performing RH without systematic PTC. Methods: One hundred and eighty‐one consecutive RH were performed in non‐cirrhotic patients, with division of the right afferent and efferent blood vessels prior to transection, without systematically using PTC. Prospectively collected data were analysed, focusing on the following endpoints: need for salvage PTC, ischaemic time, blood loss and post‐operative outcome. Results: Extra‐hepatic division of the right hepatic vessels was feasible in all patients, but was ineffective in 48 patients (26.5%) who required salvage PTC during transection. In those patients, the median ischaemic time was 20 min. The median blood loss was 500 ml (50–3000). Six patients (3.3%) experienced post‐operative liver failure. Overall morbidity, severe morbidity and mortality were 42%, 12.1% and 1.6%, respectively, with peri‐operative transfusion rate (16.6%) being the only factor associated with morbidity. Discussion: By performing RH with extra‐hepatic vascular division prior to transection, PTC can be safely avoided in the majority of patients.

Factors associated with fatal liver failure after extended hepatectomy

“…Surgical technique of liver resection and different methods of vascular control to reduce intraoperative bleeding have been described elsewhere. 6,16 Concomitant procedures performed at the time of major hepatectomy were recorded, in particular vascular and/or biliary reconstructions and major extrahepatic procedures. For each resected specimen, an experienced pathologist performed a specific histological analysis of representative sections of non-neoplastic hepatic parenchyma.…”

Tumour biology of colorectal liver metastasis is a more important factor in survival than surgical margin clearance in the era of modern chemotherapy regimens

“…The surgical techniques and the various vascular control methods used to reduce the intra-operative bleeding have been described elsewhere. 13,14 A hepatic parenchymal transection was performed mostly with a compact ultrasonic surgical aspirator (CUSA; Dissectron®; Integra LifeSciences, Plainsboro, NJ, USA) or, if not, with a Kelly clamp crushing technique. The surgical goal was to achieve complete resections with a tumour-free margin for all the initially-identified tumour deposits (including missing metastases).…”

Relevance of the ISGLS Definition of Posthepatectomy Liver Failure in Early Prediction of Poor Outcome After Liver Resection

“…17 Intermittent total portal triad clamping was applied, only if needed, in case of bleeding or for atypical surgical resections, with 15-minute clamping and 5-minute release periods. Selective vascular exclusion was performed whenever possible to preserve the remnant liver from ischemia-reperfusion injuries.…”