Surgical technique of hepatectomy combined with simultaneous resection of hepatic artery and portal vein for perihilar cholangiocarcinoma (with video)

Abstract

Perihilar cholangiocarcinomas often involve the bifurcation of the portal vein and the hepatic artery at initial presentation. Previously, vascular invasion was a major obstacle for R0 resection; therefore, such tumors were regarded as locally advanced, unresectable disease. Recently, in leading centers, these tumors have been resected using a specific technique, vascular resection and reconstruction. Vascular resection is classified into three types: portal vein resection alone, hepatic artery resection alone, and simultaneous resection of both the portal vein and hepatic artery. Of these, portal vein resection is widely performed, whereas hepatic artery resection remains controversial. Therefore, hepatectomy combined with simultaneous resection of the portal vein and hepatic artery represents one of the most complicated and challenging procedures in hepatobiliary surgery. The survival benefit of this extended procedure remains unproven, and there is only a single study reporting an unexpectedly favorable outcome in 50 patients. Considering the dismal survival in patients with unresectable disease, hepatic artery resection and/or portal vein resection may be a promising option of choice. However, the technique is highly demanding and has not been standardized. Therefore, this extended surgery may be allowed only in selected hepatobiliary centers.

Right hepatectomy for a detoured left hepatic artery in hilar cholangiocarcinoma—report of a rare but rational resection

“…In locally advanced tumors, vascular invasion, more commonly hepatic arterial invasion, remains the most serious obstacle in the resection of this disease. Owing to the refinement of surgical skills and the increase in number of cases, hepatectomy with concomitant contralateral hepatic artery resection and reconstruction has recently been conducted in leading centers [1, 4]. In our study in 2010, which is the largest series in a single institute, 49 of 50 patients underwent left-sided hepatectomy with right hepatic artery resection.…”

A successfully resected case of left trisectionectomy with arterio-portal combined resection for advanced cholangiocarcinoma

“…Eventually, a histological examination showed that there were no lymph node metastases. At present, combined resection and anastomosis of the hilar blood vessels tends to be performed after complete parenchymal transection of the liver in cases of advanced PC [ 4 , 12 ]. During warm ischemia of the remnant liver, it is important to be aware of the re-perfusion time.…”

“…In cases in which PC are surrounded by major blood vessels, appropriate diagnosis and surgical planning for combined resection, particularly regarding the location of the hepatic artery, are necessary to ensure that the treatment is curative and safe [ 3 ]. Proximal arterial or portal anastomoses, which require expert surgical skills, are sometimes needed, and preoperative imaging-based diagnosis and liver functional evaluations should be performed in such cases [ 4 ].…”

Postoperative Liver Failure Criteria for Predicting Mortality after Major Hepatectomy with Extrahepatic Bile Duct Resection

“…Biliary surgeons have also used this criterion as a criterion of PHLF after Hx with EBDR [16], but we have questioned its usefulness in this context. In addition to the lack of a validation study with Hx with EBDR, we had the following 2 reasons for scepticism.…”