The “Tenting Sign of the Hepatic Vein” Is Important for Laparoscopic Anatomical Hepatectomy Along the Major Hepatic Vein

Chiba, Naokazu; Abe, Yuta; Nakagawa, Masashi; Koganezawa, Itsuki; Yokozuka, Kei; Kobayashi, Toshimichi; Hikita, Kosuke; Ozawa, Yosuke; Sano, Tsuyoshi; Tomita, Koichi; Tsutsui, Rina; Kawa, Shigeyuki

doi:10.1007/s11605-019-04487-4

Cited by 4 publications

(5 citation statements)

References 8 publications

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“…The difficulty lies in the prevention and treatment of intraoperative hepatic vein bleeding, gas embolism and other complications. “Tenting sign of hepatic veins” is an important anatomical knowledge that can help us reduce bleeding during surgery ( 20 ). Previous studies have shown that keeping PP below 12mmhg may reduce the occurrence of carbon dioxide embolism ( 21 ).In this study, when intraoperative CO2 embolism occurred, pneumoperitoneum suspension, head high foot low right elevation, and positive end-expiratory pressure ventilation were used to rapidly improve the situation.…”

Section: Discussionmentioning

confidence: 99%

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

Feng

et al. 2023

Front. Oncol.

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With the improvement of laparoscopic surgery, the feasibility and safety of laparoscopic hepatectomy have been affirmed, but intraoperative hepatic venous system hemorrhage and carbon dioxide gas embolism are the difficulties in laparoscopic hepatectomy. The incidence of preoperative hemorrhage and carbon dioxide gas embolism could be reduced through preoperative imaging evaluation, reasonable liver blood flow blocking method, appropriate liver-breaking device, controlled low-center venous pressure technology, and fine-precision precision operation. In the case of blood vessel rupture bleeding in the liver vein system, after controlling and reducing bleeding, confirm the type and severity of vascular damage in the liver and venous system, take appropriate measures to stop the bleeding quickly and effectively, and, if necessary, transfer the abdominal treatment in time. In addition, to strengthen the understanding, prevention and emergency treatment of severe CO2 gas embolism in laparoscopic hepatectomy is also the key to the success of surgery. This study aims to investigate the methods to deal with hepatic venous system hemorrhage and carbon dioxide gas embolization based on author’s institutional experience and relevant literature. We retrospectively analyzed the data of 60 patients who received laparoscopic anatomical hepatectomy of hepatic vein approach for HCC. For patients with intraoperative complications, corresponding treatments were given to cope with different complications. After the operation, combined with clinical experience and literature, we summarized and discussed the good treatment methods in the face of such situations so that minimize the harm to patients as much as possible.

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Section: Discussionmentioning

confidence: 99%

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

Feng

et al. 2023

Front. Oncol.

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“…The LGP was safely divided on the ventral side of the Arantius ligament. The MHV was preferentially exposed to avoid “tenting” the hepatic vein [ 25 ] before liver parenchyma dissection. After devascularization of the specimen, the liver parenchyma was quickly dissected along the fluorescence boundary, thereby reducing the number and frequency of pringle manoeuvres and reducing the risk of ischaemia–reperfusion injury.…”

Section: Discussionmentioning

confidence: 99%

“…The MHV was preferentially exposed to avoid “tenting” the hepatic vein [ 25 ] before liver parenchyma dissection.…”

Section: Discussionmentioning

confidence: 99%

Laparoscopic left hemihepatectomy guided by real-time indocyanine green fluorescence imaging using the arantius-first approach

Wang,

Xu,

Lei

et al. 2023

World J Surg Onc

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Background and objective Laparoscopic hepatectomy approaches, including major hepatectomy, were rapidly developed in the past decade. However, standard laparoscopic left hemihepatectomy (LLH) is still only performed in high-volume medical centres. In our series, we describe our technical details and surgical outcomes of LLH. Methods Thirty-nine patients who underwent LLH in our institute were enrolled in the study. Among these, 13 patients underwent LLH guided by real-time ICG fluorescence imaging using the Arantius-first approach (ICG-LLH group), and the other 26 underwent conventional LLH (conventional LLH group). Demographic characteristics and perioperative data were retrospectively collected and analysed. We compared the technical and postoperative short-term outcomes of the two groups. Results There were no significant differences in the demographic or clinicopathological characteristics of the patients in the two groups. ICG-LLH required significantly fewer pringle manoeuvres (1 vs. 3 times, p < 0.0001), had a shorter parenchyma dissection time (26 vs. 78 min, p < 0.001), and required fewer vessel clips (18 vs. 28, p < 0.001). Although there was no significant difference, the ICG-LLH group had less bile leakage (0 vs. 5, p = 0.09) and less blood loss (120 vs. 165, p = 0.119). There were no significant differences in the overall complication or R0 resection rates between the two groups. Conclusion Our data demonstrate that laparoscopic left hemihepatectomy guided by real-time ICG fluorescence imaging using the Arantius-first approach is safe and feasible in selected patients, thus improving the fluency of the surgical procedure and postoperative short-term outcomes.

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“…In current practice, the hepatic vein approach can be subdivided into the caudal approach, caudal-dorsal approach, cranial-ventral approach and cranial-dorsal approach according to different target veins ( 22 – 24 ). The caudal approach or caudal-dorsal approach used in the dissection of the liver parenchyma has several limitations; for instance, it is prone to lacerate the target vein; thus, the “tenting sign of the hepatic vein” helps to identify the running of the main trunk of the hepatic vein ( 8 ), and the approach should be performed by experienced surgeons at experienced centers for well-selected patients ( 23 ). In the cranial-ventral approach or cranial-dorsal approach, the hepatic parenchyma is transected from the root of the target hepatic vein toward its distal branches.…”

Section: Discussionmentioning

confidence: 99%

“…The hepatic vein, a branch of the inferior vena cava running between hepatic segments or lobes and collecting blood from the liver parenchyma, is often used as an anatomical landmark and is continuously exposed on the plane of hepatic disconnection in OAH or LAH ( 7 ). Especially in LAH, the operator is often disoriented because of the visual field, so a path guided by the hepatic vein has become valuable ( 8 ).…”

Section: Introductionmentioning

confidence: 99%

Counterclockwise modular laparoscopic anatomical mesohepatectomy using combined glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches

Zhao

Lyu²,

Lyu³

et al. 2022

Front. Oncol.

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BackgroundAlthough laparoscopic anatomical hepatectomy (LAH) is widely adopted today, laparoscopic anatomic mesohepatectomy (LAMH) for patients with hepatocellular carcinoma (HCC) remains technically challenging.MethodsIn this study, 6 patients suffering from solitary liver tumors located in the middle lobe of the liver underwent counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches. In this process, the Glissonean pedicle approach (Takasaki approach) was first used to transect the liver pedicles of segment right anterior (G58) and segment 4 (G4). Second, the hepatic vein-guided approach was performed along the umbilical fissure vein (UFV) to sever the liver parenchyma from the caudal to cranial direction, and the middle hepatic vein (MHV) and anterior fissure vein (AFV) were then disconnected at the root. Last, the hepatic vein-guided approach was once more performed along the ventral side of the right hepatic vein (RHV) to transect the liver parenchyma from the cranial to anterior direction, and the middle lobe of the liver, including the tumor, was removed completely. The entire process was applied in a counterclockwise fashion, and the exposure or transection sequence was G58, and G4, followed by UFV, MHV, AFV, and finally, the liver parenchyma along the ventral side of RHV.ResultsThe counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches was feasible in all 6 cases. The median duration of the operation was 275 ± 35.07 min, and the mean estimated blood loss was 283.33 ml. All of the 6 patients recovered smoothly. The Clavien-Dindo Grade I-II complications rate was up to 33.33%, mainly characterized by postoperative pain and a small amount of ascites. No Clavien-Dindo Grade III-V complications occurred, and the mean postoperative hospital stay was 6.83 ± 1.47 days. Follow-up results showed that the average disease-free survival (DFS) was 12.17 months, and the 21-months OS rate, DFS rate and tumor recurrent rate were 100%, 83.33% and 16.67% respectively. ConclusionsCounterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches takes the advantages of the two approaches, is a novel protocol for LAMH. It is thought to be technically feasible for patients with a centrally located solitary HCC. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. A multicenter, large-scale, more careful study is necessary.

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The “Tenting Sign of the Hepatic Vein” Is Important for Laparoscopic Anatomical Hepatectomy Along the Major Hepatic Vein

Cited by 4 publications

References 8 publications

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

Laparoscopic left hemihepatectomy guided by real-time indocyanine green fluorescence imaging using the arantius-first approach

Counterclockwise modular laparoscopic anatomical mesohepatectomy using combined glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches

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