Hainan Medical University, P.R. China
Professor Changku Jia majored in hepatobiliary pancreatic surgery & liver transplantation and graduated from Zhejiang University, the famous university in China, as a doctor's degree holder. After graduation he entered academic practice including basic science and clinical training within liver transplantation center of Zhejiang University and Queen Mary Hospital of Hong Kong University. From August 2010 he was appointed the director of Dept. Hepatobiliary Pancreatic Surgery, First Affiliated Hospital of Hainan Medical University. He strongly experienced in clinical and fundamental work of hepatobiliary surgery and liver transplantation. Now he is the expert of hepatobiliary surgery and liver transplantation in human and heart & liver transplantation in rats. He has published more than 20 papers in reputed journals including Dig Liver Dis, Cancer Invest, J Thromb Thrombolysis, etc. He is a member of editorial board of the Journal of Transplantation Technologies & Research.
Background and aims: Anatomic liver resection not only enables enough tumor-free resection margin but also guarantees maximum preservation of remaining normal liver tissue. However, anatomic liver resection of segment 6, 7 and 8 was difficult to be performed and was not previously reported. We report herein 3 cases of hepatocellular carcinoma patients that underwent successful anatomic liver resection of segment 6, 7 and 8 by the technique of selective occlusion of hepatic inflow. Methods: Of these 3 cases, multiple tumors were found in segment 6, 7 and 8 in 1 case and 2 huge tumor involving in segment 6, 7 and 8 in 2 cases. CT volumetry analyzed that left hemi liver volume was less than the minimal limit of safe survival in these cases. Therefore, we planned to perform anatomic liver resection of segment 6, 7 and 8 to guarantee the maximum preservation of remaining normal liver tissue. Dividing right hemi liver Glissonean pedicle and segment 6 and 7 Glissonean pedicle respectively was creatively used in these 3 cases to perform selective occlusion of hepatic inflow. After occlusion of the right hemi liver Glissonean pedicle, the right hemi liver presented obvious ischemic status. Therefore the demarcation between the right hemi liver and left hemi liver, especially between segment 8 and the left liver were determined easily. After demarcation right hemi liver Glissonean pedicle was left un-occluded. Then segment 6 and 7 Glissonean pedicle was divided and ligated. So the interface between segment 6 and segment 5 was easily demarcated in that segment 6 and segment 7 presented obvious ischemic status. Then we determined the demarcation between segment 8 and segment 5 by a transverse line that located 2 cm below the segment 8 tumor. Finally a broken resection line was marked upon the diaphragmatic surface of the liver. Then the right hepatic vein was divided and ligated to reduce the risk of hematogenous metastasis. After the third hepatic portal was dissected, hepatectomy was performed by cavitron ultrasonic surgical aspirator. Right hemi liver Glissonean pedicle occlusion but not total hepatic inflow occlusion was used while performing hepatic parenchymal transection. Therefore liver ischemia reperfusion injury and homodynamic instability were maximally reduced during operation. Results ： Hepatectomies were uneventfully completed with approximate blood loss of 600ml, 450ml and 500ml repectively. After hepatectomy segment 5 and the left liver were very well. All the patients received 3 times of postoperative transcatheter arterial chemoembolization. No tumor recurrence was found in these cases after 16-month, 12-month and 8-month follow up respectively. The parameters including AFP level and liver function were in the normal range. Conclusions: By the techniques of selective occlusion of hepatic inflow and anatomic liver resection, complicated hepatectomy can be performed and irregular hepatectomy can be improved by anatomic liver resection, thus making radical cure for these patients. Anatomic liver resection of segment 6, 7 and 8 by the technique of selective hepatic inflow occlusion can be a conventional operation for those patients that tumor does not involves segment 5 to enable maximum preservation of remaining functional liver tissue. It may be an alternative modality for maximal hepatectomy in the treatment of hepatocellular carcinoma.