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Left Hepatectomy [Case 1]

Introduction

Clinical History

A 71-year old woman was diagnosed with advanced rectal cancer. She underwent neo-adjuvant chemoradiation and had an APR (abdominoperineal resection) followed by 6 cycles of FOLFOX chemotherapy. In follow-up, she had a rising level of CEA (carcinoembryonic antigen) and a CT scan showed a single liver metastasis in the left lobe. Our plan for her is to do a formal left hepatectomy.

 

Left Hepatectomy [case 1]

Imaging Analysis

Look through the patient's CT scan to identify any areas of concern for the necessary procedure.

Imaging Analysis

Look through the patient's CT scan to identify any areas of concern for the necessary procedure.

Available Image Sequences:

Axial Venous

Axial Venous CT scan
Imaging Analysis
Based on your CT findings, which issue(s) would give reason for "planned slowing down moment(s)" in this case?
Considering a standard left hepatectomy procedure, what step(s) of the operation would you do differently in this case?

Left Hepatectomy [case 1]

Surgeon's Impressions

 

 

 

Operating surgeon: Dr. Moulton

  • Critical imaging findings:
    1. Portal vein trifurcation
    2. Replaced left hepatic artery
    3. Left hepatic vein branch
    4. Preserving caudate inflow and bile duct
    5. Left bile duct

Consulting surgeon: Dr. Gallinger

  • Critical imaging findings:
    1. Tumor proximity to MHV
    2. Tumor proximity to gallbladder
    3. Portal vein
    4. Left bile duct

Watch the following videos from the operation to see some of the key moments in the case.

 

 

Watch the following video for the operating surgeon's summary of the case.

 

 

Key points from this case

  • Portal vein trifurcations: look out for anatomy of the portal vein and be mindful of any variations in anatomy.
  • Bile duct: be careful of tumor margins, especially with anterior tumors in Segment 4.
  • Gallbladder: when tumor margins are close to the gallbladder, routine cholecystectomy is not appropriate.

The issues that the surgeons collectively identified preoperatively:

  • Tumor proximity to gallbladder
  • Replaced left hepatic artery
  • Portal vein trifurcation
  • Left bile duct and preserving caudate biliary drainage
  • Tumor proximity to middle hepatic vein
  • Left hepatic vein branching

The first 4 issues were demonstrated in the intraoperative videos. Intraoperative ultrasound confirmed that the tumor was not too close to the middle hepatic vein. We were able to take it outside the liver and divide its small crossing branches during parenchymal transection, preserving the middle hepatic vein. We took the left hepatic vein outside the liver as usual.