Liver Surgery . Surgery that is carried out with the presentation of primary and secondary tumor lesions of colo-rectal origin, stomach , esophagus , pancreas , urinary system, breast, lung .
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- 1 Definition
- 2 Risk factors
- 3 Diagnostic methods
- 4 Treatment
- 1 Liver transplant as a cure alternative
- 5 Types of Cracks
- 1 Sagittal or median fissure
- 2 Umbilical porto fissure (the only one visible on the liver surface
- 3 Right lateral cleft
- 4 Left lateral cleft
- 6 Sources
Primary liver tumors ( hepatocellular carcinoma or hepatocarcinoma ) or secondary ( metastases from primary tumor lesions of colo-rectal origin , stomach , esophagus , pancreas , urinary system , breast, lung , etc.) are tumor lesions frequently diagnosed in the field of the oncology digestive that might require of liver surgery , or result in liver metastases, breast, etc. if they are not treated in time.
Risk factors for cancer of liver , breast, lung, such as virus B or C or the presence of cancer of the liver of different etiologies.
Ultrasound , helical CT, nuclear magnetic resonance , PET-CT and echolaparoscopy , these methods allow to clearly establish the evolutionary status of liver tumors . Thanks to this, an optimal and individualized therapeutic strategy for the patient can be established.
Liver surgery continues to occupy a privileged place in the treatment of these liver tumors even in the presence of disseminated disease. The number of existing liver cancer lesions , their location, connection to vascular-biliary structures , the amount and state of liver tissue to be resected are factors that have a powerful influence on deciding liver surgery with curative intent.
Initially unresectable lesions can become resectable after the application of neoadjuvant treatment. Post-operative liver failure after liver cancer currently represents the highest risk of liver surgery. The need to perform a large liver resection in patients affected by large tumor masses or with multiple liver tumors forces us to perform preoperative liver manipulation ( selective portal embolization to cause compensatory hypertrophy of the remaining liver parenchyma ).
Ablative tumor techniques such as radiofrequency, percutaneous ethanol injection , chemoembolization or radiosurgery play an important role in the treatment of liver cancer, in most cases associated with liver surgery.
Liver transplant as a cure alternative
Liver transplantation from a cadaveric donor or living donor represents an excellent therapeutic option in a very select number of patients affected by primary liver tumors with chronic liver disease. Hepatic extracorporeal liver surgery is also considered a surgical technique of recourse in a small number of patients in whom resection cannot be performed with conventional methods.
Types of Cracks
Sagittal or median fissure
It is the main fissure that divides the liver into 2 parts: right and left; It extends from the gallbladder bed to the left edge of the vena cava . In its interior is found, in a superior plane, the path of the medial suprahepatic vein and in a more inferior plane the division of the main glissonian pedicle in right and left. The common trunk of the middle suprahepatic vein occupies, in the posterior part of the fissure, the left half of the posterior triangle of insertion of the sickle ligament, since the right half is represented by the inferior vena cava.
The median suprahepatic vein is considered the vascular loop of the liver, which generally joins the left suprahepatic vein to empty into a common trunk in the inferior vena cava. This fissure forms with the underside of the liver an angle that varies from 55o to 70o, generally around 65º and cuts into the hilum at the level of the portal bifurcation . It is not totally avascular, but it is not crossed by very thick vascular branches. It is the one that we must approach to perform the right and left hemihepatectomies.
Sagittal or Median Fissure
Umbilical porto fissure (the only one visible on the liver surface
It is the only visible and well-known fissure of the ancient anatomists, inside it is determined by the Arantius canaland of the Rex recess or portoumbilical sinus (dilation of the left portal vein after it is angled right into the fissure) and on its upper side it is given by the insertion of the sickle ligament classically corresponds to the division of the liver into 2 lobes : on the left is the classic left lobe and on the right, between it and the median fissure, the medial segment or IV subsection of Couinaud, which constitutes the right lobe. In its upper part it has the sickle ligament that divides in its posterior part into 2 sheets to form the triangle of posterior insertion of this ligament that has the inferior vena cava in its right third, while in its left 2 thirds there is the common trunk by the union of the middle and left suprahepatic veins.
Sometimes this fissure is caused by an intermediate suprahepatic vein of lesser size than the average and not present in all cases. Approaching this fissure allows left and right lobectomy , currently lateral segmentectomy is very important for the new related living donor technique in pediatric patients.
Right lateral cleft
It corresponds in its interior with the path of the right suprahepatic vein and is the thickest of the suprahepatic veins. It is given in a posterior plane by the upper sheet of the right coronary ligament until it follows the origin of the right triangular ligament, at this level the fissure descends forward parallel to the lower and right edge of the liver; on the inferior aspect of the liver, it continues parallel to the vesicular border, ending at the right end of the transverse hilar chair. This fissure allows us the transparenchymal approach for anterior and posterior segmentectomies.
Left lateral cleft
Classically part of the origin or mouth of the left suprahepatic vein describing an oblique arcuate path to the left forward to end through a finger from the middle of the anterior border of the left lobe. Inside is the path of the left suprahepatic vein and it is the division limit between subsegments II and III of the left lobe, it is the approach for resections of these subsegments as in the Longmire technique for a cholangiojejunostomy.