liver anatomy (and hcc)external anatomy components of hepatectomy left rhv mhv lhv right outflow...
TRANSCRIPT
![Page 1: Liver Anatomy (and HCC)External Anatomy Components of Hepatectomy Left RHV MHV LHV Right Outflow Hepatic veins Vena Cava Inflow Hepatic artery Portal vein Parenchyma Segmental Liver](https://reader030.vdocuments.site/reader030/viewer/2022040904/5e780f399174782dd2224191/html5/thumbnails/1.jpg)
Liver Anatomy (and HCC)
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External Anatomy
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Components of Hepatectomy
Left
RHV MHV LHV
Right
OutflowHepatic veinsVena Cava
InflowHepatic arteryPortal vein
Parenchyma
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Segmental Liver Anatomy
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Right liver Left liver
IV III
II
I
Left pedicleRight pedicle
Leftpedicle
VI
VVIII
VII
Portal Pedicles
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7
84 2
6
54 3
CT Segmental Anatomy
1
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?
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Caudate
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Components of Hepatectomy
Left
RHV MHV LHV
Right
OutflowHepatic veinsVena Cava
InflowHepatic arteryPortal vein
?Extrahepatic or intrahepatic control of inflow and outflow?
Parenchyma
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Hepatic veins
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Hepatic veins
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Hepatic veins
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Outflow Control
Extra-hepatic
Intra-hepatic
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Left Liver Mobilization
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LHV and MHV Control
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Right Liver Mobilization
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Outflow ControlRight Hepatic Vein Division
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Extrahepatic Outflow ControlImportance of the Middle Hepatic Vein
• No liver hypertrophy• Large loss of normal liver
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Extrahepatic Outflow Control
RHV
MHV LHV
IVC
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Extrahepatic Outflow Control
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Hepatic artery
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CT Angiogram
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Right liver Left liver
IV III
II
I
Left pedicleRight pedicle
Leftpedicle
VI
VVIII
VII
Inflow - Intrahepatic Pedicles
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Portal Pedicles
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Portal Pedicles
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Portal vein - left
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Main Pedicles
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Right Main Pedicle
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Hepatotomies for Inflow Control
For right pedicle control
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Inflow ControlRight Pedicle Division
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Intrahepatic Inflow Control
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Extrahepatic Inflow Dissection
• Time consuming
• Difficult if previous RUQ surgery
• Associated with vascular/biliary injury on occasion
• Mandatory for perihilar tumors
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Left Portal Vein
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Inflow/Outflow Control?Hepatocellular Carcinoma
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Anterior Sectorectomy
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Colorectal metastases
Left Lateral Segment Right Posterior Sector
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Hepatocellular carcinoma
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HCC Features
DiagnosisCT/MR: Hypervascular on arterial phase with washoutAFP >500Biopsy
StagingLymph node involvementDistant disease
Treatment - Hepatic function, portal HTNResectionEmbolizationTransplant
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Cirrhosis
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“Hanging” Hepatoma
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40 y.o. F with acute RUQ pain
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Four patients with HCC
Portal vein
Tumor expanding portal vein
Tumor in posterior sectoralportal vein
Patient 2
Patient 1 Patient 3
Tumor in IVC andatrium
Tumor in middlehepatic vein
Tumor in lefthepatic vein
Patient 4
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39 y.o. Caucasian female without risk factors
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Sorafenib in Advanced HCC
NEJM 359:378-90, 2008
10.7 vs. 7.9 months
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65 y.o. drinker with pain, AFP 40
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10 year survivors HCC
Ann Surg Oncol 24:1358-66, 2017
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10 year survivors HCC
Ann Surg Oncol 24:1358-66, 2017
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50 y.o. Asian female with Hepatitis B
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Liver tumor
Nodal met
Liver tumor
20 y.o. male with pain