Extrahepatic right portal vein ligation allows parenchyma-sparing en bloc resection of segments 7, 8 and 4a for liver tumors engaging the right and middle hepatic veins

Right trisectionectomy for posterior liver tumors engaging the right and middle hepatic veins may lead to post-hepatectomy liver failure if the anticipated liver remnant is small. In such patients we developed a parenchymasparing one-step approach, that includes extrahepatic right portal vein ligation accompanied by en bloc resection only of segments 7, 8 and 4a and resection of the right and middle hepatic veins. The technique was applied in 3 patients with normal liver function, where according to the preoperative computed tomography the volume of segments 1, 2 and 3 ranged between 17% and 20% of the total liver volume. In all patients liver biochemistry improved rapidly postoperatively and a doubling of volume of segments 1, 2 and 3 was achieved by the third postoperative week, as extrahepatic right portal vein ligation ameliorated reperfusion injury of the remaining segments 5 and 6 and induced hypertrophy of segments 1, 2, 3 and 4b. There was no mortality or long-term complications.Patients are alive and free of disease 74, 50 and 17 months after the operation, respectively. We propose that the term ＂extended upper right sectionectomy＂ may be considered for the en bloc resection of segments 7, 8 and 4a, in future revisions ofthe Brisbane 2000 terminology of hepatic anatomy and resections.

Laparoscopic liver resection: Toward a truly minimally invasive approach

In the surgical treatment of hepatocellular carcinoma and colorectal liver metastasis, it is important to preserve sufficient liver volume after resection in order to avoid post-hepatectomy liver sufficiency and to increase the feasibility of repeated hepatectomyin case of intrahepatic recurrence. Parenchymasparing approach, which minimizes the extent of resection while obtaining sufficient surgical margins, has been developed in open hepatectomy. Although this approach can possibly have positive impacts on morbidity and mortality, it is not popular in laparoscopic approach because parenchyma-sparing resection is technically demanding especially by laparoscopy due to its intricate curved transection planes. "Small incision, big resection" is the words to caution laparoscopic surgeons against an easygoing trend to seek for a superficial minimal-invasiveness rather than substantial patient-benefits. Minimal parenchyma excision is often more important than minimal incision. Recently, several reports have shown that technical evolution and accumulation of experience allow surgeons to overcome the hurdle in laparoscopic parenchymasparing resection of difficult-to-access liver lesions in posterosuperior segments, paracaval portion, and central liver. Laparoscopic surgeons should now seek for the possibility of laparoscopic parenchyma-sparing hepatectomy as open approach can, which we believe is beneficial for patients rather than just a small incision and lead laparoscopic hepatectomy toward a truly minimally-invasive approach.

Extent of surgical resections for intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms(IPMNs) can involve the main pancreatic duct(MD-IPMNs) or its secondary branches(BD-IPMNs) in a segmental of multifocal/diffuse fashion.Growing evidence indicates that BDIPMNs are less likely to harbour cancer and in selected cases these lesions can be managed non operatively.For surgery,clarification is required on:(1) when to resect an IPMN;(2) which type of resection should be performed;and(3) how much pancreas should be resected.In recent years parenchyma-sparing resections as well as laparoscopic procedures have being performed more frequently by pancreatic surgeons in order to decrease the rate of postoperative pancreatic insufficiency and to minimize the surgical impact of these operations.However,oncological radicality is of paramount importance,and extended resections up to total pancreatectomy may be necessary in the setting of IPMNs.In this article the type and extension of surgical resections in patients with MD-IPMNs and BD-IPMNs are analyzed,evaluating perioperative and long-term outcomes.The role of standard and parenchyma-sparing resections is discussed as well as different strategies in the case of multifocal neoplasms.