Jinhong CHEN Pure laparoscopic left lateral hepatic lobectomy for living donor

Dear Professor Merikwani, so I will introduce myself first. I'm Dr. Jinghong Chen, Chief of the Hepato-Burial Surgery Department from Huashan Hospital and Fudan University in Shanghai.

high. In our department, we performed more than 1,000 liver resection per year and more than

250 cases liver transplantation per year. And mostly the liver resection were performed by

by Labroscope or DaVinci, maybe 70% research is performed by Labroscope or DaVinci.

And our hospital, Labroscope for LDLT is routine in our department and we just make some innovation

evaluation and our results were published in liver transplantation, HBSN, and so on.

So on that day, Professor Lu Ru from our department will present our experience on the labroscope

LDLT.

Thank you very much.

Thank you, Professor.

Okay. Dear experts, my name is Lu Ru. I come from Huashan Hospital, Fudan University.

So first of all, please allow me to brief you on the three patients undergoing the surgery today.

Can you show the PPT or can I show my PPT?

The first case is a pure laparoscopic left lateral hepatic lobectomy for living donor.

And the donor is a 37-year-old female, and the acceptor was his five-month-old girl, his daughter.

daughter, and the patient, the diagnosis was very atresia and with sclerosis.

This is the 3D reconstruction of the donor, the hepatic artery, the portal vein, the hepatic

vein, and the bioduct was normal, and we produced the surgery.

left hemi-hepatectomy for the living donor and the donor was a 76 years old female

and the acceptor was also his five years old daughter. She's diagnosis was Langheim cell

cell, hysterocytosis, and with liver cirrhosis.

This is a 3D reconstruction of the donor, and we performed the left hemiphytectomy

in laparoscopic, and the operation time was 140 minutes.

Okay, and the third case is a pleural laparoscopic right hemiphytectomy.

This is also a female donor, 43 years old, and the acceptor was his 9-year-old daughter.

She's diagnosed with a familiar intrahepatic cholestasis.

This is his 3D reconstruction of the hepatic artery and the portal vein and the hepatic vein.

This is MRCP. Let's see the donor, the hepatic artery was three to four millimeters, and this is his hepatic vein, and this is his hepatic bile duct.

And she has three hepatic vein, the main hepatic vein.

One is right hepatic vein, and another is segment 8 hepatic vein.

And the third one is right posterior inferior hepatic vein.

and this three hepatic vein was more than five millimeters,

so we reconstructing the hepatic vein.

The right hepatic vein, the main track,

and the segment eight hepatic vein, we use the graft,

and the right posterior inferior venal cover

然后右后下腔直接跟下腔静脉进行了吻合

然后整个的手术时间是三个小时

术中输血量100毫升

术后也是没有并发症

术后的住院时间是六天

It's an introduction of these three cases

好的,那我们的三个病例的情况就简单介绍到这里

那我们现在可以看一下手术的录制视频

Congratulations, very interesting cases

I don't know if we can start with the first one

I asked to start with the first one.

First of all, I am impressed that you really are an high-volume center

of leaving donor liver transplantation.

Have you any experience about the donor from brain?

The DCB1?

Yes.

Okay.

And these donors are not only from Huashan Hospital,

but also a sign according to the geographical areas.

For adults, every year we have 200 brinded donors.

Okay, we can see the video.

and the left hepatic artery and the left branch of the protein vein

was isolated and labelled with red and blue robins respectively.

首先是干地以及相关的卖馆的游离的过程,分别用红色和蓝色进行标记。

The choice of the three different donations are made based on the volume of graft, the body weight ratio, or for technical issues, or what?

Sorry, you are mentioning how to decide on which type of donor to choose?

The decision of performing the three different approaches of donation or liver donation are made based on the volume, the graft volume, or for technical aspects of the three patients.

we have the three recipients the first one is only an infant a couple of months old so we can

only retrieve we only retrieve the left lateral lobe that will be enough sometimes for infants

and these young the left lateral lobe will be too big for them that's why sometimes we need to

reduce the volume of the slope usually we will first start screening their parents or grandparents

parents to see if they fit or match. And for the second and third cases, they are six-year-old

and nine-year-old with the bigger body weight. So usually we need to do a hemi-hepatectomy

either on the left side or the right side. We also start screening their parents and then to

see if they have a fatty liver or hepatitis. If not, we will further check the anatomical

structures if they fit exactly we saw yes yes yes and please proceed yes we also view so the

the use of in the C9 the green in the C9 for verifying the correct vascular isolation and

And do you routinely use the green indocyanine?

Yeah, we use the ICG, but we use ICG for the clangorography.

Yes, we use ICG to determine the stage of gallbladder.

OK, so you use it mostly for the biliary tree anatomy, then for the vascular anatomy, OK.

Professor Lu, I have a question for you.

First, I introduce myself for many calling

because I am a friend of Professor Lu in China.

So I'm from Shanghai Cancer Center,

Fudan University.

I'm the vice director of liver surgery department.

I'm Yiming Zhao.

Professor Lu, I have a question.

It's about dealing with vascular variation.

In your experience with complex portal vein or hepatic artery variations,

what is the limiting factor in labroscopic dissection?

And how do you make the decision for convention from a laparoscopy to open to ensure the donor safety?

Okay, thank you.

动脉的一个变异并不是最主要的,因为无论它的比如说一般最常见的肝硬动脉可能发自于肠细膜上动脉等等,这些都并不是主要的一个问题,你可以先翻译一下。

Okay, to answer this question, for all the cases, preoperatively, we need to do a 3D reconstruction to know more details about the vessels and ducts we are about to face intraoperatively.

And the major limitations to retrieve donor or to decide whether this liver is suitable to be a donor, laparoscopicly, is first about bioduct variation.

For example, sometimes we will see this bile duct, especially the right posterior branch,

originating from the left hepatic duct, which is really a big concern, even if we do open

surgery for this patient.

And as I mentioned before, we will use ICG mostly to identify these kind of variations

for bile ducts during the cholangiography.

And also for the portal vein, these type of patients with the biotoxic variation are usually

in combination with the variation in portal vein as well.

For the artery side, it is not a major concern for us because, for example, for the right

hepatic artery, they will originate from the superior or the SMA, which will not be a big

headache for us.

Thank you.

Thank you also, Professor Zhao.

Nice to meet you also.

just a question professor Lou I see that you don't use any ultrasonic dissector just the

harmonic scalpel this technique or I used this technique before the that my institution had the

the kusa i also use it in open surgery still in open uh different sections uh by dissecting with

the inferior uh uh blade of the of the harmonica it's a nice technique but it can be uh for for

leaving a donation it can be quite harmful for the for the donor because as we saw some vessel

can be damaged injured so just to show you if this is your routine technique and why you prefer

because maybe you are faster with this technique it's sure and or maybe just for the left lateral

lobectomy is this technique and when you will be left Amy protect me right Amy protect me you will

Thank you for your question, Mr. McConaughey.

When we first started to make the gun-in-the-gun,

we used Q-SAR for about five rounds in the beginning.

But later on, because we were very familiar with the use of super-threads,

I think it should be a very well-trained ah so in this we feel that in the process of separation

we now do not use q3 to use the superconductor, then it may speed up the speed of our circuit

and reduce the time of the anesthesia of the patient's anesthesia. In the process of using the superconductor,

we may not have any at least a large main pipe

管道不会出现有明显的一个损伤,所以到后面为了一个是加快我们手术的,主要是为了减少患者的一个麻醉的一个时间啊,我们没有选择用这个 Q3.

Thank you for your question, Professor Manaconi.

Usually in the very beginning, when we do this donor retrieval, for the first five cases,

we use the KUSA to dissect the parenchyma, but currently we don't use it anymore, mainly

because we want to improve the efficiency and to reduce the duration of anesthetics.

and we use kusa in a very matured way so usually we will not injure the major

vessels okay professor many call many many call me in China our liver surgeon

like harmonic more than kusa because the first of all because of the speed the

speed of dissection. Second, just like Professor Lu's shoes, we use the harmonic very skillfully.

We always use the energy side up, very far from the vessel, and use the non-energy side

to touch the the vessel so in China most of us use harmonic yeah yes I I saw that

I as I told you the same technique I used to I used this seated technique

with the harmonic and sometimes also my colleague in Italy criticized me

for using all only the harmonic scalpel for dissecting for transacting the liver

parenchyma because now everybody use the accuser it's a very nice disector so but

I think that in case of leaving donation the accuser can be useful mainly for

skeletonizing the main vessels that you have to harvest uh when you uh for the graft when you

then you harvest the graft and and make the transplantation also professor you before you

use the the the harmonic very well another question professor lu uh sorry yes yes can i

Yes, just a last question.

How do you decide, Professor Lu, the transaction line?

Because I saw that you stayed a little bit far from the falciform ligament.

Maybe because you don't want a really ischemic parenchyma of the segment 4?

Or how do you decide exactly the transsection line?

那么它的一个四段的一个剩余的肝脏

可能会有部分的一个缺血

所以我们还是会偏肝中静脉一点

但是左外叶的一个肛肝

我们并不需要去暴露它的一个肝中静脉

For these parts, we don't need to overexpose the middle hepatic vein

Because as you already know, for this left lateral lobe retrieving

we actually did an extended lateral lateral lobe retrieving because for this patient as you may

already know the portal hepatitis or the hyaline part we already dissect the left hepatic vein

and the left branch of the portal vein considering the ischemia concern of segment four

And then the residue liver volume or the future liver remnant of these parts, that's why we don't need to touch, over-touch it.

Yes.

I think it was the upper branch of the left hepatic vein.

So she has two hepatic veins.

这个患者的肝静脉是有两只,一个是肝组,还有一个是上面有一个分区。

Yes, thank you, very great procedure.

When you harvest and take out the specimen, which is your perfusion, your perfusion fluid?

应该是UW

好的

Professor Manicone, we use the UW, Wisconsin

Wisconsin, yes, okay

So this is the second procedure, the left hemipectomy

这个是第二例左半肝

Yes

Left hemipectomy

So for this patient

Our surgical plan was to resect the left hepatectomy, and the main tract of the middle hepatic vein was preserved for the graft.

And while she has a segment 8 branch, a large segment 8 branch,

For this patient, we are now doing a left half liver, a supply liver acquisition, and the special thing about it is that it has the main liver of the liver meridian, and then because of the safety, we put this S8 section of this branch because it is considered to be relatively large, so it is preserved in the body of the supply liver.

So the middle hepatic vein was preserved into the graft, and what about the V8 and V5?

The sex segment 5 is also for the graft.

Okay.

So you can see we use ICG florence calendula graft graphic to show the bio-bioduct.

Professor Lu, I saw you removed the gallbladder. Is it routine in left

hemohepatectomy or because this case you need to remove the segment 5?

Yeah, it's routine, because mostly if we perform the left hematopoietic, the second

number five and the hepatic event of the second number five is we retain it to the graft.

So we can see the patient has the left hepatic artery and the middle hepatic artery.

I don't see if there is a common trunk of the left hepatic artery.

was from the right from the right okay so it's more difficult for you so we only can reconstruct

it maybe can we only choose one for this patient so you divide the the middle one and the preserve

So no reconstruction, maybe.

They are saying that it's very difficult to combine two hepatic arteries into one.

So if in some cases, both the left and right hepatic artery are important,

they will choose one branch, maybe do the anastomosis with hepatic artery,

and the other one with a GDA or splenic artery.

But in this case, hopefully, we have a very good outflow because we got the mid-hepatic vein.

What about the placement of the surgeon?

Where is the surgeon, between the legs or at the sides of the patient?

咱们数者的站位是在哪里呢?

The main surgeon was standing at the right side of the patient.

I don't know why in China the surgeon used to be always on the right side of the patient.

Here in Italy or in general in Europe we stay between the legs.

in my in my center we always on the left of the patient on the left I you I use the

harmonica with my left hand okay but I I'm a right hand yeah right then I use the left

okay yeah because of the beginning of our lonely laparoscopy we learn from French yes yes yeah I

when I my my experience in France I was for two years in France with the first professor

to Brown and professor big ETA yes and with the professor Shubran always the the standard

position was the surgeon between the legs the first assistant on the left and the the second

one on the right always also for the living donor donation or for the liver surgery the

proscopic surgery who standardized and also here in Italy we never do surgery on the side of the

patients always between the legs but it's a every surgeon has his technique

personal technique in preference

So, in general, our observation hole is at the bottom of the flag, and the other four holes are at the bottom of the flag, which is the distribution of the entire liver as the core.

So, actually, we have five trocha settings, and the observational trocha is under the umbilical side, and for the other four, we put the liver in the center.

and in a fanned fashion.

Okay.

散心分布,但是左边的两个观察孔,我们最上面的一个观察孔打在渐突下。

好的,for this, the first two, the first two are from the left side, left lateral or the left hemi, it's just the setting that I told you before, but for the third one, it is a right hemi, so it is a little bit different.

different, because for the observational one, observational trochlea, we will put it two

fingers apart from the navel, it's a little bit to the right, two fingers to the right

of the navel, and then we put the liver in the center for the other four trochlea.

The left two are the same with the left lateral or the left hemi one, but the right one are

the same but for the left one the upper one will be put under the

in your center every year how many do you do liver transplantation for colon

colon rectal liver metastasis yes we have the three different protocols

accepted by our ethical committee for transplant for performer liver

transplantation for liver mets we perform from this year for liver

transplantations for liver metastasis two cases for clasking tumors and one case for a neuroendocrine

tumor but i think that in the future it we will grow up because the the transplant oncology in

italy is growing up a lot i think the patient selection is the key of the success for the

success of the these patients and we have very very good results congratulations i'm looking

forward uh looking forward your uh your results on the papers yes we uh we already published in

europe the first randomized trial that's a transmit trial uh i don't know if you have read

read it it's it's published in Lancet and it demonstrates a survival benefit a significant

survival benefit of the liver transplantation compared to chemotherapy and right now our

Italian protocol will be I think that will be completed the next year and I think that for

the next two years we will publish our results and I think that also it will be a room for the

living donation in transplant oncology I think because right now also only for the DVD we perform

the indication of colorectal metastasis are only for dbd so not living donor okay you also have

some experience of transplant oncology in your institution in my institution or do you have some

experience of a transplantation for colorectal no no because in our hospital we don't have the

certification of liver transplantation in China because there are cancer

hospital no permission to do we do transplantation for for our hospital in

China Anita it was the same until two years ago then hopefully our committee

National Committee authorized the liver transplantation for colorectal

metastasis and also for clasking tumors

Yes, we have read the literature concerning liver transplant in patients with colorectal liver metastasis.

However, to our understanding, these patients are stage four malignant tumor patients.

Maybe some of them can receive either neoadjuvant therapy or some of them can do conversion

treatment to surgery.

I think because we have a limited number of donors in China, so we may have not that much

experience in doing transplant in this population.

Yes, that's why I think that the living donation for these patients will be a good opportunity for these patients.

可能在脑死亡的控制之外呢,可能会想考虑像活体的这种控制,会不会是一个未来发展和突破的方向?

In China, some hospitals are trying to do the salt using the waste liver.

For example, hemangioma and other benign tumor patients,

from them, they can get the waste liver.

我中文说一下,翻译老师。

好的,您说,您说。

Actually, Professor Zhao has some information on this topic.

Some Chinese hospitals are trying to use the wasted liver for the colorectal cancer liver

metastasis patients.

For example, if one patient comes to the hospital because of some benign tumor, say hemogenoma,

And after resection, resecting this benign lesion, the residue of this liver can be used in a salt surgery, as you may have already known about this type of approach and technique that is getting rid of parts of the liver and to implant or transplant the waste to the liver from the benign lesion patient.

patient and then we wait for it to grow up or wait for it become after

hypertrophy this is logical changes then we can do the further steps do you have

any comments on this thought surgery no we don't have any experience about this

strategy Chinese strategy of using the wasted liver for transplant but in the

the results about this strategy are good do you know do we have some results

about using this type of grafts no I talk and I'm doing table which I know

了解了,请赵教授帮他补充一下这部分的这种,包括患者预后转归的数据啊,还有这个手术的结局数据。

只是在做了一些个例,还没有完整的数据,科统计的数据出来。

好的。

只是初步地证明了这种技术的可行性。

Okay, we are still exploring this technique.

There are some case theories, data are undergoing collection,

just validating the feasibility of doing so.

Go ahead.

Professor Liu just mentioned that they have performed three cases of this,

the waist to the liver surgeries between 2017 to 2018.

all these three cases had this really huge mega benign lesion in the caudate lobe of the liver

two of them are hemangioma one is FNH and the reason why they did it during that years is

because at that time they think if they resect the caudate lobe totally under laparoscopic surgery

surgery will be very challenging and difficult.

So their plan back then was first they resect the left lateral lobe to expose the caudal

lobe better, and then they're going to remove the benign tumor.

And all these three cases after resection, they donate these parts to three children.

They don't have any relationship, they're not family members, and the IRB said yes to

these approaches.

The reason why they didn't proceed with this is because with better understanding of the liver anatomy and with the learning curve of these type of approaches, they can preserve the left lateral lobe and then they can resect all the caudate lobe with such preservation.

That's why they don't use this wasted liver technique after that.

现在还没有用双极呢,好像他说没看到。

对,我们确实也没有用双极,我们对于一些小的点状的初学,我们可能还是习惯用单极的更多。

For the dotted bleeding, they prefer the monopolar.

That's why you don't see any bipolar.

Professor Subran will not be happy about that.

I don't know if you know him.

He said Professor Subran may not be happy to see the monopolar.

I don't know if you two know this professor.

Because in China, a part of us use bipolar, and other use the monopolar.

Professor Lu and me came from the same center, Zhongshan Hospital.

so in hospital we do we don't use bipolar by habit me always I always use bipolar I use

also bipolar for the transaction mainly for cirrhotic liver I with the crush clamp technique

I use it for transacting the liver parenchyma because it's a very nice

device for coagulate and also for dissecting the monopolar is also very

very good energy the problem is that it can be too high as to the power is too high sometimes

so when you use it near from the biliary structure it can be it can injure some

lissonian pedicles but I agree that when you are in the in the liver parenchyma this problem may

be not so frequent but here the your technique is a very very nice so no

bleeding and so the use of bipolar is not necessary but to me for also for the

during liver resections for tumors I always use the bipolar also because I

Yeah, I very agree with Professor Menekone.

So if the bleeding is near the gluteal or near the hepatic vein, we do not use the monopolar.

Professor Lu, you didn't control the inflow blood of this patient.

Yeah, because maybe the control the inflow, maybe influence the liver function.

Mainly for the donor.

never never use right never use yeah no pringle but you prepare it no no we not use pringle uh

no no i i think i i say just you prepare the pringle for an emergency setting if you have

a real bleeding a real emergency situation you need to clamp you have already prepared

Not true to you.

Yes, thank you for your nice suggestions, because usually we would not put a clamp,

the prenatal loop in advance, but you mentioned a very good point, because it will be a very

important point for emergency like major bleeding because before your suggestion we usually in case

of such emergency we will climb the hilum or temporarily cross-climb the major vessels but

we will take your advice thank you

冒这个风险,所以的话,我们还是并没有常规进行一个肝闷的阻断。

The reason why we don't routinely do the Pringle is for worrying the ischemia reperfusion injury,

and we have read the literature published by the Japan and South Korean physicians.

They have compared Pringle versus non-Pringle for post-operative donor liver function restoration,

And according to this literature and the results, clamping for 15 minutes and declamping for 5 minutes were not significant, in fact, a post-operative lung function restoration, but just what a worry of ischemic reperfusion injury. That's why we don't routinely do it.

yes no i perfectly agree to not routinely clamp during the harvesting procedure but just prepare

the tape around the pedicle after dissection and i i do i do it also for a small laparoscopic

resection so left lateral lobectomy even if i never use it but it's just to to stay to be calmer

and to be safer for me and for patients.

Yes, he will also put this device there,

just put it next to the dry ground.

Even if it's a relatively small area of surgery,

he will put it there.

Maybe he won't use it,

but he will put it there and feel a little more safe.

Merconi, for the liver function after surgery,

after surgery consent you have a recommendation for the time of control

the blood using Pringle you mean how long to clamp I normally do an

intermittent an intermittent clamp 15 minutes of clamping and the five minutes

of the clamping yes so normally in normal years the literature says that a liver can can be clamped

also up till 60 minutes but I think that it it's too much if you want to to avoid an ischemic

injury of the liver especially steatosis liver or cirrhotic rivers I think that the intermittent

clamping of 15 minutes and five minutes of the clamping is a very good strategy I do I before

I also performed the so-called preconditioning that means five minutes you start with five

minutes of clamping in order to prepare the lever of to a clamp to clamping then

you start 15 clamping and five minute of the clamping but now it is demonstrated

that it's not so useful so you can start directly with the 15 minutes of

How many times do you do the Pringles in an exergy?

how many times i it depends uh not for anatomic uh liver resections not so many times because

you have a good ischemic line so the normally the the bleeding is not so so evident and you don't

need to clamp because i do not routinely clamp i clamp only if the transaction is

is bleeding

especially in open surgery i i clamp very rarely in laparoscopic surgery i clamp more frequently

because the the operative field it's it's larger so you have to see very well

the the transaction line but normally example three or four times sometimes

more but I don't think it's a real problem a real issue I think that if you

clamp more than 60 minutes it it can be a problem a real problem a question could be how to clamp

with the extra thoracic drain or intrathoracic or intra in intra-abdominal tape or extracorporeal

clamping how do you what do you use for clamp because me when before the robot I always

prepared the Pringle with the thoracic drain that I routinely came out through the thoracic

to through the abdominal wall in an extracorporeal fashion so when I needed to clamp just push push

down the the plastic drain and the Pringle was made now with the robot I used to put

put a vesicle catheter, a foley, around the pedicle, so it's an intracorporeal clamping.

I don't know how do you clamp, how do you prepare the Pringle?

Professor, just to clarify with you,

the Foley catheter you referred to is the one to do the urination, right?

there's a natural hole in it so that we can just pull it professor lu a question um when do you

inject the icg uh before uh visualizing it on the screen okay

the icg was injected maybe

maybe uh 19 minutes before the operation okay yes but we not use the uh for uh sorry

but the thing is about the dose we usually will dilute it to 0.05 milligram per kilogram

gram body weight because we thought if we use the standard dose the whole

liver is going to be green and then it will be very hard for us to identify the

bile duct variation yes that's why I made my question because the the

biliary tree was perfectly visualized so I wanted to to know how how did you do

Some doctors may inject ICG maybe 12 hours before the operation.

10 hours?

10?

12 hours.

12 hours, yeah.

12, ah, 12, okay.

12, yeah.

12.

what do you think uh uh do you think the robot has the advantage over the laparoscopic surgery

in the liver section well uh when i uh at the start of the of my experience i started the

robotic liver surgery two years ago when I started with the small duress actions I didn't find so

many advantage especially for for the antero anterior segments then when I started to more

difficult to liver resection posterior segments and the major a patectomy I found that the robot

is very very useful maybe easier because it's similar to the open surgery you don't have the

feedback it's true you don't have the feedback like laparoscopic surgery you don't feel the

weight of the liver you don't feed the structures but you have a very good view a 3d view and also

the how to manipulate how to put some stitches how to dissect the apathic

medical the robot I think that the robotic platform it's it's a different

technique but if you have it you should use it do you have a robotic platform in

your institution yeah we have dimension Robert yes and also for a posterior segment how when

I mobilize the deliver robotically it's I found I find it that it's very very easy you have the

the fourth arm that is like an assistant that like in this case as you see you need to put

a goes with somebody with your assistant that put the liver laterally with the robot is yourself

that manage the every movement of the liver and this movement this mobilization it's a very very

easier to me with the robotic platform and also the resections of posterior segments it's easier

because you have very comfortable movements of the with your robotic arms and instruments and

And also for you, Professor Lu and Professor Zhao, that you don't use the CRUSA, you know that there is no CRUSA in robotic surgery, so you will feel better, I think, than other liver surgeons.

Okay, thank you. Thank you for your opinion.

If the color is very green, it will affect our subsequent single-guide judgment.

So after we tried the base, there was no extensive development.

Okay, in here we do the pre-clamping of the right hepatic artery and the right branch

to observe the possible ischemic line. It's more to the right because we want to preserve

the immunohepatic vein to the donor after climbing we inject ICG to show the

parenchyma which was successful however as I mentioned before ICG is

majorly used identifying the variation and anatomy of the bile ducts we don't

want to green up the whole liver that's why after this case in our routine

practice now we don't usually inject ICG after climbing but also you have the

the ischemic line that can guide your transaction when you clamp.

I saw a nice demarcation line when you clamp.

When he saw the stop, the blood drain line was also very clear.

So he thought that the blood drain line was also a good symbol.

But when we do some normal tumor removal,

for example, when we do semi-dry,

Yes, as you may know, if we do the hemohepectomy for HCC patients and malignancy patients, ICG is very beneficial.

because for a demarcation line you only show the superficial structure but for the ICG you will

show the whole parenchyma yes you do the surgery with a 3d system and no because I maybe I not not

with the habit or with the 3d the 3d it's a nice nice tool you have to to to use it many

many times because when you start to use it maybe the view is not so clear because you have to put

the the glasses but then for also for if you have to reconstruct laparoscopically something or you

have to to to do some anastomosis we use it also for pancreatic surgery it's not so bad before

Before the robotic surgery, we used it much more.

Now we stopped.

With the robot, it's finished.

For this patient, the middle hepatic vein was produced for the donor, and the graft

has a main branch of the segment 8, the segment 8 hepatic vein from the middle hepatic vein.

we have a graft between the segment 8 and the left hippocampus vein.

And she also has a right posterior inferior branch.

You have a back-to-back branch, right?

Yes.

And which graft did you use to reconstruct the segment 8 vein?

用的是我们从那个OPO的患者身上取下来的应该是动脉的一个血管。

好的。

The graft to reconstruct the segment 8 is an artery we retrieved from an OPO patient.

Oh, okay. So you have also a bank of vessels disposable for this type of reconstructions?

It was a cryopreserved?

并不是,我们应该是保存在液体里面,并没有冰冻起来,所以它的保存时间并不会很长。

It is actually preserved in liquid according to the condition, but as it is not preserved for so long, so it is rather fresh.

No need for that nitric.

这一只是肝动静脉,是吧?

对,对。

This is the MHV.

Professor Lu, you do not perform a dengue maneuver

for separating the calva vein to the posterior aspect of the liver?

她说的是肝脏后面这一部分没有用dengue法。

Hanging, hanging maneuver.

哦,就是悬吊,没有用。

Sorry, for the translator, it's difficult sometimes to translate these terms.

Thank you so much. I'm learning.

But you are doing a great job.

Thank you.

Very good.

on the donors on the graft side of the graph side of the by duct the right by

that just for bidding okay you don't you don't are fear about some ischemic

injuring of the bile biliary stump when you will reconstruct it this is actually

a titanium clip that we use not as strong as hemlock that's why we don't

need to worry about it.

OK.

Luoluo,

你这个右前肢是保留的吗?

右前肢,

对的,

它的一个主干保留的,

但是你刚刚看到的

确实是我们断了一个右前肢,

因为这个人的右前肢

有分肢是到左内液去的,

所以你看它其实和肝中筋脉

非常近。

The right anterior branch

is really close to the

middle hepatic vein

because one of its branch

goes into the left medial lobe.

We preserve the main trunk of the right anterior branch.

But the last that was clipped

was a branch of the right anterior

because I saw a little branch that was clipped and divided.

Yes, we clip one of the branches, which goes to segment four.

Okay.

The right branch of the portable vein and also the right caudal lobe branch is on the graft side to preserve the flow for the caudal lobe.

Normally, this is totally laparoscopic procedure.

Do you perform also hand-assisted procedure?

No, we performed all the, we performed pure laparoscopic.

And the Makushi ligament at the end of the procedure?

You didn't do it, so no?

No, it's just over there, I think.

The ligaments may not be very prominent on this patient.

Yes.

And you are going to staple it, or the right hepatic vein,

you staple it, or you put a bulldog in order to have a length

and I am much more

length of the vein.

We use the Johnson & Johnson stapler.

一个是能够让肝离的血尽快的释放出来,便于后续的一个灌注,另外一个也是能够保留更多的肝积脉的长度。

And also considering the perfusion and also the length of the hepatic vein, that's why as you can see, we get rid of one side of the load, so we only keep one side, as you may already see.

yes you have to do that the hemlock are wonderful but in this case

you don't stay near from the vena cava you are quite near from the transaction line so you don't

you don't you are not worried about the the length of the right hepatic vein

very much for these three wonderful videos uh it's here in rome it's 2 p.m i don't know in

in the food on maybe it's night no it's evening yeah it's time in China it's time to dinner so

thank you very much it was a pleasure to stay with you and to know to meet you and

and congratulations again and maybe see you next year thank you thank you

professor many many Connie and welcome to Shanghai to China and looking forward

to see you thank you too bye bye

Thank you Yiming, thank you.

Bye, bye everyone.

Bye bye.