Prof. Liu Chao relive: Left trisegmentectomy with PV reconstruction and HA resection without recost

Yeah, good afternoon. Yeah, I'm ready.

Professor Liu, my name is Umberto Grandi, as I told you before, as well as Dr. Azzola-Vicardi and Dr. Maberti and Caterini, we will be with you today.

We just want to thank you for staying with us today and for accepting the kind invitation of our close friend, Giorgio Palatini.

He is from Rome. I'm from the northern part of Italy.

And it's a great pleasure for us to help him in his huge congress.

It's 35 years in a row that's been held.

And it's a great honor to accept you here.

We are so keen to listening to what you will be saying to us.

Again, it looks like I'm an addicted to Chinese surgeon.

As I had several of your colleagues, and as in the others, I have to say that I must be in a hurry because I have only two minutes to introduce you, but if I'm going to read all your curriculum vitae, I will run out of time.

So you are Vice President Binary Tract Tumor Committee of Chinese Anti-Cancer Association, Chairman of Hepato-Binary Surgeons Branch of Gungon Medical Doctor Association, and so on.

So I have to tell you, just go ahead, because it's a really huge curriculum.

Thank you so much, Professor.

Thank you.

Thank you.

It's a really great, very important.

Okay, now we have on the screen the title for the presentation.

If you want to illustrate your presentation.

Thank you.

Yes.

Yes, next I will introduce an operation about the surgical treatment of perihynal cholangiocarcinoma.

Today's operation is left trisectomy for type 4 perihynal cholangiocarcinoma with a portal

away resection and reconstruction, as well as depending on resection but without reconstruction.

Next page please. So the patient was a female 70-year-old woman. She was admitted on March 26th

due to yellow of the skin and eyes for over a month this year.

She was diagnosed with perihyal congenital carcinoma.

Next page.

In my evaluation, she was diagnosed as type 4 perihyal congenital carcinoma

with intrahepatic mass-forming type.

the tumor was left dominantly. The tumor also involved the interhepatic segment of the left

hepatic artery, the extrahepatic segment of the right hepatic artery, and the bivocation of the

right hepatic artery. That means where the right anterior and posterior arteries branch off. The

The tumor also involves the left branch of the portal vein, the bifurcation of the

main portal vein, and the right anterior branch of the portal vein. The lymph node of the common

hepatic artery and behind the main trunk of the portal vein was suspected to have tumor metastasis.

So this CT scan shows the involvement of the interhepatic segment of the left hepatic artery

as well as the extrahepatic segment of the right hepatic artery.

Next.

Yeah, this three-dimensional picture also shows the involvement of the interhepatic

segment of the left hepatic artery and the extra hepatic segment of the right hepatic

artery.

So both sides of the hepatic artery were involved by the tumor.

Next page.

So this picture shows the left branch of the portal vein, the bivocation of the main portal

as well as the right anterior branch of the portal vein were involved by the tumor.

Next.

Yeah, this is also three-dimensional reconstruction of the picture, also shows the involvement

of the left branch of the portal vein and the right anterior branch of the portal vein.

Next.

The three hepatic veins were not involved by the tumor.

tumor.

Next.

Yeah, the three-dimensional reconstruction also shows no evidence of the tumor involved

of the three hepatic veins.

Next.

The lymph node of the common hepatic artery that is named the 8A and behind the main trunk

of the portal vein was suspected to have metastasis.

Next.

So in summary of the preoperative treatment, on March 29, the patient received right hepatic

bioblast standard drainage.

On May 16, the patient received right hepatic artery embolization in order to induce the

collateral hepatic artery to form. On June 14, due to the fever, we removed the biliary

stand and switched to the ENBD drainage of the right posterior lobe. On June 24, due

Due to the fever, we performed the PTCD of the left bioduct and the operation was performed

on July 4th until the total serum bilirubin decreased to the normal range.

range. Next. So this picture shows first we perform the ENBS stand for biliary drainage.

Next. So this picture shows the MRI

embolization of the right hepatic artery next so this picture shows we we change the

EMBS to EMBD next yeah after embolization of the right hepatic artery the right posterior lobe

is supplied by the right sub-phrenic artery, next, yeah, this, this, next, yeah,

these peaks should clearly, the right hepatic artery was disappeared after

the embolization, but the right sub-phrenic artery is enlarged, next, the

This CT scan we performed before the operation also shows the involvement of the left branch

of the portal vein and the portal bifurcation and the involvement and the memory of the

right anterior branch of the portal vein.

Next please. Yeah, this is the MR scan also shows the involvement of the portal vein

because the anterior branch of the portal vein and the left portal vein were involved. So we should

perform the tri-segment data. Next. This is also the estimation before the operation. So the

In the posterior lobe, the volume of the plurinomal is about 640 cm2,

and the volume is about 57% of the standard total liver volume.

And also the ICG rotation rate at 50 minutes is within the normal range, only 4.7.

Next.

So on July 4th, we performed the operation on this patient.

The operation involved a block resection of the left trisegment, total caudal lobe, and

the hepatic duodenal ligament, including the resection of the extrahepatic artery, but

without reconstruction.

After we resected the main portal vein and the right portal vein, we performed the end-to-end

anastomosis between the main portal vein and the right posterior portal vein with the anogenic

calaveric vascular graft at the interperitoneal. Next. Next page, please. So the operation

time lasts 30 hours. The bleeding, the blood loss is about 400 mm, and the interoperative

blood transfusion is three units.

This CT which was taken 45 days postoperatively, on this CT, on the artery face, you can still

you see the interhepatic posterior hepatic artery, right posterior hepatic artery can

be visualized. This shows the right posterior portal vein was patent. This is on the coronary

plane, we can also see the portal vein was patent.

Next.

In spite of the patient developed a bile leakage and the liver dysfunction post-operative,

She also developed gastroparesis, but she was discharged 61 days after the operation

with normal liver function.

The post-operative pathology was ideal resection, but with the stage 4A.

So, this is the illustration of our video operation. Thank you.

Thank you. This is a real, very hard surgical problem and you have a very impressive way to resolve it.

we look with many interesting the video of the operation thank you thank you

this operation we only show part of the whole process so we will I would like to

show you how we isolated the right posterior right posterior pedicle here

Here we already resect the extrahepardic artery as well as the bile duct.

Now we mark the demarcation line between the right anterior and right posterior liver.

in order to preserve the collateral artery supply from the right subpharyngeal artery

as well as from the corollary and the triangular ligament.

May I ask you which kind of laparotomy did you perform to achieve this exposure?

For sure.

I'm sorry.

我想问一下我们这个就是开辅过程当中

我们选择的入路或者是切口

是怎么样的一个切口?

Oh, right coast, right coast.

就是右乐园下切口。

Okay, so there's an incision along with the right coastal margin.

Oh, but extending to the, uh, uh, actually for it, the, on the, in the middle.

Yeah.

Extend it to the middle.

Thank you.

We call it Mercedes incision.

But, but without, uh, uh, only two sides, only two, uh, two in there.

Oh, I've heard.

Okay.

Reverse L also in them, reverse L incision.

Because we don't need to, now we cut the right posterior pedal.

We cut the right posterior bioduct.

We try to isolate the right posterior portal vein from the hepatic artery and the bioduct.

there was no loose space between the baroduct and the portal vein and the

hepatic artery. Here is a small branch of the portal vein, so we isolated it.

Now we isolated the hepatic artery, supply the right

posterior lobe. In spite of the extra hepatic artery was embolized. Now we

check that if there is a bank flow of the hepatic artery. If there is a bank

flow that means there is still artery supply to the right posterior lobe.

We check if there is a bank flow of the right posterior hepatic artery. You see

See, there is still the red color blood coming from the right posterior heart.

That means in spite we embolize the right side hepatic artery, but there is still arterial

supply coming from the collateral vessels, such as the right subpharyngeal hepatic artery.

Here, on the left side, you can see the cut end of the right posterior duct.

Now we try to dissect the right posterior portal vein.

Here we, during this part, we will meet a small branch supply to the segment 8.

reconstruction.

Here we made a branch, this is not the anterior branch of the portal vein, this is a small

branch to segment 8.

the right right posterior portal way not enough for the reconstruction and then we complete the

they say the transaction of the uh parent chamber between the right anterior and the right posterior

The most important is to preserve the right hepatic vein, but to resect the segment 8 completely.

Actually, intra-hepatitis, there's no clear demarcation line between the right anterior and the right posterior.

That's the reason why we have more biliary leakage after the left trisegment actin.

Now the left trisegment and the right posterior segment is only connected by the portal vein.

This is right posterior portal vein.

now we transect the right posterior portal vein and the main portal vein and

remove the left trisegment and as well as the total caudal lobe and

extrahepardic bar duct we use homogeneous graft from the cadaveric

or as an interpretation.

I suggest to speed up the broadcasting

because this is not so interesting.

It took too long.

No problem at all, Professor.

You have plenty of time.

Anyway, we would like to...

We appreciate it.

We appreciate that.

Anyway, behave as you like, Professor, of course.

Okay, so it is notified that we cannot accelerate the video, so we can have some more time for

the discussion during this part.

Do you have any questions or comments?

You can raise it at any time.

Yeah, Professor Liu, I'm Dr. Mabertia from Rome. I'm also talking with a very expert liver surgeon,

which is Professor Catalini, which comes from a very important hepatic surgical school from

Professor Landi. He also, of course, compliments you for the excellent procedure. The only thing

that he said that they don't use the cadaver homologous graft but otherwise everything was

absolutely perfect for this long standing 30 hours journey operation thanks very much

Okay, so thank you for the very nice question.

Since Professor Liu's center is also a big liver transplant center,

they will have a big tissue bank for vessels.

So what they are adopting is the fresh allogenous vessel, vascular graft.

So from those with the same blood type.

So this kind of graft has very good biocompatibility after being transplanted.

And they are not adopting the artificial vessel because the artificial vessel usually are predisposed to thrombosis.

And after this kind of allogenous transplant graft vessel being used, they have very good patency rate.

In this case, it's now four months.

The vessels are still patent, no problem.

bismuth type 4 tumor located mainly on the left side,

especially when the anterior branch or the portal vein were involved.

Normally, compared with the left hemohepatic ectomy, left trisegmental ectomy can resect

even lung right posterior by duct.

As I mentioned before, the key to this operation is never, never mobilize the right liver in

in order to preserve the right hepatic artery supply,

in order to keep the artery supply from the collateral

inside the ligament and the right subphalic artery.

After embolization, of course, you can say,

you can reconstruct.

We also reconstruct the right hepatic artery,

or even the right posterior artery in some cases, but not every case you can

reconstruct the hepatic artery. In this way, the operation becomes much easier

because you needn't to consider to preserve the extra hepatic artery.

like to know if there is any other question from the audience. Perihynal

cholangiocarcinoma is a slow-growing tumor, seldom metastasized to

the distal part so the radical resection can still give the patient a chance

a fully drainage, a preoperative biliary drainage, until the total biliary serum,

a serum total biliary return to normal, and then we can perform extensive surgery for her.

hepatic artery flow so this is the integration between the main portal vein and the right

posterior portal vein yeah there's no ischemia no obvious ischemia on the right posterior lobe

there's only one right posterior duct we repeatedly check it and then we make a

to the question and the discussion from the audience thanks very much professor Yu from Oluwaz of course

on behalf of Professor Pallazzini for the excellent exposure of this very long, although

short, procedure. Again, congratulations from all of us. Thanks a lot. Thanks, thanks. It's a really great

pleasure for me. Thank you so much also for me for your excellent presentation in so hard clinical

It took some time, some hours, 13 hours, and we could see this procedure if we start at

8 o'clock in the morning here in Palazzini's Congress.

And this really is simply great to show your great skill as best compliments, Professor.

Professor, and we just want to thank you again for staying with us, and we really hope to see you in a very soon future, why not, here in Rome, or again in the number 36 Congress of Professor Palacini. That was really, thank you so much, Professor.

Thank you, Professor.

Thank you, Professor.

Thank you.

As I said, it's really a great pleasure for me to make a presentation before you.

Thanks.

Welcome to Guangzhou.

Welcome to Science and Memory Hospital.

We really would love to.

So good night.

Also, thank you for staying with us late in the night, because it's a seven-hour lag

in between Rome and China.

in china yeah so so it's it's late it's late in the evening and thanks also for this thank you

professor okay thank you also send my teams okay bye-bye thank you to your queue thank you

ciao ciao thank you bye-bye thank you very

It looks like I may see you in China or in Rome.

Yeah, yeah, sure. I will be there.

I'm a very good Italian surgeon.

I'm not sure if you know Professor Massimo Malago.

Professor Massimo Malago, yeah.