Application experience of left hemihepatectomy with left glissonian pedicle transverse method combined cholangiolithotomy via anterior bile duct wall to treat left Hepatolithiasis

doi:10.21203/rs.3.rs-2604425/v1

Download PDF

Research Article

Application experience of left hemihepatectomy with left glissonian pedicle transverse method combined cholangiolithotomy via anterior bile duct wall to treat left Hepatolithiasis

https://doi.org/10.21203/rs.3.rs-2604425/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Objective. To investigate the clinical significance of left hemihepatectomy with left glissonian pedicle transverse method combined cholangiolithotomy via anterior bile duct wall to treat left hepatolithiasis.

Methods. A retrospective analysis was performed on the clinical data of 12 patients who underwent laparoscopic anatomic left hemihepatectomy with left glissonian pedicle transverse method combined cholangiolithotomy via anterior bile duct wall to treat left hepatolithiasis from October 2021 to October 2022. Including general information (age, sex, BMI, preoperative diagnosis), operation-related information (intraoperative blood loss, hepatic function index, operation time, postoperative complications, drainage tubes removal time, postoperative hospital stay) and postoperative pathological diagnosis.

Results. All patients, with an average age of (50±8.73) years and an average BMI of (23.61±2.47) kg/m^2, 1 male and 3 females, were successfully performed laparoscopic 0a0n6..atomic left hemihepatectomy by improved method. The median intraoperative blood loss was 150 (50, 200) mL, median operation time was 212.5 (175, 240) minutes. Hypoproteinemia occurred in 1 patient. The drainage tubes were removed on 6 (5, 9) days. The patients were discharged 8 (6, 10) days after surgery. All patients recovered well after operation.

Conclusion. Left hemihepatectomy with left glissonian transverse method combined cholangiolithotomy via anterior bile duct wall provides a new entry point to treat left hepatic stones, which simplifies the operation process and is safer and more effective. This method especially suitable for the cases with multiple biliary tract operations and difficult dissection of hilum. It can greatly improve the surgical success rate of those who are new to start this kind of operation and lack of skillful suture technique.

Laparoscopic Left Hemihepatectomy

Hepatolithiasis

Left Glissonian Pedicle

Hepatolithiasis refers to stones locating anywhere in the left and right bile duct. The majority of hepatolithiasis patients were bile duct stones in the left liver. It mainly occurs in East Asia and Southeast Asia, and the incidence in Western countries is gradually on the rise in recent years. The incidence in China ranks first in the world^[1^-^2]. The etiology of hepatolithiasis is complex, related to bile duct infection, cholestasis and bile duct parasitic infection. Hepatolithiasis with repeated infection can cause liver fibrosis, atrophy, hepatic failure, even malignant tumor^[3]. At present, the treatment of hepatolithiasis mainly follows the principle of removing lesions, removing stones, correcting stenosis, maintaining unobstructed drainage and preventing recurrence^[4^-5]. Treatment on hepatolithiasis is complex due to high recurrence rate, high reoperation rate, and various complications^[3^-^4]. Surgical resection of the liver parenchyma and pathological bile duct is currently considered the best treatment option^[6^-^7]. Since the introduction of laparoscopic hepatectomy by Gagner et al in 1992, laparoscopic hepatectomy has been increasingly used to treat hepatolithiasis^[8]. However, the coventional dissection of first hilus hepatis with severe adhesion which always leads to indistinguishable structure, bleeding, bile duct injury is too difficult to be performed on patients with previous abdominal surgery history. Aim to solve this problem, our team improved the conventional laparoscopic anatomic left hepatectomy via anterior approach (requiring dissection of the first hepatic portal) for left hepatolithiasis, and attempted to perform laparoscopic anatomic left hepatectomy with left glissonian pedicle transverse method combined cholangiolithotomy via anterior bile duct wall for 4 patients with left intrahepatic bile duct stones, and achieved initial success. It will be reported below.

All patients underwent laparoscopic anatomic left hemihepatectomy using the newly improved operation method in hepatobiliary combined pancreatic Surgery department of Nanchang University Second Affiliated Hospital since October 2021 to October 2022 were continuously enrolled in this study. All patients had surgical indications and no contraindications. Patients and their families were informed of the risks of surgery before surgery and informed consent was obtained. Inclusion criteria: Patients with left intrahepatic cholangiolithiasis clearly diagnosed by ultrasound, contrast-enhanced computed tomography (CT) or magnetic resonance cholangiopancreatography (MRCP) (Fig.1) examination, and laparoscopic anatomic left hepatectomy was determined after discussion; Child-Pugh liver function is grade A; Complete clinical data. Exclusion criteria: Cholangiocarcinoma; Stones confined to the left lateral lobe of liver; Severe cardiopulmonary and other important organ dysfunctions.

Operative procedure

Step1: After endotracheal intubation and general anesthesia, patients were placed in the supine position and in a dorsal, elevated position (anti‑Trendelenburg position). A vertical incision with a length of 1cm was taken below the umbilicus to establish pneumoperitoneum, and the pressure was set at 12mm-Hg. Laparoscopy probed the liver surface, bile duct, gallbladder and other abdominal and pelvic organs. After no other obvious abnormalities were observed, Trocars were inserted with 5-holes puncture method (under xiphoid process, 2cm below costal margin of left and right midclavicular line, 2cm below costal margin of left and right axillary front) under direct view.

Step2: Cholecystectomy.

Cholecystectomy could be performed first for patients with gallstone.

Step3: Anatomic left hemihepatectomy through left glissonian pedicle.

The round liver ligament, falciform ligament, left coronary ligament and left triangle ligament were detached to the second portal, and the left hepatic vein (LHV) and middle hepatic vein (MHV) root were dissected carefully. A hilus block band was preseted through the Winslow hole. Before the liver was cutted, the stones and MHV were located by ultrasound, and pretangency was marked with electrocantery along the left side of the MHV on the liver surface. Tightening the blocking to band block the first hilus hepatis (Fig.2a). The liver parenchyma was dissected along the pre-tangent line to head side (Fig.2b). The MHV was exposed, the main trunk of MHV was carefully detached, and the liver parenchyma was separated with the guidance of MHV walking, so as to expose the full truck of MHV as much as possible (Fig.2c). In the process of hepatotomy, if there are small vessels, they will be cutted after being clamped with hem-o-lok clips. The left glissonian pedicle was exposed (Fig.2d). If intraoperative ultrasound is not available, anatomic left hemihepatectomy can be performed via cephalic approach(Fig.2e). On the basis of full dissociation of the second hilum, dissecting the liver parenchyma along the left side of MHV root. After fully exposing the left glissonian pedicle removing the stones and severing pedicle as described above.

Step4: Bile duct exploration via anterior wall of left bile duct.

An transverse incision about 1cm on the anterior wall of the left hepatic duct was made with electrocantery as far as possible away from the cnfluence of the left and right hepatic ducts, and bile spillover was observed (Fig.2f). Choledochoscope was placed to explore the bile duct from the incision to common bile duct. When choledochoscope arrived at the confluence of the left and right hepatic ducts, turning to the right hepatic duct and exploring the common bile duct finally. Combined with stone forceps, stone basket, electrohydraulic shockwave lithotripsy(ESL), water flushing and other methods to remove all stones on the way (Fig.2g). To ensure that there are no stones on the separation path of Endo-GIA. Detecting bile duct again by ultrasonud probe again to confirm that there was no stone residue in the separation path of Endo-GIA. The left half of the liver was detached by two Endo-GIA at the root of left glissonian pedicle (Fig.2h) and the root of LHV (Fig.2i).

Step5: Two abdominal drainage tubes were placed in the liver section and the Winslow hole respectively. No blood and bile leakage observed in the liver section, the observation hole was extended to 3cm and the specimen was removed. In the end, operators exited the laparoscope and sutured each puncture holes. Operation was completed.

After surgery, blood routine examinations, liver function, and electrolytes were performed on the 1st postoperative day, and then every 3 days again. The juice of the abdominal drainage tubes needed to be observed closely. When the clear drainage juice extracted from drainage tubes was less than 10mL/d, the abdominal drainage tubes could be removed.

Intermittent hepatic protal occlusion applied to operations. Our team was used to blocking the first protal hilus for 15minutes, and then releasing the blocking band for 5minutes, repeating if necessary. In the process of liver resection, infusion speed was slowed down, and central venous pressure (CVP) was controlled as 0-5cmH₂O.

Observation targets

(1) General information (gender, age, BMI, preoperative diagnosis) (Table. 1);

Table.1 General information

	Gender	Age(year)	BMI(Kg/m^2)	Pre-operative diagnosis
1	male	33	22.98	hepatolithiasis, hepatatrophy
2	female	51	22.85	hepatolithiasis, cholecystolithiasis
3	female	40	20.93	hepatolithiasis
4	female	50	28.13	hepatolithiasis
5	male	52	24.05	choledocholithiasis,hepatolithiasis
6	male	46	26.21	hepatolithiasis,
7	female	62	21.17	hepatolithiasis,cholecystolithiasis
8	male	57	23.55	choledocholithiasis,hepatolithiasis
9	female	61	27.36	choledocholithiasis,hepatolithiasis
10	male	57	20.49	hepatolithiasis,hepatatrophy
11	female	49	23.20	hepatolithiasis,cholecystolithiasis
12	female	42	22.42	hepatolithiasis

(2) Operation-related information (hepatic function index, postoperative complications, drainage tubes removal time, postoperative hospital stay) (Table 2);

(3) Postoperative pathological diagnosis (Table 2).

Table.2 Operation-related information

No.	intraoperative blood loss (mL)	operation time (minutes)	Postoperative DBIL¹ (μmol/L)	Postoperative ALB² (g/L)	postoperative complications	drainage tubes removal time⁴ (days)	postoperative hospital stay (days)	Postoperative pathological diagnosis
1	100	175	7.68	38.01	No	6 and 6	6	cholangitis, hepatatrophy
2	150	235	4.68	28.26	Hypoproteinemia³	5 and 8	8	cholangitis，cholecystitis
3	50	210	7.13	35.27	No	5 and 8	9	cholangitis
4	200	215	8.87	41.22	No	5 and 5	9	cholangitis
5	50	220	19.56	39.79	No	5 and 6	6	cholangitis
6	50	190	8.60	40.24	No	5 and 6	6	cholangitis
7	150	240	12.54	36.16	No	6 and 8	8	cholangitis，cholecystitis
8	200	180	22.17	36.20	No	7 and 9	9	cholangitis
9	150	180	24.56	38.17	No	5 and 7	8	cholangitis
10	200	210	7.82	40.02	No	6 and 6	7	cholangitis,hepatatrophy
11	100	220	11.55	38.77	No	5 and 7	8	cholangitis，cholecystitis
12	150	215	9.41	36.38	No	7 and 9	10	cholangitis

¹DBIL: serum direct bilirubin; ²ALB: serum albumin; ³Hypoproteinemia: ALB (g/L) < 30; ⁴drainage tubes removal time (days): All patients have two drainage tubes.

All patients (n=12) underwent laparoscopic anatomic left hemihepatectomy with left glissonian pedicle method combined cholangiolithotomy via anterior bile duct wall, including 1 male and 3 females; average age (50±8.73) years; BMI averaged (23.61±2.47) Kg/m^2. The median intraoperative blood loss was 150 (50, 200) mL, without blood transfusion, median operation time was 212.5 (175, 240) minutes. After operation, 1 patient developed hypoproteinemia (preoperative ALB 33.26 g/L), which was cured after symptomatic and supportive treatment. None of the patients developed postoperative liver dysfunction, biliary leakage, bleeding and death. The abdominal drainage tubes were removed on 6 (5, 9) days after surgery. The patients were discharged 8 (6, 10) days after surgery. Postoperative pathological results: 7 cases of chronic cholangitis, 2 cases of chronic intrahepatic cholangitis and hepatatrophy, 3 cases of chronic intrahepatic cholangitis and cholecystitis. All patients recovered well after surgery.

Compared with open left hemihepatectomy, laparoscopic left hemihepatectomy has higher requirements for operators, and its postoperative wound infection rate is lower, blood loss is less, drainage tubes removal time and hospital stay is shorter. There is no increase in operative time or complications, and postoperative recovery speed is faster^[9].

The management of the glissonian pedicle is extremely important in the left hemihepatectomy for intrahepatic bile duct stones. The current clinical practice is dissecting the first hilum, ligaturing and detaching the left hepatic artery (LHA) and the left portal vein (LPV) respectively, then performing left anatomic hepatolithiasis along the ischemia line from cranial to caudal. After left hepatic duct is exposed, the dissection is performed, then suturing left hepatic duct residue.

However, adhesion around the first hilus hepatis is so dense to separate toughly in patients with multiple surgery history and severe inflammation. Transsection of the left glissonian pedicle avoids the dissection of the first hilum, and avoids the damage of surrounding important tissues or organs caused by hasty dissection when the anatomical structure is unclear, such as biliary leakage caused by bile duct injury, hemorrhage caused by hepatic artery injury or portal vein injury, reduced blood supply to normal liver tissue caused by hepatic vascular misalignment, intestinal perforation caused by duodenal injury and other intraoperative and postoperative complications^[10^-^11]. Improvement in surgical method as our practice mentioned above simplified the procedure in laparoscopic left hemihepatectomy, reduced the operative time and amount of bleeding during operation^[12].

Furthermore, since there are often stones in the bile duct, we hardly cut duct with Endo-GIA to prevent the "nail explosion" accident caused by stones. However, for the left half liver tumor or liver atrophy and other cases without stone, it could be directly severed by Endo-GIA.

The stones in the proximal end of the left hepatic duct, common hepatic duct and common bile duct can be successfully detected and removed. After stones are removed, the risk factor of " nail explosion " are removed, and the left glissonian pedicle can be severed at the root of the left glissonian pedicle (the proximal end of the left hepatic duct exploration mouth) with an Endo-GIA (usually no calculi existing on the dissociation path is reconfirmed by intraoperative ultrasound), so that the left hepatic duct, the LPV, the LHA and part of the liver parenchyma around pedicle can be dissected together. Suture of left bile duct residue can be omitted. The procedure is more simplified and improves the safety of surgery. It is especially suitable for the cases with multiple biliary tract operations and difficult dissection of hilum. Furthermore, this method is suitable for open surgery.

The ischemia line cannot be determined without dissection of the first hilum. To solve this question, intraoperative ultrasound was used to label the MHV to determine the resection scope. If intraoperative ultrasonud is not available, left hemihepatectomy can be performed via head side approach. In fact, this method is not reject dissection of the first hilum. If there is neither intraoperative ultrasound nor cephalic approach experience, and the operator is skilled in the dissection of the first hilum, left glissonian transverse method combined cholangiolithotomy via anterior bile duct wall still can be performed after dissecting the first hilum, ligating the LHA and the LPV, labeling ischemia line, and breaking liver from caudal to cephalic. It should be noted that the hem-o-lok clips should be avoided when dissecting the first hilum, in order to avoid affecting dissociation of glissionian pedicle by Endo-GIA.

Although this study has achieved preliminary results, there are still limitations such as small sample size and unclear long-term complications, which need further research and discussion.

Laparoscopic anatomic left hemihepatectomy with left glissonian pedicle transverse method combined cholangiolithotomy via anterior bile duct wall is proved to be safer and more effective to treat left hepatolithiasis. It has practical guiding significance for the cases with multiple biliary tract operations and difficult dissection of hilum.

Ethics approval and consent to participate,

This study was in accordance with the Declaration of Helsinki and has been approved by the Second Afliated Hospital of Nanchang University Medical Research Ethics Committee . Written informed consent were obtained from each patient in this cohort.

Consent to publish,

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Availability of data and materials,

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests

The authors declare that they have no competing interests.

Funding

Not available

Acknowledgement

Not applicable

Authors Contribution

Junjie Li and Lingpeng Liu: Data curation, Formal analysis, Writing - original draft, Writing - original draft

Xiahui Huang and Jun Wang: Methodology, Writing - original draft.

Yong Huang and Mingwen Huang: Conceptualization, Supervision, Writing - review & editing.

Hongliang Liu: Correspondence, Conceptualization, Supervision, Writing - review & editing.

2012;14(9):604-610. Li SQ, Hua YP, Shen SL, Hu WJ, Peng BG, Liang LJ. Segmental Bile Duct-Targeted Liver Resection for Right-Sided Intrahepatic Stones. Medicine (Baltimore).2015;94(28):e1158.
Geng XP. Treatment strategies of hepatolithiasis based on clinical classification. Chin J Dig Surg. 2020;19:804–807.
Wang, Xiaoji et al. “Comparison of the Safety and Efficacy of Laparoscopic Left Lateral Hepatectomy and Open Left Lateral Hepatectomy for Hepatolithiasis: A Meta-Analysis.” Frontiers in surgery vol. 8 749285. 16 Nov. 2021.
Jarufe N, Figueroa E, Muñoz C, et al. Anatomic hepatectomy as a definitive treatment for hepatolithiasis: a cohort study. HPB (Oxford).
Yoon YS, Han HS, Shin SH, Cho JY, Min SK, Lee HK. Laparoscopic treatment for intrahepatic duct stones in the era of laparoscopy: laparoscopic intrahepatic duct exploration and laparoscopic hepatectomy. Ann Surg. (2009) 249:286–91.
Yang T, Lau WY, Lai EC. et al. Hepatectomy for bilateral primary hepatolithiasis: a cohort study. Ann Surg. 2010;251(1):84–90.
Li SQ, Liang LJ, Peng BG. et al. Outcomes of liver resection for intrahepatic stones: a comparative study of unilateral versus bilateral disease. Ann Surg. 2012;255(5):946–953.
Gagner M, Rogula T, Selzer D. Laparoscopic liver resection: benefits and controversies. Surg Clin North Am. 2004;84(2):451–462.
Yin X, Luo D, Huang Y, Huang M. Advantages of laparoscopic left hemihepatectomy: A meta-analysis. Medicine (Baltimore). 2019;98(23):e15929.
Wang HQ, Yang J, Yang JY, et al.Bile leakage test in liver resection:a systematic review and meta-analysis[J].World J Gastroenterol, 2013, 19 (45) :8420-8426.
Maddah G, Rajabi Mashhadi MT, Parvizi Mashhadi M, Nooghabi MJ, Hassanpour M,Abdollahi A. Iatrogenic injuries of the extrahepatic biliary system. J Surg Res.2017; 213:215-221.
Machado MA, Makdissi FF, Herman P, Surjan RC. Intrahepatic Glissonian approach for pure laparoscopic left hemihepatectomy. J Laparoendosc Adv Surg Tech A. 2010;20(2):141-142.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Application experience of left hemihepatectomy with left glissonian pedicle transverse method combined cholangiolithotomy via anterior bile duct wall to treat left Hepatolithiasis

Status:

Version 1

Abstract

Figures

Introduction

Patients And Methods

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1