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Activation of the AKT/mTOR and Ras/MAPK pathways and the lipogenic phenotype are evident both in human hepatocellular carcinoma and in the rat model of insulin-induced hepatocarcinogenesis in the earliest preneoplastic lesions, i.e. clear cell foci (CCF) of altered hepatocytes. These CCFs have also been described in the human liver but characterization of molecular and metabolic changes are still pending. In this study, human sporadic CCFs were investigated in a collection of human non-cirrhotic liver specimens using histology, histochemistry, immunohistochemistry, electron microscopy and molecular pathological analysis. Human CCFs occurred in approximately 33 % of non-cirrhotic livers and stored masses of glycogen in the cytoplasm, largely due to reduced activity of glucose-6-phosphatase. Hepatocytes revealed an upregulation of the AKT/mTOR and the Ras/MAPK pathways, the insulin receptor, glucose transporters and enzymes of glycolysis and de novo lipogenesis. Proliferative activity was 2-fold higher than in extrafocal tissue. The CCFs of altered hepatocytes are metabolically and proliferatively active lesions even in humans. They resemble the well-known preneoplastic lesions from experimental models in terms of morphology, glycogen storage, overexpression of protooncogenic signaling pathways and activation of the lipogenic phenotype, which are also known in human hepatocellular carcinoma. This suggests that hepatic CCFs also represent very early lesions of hepatocarcinogenesis in humans.

Aim: The aim of this study was to evaluate treatments for haemostasis and the potential hospital resource use implications of these treatments by way of expert assessment. Methods: This analysis was based on data from a non-interventional surveillance study, which enrolled 3098 patients at 227 centres in 12 European countries. All patients received a haemostatic sealing patch (TachoSil ® , Nycomed GmbH, Zurich, Switzerland), with the decision to use TachoSil made by the surgeon. Data on duration of surgery, hospital length of stay (LOS) and use of blood products were collected. Surgeons were asked to compare TachoSil with products or procedures they would otherwise have used. Results: Mean duration of surgery was 192.1 minutes and mean hospital LOS was 17.5 days. According to surgeons, operating time would have been significantly reduced with TachoSil versus the potential alternative in 55.5 % of patients (p Conclusion: The use of topical haemostatic agents such as TachoSil may offer benefits with regard to hospital resource use.

Aims Radiofrequency ablation is gaining popularity as the interventional therapy of choice for unresectable hepatic malignancies. However, little attention has been paid to the importance of operator experience in this therapy. This study aims to evaluate the results of RFA treatment dependent on operator experience and learning curve. Patients and methods Between 2/2000 and 11/2004 we have undertaken 116 RFA procedures to ablate 404 unresectable primary or metastatic liver tumours in 84 patients. The clinical data of all patients were recorded prospectively and treatment results of the first 42 patients (group I) and the second 42 patients (group II) were compared. All patients were treated by the same surgeon or interventional radiologist. Results RFA was performed percutaneously in 44 procedures (group I n =35, group II n =9), via laparotomy in 64 procedures (group I n =27, group II n =37) and via laparoscopy in eight procedures (group I n =1, group II n =7). The complication rate was comparable in both groups with 7.9% in group I and 7.5% in group II. Group II had a higher complete ablation rate (96.2 vs 93.7%) than group I. One- and two-year survival rates of 92 and 89% in group II were significantly higher than in group I with 69 and 46% ( p =0.015). Conclusion By the experience conditional optimization of indication and performance by a specialized RFA team the results could be improved significantly. The data on hand speak for a considerable learning curve in the RFA and demonstrate the importance of the experience of the therapist for the outcome of the patients.

Radiofrequency-ablation (RFA) is increasingly used for destruction of unresectable primary and secondary liver tumors. We report our experience in the use of RFA for the management of unresectable hepatic malignancies. Between February 2000 and December 2004 we have undertaken 120 RFA procedures to ablate 426 unresectable primary or metastatic liver tumors in 88 patients. RFA was performed via laparotomy (n=68), laparoscopy (n=9) or a percutaneous approach (n=43). Primary liver cancer was treated in seven patients (8%) and metastatic liver tumors were treated in 81 patients (92%). All patients were followed to assess complications, treatment response and recurrence of malignant disease. Procedure-related complication rate was low (3.4%). During a mean follow-up of 21.2 months, 15 patients had local tumor progression (17%), 21 patients (23,9%) had new malignant disease and 27 patients (30.7%) died from intervention-unrelated complications of their malignant disease. Additional liver lesions were identified in 27 (35%) of 77 cases by intraoperative ultrasound. Thirty-six patients received simultaneous resection and RFA. RFA is a safe, well-tolerated and effective treatment for patients with unresectable primary and secondary liver malignancies.

Introduction Left-sided diverticulitis is a common disease in Western countries, whereas right-sided diverticultitis is rare and symptoms are often similar to the clinical signs of an acute appendicitis. It was the aim of this study to analyse surgical experience in right-sided diverticulitis. Methods All patients who underwent resectional surgery for both right-sided and sigmoid diverticular disease were entered prospectively in a registry database (8-year observation period, 1996-2003). For the current study, a retrospective analysis of all patients who underwent ileocolic resection or right colectomy for right-sided colonic diverticulitis was performed, specifically focussing on incidence, clinical symptoms, indication for surgery, type of procedure, and histopathological parameters including immunohistochemistry, and outcome in right-sided diverticulitis. Results Within eight years, 481 patients were treated surgically for chronically recurrent or acute complicated diverticular disease: 468 patients with sigmoid diverticulitis, 12 patients with right-sided diverticulitis, and 1 patient with combined right-sided and sigmoid diverticular disease. This corresponds to an incidence of right-sided diverticulitis of 2.5 % related to the total number of resections for diverticulitis, and an incidence of 1.3 % in relation to the appendectomies in our patients. In 4 patients, acute appendicitis was presumed preoperatively. Most common diagnostic tool was ultrasonography. Right colectomy was performed in 9 patients with complicated cecal diverticulitis, whereas ileocolic resection was performed in 2 patients and simultaneous ileocolic and sigmoid resection was carried out in one patient. Postoperatively, no morbidity occurred. Histopathological assessment showed local perforation in 75 % (9/12). Hypoganglionosis or aganglionosis was detected in 5 of 12 resected specimen. Discussion As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis can be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis, and surgery is only indicated in complicated right-sided diverticulitis. Resection of the inflamed colon with primary anastomosis is safe and can be performed by laparoscopy in experienced centers. At present, it can only be speculated whether hypoganglionosis or aganglionosis are causative factors in the etiology of right-sided diverticulitis.

Adult stem cells are undifferentiated cells found within fully developed tissues or organs of an adult individuum. Until recently, these cells have been considered to bear less self-renewal ability and differentiation potency compared to embryonic stem cells. In recent studies an undifferentiated cell type was found in primary cultures of isolated acini from exocrine pancreas termed pancreatic stellate cells. Here we show that pancreatic stellate-like cells have the capacity of extended self-renewal and are able to differentiate spontaneously into cell types of all three germ layers expressing markers for smooth muscle cells, neurons, glial cells, epithelial cells, chondrocytes and secretory cells (insulin, amylase). Differentiation and subsequent formation of three-dimensional cellular aggregates (organoid bodies) were induced by merely culturing pancreatic stellate-like cells in hanging drops. These cells were developed into stable, long-term, in vitro cultures of both primary undifferentiated cell lines as well as organoid cultures. Thus, evidence is given that cell lineages of endodermal, mesodermal, and ectodermal origin arise spontaneously from a single adult undifferentiated cell type. Based on the present findings it is assumed that pancreatic stellate-like cells are a new class of lineage uncommitted pluripotent adult stem cells with a remarkable self-renewal ability and differentiation potency. The data emphasize the versatility of adult stem cells and may lead to a reappraisal of their use for the treatment of inherited disorders or acquired degenerative diseases.

After establishing an ultrasound-navigated resection in metastatic liver disease by using a navigated parenchymal-dissecting instrument, we intend to transfer this technique from open to laparoscopic liver surgery. A special adapter was developed to connect an ultrasound-based navigation system to laparoscopic instruments. We present first results about technical aspects and feasibility.

The functional–anatomical structuring of the liver according to Couinaud regarding the intrahepatical course of the vascular structures is the base of every modern liver surgery. Consequently, using intraoperative ultrasound is an undisputed requirement for every liver resection. Exact following of the planned resection plane can only be realized with the application of a permanent online navigation, based on intraoperative ultrasound during the dissection of the hepatical tissue. We present the combination of a navigation system (US-Guide 2000®) with an intraoperative ultrasound probe and a waterjet dissection instrument for intraoperative online navigation of parenchymal dissection. The use of the navigated liver resection is being shown by the example of a 79-year-old patient with a HCC in segment 5 and 6.

Die Radiofrequenzablation (RFA) stellt eine neue Methode zur lokalen Destruktion von Lebertumoren dar. Indikationsstellung und Durchfuhrung sind gegenwartig nicht ausreichend validiert. Zur Erfassung des aktuellen Standes der RFA in Deutschland wurden 2026 Kliniken mittels standardisiertem Fragebogen befragt. Bei einer Rucklaufquote von 17,5% setzten 58 Abteilungen die RFA zum Befragungszeitpunkt ein und behandelten ca. 1700 Patienten. 25,9% sahen eine Indikation bereits bei potenziell kurativ resezierbaren Tumoren, 22,4% auch bei erwarteter inkompletter Ablation zur Tumormassenreduktion. 75% kombinieren Resektion und RFA zur Erzielung einer „R-0-Situation“. Die maximale Tumorgrose zur vollstandigen Ablation wird mit 3–11 cm angegeben. Als Kontraindikationen wurden am haufigsten Tumorgrose, Tumoranzahl, kritische Tumorlokalisationen und Einschrankungen der Leberfunktion genannt. Die Umfrage dokumentiert eine landesweit erhebliche Diskrepanz bei Indikation, Durchfuhrung und Ergebnissen der RFA in der Behandlung von Lebertumoren. Fehlende Standards und eine Uberschatzung der methodischen Moglichkeiten konnen zu einem unkritischen Einsatz, Abweichung von Standardtherapien oder unbefriedigenden Ergebnissen fuhren.

AIM Ultrasound-guided interventions are presently performed as free-hand-type procedures or using biopsy transducers. In this article we report on our experience with a new navigation-system for sonographically guided interventional procedures under OR-conditions. METHODS The US-Guide 2000 trade mark is an electromagnetic guidance system that assists physicians in ultrasound-guided interventional procedures. This system accommodates both in-plane and out-of-plane needle placement. We evaluated this system for the first time under OR-conditions. Overall, for 39 interventional procedures (23 thermoablations of malignant liver lesions, 16 diagnostic punctures) were performed. RESULTS All targets were reached successfully without any complications. No interactions with other OR-devices were seen. CONCLUSION The US-Guide 2000 trade mark as a virtual needle-guiding system allows a safe and accurate sonographically assisted intervention. The major advantage is the possibility of out-of-plane needle placement and the combination of flexibility of free-hand-type procedures with the accuracy of a biopsy transducer. This increases the safety of punctures especially when lesions are difficult to reach and/or are situated next to vulnerable structures. It also reduces the interventional trauma.

Interventional Therapy of Liver Metastases If non-resectable liver metastases remain untreated, the median survival only comes to a few months. While searching for alternative therapies, a number of procedures, which cause devitalization of metastases by different modes of action, has been invented. Among these procedures count thermal radiofrequency ablation (RFA), laser-induced thermotherapy, cryoablation, transarterial chemoembolization, focused ultrasound, microwave ablation, intratumoral injection of cytotoxic substances and electrolysis. In the meantime, numerous methods have left the experimental stage and are clinically evaluated at present. However, existing data are offen still poor. Thermal radiofrequency ablation is favored by many users because of its results, its easy handling, different modes of application and consecutive individual optimal usage as well as its cost efficiency in spite of apparent comparable effectiveness to other interventional procedures. Before their oncological role is evaluated with certainty, all procedures should be limited to palliative situations, i.e. to the treatment of patients, who are not suitable for surgical resection. In the future, prospective studies must evaluate the role of RFA and other procedures in the treatment of liver metastases.

BACKGROUND In orthotopic liver transplantation the incidence of biliary complications is up to 49%. In view of the relative frequency of such complications despite seemingly good preconditions, method-related disadvantages of conventional suture must also be considered as a possible cause. These include perforating needle injury of the choledochal wall with at least temporary exposure of suture material in the lumen, suboptimal approximation of the mucosa, and an additional decrease in blood flow in the choledochal stumps as a result of suture-related tissue strangulation. Hence the search for alternative anastomosis techniques. METHODS To evaluate the surgical suitability of extramucosal titanium clips (Vascular Closure Staples; VCS) in comparison with conventional manual suture, a study was performed in 36 pigs, which were randomly assigned to 4 groups, each containing 9 animals. Choledochal excision was performed in 18 pigs and transection in the other 18 pigs; end-to-end anastomosis was then carried out, using a VCS stapler in half of the animals in each of these two groups and conventional manual suture in the other half. Pre- and postanastomotic blood flow was measured during the surgery with the aid of a laser Doppler flow meter. The long-term behavior of the closure techniques was ascertained by regular laboratory checks over the ensuing 6-month observation period, after which the pigs were killed so that the specimens could be harvested. RESULTS Using medium-sized VCS clips, we were able to create a tension-free, everted biliary anastomosis with exact mucosal approximation and no narrowing of the lumen, and without any technical problems during the performance of the procedure. Measurements with the laser Doppler flow meter showed well-preserved anastomotic blood flow after clip reconstruction, with significantly higher perfusion values than after manual suture. The postoperative courses of the investigated laboratory parameters did not reveal any significant differences between the two methods. In contrast, histomorphometric evaluation showed wall thickness and thus fibrosis in the anastomosis region to be less in the clip group than in the suture group (median: 510 microm versus 660 microm, P

Background: Lesions of vascular structures are rare but serious complications of laparoscopic cholecystectomy. The purpose of this blind randomized animal study was to investigate the possibility of detecting different vascular lesions within the hepatoduodenal ligament using laparoscopic color Doppler ultrasound (LCDU). Methods: Twenty-four lesions of the hepatic artery and portal vein were created laparoscopically in six farmer pigs using titanium clips. The following injuries were studied: (a) partial occlusion of the hepatic artery (eight cases), (b) complete occlusion of the hepatic artery (eight cases), (c) partial occlusion of the portal vein (eight cases). There were also eight cases without lesions of the vascular vessels. The order in which the injuries were created was randomly assigned. The study was performed in a blind fashion. Recognition of the injuries was attempted with LCDU. Results: All injuries were recognized correctly by LCDU. There were no false positive results. The clips were reliably located. Using color Doppler imaging, partial occlusions of the hepatic artery and portal vein were visualized by changes of the blood flow from laminar to turbulent behind the clip. Complete occlusion of the hepatic artery was recognized as a complete cessation of the colored blood flow. Conclusion: LCDU is a very efficient tool for visualizing vascular structures and evaluating the bloodstream. Partial or complete vascular occlusion by clips that may occur as a result of difficult dissection during laparoscopic cholecystectomy can be visualized reliably using this technique.

Background: Intestinal bleeding of unknown origin can lead to a difficult workup. Abdominal colic, melena/hematemesis, and jaundice represent the pathognomonic triad for hemobilia, but clinical presentation and etiology of this entity are varying. Seldom all of these symptoms are present, and rarely does hemobilia cause melena or hematemesis. Often the correct diagnosis is missed. Patients frequently have a long history of complaints and inadequate therapy. Case Report: We report on a patient who complained of repeated, severe epigastric pain and massive melena induced by exercise activity. After 2 years of complaints and an unnecessary operation, ultrasound detected a liver hemangioma. It was supposed that the hemangioma was causing hemobilia during strenuous physical activity. The patient underwent a partial liver resection to eliminate the hemangioma. All complaints resolved, and the patient remained asymptomatic postoperatively. Conclusions: Physicians should be aware of hemobilia as a rare cause of upper gastrointestinal bleeding, especially if esophagogastroduodenoscopy cannot demonstrate any bleeding source. Ultrasound is able to visualize many diseases leading to hemobilia and should be integrated into the early workup of unclear intestinal bleedings.

Introduction: Despite use of intraoperative cholangiography (IOC), only one-third or less of bile duct injuries that occur during laparoscopic cholecystectomy are detected at the primary operation. Therefore, there is a need to investigate other intraoperative diagnostic methods, especially laparoscopic ultrasound, for detecting bile-duct injuries. Materials and methods: Detection of different bile-duct injuries by laparoscopic intraoperative ultrasonography was evaluated in a blind, randomized animal study. Fifty bile-duct injuries were created using laparoscopic techniques in 23 pigs. The number of single lesions and the order in which the injuries were created was randomly assigned. The lesions created were: (1) partial occlusion by a clip, (2) complete occlusion by a clip, (3) partial laceration, (4) transection without clips, (5) transection between clips and (6) excision between clips. In addition, there were cases without lesions. Different types of clips were used. A screening of the injuries by laparoscopic ultrasound using a flexible probe was attempted. The study was performed in a blind fashion. Results: Complete ultrasonographical imaging of the hepatic and common bile duct between its bifurcation and its insertion into the duodenum was accomplished in all 23 animals before surgery was performed. Eight cases without lesions were correctly recognized. In 48 of 49 cases, the injuries were detected (sensitivity 98%). In one instance, the injury was obvious without the use of ultrasound. Forty-four cases were correctly diagnosed and, in 12 cases, the injuries were equivocally differentiated (specificity of 100%, overall accuracy of 98.3%). There was only one false diagnosis. The different types of clips were also reliably differentiated. Conclusions: We conclude that laparoscopic ultrasonography can reliably visualize most relevant bile-duct injuries. A standard for doing the ultrasound examination is proposed. Direct and indirect ultrasound signs of bile-duct injuries are explained.

Background: Iatrogenic common bile duct injury is the worst complication of laparoscopic cholecystectomy. The goal of this study is to increase awareness of the problem and educate surgeons about the consequences of these injuries.

We performed a prospective randomized comparison of laparoscopic intraoperative ultrasonography (LIOU) and dynamic intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC).LIOU and IOC were attempted in 518 consecutive patients scheduled for laparoscopic cholecystectomy. The order in which the diagnostic procedures were performed was randomly assigned.LIOU failed in two patients (0.4%), and there were 41 (7.9%) failed IOC. The common bile duct (CBD) was visualized reliably with both methods. Our patients showed sensitivities of 83.3% and 100% and specificities of 100% and 98.9%, with an overall accuracy of 99.2% and 98.9% for LIOU as compared to IOC for identifying unsuspected common bile duct stones. The time necessary for the examination was significantly shorter in LIOU than in IOC (7 versus 16 min).LIOU performed by experienced surgeons is a good and effective method to assess the CBD, including the neighboring structures of hepatoduodenal ligament. Using powerful, flexible-tip ultrasound probes, CBD exploration can be done in a longitudinal fashion, which is necessary for good anatomical clarity. A lack of adverse effects, shorter examination times, and lower costs are some of the advantages of this method. The most important advantage is the possibility of unlimited repetition, especially if there is difficulty identifying anatomic structures. In addition, there are some indications that LIOU has the potential to recognize major iatrogenic bile duct injuries.

The purpose of this study was to investigate the possibility of detecting bile duct injuries using laparoscopic intraoperative ultrasound (LIOU).Fifty bile duct injuries were created using laparoscopic techniques in ten farmer pigs. The lesions created were: (1) partial occlusion, (2) complete occlusion (1 clip), (3) complete occlusion (2 clips), (4) transection between clips, (5) excision between clips.All injuries were easily visualized using LIOU. The relation of clips impinging upon or occluding the bile duct was readily visualized on LIOU in all cases. In some cases it was difficult to distinguish between partial and complete occlusion. It was also difficult to distinguish between transection and excision due to retraction of the severed bile duct.In cases of iatrogenic occlusion of the bile duct involving hemoclips (including transection or excision between clips), LIOU is a potentially useful modality that may allow earlier recognition and repair. Further studies are needed to evaluate the efficacy of LIOU in detection of bile duct injuries that do not involve hemoclips.

An der I. Chirurgischen Klinik fur Allgemein- und Thoraxchirurgie des Diakoniekrankenhauses Rotenburg (Wumme) wuden im Zeitraum vom Oktober 1992 bis Dezember 1995 1154 Hernien bei 997 Patienten mit der transabdominellen praperitonealen Patch-Plastik (TAPP) versorgt. 761 Patienten mit 895 Hernien (107 Rezidivhernien, nach konventioneller Voroperation) mit wenigstens 3 Monate zuruckliegender Operation wurden retrospek-tiv analysiert. Im postoperativen Nachbeobachtungszeitraum von 3-35 Monaten kamen 10 Fruhrezidive zur Beobachtung, keines davon bei den laparoskopisch operierten Rezidivhernien. Implantatinfektionen oder -unvertraglichkeiten wurden nicht beobachtet. Mogliche Vor- und Nachteile der konventionellen und der laparoskopischen Versorgung von Inguinalhernien werden diskutiert, und anhand vorliegender Schrifttumsangaben sowie der eigenen Leistungsdaten wird gefolgert, daβ die TAPP ein ausgereiftes und sicheres Operationsverfahren, insbesondere zur Versorgung von Rezidivleistenhernien, zu sein scheint.

Das Ausmas des Lymphknotenbefalls stellt auch bei hepatobiliaren Tumoren neben der R0-Resektion den entscheidenden prognostischen Parameter dar. Die abdominelle Lymphknotendissektion ist nach chirurgischem Verstandnis fester Part der operativen Therapie gastrointestinaler Malignome (Weitz u. Buchler 2010). Die Bedeutung der Entfernung des lokalen Lymphabstromgebietes als therapeutischer Bestandteil jeder onkologischen Leberresektion ist derzeit nicht abschliesend geklart.

Die im ▶ Kapitel 9 ausgefuhrten allgemeinen Aussagen zur Lagerung gelten analog auch fur die Pankreaschirurgie. Die Standardlagerung bei offenen und laparoskopischen Pankreasoperationen ist die Ruckenlagerung des Patienten mit ausgelagertem rechten Arm auf einem Operationstisch, der vorzugsweise eine intraoperative Rontgenuntersuchung zulasst. Durch die zusatzliche Benutzung einer Lagerungsrolle unter den unteren Thoraxbereich auf Hohe des Xiphoids zur Betonung der dorsolumbalen Lordose kann eine verbesserte Exposition der Oberbauchorgane erreicht werden (⊡Abb. 9.1).

Auch nach der Erstbeschreibung einer Leberresektion durch von Langenbuch vor uber 100 Jahren galt die Leber viele Chirurgengenerationen lang als »operationsfeindliches« Organ. Bis in die 70er Jahre blieben Leber resezierende Eingriffe insbesondere wegen des hohen operativen Risikos die Ausnahme. Das Verstandnis der funktionellen Leberanatomie, onkologischer Grundlagen sowie entscheidende Verbesserungen der operativen Taktik und Technik und des perioperativen Managements haben mittlerweile zu einem konzeptionellen Umbruch gefuhrt.

Leberzysten und Leberhamangiome stellen die haufigsten gutartigen Lasionen der Leber dar. Man unterscheidet zwischen erworbenen Leberzysten, z.B. bei Zustand nach Trauma und den kongenitalen oder dysontogenetischen Leberzysten. Histologisch handelt es sich um flussigkeitsgefullte Hohlraume, die durch ein Epithel begrenzt werden.

Nach Abgabe des Resektats erfolgt bei noch bestehender kapillarer Blutung eine kurzfristige Tamponade mit einem feucht-heisen Bauchtuch. Es schliest sich eine sorgfaltige Uberprufung der Resektionsflache hinsichtlich persistierender kleinerer Blutungen und Galleleckagen an, die subtil mit 6-0 PDS ubernaht oder kleinen Titanclips verschlossen werden. Bezuglich des weiteren Managements der Resektionsflache existieren verschiedene Moglichkeiten.

Einen besonderen Stellenwert hat die Kombinationsbehandlung durch lokal ablative und resektive Verfahren im Sinne einer chirurgisch-interventionellen Strategie.

Nach der ersten laparoskopischen Cholezystektomie 1985 durch Muhe wurde mit Beginn des folgenden Jahrzehnts die minimal invasive Chirurgie auf alle Viszeralorgane mit unterschiedlichem Erfolg ausgeweitet (Schwandner et al. 2004, Friedmann et al. 1996, Gagner et al. 1997, Gagner u. Pomp 1997).

Im letzten Jahrzehnt hat die moderne hepatobiliare und Pankreaschirurgie einen hohen Standard erreicht und ist zugleich in rasanter Entwicklung.

Leberresektionen sind mittlerweile gut standardisierte Operationen, die sich in eine Reihe einander abfolgende operationstechnische Einzelschritte untergliedern lassen: Lagerung und Zugang (► Kap. 9) Exploration und intraoperative Sonographie (► Kap. 4.4) Mobilisation der Leber Praparation im Lig. hepatoduodenale/Leberhilus Praparation der Lebervenen incl. Einmundung in die V. cava Dissektion des Leberparenchyms Versorgung der Resektionsflache Fakultativ: Anlage biliodigestiver Anastomose(n) ggf. Refixation der Restleber, Spulung, Drainage, Abdomenverschluss

Die chirurgische Resektion stellt nach wie vor den Goldstandard fur die Therapie von primaren und sekundaren Lebermalignomen dar. Die Sinnhaftigkeit jeglicher onkologischen Resektion wird bei vertretbarem perioperativen Risiko v.a. durch den erreichbaren Langzeitverlauf bestimmt. Weitgehende Einigkeit herrscht in der Literatur daruber, dass nur dann, wenn durch den Eingriff eine R0- Situation erzielt werden kann und zugleich kein extrahepatischer Tumor vorliegt (mit Ausnahme resezierbarer Lungenfiliae), eine potenzielle Chance zur Heilung besteht und die Indikation zur Resektion uberpruft werden sollte. Jedoch kommen nur maximal 5–15% der Patienten mit neu diagnostiziertem hepatozellularem Karzinom bzw. 20–25% aller Metastasentrager fur eine Resektion in Betracht (Blaker et al. 2001, Lehnert u. Golling 2001).

Jede Lagerung des Patienten sollte auf der einen Seite eine optimale Exposition des Situs gewahrleisten, auf der anderen Seite sicherstellen, dass der Patient auch bei mehrstundigen Operationen keinen Schaden nimmt. Im eigenen Vorgehen wird eine leicht uberstreckte Ruckenlagerung mit Auslagerung des rechten Arms bevorzugt (⊡ Abb. 9.1). Durch die Benutzung einer Lagerungsrolle bzw. eines aufblasbaren Kissens unter dem unteren Thoraxbereich auf Hohe des Xiphoids zur Betonung der dorsolumbalen Lordose kann eine verbesserte Exposition der Oberbauchorgane erreicht werden.