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Introduction Left-sided liver resection (LLR) for perihilar cholangiocarcinoma (PHC) may require right hepatic artery (RHA) resection and reconstruction because of its intimate relationship with the biliary confluence. Consequently right-sided resections (RLR) are preferred for Bismuth-Corlette IIIb tumours, and resections avoided in Bismuth-Corlette IV tumours with left lobar atrophy when the RHA is involved by tumour. Methods A retrospective analysis of patients with PHC who presented between December 2009 and June 2015. Results Thirty-six patients underwent resection for PHC (23 LLR, 13 RLR). The number of Bismuth-Corlette IV patients undergoing LLR was significantly greater than those undergoing RLR (8/23 vs 0/13, p = 0.032). The need for arterial reconstruction (AR) was significantly greater during LLR than RLR (10/23 vs 0/13, p = 0.006). Postoperative liver dysfunction was greater after RLR (5/13 vs 0/23, p = 0.003), and hospital stay was shorter after LLR (10 vs 15 days, p = 0.013). Conclusions Safe AR increases the ability to perform potentially curative LLR for PHC. This improves the resectability rate for PHC, particularly for Bismuth-Corlette Type IV tumours. The larger liver remnant after LLR results in less postoperative liver dysfunction and shorter hospital stay without increased operating time, blood loss or morbidity.

Objectives An aberrant right hepatic artery (aRHA) may pose technical and oncologic challenges during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA) as a result of its proximity to the head of the pancreas. The aim of this study was to assess the impact of an aRHA on resectability, and perioperative and oncologic outcomes after PD for PA. Methods An 11-year retrospective cohort study was conducted. A total of 289 patients with PA scheduled for PD with intent for resection were included in the study. Results Of 289 patients, 249 underwent PD and 40 were found to have unresectable tumours. Incidences of aRHA in the resectable (14.9%) and unresectable (7.5%) groups were similar (P = 0.2); the main reasons for aborting PD were not directly related to the presence of an aRHA. In patients who underwent resection, complications occurred more frequently in the standard PD group (41.5% versus 24.3%; P = 0.04), but there was no difference in rates of positive margin (R1) resection (10.8% versus 16.0%; P = 0.4) or median overall survival (17 months versus 23 months; P = 0.1) between patients with and without an aRHA. Conclusions The presence of an aRHA in patients with PA does not affect resectability. In patients with resectable tumours, the presence of an aRHA does not increase morbidity or R1 resection rates and does not impact on overall survival.

BackgroundEn-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure.MethodsThe authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed.ResultsIn both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months.ConclusionsThis new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.

Background Aberrant arterial anatomy is a common finding during foregut surgery. Anomalies to the right hepatic lobe are especially relevant during pancreaticoduodenectomy (PD) and their recognition serves to protect the blood supply to the liver and bile ducts. We report our experience with aberrant right hepatic arterial anatomy (ARHAA) found during PD. Methods All patients who underwent PD between February 2003 and June 2007 were retrospectively reviewed and those with ARHAA were identified. Preoperative imaging studies were assessed by one radiologist, graded according to the presence of ARHAA and compared with the original interpretations. Results We found ARHAA in 31 of 191 patients (16.2%). Operative management included dissection and preservation in 24, transection and reconstruction in four, and transection and primary anastomosis in three patients. Reconstruction of ARHAA was carried out through interposition grafts in two patients and implantation into the gastroduodenal stump in two patients. No cases of arterial thrombosis, liver infarction, abscess formation or biliary fistula were demonstrated in the immediate postoperative period. Review of preoperative imaging interpretations found that only nine of 23 reports indicated the presence of ARHAA; however, the retrospective review of the images found that ARHAA was readily apparent in 24 patients. Discussion Recognition of aberrant vasculature to the liver before PD is important. Preoperative imaging studies will often be adequate to identify these anomalies, but interpreting radiologists may not be aware of its clinical significance. Surgeons performing PD must be adept at managing ARHAA safely.

Although formal laparoscopic hepatic lobectomies are performed routinely, concerns including the risk of major intra-operative haemorrhage remain regarding such an approach.1,2 Control of the inflow vasculature prior to parenchymal transection reduces intra-operative blood loss during major hepatectomy3, and extra-hepatic dissection, ligation and division of the right hepatic artery and right portal vein (RPV) is effective in reducing intra-parenchymal haemorrhage. Laparoscopic exposure and stapled division of the RPV is limited owing to the weight of the liver and the RPV anatomical position. Excessive tension or torque on the vein while positioning the stapler can result in catastrophic consequences. A major impediment to smooth introduction of the stapler is the caudate process posterior to the RPV. This report and accompanying video describe the author's approach to address these issues. Specific gallbladder retraction and division of the caudate process after hepatic mobilization is crucial (Fig. 1). The approach is summarized as a checklist in Fig. 2. This method (TorCH manoeuver) is readily teachable and can be included in curricula for continuing medical education or for fellows and established surgeons learning laparoscopic techniques. Figure 1 Completed TorCH manoeuver with a stapler around the right portal vein. Illustrated by: Laura Maaske Figure 2 Checklist summarizing the steps of the TorCH manoeuver

Background. Haemobilia occurs in only 1.2–5% of patients with accidental liver trauma. We describe an unusual case 2 weeks after penetrating thoracic injury. Case outline. A 27-year-old man underwent laparotomy for hepatic bleeding after a low thoracic stab wound. Two weeks later rectal blood loss occurred. CT scan and angiography revealed intrahepatic contrast extravasation at the previous stab wound site. Coils were successfully placed into two branches of the right hepatic artery. Discussion. Haemobilia should be considered in patients presenting with gastrointestinal blood loss after liver injury. It is diagnosed with angiography and preferably treated by embolisation.

Background The widespread use of CT has led to the increased detection of asymptomatic hepatic artery aneurysm. The usual causes of this condition are trauma and transcatheter arterial embolisation; risk of rupture and death is high. We describe a patient with multiple, congenital, intra-hepatic aneurysms. Case outline A 63-year-old woman presented with epigastric pain and jaundice following treatment with penicillin and flucloxaciliin. She was treated for presumed flucloxacillin-induced hepatitis, but returned 3 weeks later with jaundice, fever and anaemia. Results US showed a vascular lesion in the liver. CT, MRI and a selective angiogram confirmed a bi-lobed intra-hepatic aneurysm in the right hepatic artery and a second aneurysm in the left hepatic artery which, 2 weeks later showed thrombosis. Two weeks following referral the patient collapsed with an ultimately fatal intra-abdominal bleed, following rupture of one of the aneurysms. Discussion The treatment of choice for intra-hepatic aneurysms is embolisation, but in this case it was felt that bilateral embolisation was likely to result in major hepatic dysfunction. Lobectomy has been suggested as a possible treatment for intra-hepatic aneurysms, but is often limited by the location of the aneurysms and the poor hepatic reserve; this was the situation with this patient.