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The principle of auxiliary liver transplantation is the implantation of a right or left hemiliver into the abdominal cavity to restore normal liver function temporarily, while the native liver recuperates. Once the native liver has recovered, the graft can be removed or left in place without immunosuppression leading to atrophy. [ABSTRACT FROM AUTHOR]

Access is gained through a bilateral subcostal incision with cranial extension. The falci-form ligament is divided leaving enough length on the liver side as it needs to be fixed in the recipient. Finally a retractor (e.g., Takasago retractor) is installed (A). [ABSTRACT FROM AUTHOR]

Age 18 and 60 yearsABO compatibility between donor and recipientNo major medical problemsSignificant long-term emotional relationship to the potential recipientDonor competent to give informed consent [ABSTRACT FROM AUTHOR]

In 1989 Pichlmayr et al. were the first to report a case of splitting a cadaveric liver for two recipients, an adult and a child. In the same year, Bismuth et al. performed the first transplantation of a single liver into two adult recipients with fulminant hepatitis. Today, donor livers are split for an adult and a pediatric recipient or, less frequently, for two adults. [ABSTRACT FROM AUTHOR]

Since its introduction into clinical practice in 1963 by Starzl et al., the technique of orthotopic liver transplantation has been refined progressively. The original technique included resection of the recipient inferior vena cava (IVC) and the use of extracorporeal venovenous bypass. More confidence with the technique and the more frequent use of technical variants in pediatric liver transplantation have led to the development of recipient cava-preserving hepatectomy techniques without use of venovenous bypass and with or without use of a temporary portocaval shunt, independently of anatomical and general status of the recipient. Regardless of the exact technique, orthotopic liver transplantation is characterized by three stages: the pre-anhepatic, the anhepatic and the post-anhepatic stage. The technique of orthotopic liver transplantation, either with or without preservation of the recipient IVC, will be described following these three stages. [ABSTRACT FROM AUTHOR]

The growing success of liver transplantation led to the development of a flexible procedure for multiple cadaveric organ procurement as introduced by Starzl in 1984. The subsequent development of pancreas, multivisceral and intestinal transplantation has required modification and improvement of the initially described technique. [ABSTRACT FROM AUTHOR]

Liver injuries most often (>90% of all cases) are associated with other injuries such as ipsilateral rib fractures, lung contusions, other intra-abdominal lesions, or injuries of the extremities, the pelvis and the head. Hepatic injuries are graded according to the Organ Injury Scale of the American Association for the Surgery of Trauma (AAST-OIS) (Table1). [ABSTRACT FROM AUTHOR]

Hepatic cysts are classified according to the presence or absence of a parasitic etiology. They seldom lead to hepatic dysfunction and are mostly asymptomatic. The treatment is always individualized according to the origin and presence of symptoms. The choice between unroofing versus resection is dictated by site, number of cysts, malignant potential (cystadenoma/cystadenocarcinoma), and parasitic infection (see next chapter). Malignant potential is rare and is not a primary concern. [ABSTRACT FROM AUTHOR]

Patients with hydatid cysts in the liver used to present a therapeutic challenge. Although surgical techniques have improved, considerable controversy still exists regarding the most effective operative technique. The main principle of the surgery is to eradicate the parasite and prevent intraoperative spillage of cyst contents avoiding peritoneal spread. Pericystectomy provides a radical treatment removing the whole cyst "en bloc" including the adventitia without resection of healthy liver tissue. [ABSTRACT FROM AUTHOR]

Hepatic intra-arterial infusion pump (HAIP) placement provides hepatic specific continuous infusion of chemotherapeutic agents. The chemotherapeutic agents selected for use with HAIP should exhibit a high degree of first pass kinetics in order to minimize systemic toxicity. Agents used include cisplatin, fluodeoxyuridine (FUDR), mitomycin C, and Adriamycin. [ABSTRACT FROM AUTHOR]

Unresectable malignant tumors of the liver (e.g., hepatocellular carcinoma, colorectal metastases, neuroendocrine tumors, selected other types of metastases)Tumors <5cm in size (most effective for lesions <3cm)Palliative treatment of symptomatic tumors (e.g., neuroendocrine metastases)Bridge to liver transplantation (hepatocellular carcinoma)Access: Open: In combination with resectionWhen resection is planned, but unresectability is found at time of laparotomyIn difficult locations or selected cases when multiple ablations are requiredpercutaneus: not discussed in this atlasLaparoscopic: Patient fulfills basic requirements to undergo surgeryLesion(s) amenable to laparoscopic approachpercutaneus: not discussed in this atlas [ABSTRACT FROM AUTHOR]

Unroofing of symptomatic simple liver cysts was the first laparoscopic liver procedure to be performed followed by resection of superficial, small-sized benign tumors. The first laparoscopic anatomical liver resection, a left lateral sectionectomy, was reported in 1996. More recently, larger hepatectomies and liver resections for malignant tumors have been described. Today, about 15-20% of liver resections might be considered for a laparoscopic approach. [ABSTRACT FROM AUTHOR]

The goal of hepatic cryosurgery is complete destruction of tumors for curative or palliative reasons as an alternative to resection where resection is not feasible. [ABSTRACT FROM AUTHOR]

The extended right hemihepatectomy (also called right trisectionectomy) includes resection of segments 4-8. For cholangiocarcinoma of the liver hilum (Klatskin's tumor) or carcinoma of the gallbladder, an en-bloc resection including segments 1 and 9 is usually performed. This procedure should only be performed if the remnant liver (segments 2 and 3) provides sufficient liver function. Therefore, preoperative assessment of liver function, a volumetric assessment of the expected remnant liver volume, and exclusion of liver fibrosis or cirrhosis are essential before extended resections. [ABSTRACT FROM AUTHOR]

Since hepatocellular carcinoma (HCC) and most metastatic diseases of the liver spread via intrahepatic portal branches, anatomical resection of a tumor bearing portal area, resection of a segment or a section, are basic procedures for treating liver tumors. [ABSTRACT FROM AUTHOR]

The abdomen is opened through a subcostal incision and the round and falciform ligaments are divided. The left hemiliver is mobilized by dividing the left triangular and coronary ligament (A). Once the left hemiliver is mobilized, the liver can be evaluated by ultrasound. After confirmation of the resectability, the Pringle maneuver is prepared for by opening the hepatogastric ligament as shown in the chapter "Techniques of Vascular Exclusion and Caval Resection."At this point an aberrant left hepatic artery can be isolated for later clamping with a bulldog clamp. [ABSTRACT FROM AUTHOR]

After a right subcostal incision, the round and falciform ligaments are divided, a retractor (e.g., Thompson) is installed and the abdomen is explored (A-1). Tumor size, number, and location in relation to vascular structures are evaluated by intraoperative ultrasound and a definitive decision regarding resectability of the lesion is made (A-2). [ABSTRACT FROM AUTHOR]

In addition to the conventional approach described for liver resection in the chapters on conventional hepatectomies, the hanging maneuver has gained wide acceptance among liver surgeons. Depending on the situation, it can be used for resective liver surgery or for living related liver donation. [ABSTRACT FROM AUTHOR]

Vascular exclusion techniques in liver surgery include continuous inflow occlusion (Fig. 1A) (first described by J.H. Pringle in 1908), intermittent inflow occlusion (Fig. 1B) (first described by M.Makuuchi in the late 1970s), and ischemic preconditioning (Fig. 1C) and (continuous) total vascular exclusion. The use of inflow occlusion varies considerably among centers - some use it routinely,while others use it only exceptionally. When using inflow occlusion, a low central venous pressure (CVP) (<3 mm Hg) needs to be maintained to reduce bleeding. The effect of a low CVP associated with a Pringle maneuver can be equivalent to total vascular exclusion. Total vascular exclusion, on the other hand, can lead to cardiovascular instability by reduced cardiac preload, and adequate volume loading with a high CVP (>10 mm Hg) needs to be maintained. A venovenous bypass is sometimes used in this setting. [ABSTRACT FROM AUTHOR]

Parenchyma dissection of the liver may cause complications including blood loss, hematoma, infection, bile leakage and liver failure.Various surgical techniques have been developed for careful and safe dissection of the liver parenchyma to prevent intraoperative and postoperative complications. [ABSTRACT FROM AUTHOR]

In 1998 at its meeting in Berne, Switzerland, the Scientific Committee of the International Hepato-Pancreato-Biliary Association (IHPBA) established a Terminology Committee to deal with the confusion in terminology of hepatic anatomy and liver resections (see below: members of the committee). The recommendations of the Terminology Committee were presented to the Scientific Committee at the biannual meeting of the IHPBA in Brisbane,Australia, in 2000. These recommendations, consisting of a new terminology termed The Brisbane 2000 Terminology of Liver Anatomy and Resections, were unanimously accepted by the Scientific Committee of the IHPBA and were presented to the membership as the official terminology of the IHPBA. The terminology was published in the official journal of the IHPBA in 2000. The terminology shown below is based on the hepatic artery and bile duct (Figures 1-3). A terminology based on the division of the portal vein was added as an addendum. [ABSTRACT FROM AUTHOR]

Nonparasitic cyst >5cm with and without symptomsNonparasitic cyst <5cm with symptomsParasitic cystCyst-related complications (spontaneous or traumatic rupture, abscess formation)Neoplastic cysts [ABSTRACT FROM AUTHOR]

Injuries to the spleen, when patients are hemodynamically stable.Hemodynamic instabilityLife-threatening concomitant injuries which are likely to cause hemodynamic compromise in the postoperative period, e.g., severe liver injuries or significant pelvic fracturesCoagulopathy — the most common cause of coagulopathy in this patient group is hypothermiaGrade V injuries or the pulverized spleen [ABSTRACT FROM AUTHOR]

Selected Class II-III-IV splenic injury with the following:Hemodynamic stabilityNo evidence of other intra-abdominal organ injuryNo associated head injuryNo coagulopathyCT confirmation of isolated splenic injury [ABSTRACT FROM AUTHOR]

For indications, contraindications and preoperative investigations, see "Open Splenectomy." [ABSTRACT FROM AUTHOR]

TraumaBlood dyscrasias, e.g., idiopathic thrombocytopenic purpuraSymptomatic relief, e.g., Gaucher's disease, chronic myeloid or lymphatic leukemiaSplenic cysts and tumors [ABSTRACT FROM AUTHOR]

Although distal pancreatectomies for diffuse chronic pancreatitis have gone out of favor, there are still selected situations when a localized, anatomic distal pancreatectomy is indicated. The following two procedures describe open and laparoscopic techniques — each of which may have selected indications/contraindications. [ABSTRACT FROM AUTHOR]

Severe acute pancreatitis remains a life-threatening disease. The first phase (about 10-14 days) is characterized by formation of pancreatic and peripancreatic necrosis and development of a systemic inflammatory response syndrome. This systemic response to the pancreatic inflammation/necrosis causes early organ failure that necessitates intensive care therapy. In the second phase (after 2 weeks), the leading cause of morbidity and mortality is superinfection of necrosis with development of septic multiple organ failure. In the last 2 decades, treatment has evolved considerably, and with improved intensive care management, there is a worldwide trend toward a more conservative strategy with operative intervention initiated primarily because of the local and systemic manifestations of infected necrosis and less so for sterile necrosis. However, today, septic complications caused by pancreatic infection account for 80% of the mortality, and infected necrosis therefore usually remains an absolute indication for same form of invasive intervention. [ABSTRACT FROM AUTHOR]

The global concept of preoperative staging of malignancies is to select, as best as possible, those patients who are or are not candidates for operative resection. In the case of periampullary neoplasms, we have good, non-operative "palliation" for patients with non-curable neoplasms. Because a celiotomy for a periampullary neoplasm that proves to be non-resectable is not therapeutic and obligates the patient to an "unnecessary" postoperative recuperation/recovery, preoperative staging laparoscopy can help to select those patients who are at highest chance for potentially curative resection and will prevent celiotomy in most of those with unresectable disease. [ABSTRACT FROM AUTHOR]

Gastrin-secreting neoplasms were first described by Zollinger and Ellison in 1955. These unusual neoplasms can be either benign or malignant. The diagnosis of the Zollinger-Ellison syndrome depends on an increased fasting serum gastrin concentration (>100pg/ml), increased basal acid output (>10mEq/l), and an abnormal secretin test (increase of >200pg/ml in serum gastrin concentration after 2U/kg of intravenous secretin). While originally believed to be primarily neoplasms of the pancreas, today we know that most "curable" gastrinomas arise in the wall of the proximal duodenum. Gastrinomas can occur as sporadic (non-familial) neoplasms or as one of the manifestations of multiple endocrine neoplasia-1 syndrome (MEN-1); MEN-1 includes neoplasms of the pituitary and parathyroids, neuroendocrine neoplasms of the duodenum and pancreas, and carcinoid neoplasms of the foregut and midgut. [ABSTRACT FROM AUTHOR]

As our knowledge of the pathogenesis of pancreatitis-associated pain has matured and as experience with formal operative pancreatectomies has grown, the emphasis on operative treatment of patients with symptomatic chronic pancreatitis has switched from distal-based resections (60%→80%→95% pancreatectomies) to proximal based resections (pancreatoduodenectomy) and more recently to non-anatomic, duodenumpreserving subtotal resections. The following sections will address proximal and distal resections, respectively. [ABSTRACT FROM AUTHOR]

The aim of pancreas transplantation is to restore normal glycemia in diabetics and to attempt to stop the vascular pathophysiology of diabetes, i.e., microangiopathy and, whenever possible, to reverse established renal, ophthalmologic, and neurologic complications of microangiopathy. Pancreas transplantation can be performed either simultaneously with or sometimes after a previous kidney transplant, or less commonly as a primary procedure alone. [ABSTRACT FROM AUTHOR]

Halsted reported the first ampullary resection of a periampullary carcinoma in 1899. [ABSTRACT FROM AUTHOR]

Enucleation of functioning neuroendocrine neoplasms (insulinomas, selected gastrinomas) and non-functioning, well-circumscribed neuroendocrine neoplasms <2cm has been shown to be appropriate therapy for these benign neoplasms. Overtly malignant neuroendocrine neoplasms require a formal anatomic pancreatic resection. [ABSTRACT FROM AUTHOR]

Simple division (5mm) of the anterior surface of the sphincter of Oddi (sphincterotomy) was utilized extensively in the mid 20th century for presumed biliary-pancreatic pain from biliary dyskinesia. Lack of success led to a more generous longer (2-3cm) division of the sphincter with formal sphincteroplasty with only marginal improvement in outcome. Our group and others have utilized a generous sphincteroplasty with division of the transampullary septum to include division of the pancreatic component of the sphincter; with this extended approach, we have achieved good to excellent results in appropriately selected patients. The rationale for the procedure is to allow free egress of bile and pancreatic juice into the duodenum after stimulation from ingestion of a meal. Stenting of even the septotomy can now be accomplished after endoscopic sphincteroplasty in experienced hands. [ABSTRACT FROM AUTHOR]

The majority of pancreatic fistulae will resolve with conservative measures, including improving pancreatic duct drainage through the ampulla, nutritional support, and somatostatin analogues. When pancreatic fistulae result from pancreatic ductal disruption and pancreatic secretions produced in a portion of the pancreas do not flow into the GI tract, operative intervention is indicated. [ABSTRACT FROM AUTHOR]

With the increased experience of centers of expertise in pancreatic diseases, pancreatectomy for neoplasms has become routine, with acceptable morbidity and mortality. Improvements in imaging modalities and heightened awareness of less well-appreciated pancreatic neoplasms (non-functional neuroendocrine neoplasms, the spectrum of primary cystic neoplasms of the pancreas, and especially intraductal papillary mucinous neoplasms) has increased the visibility of formal pancreatectomy. The following sections address specific types of anatomic pancreatic resections. [ABSTRACT FROM AUTHOR]

The concept of draining an apparently obstructed main pancreatic duct was first addressed by opening either the proximal end of the pancreatic duct at the ampulla by doing a sphincterotomy or at the distal end of the pancreatic duct by removing the tail (Duval procedure). Puestow is credited with the concept of a longitudinal incision along the main pancreatic duct through the body and the head of the pancreas. This procedure was first described as a modification of a Duval procedure and therefore included resection of the pancreatic tail. Partington and Rochelle determined that a tail resection was unnecessary and carried out only a side-to-side lateral pancreaticojejunostomy. The principle of the procedure is to decompress an apparently obstructed main pancreatic duct (and maybe to also decompress the pancreatic parenchyma — the pancreatic compartment syndrome suggested by Reber). This assumption is based on the fact that the pancreatic duct is markedly dilated, suggesting a restriction to flow. [ABSTRACT FROM AUTHOR]

The pain of both benign and malignant pancreatic disease can be incapacitating. Attempts to relieve pancreatic pain by extensive operative denervation have proved not to be effective. Newer, less-invasive techniques of selective denervations appear effective as shorter medium-term palliation. [ABSTRACT FROM AUTHOR]

The goals of surgical treatment of most pancreatic pseudocysts are to provide a pathway of internal (enteric) drainage of the "leaking" exocrine secretions to allow the pseudocyst cavity to collapse, thereby either "sealing off" the ductal leak or creating a permanent internal fistula for drainage. Internal drainage includes cystogastrostomy, cystojejunostomy, and less commonly cystoduodenostomy. Internal drainage can also be accomplished by endoscopic cystogastrostomy or cystoduodenostomy in selected patients. [ABSTRACT FROM AUTHOR]

To improve the effect of Walker's simple esophageal transection, Sugiura and colleagues refined the technique of esophageal transection, adding the extensive paraesophageal devascularization via abdominal and thoracic incisions. The resulting procedure has been known as the Sugiura procedure. Three different approaches will be described including a spleen preserving procedure as well as a procedure with an abdominal approach only (i.e., without thoracotomy). [ABSTRACT FROM AUTHOR]

Bleeding esophageal or gastric varices (BEV or BGV) due to portal hypertension caused by cirrhosis, or, much less commonly, caused by other liver diseases (e.g., schistosomiasis)Bleeding from portal hypertensive gastropathy unresponsive to pharmacologic therapyBudd-Chiari syndrome with patent inferior vena cavaIntractable ascites unresponsive to nonsurgical therapyFailed transjugular intrahepatic portasystemic shunt (TIPS) [ABSTRACT FROM AUTHOR]

Control of acute hemorrhage from esophageal varices not amenable to or failing medical therapy, e.g., pharmacotherapy, balloon tamponade, endoscopic variceal sclerotherapy, in patients with liver cirrhosis and portal hypertensionControl of bleeding gastric or intestinal varicesPrevention of recurrent variceal bleeding after initial controlComplicated Budd-Chiari syndrome [ABSTRACT FROM AUTHOR]

The mesocaval shunt decompresses portal hypertension with an interposition graft between the superior mesenteric vein (SMV) and the inferior vena cava (IVC). Popularized by Drapanas in the 1970s, it has had several proponents since, and most highlight that it is a shunt performed remote from the hepatic hilus. Similar in physiology to a side-to-side portacaval shunt, a mesocaval shunt diverts all portal flow if ≥12mm diameter, while if 8-10mm diameter some prograde portal flow is maintained. [ABSTRACT FROM AUTHOR]

The distal splenorenal shunt (DSRS) is widely known as the Warren shunt, and was introduced in 1966 by W. Dean Warren when he worked in Miami. Its development in conjunction with Drs. Zeppa and Foman brought together expertise in decompression of varices and devascularization procedures. The concept of selective decompression of the gastroesophageal segment to control variceal bleeding was combined with maintenance of portal hypertension in the portal vein to keep portal perfusion to the liver. The principle of the procedure is, therefore, that the shunt will control variceal bleeding, and maintenance of portal perfusion will preserve hepatic function. [ABSTRACT FROM AUTHOR]

The earliest description of choledochal cysts is by Douglas in 1952 of a 17-year-old girl with jaundice, fever and a painful mass in the right hypochondrium. Choledochal cysts in Western countries have an incidence of around 1 in 200,000 live births. There is a higher incidence in Asia. Presentation is usually in childhood and 25% are diagnosed in the first year. Frequent association with other hepatobiliary diseases, such as hepatic fibrosis, has been noted. There is an association with an aberrant pancreaticobiliary duct junction. [ABSTRACT FROM AUTHOR]

Bile duct injuries have become more common since the introduction of laparoscopic surgery and are a major source of morbidity and litigation. Bile duct injuries may take many forms. Simpler injuries such as types A and D may be treated in the community setting when discovered intraoperatively or by endoscopic or percutaneous techniques when they present in the postoperative period. Some more complex injuries such as E1 and E2 types may also be treated by nonsurgical techniques when they present as strictures. This chapter deals with the more complex injuries that require hepaticojejunostomy for repair (types B and C injuries and most to type E injuries). [ABSTRACT FROM AUTHOR]

For any patient with a life expectancy of greater than 6 months, surgical biliary bypass can provide durable palliation for jaundice. The preferred surgical method for palliative treatment of biliary obstruction is a side-to-side anastomosis, because it allows the possibility of making a large anastomosis, and of draining the intrahepatic bile duct as well as the part of the bile duct distal to the anastomosis. If local anatomy does not allow a side-to-side anastomosis, an end-to-side anastomosis should be made taking into account the possibility of stasis of pancreatic juice in the pancreatic part of the bile duct. [ABSTRACT FROM AUTHOR]

When the hilus of the liver is not accessible for decompression of obstructive jaundice, use of intrahepatic ducts for surgical bypass is a safe and effective technique as originally described by Bismuth and Corlette in 1975 and later by Blumgart and Kelly in 1984. The general principle is to identify intrahepatic healthy bile duct mucosa proximal to a point of biliary obstruction and to create a mucosa-to-mucosa anastomosis to a long Roux-en-y loop of jejunum. Anastomosis should provide biliary drainage and relief of symptoms such as jaundice and pruritis. [ABSTRACT FROM AUTHOR]

The technique for reestablishing continuity of the extrahepatic bile ducts to the intestinal tract is described. Multiple biliary lumen may be encountered even with minor dissection into the hepatic parenchyma. All lumens should either be anastomosed or ligated with permanent sutures. [ABSTRACT FROM AUTHOR]