Anatomical resection of giant hepatic cavernous hemangioma of the third porta hepatis

Dissection of the third hepatic giant hepatic cavernous hemangioma for surgical treatment of hepatic cavernous hemangioma. The hepatic cavernous hemangioma close to the vena cava is resected. The third hepatic hilum is dissected first, so that the tumor is separated from the vena cava, and then the liver is cut under the hilar block. This is to ensure that the cranial vein is not damaged when the liver is cut, and it is effective. The surgical method of controlling the second hepatic hilum. This procedure mainly introduces the resection of the right trifoliate and left trilobal hemangiomas. Treatment of diseases: hepatic hemangioma Indication Anatomy of the 3rd hepatic giant hepatic cavernous hemangioma resection is applicable to: 1. The patient's general condition is good, the main organ function and coagulation mechanism are normal, no jaundice or ascites. 2. Surgical resection can be considered if the hemangioma is in close contact with the vena cava or across the vena cava. Care should be taken when the tumor has invaded the three hepatic veins or the left and right hepatic hilum. Preoperative preparation 1. Do liver function, third antibody, alpha-fetoprotein, biochemistry, coagulation mechanism, electrocardiogram, lung function, chest radiograph, gastroscope and other examinations. 2. Liver imaging examination to understand the relationship between the tumor and the hilar, especially the contralateral hepatic vein and hepatic hilar invasion. 3. Carry out liver protection and injection of vitamin K11 and other treatments. The blood preparation determines the blood volume according to the size and position of the tumor, the presence or absence of transcatheter arterial embolization (TAE) and hepatic artery ligation. Surgical procedure 1. Incision Cut the incision of the right hepatic right rib margin, from the xiphoid to the right midline, if necessary, can be extended to the left rib. Cut the "human" shaped incision under the left hepatic rib. The laparotomy should be very careful to prevent major bleeding from damage to the peritoneal tumor, especially those who have had TAE or hepatic artery ligation. It is advisable to enter the abdomen on the left side of the right tumor and the right side of the left tumor. 2, exploration Absolutely prevent massive bleeding caused by rupture of the tumor due to exploration. The number of probes should be minimized. If there is adhesion, the full exploration should be suspended, and the adhesion should be separated before proceeding. Pay attention to the size of the tumor, the extent of invasion of the liver, and the relationship with the caudate lobe. Pay special attention to the involvement of the first and second hilars, the relationship between the tumor and the surrounding organs, and the compensation of the contralateral liver. 3, right trifoliate and caudate lobe hepatic hemangioma resection (1) Right hepatic artery ligation. After the hepatic artery is ligated, the tumor becomes soft and narrow, which facilitates the separation of adhesions and perihepatic ligament. If the artery is difficult to connect, it can be separated under the hilar block. (2) Liver ligament treatment. The sutured hepatic round ligament, the sacral ligament, the right triangular ligament, the coronary ligament, and the liver and kidney ligament were cut. Separate the ligaments carefully, especially the coronary ligament must be carried out in the bare area, the loose area in the bare area, can be gently pushed open with your fingers, separated to the right side of the spine, should not be broken into the tumor, once the rupture avoids the use of vascular clamp Clamp, so as not to cause more tears, such as high degree of fibrosis of the tumor can be sutured to stop bleeding, the degree of fibrosis, the thin wall of the tumor can not be sutured, can be covered with saline pad, hand pressure, free liver and remove the tumor as soon as possible . (3) Treatment of the third hepatic hilum. This is the key to the operation, the operation steps and points of attention: 1 From the lower edge of the posterior vena cava, push the tumor to the left, push the inferior vena cava as much as possible, cut the posterior peritoneum of the vena cava surface, along the tumor Gradual and blunt separation between the body and the vena cava must be performed under direct vision, and the short hepatic vein, vena cava, and tumor cannot be damaged. 2 The short vein of the liver is located in the left and right sides of the vena cava 4-8, of which the right posterior hepatic vein is thicker and the diameter can reach 1.5cm. For the treatment of short hepatic veins, the loose tissue around it should be pushed open. After seeing the direction and the diameter of the canal, you can use the Mi's forceps to guide the vein end of the 4th line, and then cut and ligation after clamping at both ends. Tie, the action should be light to prevent tearing when sewing. 3 After treatment, continue to separate upward and inward along the wall of the vena cava, and cut all the short hepatic veins one by one by the same method. The stump of the stump should be protected to prevent bleeding due to friction and suction of the attractor. 4 When the second hepatic hilum is isolated, pay attention to the right and middle hepatic veins. The hepatic vein is thicker into the inferior vena cava. The lower edge of the blood vessel can be seen. It is difficult to see the entire diameter of the vessel. Therefore, the hepatic vein can not be treated temporarily. To be treated in the removal of the tumor. 5 The left hand of the surgeon extends into the back of the tumor to hold the tumor. At this time, the tumor is located on the volar side, the vena cava is located on the dorsal side, and the tumor is completely separated from the vena cava. (4) Gallbladder treatment. The tumor has often invaded the gallbladder bed. Therefore, the gallbladder should be removed. After the cystic duct is cut and sutured, the gallbladder neck should be properly separated. It is not necessary to cut the gallbladder, and it can be removed when the tumor is removed. The possibility of tumor damage. (5) Resection of the tumor. After the hepatic hilar block, the surgeon's left hand extends into the tumor and holds the tumor to grasp the direction of resection and can avoid the damage of the vena cava. The main steps and points of attention: 1 tangentially from the tumor 1cm, bluntly separate the liver parenchyma, along the tumor The medial margin cuts the vascular and bile ducts one by one. 2 When cutting to the first hepatic hilum, use the surgical shank to separate the tumor to the right side to avoid the left hepatic hilum. The small ducts that are separated from the hilar into the tumor should be properly ligated. I have been separated into the gallbladder bed, and the suture is cut and clamped 1.5 cm away from the portal vein and the common hepatic duct. 3 The treatment of the second hepatic hilum was performed after most of the tumor was removed. The left hand of the surgeon was placed as close as possible to the second hepatic hilum, and the thumb was in front of the second hepatic hilum. This effectively controlled the three hepatic veins. The top edge of the tumor was carefully separated. The tumor was gently pushed away from the hepatic vein with a shank. After the partial vein was exposed, the root of the right hepatic vein was sutured with the 7th line under the guidance of the index finger behind the tumor. The whole tube is sutured, the needle can not be inserted into the vena cava, and the jaw is double clamped at the end of the vena cava. The middle hepatic vein is often combined with the left hepatic vein into the inferior vena cava, so as far as possible away from the junction, first suture and then double clamp and cut the ligation. 4 liver section in the hepatic hilar block release after careful examination of bleeding and bile leakage, suture should be particularly careful, do not damage the hilar duct, especially the bile duct, cross-section suture or omentum covering. 4, left trifoliate and caudate lobe hepatic hemangioma resection (1) After the left hepatic artery is ligated, the hepatic round ligament, the falciform ligament, the left and right coronary ligament, the left and right triangular ligament, the liver and stomach ligament, the hepatic colon and the liver and kidney ligament are separated and cut off. Because of the difficulty in separating the left triangular ligament, the forceps Avoid cutting the spleen, stomach and tumor when the clip is cut. The left triangle ligament stumps 7 and 4 are double-ligated. If the left triangular ligament cannot be separated, some liver tissue can be left and treated after the tumor is removed. Gallbladder treatment is the same as right thoracic hepatectomy, and is removed together with the tumor. (2) tumor removal. Due to the obstruction of the hepatoduodenal ligament, it is generally not possible to treat the short hepatic vein on the left side of the extraluminal vena cava, or to dissect and ligature all the short hepatic veins through the right side of the vena cava, but often due to the invasion of the tumor In addition to the middle hepatic vein, it is also close to the right hepatic vein. It is easy to be damaged during resection. Therefore, it is very important to preserve the right hepatic vein to ensure the right hepatic blood return. Therefore, the hepatic short vein is cut and cut in the liver when the liver is cut. The following points should be noted for the resection of the tumor: 1 After the hepatic occlusion, the surgeon is placed on the left side of the left hand and then inserted into the tumor, and the tumor is cut 1 cm away from the tumor, and then bluntly separated along the tumor by the shank. A small tube that enters the tumor is cut and ligated. 2 Separation to the first hepatic hilum often varies due to the anatomical location of the large tumor. The shank can be separated to the left side as far as possible along the tumor. All the small tubes must be properly ligated and must be separated into the duodenum. The left side of the ligament is equivalent to the left longitudinal groove, and the left portal vein, the left hepatic duct, and the left hepatic artery are cut and sewn together. 3 When treating the short venous hepatic vein, separate the liver section as far as possible, separate along the surface of the vena cava, and cut the end of the short vein of the liver, and then double-end the vena cava, so that the tumor and the vena cava are separated directly to the second hepatic hilum. 4 The left hand of the surgeon through the liver section as close as possible to the second liver gate to support the tumor, the thumb in front of the left and middle hepatic veins, and the tumor is pulled downward, along the upper edge of the tumor to open with a handle blunt The partial hepatic vein was separated and the left and middle hepatic veins were sutured with a 7-gauge thread under the guidance of the operator's index finger. After double clamping, the ligation was performed and the tumor was completely removed. 5 Check the liver section if there is bleeding and bile leakage, the "8" word is sutured, the liver section is close to the suture, and the hepatic hilus can not be sutured too tightly, so as not to affect the retention of hepatic blood circulation.