# Segment 4 and 5 liver resection help please



## lindacoder (Feb 10, 2015)

OPERATIVE REPORT


PREOPERATIVE DIAGNOSIS:
Metastatic colorectal carcinoma to segment 4 of the left lobe of the liver, segment 5 of the right lobe of the liver.

POSTOPERATIVE DIAGNOSIS:




NAME OF PROCEDURE:
Segment 4B and segment 5 resection of the left and right lobes of the liver, respectively.  In addition, segment 7 excisional biopsy was performed for a nodule in segment 7.


SURGEON:


OPERATIVE PROCEDURE:
Under satisfactory general anesthesia, with the patient supine, the previous subcostal incision was extended superiorly with roof-top extension using electrocautery.  The liver was then mobilized along the round ligament, all the way down to the round ligament.  The ligamentous attachments to the dome of the diaphragm were taken down, all the way to the hepatic veins.  The liver was then mobilized on the right side, completely out of the retroperitoneum.  The posterior attachments to the liver were all taken down all the way to the vena cava so the liver could be elevated superiorly out of the abdomen.  This allowed us to elevate the liver and apply pressure for the segment 4 and 5 resections to prevent bleeding.  After this was fully mobilized, the Bookwalter retractor was inserted, and the exposure was obtained.  The porta hepatis was isolated with a Pringle maneuver.  This was done using a 0.25-inch Penrose with a Potts tie.  After this was completed, segment 4A was marked, as was segment 5.  The tumor was felt to be contained completely in these 2 segments.  Prior to this, a small nodule was palpated in the dome of the liver near segment 7.  This was excised completely and was sent for histopathologic examination.  The capsule of the liver was then closed with 3 figure-of-eight sutures of #0 chromic using a big liver stitch.  After this was accomplished, pressure was applied on either side of the hepatic parenchyma along segment 5.  Segment 5 along with the masses was then resected down toward the hilum.  This was carried across segment 4A.  All of the liver metastases were excised.  Extra tissue was taken in 1 area where the margin was close, and this was sewn to the specimen to orient pathology.  Pathology cut the specimens, and the nearest margin was approximately a centimeter.  Meticulous hemostasis was obtained.  The bile ducts on the surface of the liver were oversewn with 4-0 PDS.  The portal triads were oversewn where necessary with 2-0 silk figure-of-eight sutures.  Hepatic veins were also oversewn with 2-0 silk sutures.  After excellent hemostasis was obtained, the porta hepatis was released and, again, there was some bleeding, but this was oversewn with 2-0 silks.  The liver surface was then treated with Argon beam __________, and no bile leaks were seen with any pads.  After this was accomplished, a piece of Surgicel was laid over the raw surface of the liver.  This was definitely attached.  The liver was returned to its normal anatomic position.  A round 15-French drain was placed in the liver bed for any bile leaks.  This was exited through a lateral stab incision, and secured to the skin with 4-0 nylon.  All areas were checked for meticulous hemostasis and there was no further bleeding.  The midline incision was closed with running #1 PDS loops.  The posterior rectus sheath was closed with continuous running #1 PDS loops.  The anterior rectus sheaths were closed with continuous running #1 PDS loops.  These were all tied to themselves.  The skin was closed with stainless steel clips.   


The patient tolerated the procedure well.  Blood loss was about 300 mL.  Sponge, needle, and instrument counts were correct.   


The colon resection prior to this operation was dictated by Dr. Berntsen.  All anastomoses appeared intact at the end of the procedure, and there was minimal, if any, bleeding.




Confused as to whether it should be 47100 rt and lt or 47122???


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## cynthiabrown (Feb 10, 2015)

47122


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