# Venous dissection



## bmanus (Mar 25, 2013)

Can anyone help me with the venous dissection of this report?

PREOPERATIVE DIAGNOSIS:  Hepatocellular carcinoma and chronic hepatitis
C.
POSTOPERATIVE DIAGNOSIS:  Hepatocellular carcinoma with right portal
vein thrombosis.
PROCEDURE:  Diagnostic laparoscopy, intraoperative ultrasound, open
right hepatectomy, cholecystectomy and portal vein exploration and
repair.  Placement of On-Q pain pump.  Modifier 22 because of the length
of the procedure and the complexity of the dissection around the portal
vein secondary to prior intra-arterial yttrium 90 injection and tumor
thrombosis of the right portal vein.
ANESTHESIA:  General endotracheal.
ANESTHESIOLOGISTS:  
1.  No peritoneal metastases.
2.  Left lobe was free of lesions.
3.  There was a heterogeneous mass in the right lobe of the liver with
what appeared to be an extension of the mass into the right portal vein.
4.  The right portal vein was thrombosed up to the level of the
bifurcation of the main portal vein into the left and right sides.
There is about 1 cm of right portal vein, which appeared free of tumor
based on the ultrasound findings.
5.  There is diffuse chronic inflammation and fibrosis surrounding the
porta hepatitis and, in particular, the right portal vein.
6.  The right lobe of the liver was shrunken and fibrotic in appearance.
7.  The left part of the liver was pink and did not appear fibrotic or
cirrhotic.  The parenchyma was smooth.
8.  The margins were grossly negative when the specimen was dissected
(Document continuation)                   after removal.
9.  The tumor weight was 440 grams.
10.  The frozen pathology of the right portal vein margin was negative
for tumor.
SPECIMENS:
1.  Right liver resection.
2.  Gallbladder.
3.  Portal vein margin on the right side.
ESTIMATED BLOOD LOSS:  700 mL
IV FLUIDS:  3450 mL
URINE OUTPUT:  900 mL
COMPLICATIONS:  None.
INDICATIONS:  The patient is a 53-year-old man with hepatitis C and
history of heavy alcohol use who was diagnosed with hepatocellular
carcinoma 1 year ago.  He underwent transarterial radio embolization
with yttrium-90 on 08/28/2012 for what at that time was a 4.5-cm HCC
with associated satellite lesion and right portal vein thrombosis.  He
had a dramatic response to treatment with devascularization of the tumor
and shrinkage of the entire right lobe.  Over the past 8 months, he has
not developed any intrahepatic metastases or distant metastases and
therefore he was brought to the wrist operating room for a planned right
hepatectomy.  Of note, the patient was a heavy drinker and smoked
cigarettes for most of his life, but quit both alcohol and cigarette
smoking after the initial surgical consultation 01/14/2013.  He was,
therefore, completely sober for exactly 1 month prior to his surgery.
DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room
and placed supine on the operating table.  Intravenous antibiotics were
administered.  Venodyne boots were placed.  The patient was positioned
comfortably supine with his arms outstretched.  General anesthesia was
induced and he was intubated with no problem.  A right IJ central venous
catheter was placed, in addition to a left radial artery catheter.  A
Foley catheter was inserted and an orogastric tube was placed, which was
removed at the end of the case.  The patient's abdomen was prepped and
draped in the standard surgical fashion.
An incision was marked out for a planned open subcostal incision with
the midline extension up to the sternum.  Initially, a small incision
was made in the midline.  The fascia was elevated with a tracheostomy
hook and a Veress needle was inserted through the fascia and peritoneum
in order to establish pneumoperitoneum with carbon dioxide to a pressure
(Document continuation)                                                                                                          of 50 mmHg.  A 10-mm trocar was inserted at this site and the
laparoscope was passed within.  The findings were as described above.  A
2nd trocar was placed in the line of the planned subcostal incision.
This was a 10-mm trocar.  Both trocars were placed after local
anesthesia was injected.  An ultrasound was performed of the liver.
There were no suspicious lesions in the left lobe of the liver.  There
was an approximately 3-mm hyperechoic, round, well-circumscribed lesion
in the left lateral lobe, which was too small to biopsy, which did not
appear suspicious.  The tumor and portal vein thrombosis are as
described above.  There were no additional satellites along the line of
transection, although the mass itself and the right lobe was quite
heterogeneous and it was difficult to discern which areas were
representing tumor versus fibrotic response to the prior treatment.
We then opened the incision in the planned subcostal with superior
midline extension.  The falciform ligament was divided with cautery and
a self-retaining retractor was used to expose the right upper quadrant
under moist lap pad.  Because there were no adhesions from the tumor to
the abdominal wall, it was easy to perform the initial exposure, which
included dividing the falciform back to the inferior vena cava and
dividing the left triangular and right triangular ligaments, in order to
expose the right hepatic vein.  Care was taken to avoid injury to the
phrenic vein draining into the IVC in this area.  Once the liver was
partially mobilized, we began our dissection of the porta hepatitis.
Findings were as described above.  The common hepatic artery was
identified as well as the left and right hepatic arteries.  The right
hepatic artery coursed underneath the main bit coursing underneath the
bile duct.  A cholecystectomy was performed starting at the dome and
working downward to remove the gallbladder off of the liver bed.  There
was some bleeding encountered from the small veins and arteries draining
into the gallbladder.  The cystic artery was identified and tied with
suture.  The cystic duct was identified, tied and divided and the
specimen was passed off the field for pathology.  The cystic plate was
dissected in order to expose the right hepatic artery.  This was
initially looped and ultrasound was performed to confirm the structures
within the porta hepatis.  The right hepatic artery was then doubly
ligated, suture ligated and then divided.  A 2nd branch of the right
hepatic artery was then identified more posteriorly and laterally.  This
was also doubly ligated and divided.  These were retracted medially in
order to expose the portal vein below.  We initially thought that the
portal vein visible beneath the right hepatic artery represented the
main portal vein and it was therefore followed upward toward the hilar
plate, which was taken down.  However, ultrasound demonstrated that this
artery was thrombosed and we, therefore, carried the dissection downward
toward the duodenum.  After a long slow and meticulous dissection, we
were finally able to identify the left portal vein and main portal vein.
 The bifurcation was quite low in the porta hepatis, in fact, was only
(Document continuation)                                                                                                      about 1-2 cm above the duodenum.  This was dissected out a fair ways to
confirm the anatomy and also ultrasound was used to guide the
dissection.  The main left and right portal veins were all looped with
vessel loops.  The common bile duct was retracted medially along with
the common hepatic artery in order to expose the portal vein
bifurcation.  With the main and left portal veins looped, the right
portal vein was occluded at its origin off of the main portal vein using
a small Satinsky clamp.  The distal right portal vein was ligated.  The
right portal vein was then divided sharply with a cuff on the proximal
margin next to the main portal vein.  This cuff was oversewn with a 5-0
Prolene suture in a vertical fashion.  When the Satinsky clamp was
released, there was a gentle arching curve from the main portal vein
into the left portal vein with no pink or distortion or narrowing
visible.  The distal right portal vein was suture ligated in order to
ensure that the tie did not fall off when a small amount of tissue was
taken off of that right portal vein, in order to send for frozen
pathology.  This portal vein dissection entailed about 2-1/2 to 3 hours
of careful dissection.We next moved on to a complete mobilization of the right lobe of the
liver.  All of attachments to the retroperitoneum and diaphragm were
divided.  The inferior vena cava was exposed.  Short hepatic veins were
cauterized using a 5-mm LigaSure.  The IVC ligament was identified and
divided with a gray load of an Endo-GIA stapler.  The right hepatic vein
was dissected superiorly and was then divided with a gray load of an
Endo-GIA stapler.  We next moved on to the parenchymal transection.
Ultrasound was used to identify the tumor and to identify the course of
the middle hepatic vein and right hepatic vein.  The line of demarcation
made evident following the vascular control of the right portal
structures was along the line of the middle hepatic vein.  Because of
the location of the tumor near the right portal structures, our plan was
to divide the parenchyma about almost exactly the line of demarcation
starting from the left of the gallbladder fossa, with attention being
paid to coming straight down onto the porta and not straying to the
right side, as the margin on the tumor was estimated to be about 1 cm at
this transection line.  In addition, we knew we would encounter the
middle hepatic vein intraparenchymally, but our plan was to conserve the
majority of the middle hepatic vein near the IVC.  The parenchymal
transection was then performed.  An umbilical tape was passed around the
entire porta hepatis in preparation for a Pringle as needed.  However,
no Pringle maneuver was performed at all during the parenchymal
transection because there was never any bleeding to necessitate that
maneuver.  The transection was performed with a combination of blunt
dissection with Metzenbaum scissors and electrocautery as well as a 5-mm
LigaSure device.  The middle hepatic vein was identified within the
parenchyma and was divided with a gray load of and then died Endo-GIA
stapler.  Additional large branches of the middle hepatic and right
(Document                                                                                                       hepatic veins were encountered deeper in the parenchyma and these were
also divided with a single firing of the grey load Endo-GIA stapler.
Each firing of the stapler was around a well-defined vessel which was
looped with a vessel loop prior to firing of the stapler.  Medium-sized
vessels and ducts were clipped using 5-mm clips.  The right bile duct
was stapled with a gray load Endo-GIA stapler.  Once the right liver was
removed off the field for pathology, there was good hemostasis.  A few
5-0 Prolene sutures were placed in the parenchyma to control small
oozing around the staple lines.  A lap pad was placed on the liver bed
for 5 minutes and there was no bile leak.  Argon beam coagulation was
used to create char over the entire raw surface of the liver.  There was
excellent hemostasis and zero oozing at the end of the case.  The right
upper quadrant was irrigated with warm saline.  The abdominal cavity was
rechecked and there were no retained foreign bodies.  There were no
missed injuries.  Pain pump catheters were placed from the lateral
abdominal wall, coursing on either side of the subcostal incision.  The
fascia was closed in 2 layers with a single arm 0 PDS suture.  The wound
was irrigated and then the skin was reapproximated with skin staples.  A
dry sterile dressing was applied.  The patient was awoken from
anesthesia, extubated, and brought to the recovery room in stable
condition.  He was never on any pressor support during the case.
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