11jmorrow
New
can anyone help me where to start on this procedure
received surgery followed by chemotherapy. He responded very well, both radiographically and biologically. The plan was to proceed with a 2 stage hepatectomy including the left lobe of the liver, followed by a formal right hepatectomy after portal vein embolization. As such, the risks versus benefits were discussed with the patient, he agreed to proceed. The risks include but not limited to bleeding, infection, bile leak, liver failure and need for further surgery.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. General anesthesia was induced. An arterial line as placed. He was prepped and draped in the usual sterile fashion. Critical pause was performed to identify the patient and procedure. Next only a vertical midline incision was made above the umbilicus. The wound was deepened using electrocautery. A Thompson Farley retractor was placed for better exposure. The falciform ligament was taken down to the IVC. The dissection was kept to a minimum not to disrupt further planes for the formal right hepatectomy. The left hepatic vein was identified and encircled, the left triangular ligament was divided the pars flaccida was divided and there was no replaced left hepatic vessel. A Pringle maneuver was then secured. An intraoperative ultrasound of the liver with interpretation was performed. The patient had 3 cysts in the left lateral section of the liver, one on the left hepatic vein, one between segments 2 and 3 and one more anteriorly and she had only 2 metastatic lesions to the left lateral section of the liver, one in segment 3 and one in segment 2. Both of these were marked with electrocautery and both of them had traction sutures placed consisting of 3-0 Prolene. Next, using a Pringle maneuver and 2-surgeon technique using a CUSA and Tissue Link, the lesions were divided. On segment 3, we followed the pedicle of segment 3 to preserve as much liver tissue on the left side to allow regeneration. I observed the tumor all along the way removing it flush on the pedicle, knowing that the margin would be close; however, knowing that there was no residual tumor left. This was similarly performed for a segment 2 lesion. Following removal of both lesions, the liver bed was ablated to make sure that there is no residual tumor. Segment 4B and segment 4A had separate lesions measuring between 1-2 cm. Margins were similarly marked and a two-surgeon technique under a Pringle maneuver were used to perform the resections. Smaller vessels were divided with the Harmonic. Larger vessels were clipped and pedicles were divided with a vascular load stapler delivering both and labeling them as segment 4A and segment 4B. Ultrasound of the liver identified 2 lesions along the course of the middle hepatic vein. One was a 5-6 mm and the other was a 1 cm. Using the Neuwave probe PRXT and using a 1 cm burn time for the subcentimeter lesion with 65 watts and a 2-minute burn for the larger lesion measuring 1 cm was performed under ultrasound guidance. After complete destruction of both lesions we were done. Hemostasis was achieved using electrocautery. Surgicel and Vistaseal was applied. The falciform ligament was tacked over the major resection area. Gloves were changed. Counts were correct. The abdomen was irrigated. A 19-French JP drain was placed and tied down with a 2-0 nylon suture. The midline wound was closed with 2 running #1 looped PDS sutures. The skin was irrigated and closed with skin staples. The patient tolerated the procedure very well.
received surgery followed by chemotherapy. He responded very well, both radiographically and biologically. The plan was to proceed with a 2 stage hepatectomy including the left lobe of the liver, followed by a formal right hepatectomy after portal vein embolization. As such, the risks versus benefits were discussed with the patient, he agreed to proceed. The risks include but not limited to bleeding, infection, bile leak, liver failure and need for further surgery.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. General anesthesia was induced. An arterial line as placed. He was prepped and draped in the usual sterile fashion. Critical pause was performed to identify the patient and procedure. Next only a vertical midline incision was made above the umbilicus. The wound was deepened using electrocautery. A Thompson Farley retractor was placed for better exposure. The falciform ligament was taken down to the IVC. The dissection was kept to a minimum not to disrupt further planes for the formal right hepatectomy. The left hepatic vein was identified and encircled, the left triangular ligament was divided the pars flaccida was divided and there was no replaced left hepatic vessel. A Pringle maneuver was then secured. An intraoperative ultrasound of the liver with interpretation was performed. The patient had 3 cysts in the left lateral section of the liver, one on the left hepatic vein, one between segments 2 and 3 and one more anteriorly and she had only 2 metastatic lesions to the left lateral section of the liver, one in segment 3 and one in segment 2. Both of these were marked with electrocautery and both of them had traction sutures placed consisting of 3-0 Prolene. Next, using a Pringle maneuver and 2-surgeon technique using a CUSA and Tissue Link, the lesions were divided. On segment 3, we followed the pedicle of segment 3 to preserve as much liver tissue on the left side to allow regeneration. I observed the tumor all along the way removing it flush on the pedicle, knowing that the margin would be close; however, knowing that there was no residual tumor left. This was similarly performed for a segment 2 lesion. Following removal of both lesions, the liver bed was ablated to make sure that there is no residual tumor. Segment 4B and segment 4A had separate lesions measuring between 1-2 cm. Margins were similarly marked and a two-surgeon technique under a Pringle maneuver were used to perform the resections. Smaller vessels were divided with the Harmonic. Larger vessels were clipped and pedicles were divided with a vascular load stapler delivering both and labeling them as segment 4A and segment 4B. Ultrasound of the liver identified 2 lesions along the course of the middle hepatic vein. One was a 5-6 mm and the other was a 1 cm. Using the Neuwave probe PRXT and using a 1 cm burn time for the subcentimeter lesion with 65 watts and a 2-minute burn for the larger lesion measuring 1 cm was performed under ultrasound guidance. After complete destruction of both lesions we were done. Hemostasis was achieved using electrocautery. Surgicel and Vistaseal was applied. The falciform ligament was tacked over the major resection area. Gloves were changed. Counts were correct. The abdomen was irrigated. A 19-French JP drain was placed and tied down with a 2-0 nylon suture. The midline wound was closed with 2 running #1 looped PDS sutures. The skin was irrigated and closed with skin staples. The patient tolerated the procedure very well.