liver anatomy (and hcc)external anatomy components of hepatectomy left rhv mhv lhv right outflow...
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Liver Anatomy (and HCC)
External Anatomy
Components of Hepatectomy
Left
RHV MHV LHV
Right
OutflowHepatic veinsVena Cava
InflowHepatic arteryPortal vein
Parenchyma
Segmental Liver Anatomy
Right liver Left liver
IV III
II
I
Left pedicleRight pedicle
Leftpedicle
VI
VVIII
VII
Portal Pedicles
7
84 2
6
54 3
CT Segmental Anatomy
1
?
Caudate
Components of Hepatectomy
Left
RHV MHV LHV
Right
OutflowHepatic veinsVena Cava
InflowHepatic arteryPortal vein
?Extrahepatic or intrahepatic control of inflow and outflow?
Parenchyma
Hepatic veins
Hepatic veins
Hepatic veins
Outflow Control
Extra-hepatic
Intra-hepatic
Left Liver Mobilization
LHV and MHV Control
Right Liver Mobilization
Outflow ControlRight Hepatic Vein Division
Extrahepatic Outflow ControlImportance of the Middle Hepatic Vein
• No liver hypertrophy• Large loss of normal liver
Extrahepatic Outflow Control
RHV
MHV LHV
IVC
Extrahepatic Outflow Control
Hepatic artery
CT Angiogram
Right liver Left liver
IV III
II
I
Left pedicleRight pedicle
Leftpedicle
VI
VVIII
VII
Inflow - Intrahepatic Pedicles
Portal Pedicles
Portal Pedicles
Portal vein - left
Main Pedicles
Right Main Pedicle
Hepatotomies for Inflow Control
For right pedicle control
Inflow ControlRight Pedicle Division
Intrahepatic Inflow Control
Extrahepatic Inflow Dissection
• Time consuming
• Difficult if previous RUQ surgery
• Associated with vascular/biliary injury on occasion
• Mandatory for perihilar tumors
Left Portal Vein
Inflow/Outflow Control?Hepatocellular Carcinoma
Anterior Sectorectomy
Colorectal metastases
Left Lateral Segment Right Posterior Sector
Hepatocellular carcinoma
HCC Features
DiagnosisCT/MR: Hypervascular on arterial phase with washoutAFP >500Biopsy
StagingLymph node involvementDistant disease
Treatment - Hepatic function, portal HTNResectionEmbolizationTransplant
Cirrhosis
“Hanging” Hepatoma
40 y.o. F with acute RUQ pain
Four patients with HCC
Portal vein
Tumor expanding portal vein
Tumor in posterior sectoralportal vein
Patient 2
Patient 1 Patient 3
Tumor in IVC andatrium
Tumor in middlehepatic vein
Tumor in lefthepatic vein
Patient 4
39 y.o. Caucasian female without risk factors
Sorafenib in Advanced HCC
NEJM 359:378-90, 2008
10.7 vs. 7.9 months
65 y.o. drinker with pain, AFP 40
10 year survivors HCC
Ann Surg Oncol 24:1358-66, 2017
10 year survivors HCC
Ann Surg Oncol 24:1358-66, 2017
50 y.o. Asian female with Hepatitis B
Liver tumor
Nodal met
Liver tumor
20 y.o. male with pain