Liver hanging maneuver: an anatomic and clinical review (original) (raw)
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Two Hundred Liver Hanging Maneuvers for Major Hepatectomy
Annals of Surgery, 2007
To establish the indications of the liver hanging maneuver for major hepatectomy. Summary Background Data: The liver hanging maneuver, which is a technique of passing a tape along the retrohepatic avascular space and suspending the liver during parenchymal transection, facilitates anterior approach of major hepatectomy. However, the feasibility and limits of this maneuver have never been established in patients with different clinical backgrounds. Methods: Medical records of 242 consecutive patients considered for major hepatectomy using the hanging maneuver were reviewed. Results: Among 242 patients, 14 patients (6%) were considered to have contraindication for this maneuver preoperatively because of tumor infiltration to anterior surface of retrohepatic inferior vena cava (IVC). It was successful in 201 patients with overall feasibility of 88%. The feasibility increased significantly in the recent years as compared with the initial years (94% in 2003-2005 vs. 76% in 2000-2002, P Ͻ 0.0001). Bleeding during the retrohepatic dissection occurred in 5 patients (2%), which was minor due to injury of hepatic capsule in 3 (1%) and major due to injury of short hepatic vein in 2 (1%). In all cases, bleeding stopped spontaneously. The maneuver was abandoned in 27 patients, including 15 related to severe adhesion between liver and IVC. Univariate analysis showed that adhesion between IVC and liver was the only significant negative predictor affecting the feasibility. Cirrhosis, large tumor, preoperative radiologic treatments did not influence on the feasibility. Conclusions: The liver hanging maneuver has 94% feasibility in recent years. Absolute contraindication is tumor infiltration to the retrohepatic avascular space. Adhesion between the IVC and liver has a negative impact of the feasibility. According to this indication, the hanging maneuver is easily achievable without risk of the major bleeding during the retrohepatic dissection.
Anatomical basis of liver hanging maneuver: a clinical and anatomical in vivo study
The American surgeon, 2007
Liver Hanging Maneuver (LHM) provides better exposure of the deeper section plane together with Inferior Vena Cava (IVC) protection during right hepatectomies without primary liver mobilization. This study assessed the feasibility and complication rates of LHM focusing on the anatomical distribution of the accessory hepatic veins in the retrohepatic portion of the IVC. From January 2002 to December 2005, LHM was planned in 49 consecutive major hepatectomies. The IVC retrohepatic portion was studied during the anhepatic phase in 17 liver transplantations with IVC preservation. The diameter and location of the vein openings were recorded after IVC division into nine portions. LHM was achieved in 47/49 patients (96%). Bleeding occurred in only one patient (2%) and did not entail procedure interruption. The anatomical study revealed a total of 86 veins present in 17 cases (5.18 +/- 4 per patient) and classified them according to diameter (<3, 3 to 6, and >6 mm), as small (n=40), m...
Molecular and clinical oncology, 2017
Liver resections are safe when performed by specialized hepatobiliary teams. However, complex liver resections are accompanied by significant perioperative risk and they may require modifications of the conventional surgical techniques. We herein report the case of a 54-year-old male patient who underwent an extended right liver resection with en bloc resection and reconstruction of the inferior vena cava. For this complex resection, a modification of the standard operative technique was required. A modified hanging manoeuvre was performed using two 19Fr nasogastric tubes outside the traditional avascular plane to facilitate resection. This modification of the hanging manoeuvre was proven to be feasible and safe, and it is recommended for inclusion in the armamentarium of hepatobiliary surgeons when complex resections are required.
World Journal of Surgery, 2010
Background Resection of a large hepatocellular carcinoma (HCC) is difficult and is associated with a poor outcome. Herein we describe our experience with the use of a liver hanging maneuver (LHM) in conjunction with the anterior approach (AA) in patients with large HCC ([10 cm) and compare the perioperative outcome with the conventional method (CM) for hepatic resection. Methods Patients who underwent major hepatic resections for large HCC ([10 cm) were categorized as group 1 (n = 14), treated with LHM and AA, versus group 2 (n = 11), treated with CM. Variables including patient age, tumor size, operative time and transection time, blood loss, blood transfusion requirements, and postoperative ICU and hospital stay were used to compare the two groups. Results There were 14 and 11 patients in groups 1 and 2, respectively. The variables in group 1 and 2 of median tumor size, median operative time, median transection time, median ICU stay, and median hospital stay were comparable. In contrast, the intraoperative blood loss and the blood transfusion requirements were significantly higher in group 2. Patients under LHM and AA and CM had a median blood loss of 375 ml (237.5-850) and 1,000 ml (500-1,200), requirement of blood transfusion of 3 (21.42%) and 8 (72.7%), respectively. Postoperative complications were comparable in the two groups. There were no deaths in the series. Conclusions The liver hanging maneuver in conjunction with AA is a safe and highly feasible procedure, particularly in patients with sizable ([10 cm) tumors and tumors found to be adherent to the diaphragm and retroperitoneum. The use of the procedure eventuated in lower blood loss as well as fewer blood transfusion requirements when compared to the conventional method.
An Early Experience of “Hanging Maneuver of Liver resection":A Cross-Sectional Study
Journal of College of Medical Sciences-Nepal
Introduction The posterior approach to liver resection is technically difficult, especially when there is a bulky tumor or dense adhesion of right lobe of liver with the risk of tumor dissemination and hepatic vein avulsion. To prevent this, anterior approach of liver resection was used; however, it is technically challenging and can lead to a false line of transection and difficulty in controlling bleeding in deeper parenchymal plane. These technical difficulties are overcome by hanging maneuver liver resection which eases the process of anterior approach. The Objectives of our study were to observe the technical safety, operative duration, operative blood loss, and perioperative complications of hanging maneuver in liver resection. Methods This is a cross-sectional study on the patients who underwent hanging maneuver of liver resection at our center. The perioperative data were analyzed. Descriptive variables were described using frequency and percentage; continuous variables were...
Journal of Gastrointestinal Surgery, 2013
Introduction Variations in portal vein anatomy occur in 20-35 % of individuals. A non-bifurcating portal vein (PV) was suspected on preoperative imaging in a patient with a large right lobe hepatocellular carcinoma. The single PV curved within the liver parenchyma from right to left supplying second-order branches along its course. Case Report Utilizing the hanging maneuver, an extended right hemihepatectomy was safely performed. This approach allowed for preservation of the main PV and its left-sided branches while easily identifying the second-order right branches for ligation. Conclusion Knowledge of portal vein variations and identification preoperatively by cross-sectional imaging are critical. The hanging maneuver aids in the preservation of the main portal vein and its left-sided branches during right hemihepatectomy in the presence of portal vein anomalies, and this technique can be used to improve safety in hepatobiliary surgery.
Laparoscopy-Assisted Major Liver Resections Employing A Hanging Technique
Annals of Surgery, 2010
Objective: To assess the feasibility, safety, and short-term outcomes of laparoscopy-assisted major liver resections. Summary of Background Data: The number of reports of laparoscopic major hepatectomies has gradually increased, and living donor hepatectomies for liver transplant have also recently been performed. However, because of the high degree of proficiency required, major hepatectomies have not been widespread. We developed an original procedure in which the liver is mobilized laparoscopically and resected by a hanging technique through a small incision. Methods: Between November 2002 and December 2008, 43 patients underwent laparoscopy-assisted major liver resections (LAMLRs) in our institution for hepatocellular carcinoma, metastatic liver cancer, and benign diseases. Results: LAMLRs were completed for 42 patients (97.7%). The median age was 62 years (range: 24 -83 years). Preoperative diagnoses were hepatocellular carcinoma (n ϭ 15), metastatic liver cancer (n ϭ 19), and benign disease (n ϭ 8). The types of liver resection consisted of the following: right trisectionectomy (n ϭ 2), right hepatectomy (n ϭ 14), left hepatectomy (n ϭ 16), trisegmentectomy 4, 5, 8 (n ϭ 2), right anterior sectionectomy (n ϭ 4), and extended right posterior sectionectomy (n ϭ 4). The median operating time was 317 minutes (range: 192-542 minutes) and median blood loss was 631 mL (range: 68 -2785 mL). There were neither perioperative deaths nor reoperations. Five patients (11.9%) experienced postoperative complications, 2 patients (4.8%) showed bile leakage, and 3 patients (7.1%) developed wound infections. The median postoperative hospital stay was 13.5 days (range: 6 -154 days).
Histological basis of the liver hanging maneuver
Surgical and Radiologic Anatomy, 2008
Background Liver hanging maneuver (LHM) consists in passing a tape between the retrohepatic inferior vena cava (RHIVC) and the liver to perform various kinds of hepatectomies. LHM is a well-known procedure but its histological basis remains poorly documented. Methods Ten anatomical specimens comprising RHIVC, and surrounding hepatic parenchyma were studied after conventional staining and immunohistochemistry with spe-ciWc antibody for alpha smooth muscle actin. Results RHIVC wall structure consists of a thick muscular layer of longitudinal smooth muscle Wbers and a peripheral loose connective tissue without smooth muscle Wbers adherent to the liver parenchyma. This loose connective tissue between the liver and the RHIVC is the avascular plane for the passage of the clamp during LHM. Conclusion The histological structure of the RHIVC does not seem to have any special hemostatic property. The low bleeding rate during LHM can be only explained by the very low density of RHIVC aVerent veins.
Bimanual 'bi-finger' liver hanging maneuver: an alternative and safe technique for liver hanging
HPB, 2007
Background. Currently, a popular method for right hepatectomy is hepatic resection with the liver hanging maneuver. The aim of this study is to present an alternative and safe approach during this maneuver without using any instrument, thus avoiding injury. Patients and methods. From March 2005 to April 2006, a bimanual 'bi-finger' liver hanging maneuver (BBLHM) was planned in 22 right hepatectomies and the data were collected prospectively after operation. Results. BBLHM was performed in 21/22 patients (95%). The maneuver was stopped in one patient, due to manual detection of an accessory hepatic vein during finger dissection in the retrohepatic space. This vein did not allow completion of the BBLHM. The indications for right hepatectomy included 11 primary hepatic tumors (52%), 8 metastatic right hepatic tumors (38%), and 2 hydatid cysts (9%). Intraoperative ultrasound (IOUS) demonstrated the normal anatomical configuration type of the hepatic veins. Bleeding occurred in one patient (4%), which was interrupted with the use of continuous 6/0 polypropylene suture. Discussion. The most important step during the liver hanging maneuver is to develop the avascular space without any complication. In the present study, the index fingers were used instead of forceps during the blind dissection. BBLHM not only reduced the rate of damage to the hepatic veins but was also predictive for the presence of any accessory vein by its manual detection prior to injury. This maneuver allowed easier clamping of the hepatic veins and controllable hepatic resection. Dissection of retrohepatic space with the BBLHM produces a safer method, using both index fingers instead of a surgical instrument.