右三叶切除联合门静脉切除的肝门部胆管癌

Right trisectionectomy with portal vein resection for hilar cholangiocarcinoma

                               
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Li Xiangcheng, Wang ke, Yao aihua, Wu xiaofeng , Jiao chenyu, Peng rui, Wang Yun,Zhang Hai, Wang Xuehao
Liver Transplantation Center，Department of Surgery, Jiangsu Province Hospital ,Nanjing Medical University, Nanjing Jiangsu, China

Abstract

The most favorable long-term survival rate for hilar cholangiocarcinoma is achieved by a R0 resection. Anatomic right trisectionectomy with caudate lobectomy can gain a longer bile duct resection margin to increase the chance for R0 resection. This video shows resection of portal vein together with right trisectionectomy and caudate lobectomy .
A 65-year-old man presents with right upper abdominal pain and progressive jaundice for two weeks. He was diagnosed with hilar cholangiocarcinoma. Then he underwent percutaneous biliary drainage for palliation. his total bilirubin was decreased after PTCD. CT scan showed a resectable tumor.and atrophy of the right lobe, compensatory hypertrophy of segments 2 and 3. Surgical decision had been made to perform a right trisectionectomy and caudate lobectomy with portal vein resection
The operation began with hilar dissection. Right lobe was mobilized and detached from retrohepatic vena cava. The distal common bile duct was transected. Right hepatic artery was ligated and divided. Portal vein was dissected and encircled. After parenchymal transsection, Right and middle hepatic veins were cut and closed with vascular stapler. Portal vein bifurcation was resected. then portal vein anastomosis was done by end-to-end with 6-0 Prolene. And then specimen was removed. Ultrasound confirmed normal portal flow. The patient recovered uneventfully, Pathology confirmed hilar cholangiocarcinoma and R0 resection. Portal vein showed microscopic invasion. Patient was discharged on the 20th postoperative day.
Right trisectionectomy with portal vein resection is feasible and may increase the chance for R0 resection and gain better outcome, especially in cases when portal vein is microscopically involved only. This precedure can obtain relatively longer proximal resectable margin. Extended hepatectomy should be indicated for right-side predominant Bismuth type IV hilar cholangiocarcinoma, if liver function is adequate.