Skip to main content
SpringerLink
Log in

Lebertranssektion: moderne Verfahren

Technik, Ergebnisse und Kosten

Liver transection: modern procedure

Technique, results and costs

  • Übersichten
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Die Leberresektion gehört dank moderner Resektionsverfahren, guter Kenntnisse der Anatomie, präziser präoperativer Bildgebung und optimiertem anästhesiologischem Management, das einen niedrigen zentralvenösen Blutdruck zum Ziel hat, zu den chirurgischen Standardverfahren mit geringer postoperativer Morbidität und Mortalität. Während in der Vergangenheit Blutungskomplikationen im Vordergrund standen und als Folge dessen das Pringle-Manöver angewendet werden musste, gehört heute das Galleleck zu den Hauptproblemen in der Leberchirurgie. Für die Parenchymtranssektion stehen verschiedene Techniken zur Verfügung, die sich der Ultraschalldissektion über Klammernahtgeräte und hochfrequenten Strom bis hin zur lokalen Mikrowellenablation bedienen, wobei auch die klassische Clamp-crush-Technik weiterhin Bedeutung hat. Gerade in den letzten Jahren sind auch minimal-invasive Techniken in der Leberchirurgie untersucht worden, die zwar an Bedeutung gewinnen, zurzeit aber nur bei ausgewählten Patienten angewandt werden. Die Wahl der jeweiligen Technik hängt stark vom Resektionstyp (atypisch oder anatomisch) ab, aber auch von der Parenchymbeschaffenheit, der Lebererkrankung, Kosten und persönlichen Erfahrungen. In diesem Artikel werden verschiedene Verfahren der Parenchymdurchtrennung bei Leberresektion vorgestellt und im Hinblick auf deren Ergebnisse mit besonderem Augenmerk auf Transsektionsdauer, Blutverlust und Gallefistelrate sowie Kosten analysiert.

Abstract

Liver resection has developed into the current standard procedure due to modern resection techniques, profound knowledge of the liver anatomy and optimized surgical and anesthesiological strategies to allow extended resections with both low morbidity and mortality. Initially major blood loss was the biggest concern with liver resection and a Pringle’s manoeuvre was necessary. Nowadays, biliary leakage is the major problem after liver surgery. Besides the classical conventional clamp crushing technique for parenchymal transection, various devices including ultrasound, microwaves and staplers have been introduced. Minimally invasive techniques have become increasingly important for liver resection but are still applied in selected patients only. The selection of the resection technique and device mainly depends on the extent of the resection and also on the liver parenchyma, the liver disease, costs, personal experiences and preferences. This article presents a selection of techniques used in modern parenchymal transection during liver resection with special focus on transection time, blood loss, bile leakage and costs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. Alexiou VG, Tsitsias T, Mavros MN et al (2013) Technology-assisted versus clamp-crush liver resection: a systematic review and meta-analysis. Surg Innov 20:414–428

    Article  PubMed  Google Scholar 

  2. Arita J, Hasegawa K, Kokudo N et al (2005) Randomized clinical trial of the effect of a saline-linked radiofrequency coagulator on blood loss during hepatic resection. Br J Surg 92:954–959

    Article  CAS  PubMed  Google Scholar 

  3. Azagra JS, Goergen M, Gilbart E et al (1996) Laparoscopic anatomical (hepatic) left lateral segmentectomy-technical aspects. Surg Endosc 10:758–761

    Article  CAS  PubMed  Google Scholar 

  4. Bismuth H (1982) Surgical anatomy and anatomical surgery of the liver. World J Surg 6:3–9

    Article  CAS  PubMed  Google Scholar 

  5. Bismuth H, Castaing D, Garden OJ (1989) Major hepatic resection under total vascular exclusion. Ann Surg 210:13–19

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  6. Bruns H, Hoffmann K, Schemmer P (2014) Aktuelle Konzepte in der Leberchirurgie bei malignen Tumoren. Passion Chirurgie (im Druck)

  7. Bruns H, Krätschmer K, Hinz U et al (2010) Quality of life after curative liver resection: a single center analysis. World J Gastroenterol 16:2388–2395

    Article  PubMed Central  PubMed  Google Scholar 

  8. Bruns H, Schemmer P (2014) Moderne Leberchirurgie. Chir Allg Z 15(3):175–180

    Google Scholar 

  9. Bruns H, Frankenberg M von, Radeleff B et al (2009) Chirurgische Therapie des Lebertraumas. Chirurg 80:915–922

    Article  CAS  PubMed  Google Scholar 

  10. Campagnacci R, De Sanctis A, Baldarelli M et al (2007) Hepatic resections by means of electrothermal bipolar vessel device (EBVS) LigaSure V: early experience. Surg Endosc 21:2280–2284

    Article  CAS  PubMed  Google Scholar 

  11. Capussotti L, Polastri R (1998) Operative risks of major hepatic resections. Hepatogastroenterology 45:184–190

    CAS  PubMed  Google Scholar 

  12. Couinaud C (1999) Liver anatomy: portal (and suprahepatic) or biliary segmentation. Dig Surg 16:459–467

    Article  CAS  PubMed  Google Scholar 

  13. Couinaud C (1954) Lobes et segments hepatiques: Notes sur l’architecture anatomique et chirurgicale de foie. Presse Med 62:709–712

    CAS  PubMed  Google Scholar 

  14. Demirbas T, Bulutcu F, Dayangac M et al (2013) Which incision is better for living-donor right hepatectomy? Midline, J-shaped, or Mercedes. Transplant Proc 45:218–221

    Article  CAS  PubMed  Google Scholar 

  15. Doklestic K, Karamarkovic A, Stefanovic B et al (2012) The efficacy of three transection techniques of the liver resection: a randomized clinical trial. Hepatogastroenterology 59:1501–1506

    PubMed  Google Scholar 

  16. Dokmak S, Fteriche FS, Borscheid R et al (2013) 2012 Liver resections in the 21st century: we are far from zero mortality. HPB (Oxford)

  17. Dulucq JL, Wintringer P, Stabilini C et al (2005) Laparoscopic liver resections: a single center experience. Surg Endosc 19:886–891

    Article  CAS  PubMed  Google Scholar 

  18. Fancellu A, Rosman AS, Sanna V et al (2011) Meta-analysis of trials comparing minimally-invasive and open liver resections for hepatocellular carcinoma. J Surg Res 171:e33–e45

    Article  PubMed  Google Scholar 

  19. Fischer L, Seiler CM, Broelsch CE et al (2011) Hemostatic efficacy of TachoSil in liver resection compared with argon beam coagulator treatment: an open, randomized, prospective, multicenter, parallel-group trial. Surgery 149:48–55

    Article  PubMed  Google Scholar 

  20. Fischer L, Tetzlaff R, Schobinger M et al (2010) How many CT detector rows are necessary to perform adequate three dimensional visualization? Eur J Radiol 74:e144–e148

    Article  PubMed  Google Scholar 

  21. Gauzolino R, Castagnet M, Blanleuil ML et al (2013) The ALPPS technique for bilateral colorectal metastases: three „variations on a theme“. Updates Surg 65:141–148

    Article  PubMed  Google Scholar 

  22. Gavelli A, Ghiglione B, Huguet C (1993) Risk factors of hepatectomies: results of a multivariate study. Apropos of 113 cases. Ann Chir 47:586–591

    CAS  PubMed  Google Scholar 

  23. Guillaud A, Pery C, Campillo B et al (2013) Incidence and predictive factors of clinically relevant bile leakage in the modern era of liver resections. HPB (Oxford) 15:224–229

  24. Gurusamy KS, Samraj K, Davidson BR (2007) Routine abdominal drainage for uncomplicated liver resection. Cochrane Database Syst Rev: CD006232

    Google Scholar 

  25. Heisterkamp J, Marsman HA, Eker H et al (2008) A J-shaped subcostal incision reduces the incidence of abdominal wall complications in liver transplantation. Liver Transpl 14:1655–1658

    Article  PubMed  Google Scholar 

  26. Huang ZQ, Xu LN, Yang T et al (2009) Hepatic resection: an analysis of the impact of operative and perioperative factors on morbidity and mortality rates in 2008 consecutive hepatectomy cases. Chin Med J (Engl) 122:2268–2277

    Google Scholar 

  27. Huguet C, Gavelli A, Bona S (1994) Hepatic resection with ischemia of the liver exceeding one hour. J Am Coll Surg 178:454–458

    CAS  PubMed  Google Scholar 

  28. Ikeda M, Hasegawa K, Sano K et al (2009) The vessel sealing system (LigaSure) in hepatic resection: a randomized controlled trial. Ann Surg 250:199–203

    Article  PubMed  Google Scholar 

  29. Imamura H, Seyama Y, Makuuchi M et al (2008) Sequential transcatheter arterial chemoembolization and portal vein embolization for hepatocellular carcinoma: the university of Tokyo experience. Semin Intervent Radiol 25:146–154

    Article  PubMed Central  PubMed  Google Scholar 

  30. Jarnagin WR, Belghiti J, Blumgart LH et al (2012) Blumgart’s surgery of the liver, biliary tract, and pancreas, Bd 2. Elsevier Saunders, Philadelphia, (xxxi, 1844, 1830 p)

  31. Jones RM, Moulton CE, Hardy KJ (1998) Central venous pressure and its effect on blood loss during liver resection. Br J Surg 85:1058–1060

    Article  CAS  PubMed  Google Scholar 

  32. Kadry Z, Malekkiani N, Clavien PA (2001) Treatment of primary and secondary liver malignancy. Swiss Med Wkly 131:338–345

    CAS  PubMed  Google Scholar 

  33. Koo BN, Kil HK, Choi JS et al (2005) Hepatic resection by the Cavitron Ultrasonic Surgical Aspirator increases the incidence and severity of venous air embolism. Anesth Analg 101:966–970 (table of contents)

    Article  PubMed  Google Scholar 

  34. Lang H (2007) Technik der Leberresektion Teil I. Leberanatomie und Operationsplanung. Chirurg 78:761–773 (quiz 774)

    Article  CAS  PubMed  Google Scholar 

  35. Lang H, Sotiropoulos GC, Malago M et al (2003) Mesohepatectomy, caudate lobectomy and resection of hilar bifurcation with biliary reconstruction by 6 hepaticojejunostomies for Klatskin tumor. Hepatogastroenterology 50:1327–1329

    PubMed  Google Scholar 

  36. Langenbuch C (1888) Ein Fall von Resektion eines linksseitigen Schnürlappens der Leber. Heilung. Berliner Klin Wochenschr 25

  37. Lesurtel M, Selzner M, Petrowsky H et al (2005) How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies. Ann Surg 242:814–823

    Article  PubMed Central  PubMed  Google Scholar 

  38. Li J, Malago M, Sotiropoulos GC et al (2009) Intraoperative application of „white test“ to reduce postoperative bile leak after major liver resection: results of a prospective cohort study in 137 patients. Langenbecks Arch Surg 394:1019–1024

    Article  PubMed  Google Scholar 

  39. Li M, Zhang W, Li Y et al (2013) Radiofrequency-assisted versus clamp-crushing parenchyma transection in cirrhotic patients with hepatocellular carcinoma: a randomized clinical trial. Dig Dis Sci 58:835–840

    Article  PubMed  Google Scholar 

  40. Lim C, Farges O (2012) Portal vein occlusion before major hepatectomy in patients with colorectal liver metastases: rationale, indications, technical aspects, complications and outcome. J Visc Surg 149:e86–e96

    Article  CAS  PubMed  Google Scholar 

  41. Lin TY (1974) A simplified technique for hepatic resection: the crush method. Ann Surg 180:285–290

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  42. Lin TY, Hsu KY, Hsieh CM et al (1958) Study on lobectomy of the liver; a new technical suggestion on hemihepatectomy and reports of three cases of primary hepatoma treated with total left lobectomy of the liver. J Formosan Med Assoc 57:742

    Google Scholar 

  43. Lordan JT, Stenson KM, Karanjia ND (2011) The value of intraoperative ultrasound and preoperative imaging, individually and in combination, in liver resection for metastatic colorectal cancer. Ann R Coll Surg Engl 93:246–249

    Article  PubMed Central  PubMed  Google Scholar 

  44. Lupo L, Gallerani A, Panzera P et al (2007) Randomized clinical trial of radiofrequency-assisted versus clamp-crushing liver resection. Br J Surg 94:287–291

    Article  CAS  PubMed  Google Scholar 

  45. Mehrabi A, Kashfi A, Fonouni H et al (2006) Comparative analysis of the biliostatic effect of two modern sealants after liver resection in a porcine model. Chirurgisches Forum 2006 für experimentelle und klinische Forschung, 123. Kongress der Deutschen Gesellschaft für Chirurgie Berlin 35:305–307

    Google Scholar 

  46. Nijkamp MW, Van Der Bilt JD, Snoeren N et al (2010) Prolonged portal triad clamping during liver surgery for colorectal liver metastases is associated with decreased time to hepatic tumour recurrence. Eur J Surg Oncol 36:182–188

    Article  CAS  PubMed  Google Scholar 

  47. O’rourke N, Fielding G (2004) Laparoscopic right hepatectomy: surgical technique. J Gastrointest Surg 8:213–216

    Article  Google Scholar 

  48. Okabe H, Beppu T, Chikamoto A et al (2014) Remnant liver volume-based predictors of postoperative liver dysfunction after hepatectomy: analysis of 625 consecutive patients from a single institution. Int J Clin Oncol 19(4):614–621

    Article  PubMed  Google Scholar 

  49. Pai M, Frampton AE, Mikhail S et al (2012) Radiofrequency assisted liver resection: analysis of 604 consecutive cases. Eur J Surg Oncol 38:274–280

    Article  CAS  PubMed  Google Scholar 

  50. Piccolboni D, Ciccone F, Settembre A et al (2008) Liver resection with intraoperative and laparoscopic ultrasound: report of 32 cases: ultrasonic shears device for liver parenchymal transection. Surg Endosc 22:1421–1426

    Article  PubMed  Google Scholar 

  51. Platzer W, Maurer H (1966) On the segmental arrangement of the liver. Acta Anat 63:8–31

    Article  CAS  PubMed  Google Scholar 

  52. Pringle JH (1908) V. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg 48:541–549

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  53. Rahbari NN, Wente MN, Schemmer P et al (2008) Systematic review and meta-analysis of the effect of portal triad clamping on outcome after hepatic resection. Br J Surg 95:424–432

    Article  CAS  PubMed  Google Scholar 

  54. Rauchfuss F, Voigt R, Gotz M et al (2009) Damage-control-Konzept bei Leberverletzungen. Chirurg 80:923–928

    Article  CAS  PubMed  Google Scholar 

  55. Reith HB (1995) Historisches zum Lebertrauma. Chir Gastroenterol 11:11–17

    Article  Google Scholar 

  56. Richter S, Kollmar O, Schuld J et al (2009) Randomized clinical trial of efficacy and costs of three dissection devices in liver resection. Br J Surg 96:593–601

    Article  CAS  PubMed  Google Scholar 

  57. Saiura A, Yamamoto J, Koga R et al (2006) Usefulness of LigaSure for liver resection: analysis by randomized clinical trial. Am J Surg 192:41–45

    Article  PubMed  Google Scholar 

  58. Salky B, Bauer J, Easter DW et al (1992) 1992 Scientific Session of the Society of American Gastrointestinal Surgeons (SAGES) Washington, D.C., USA, April 11–12, 1992. Surg Endosc 6:85–110

    Article  Google Scholar 

  59. Sanjay P, Watt DG, Wigmore SJ (2013) Systematic review and meta-analysis of haemostatic and biliostatic efficacy of fibrin sealants in elective liver surgery. J Gastrointest Surg 17:829–836

    Article  PubMed  Google Scholar 

  60. Savlid M, Strand AH, Jansson A et al (2013) Transection of the liver parenchyma with an ultrasound dissector or a stapler device: results of a randomized clinical study. World J Surg 37:799–805

    Article  PubMed  Google Scholar 

  61. Schemmer P, Bruns H, Weitz J et al (2008) Liver transection using vascular stapler: a review. HPB (Oxford) 10:249–252

  62. Schemmer P, Friess H, Dervenis C et al (2007) The use of endo-GIA vascular staplers in liver surgery and their potential benefit: a review. Dig Surg 24:300–305

    Article  PubMed  Google Scholar 

  63. Schemmer P, Friess H, Hinz U et al (2006) Stapler hepatectomy is a safe dissection technique: analysis of 300 patients. World J Surg 30:419–430

    Article  PubMed  Google Scholar 

  64. Schmidbauer S, Hallfeldt KK, Sitzmann G et al (2002) Experience with ultrasound scissors and blades (UltraCision) in open and laparoscopic liver resection. Ann Surg 235:27–30

    Article  PubMed Central  PubMed  Google Scholar 

  65. Schnitzbauer AA, Lang SA, Goessmann H et al (2012) Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg 255:405–414

    Article  PubMed  Google Scholar 

  66. Shindoh J, Vauthey JN, Zimmitti G et al (2013) Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach. J Am Coll Surg 217:126–134

    Article  PubMed  Google Scholar 

  67. Takacs I, Furka A, Kovacs G et al (2007) Mesohepatectomy without hilar dissection in the treatment of malignant focal liver diseases. Hepatogastroenterology 54:201–205

    CAS  PubMed  Google Scholar 

  68. Takayama T, Makuuchi M, Kubota K et al (2001) Randomized comparison of ultrasonic vs clamp transection of the liver. Arch Surg 136:922–928

    Article  CAS  PubMed  Google Scholar 

  69. Van Der Bilt JD, Kranenburg O, Borren A et al (2008) Ageing and hepatic steatosis exacerbate ischemia/reperfusion-accelerated outgrowth of colorectal micrometastases. Ann Surg Oncol 15:1392–1398

    Article  Google Scholar 

  70. Van Der Bilt JD, Kranenburg O, Nijkamp MW et al (2005) Ischemia/reperfusion accelerates the outgrowth of hepatic micrometastases in a highly standardized murine model. Hepatology 42:165–175

    Google Scholar 

  71. Van Lienden KP, Van Den Esschert JW, De Graaf W et al (2013) Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol 36:25–34

    Article  Google Scholar 

  72. Vibert E, Perniceni T, Levard H et al (2006) Laparoscopic liver resection. Br J Surg 93:67–72

    Article  CAS  PubMed  Google Scholar 

  73. Weiss MJ, Ito H, Araujo RL et al (2013) Hepatic pedicle clamping during hepatic resection for colorectal liver metastases: no impact on survival or hepatic recurrence. Ann Surg Oncol 20:285–294

    Article  PubMed  Google Scholar 

  74. Xiaobin F, Shuguo Z, Jian Z et al (2012) Effect of the pringle maneuver on tumor recurrence of hepatocellular carcinoma after curative resection (EPTRH): a randomized, prospective, controlled multicenter trial. BMC Cancer 12:340

    Article  PubMed Central  PubMed  Google Scholar 

  75. Xiaobin F, Zipei L, Shuguo Z et al (2009) The Pringle manoeuvre should be avoided in hepatectomy for cancer patients due to its side effects on tumor recurrence and worse prognosis. Med Hypotheses 72:398–401

    Article  PubMed  Google Scholar 

  76. Yamamoto Y, Ikai I, Kume M et al (1999) New simple technique for hepatic parenchymal resection using a Cavitron Ultrasonic Surgical Aspirator and bipolar cautery equipped with a channel for water dripping. World J Surg 23:1032–1037

    Article  CAS  PubMed  Google Scholar 

Download references

Danksagung

Die Autoren bedanken sich bei Frau Kirsten Braun für das ausgezeichnete Lektorat des Artikels.

Einhaltung ethischer Richtlinien

Interessenkonflikt. H. Bruns, M.W. Büchler und P. Schemmer geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Author information

Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ruprecht-Karls-Universität, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    H. Bruns, M.W. Büchler &  P. Schemmer

Authors
  1. H. Bruns
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M.W. Büchler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. P. Schemmer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. Schemmer.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bruns, H., Büchler, M. & Schemmer, P. Lebertranssektion: moderne Verfahren. Chirurg 86, 552–560 (2015). https://doi.org/10.1007/s00104-014-2892-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-014-2892-x

Schlüsselwörter

Keywords

Search

Navigation