Combined Cardiothoracic and Abdominal Approach
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A combined cardiothoracic-abdominal approach may be required during liver surgery: when a liver tumor extends into the vena cava or right atrium, when it invades the diaphragm, and when it requires an extensive mobilization of the liver from the inferior vena cava at the hepatocaval confluence. In liver transplantation (LT), a combined approach is required when the LT is performed in combination with heart or lung transplantation, when concomitant coronary bypass and aortic valve replacement are mandatory to perform the transplantation, and when the upper caval anastomosis should be performed directly on the right atrium. In this chapter we describe the surgical technique to perform a liver resection under cardiopulmonary bypass or deep hypothermia and circulatory arrest; furthermore, we present some strategies to handle a diaphragm defect deriving from an en bloc resection and the technique to access the liver through a thoraco-phreno-abdominal approach. Surgical techniques for combined liver and thoracic organ transplantation are presented as well. Liver resection surgery requiring a combined approach is generally burdened by high postoperative morbidity (ranging from 20.7% to 40%) and poor long-term survival (median survival ranging from 16.4% to 30.8%); combined liver and thoracic organ transplantation reaches results similar to those of isolated single organ transplantation.
KeywordsLiver surgery Liver transplantation Combined surgery Combined transplantation Extreme surgery
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