Subscribe to RSS
DOI: 10.1055/s-2004-832402
© Georg Thieme Verlag Stuttgart · New York
Funktionelle Lebermorphologie und anatomiegerechte Prinzipien der Leberchirurgie
Functional Liver Morphology and Anatomical Principles of Liver SurgeryPublication History
Publication Date:
01 December 2004 (online)
![](https://www.thieme-connect.de/media/viszeralchirurgie/200406/lookinside/thumbnails/10.1055-s-2004-832402-1.jpg)
Zusammenfassung
Die Leberchirurgie hat sich in den letzten Jahren zu einer standardisierten und sicheren Operation innerhalb der Viszeralchirurgie entwickelt. Die Mortalität liegt in erfahrenen Zentren heute unter 5 %, die Morbidität unter 30 %. Die Kenntnisse der intrahepatischen Anatomie und technischen Fähigkeiten des Chirurgen sind die maßgeblichen Faktoren, die diese Ergebnisse ermöglichen. Die postoperative Leberinsuffizienz ist die häufigste Ursache komplizierter Verläufe nach Leberteilresektion. Daher kommt der Bestimmung des prospektiven Leberrestvolumens und der -funktion eine besondere Bedeutung zu. Während das Restlebervolumen heute mittels CT oder MRT leicht bestimmt werden kann, basiert die Einschätzung der prospektiven Restleberfunktion in Ermangelung aussagefähiger Funktionstests noch heute auf die Erfahrung des Chirurgen. Bei normaler Leberqualität sollte das prospektive Leberrestvolumen mehr als 0,5 % des Körpergewichtes betragen. Mit einer Unterschreitung dieser unteren Grenze ist nur bei der erweiterten Hemihepatektomie rechts zu rechnen. Wird diese Grenze unterschritten, kann durch eine Pfortaderligatur, oder -embolisation der zu resezierenden Lebersegmente das prospektive Leberrestvolumen vergrößert werden. Bei eingeschränkter Leberqualität (Leberfibrose, -zirrhose, Fettleber, Cholestase, Z. n. Chemotherapie) können diese Methoden ebenfalls zur Verbesserung der postoperativen Leberfunktion beitragen. Die Anwendung in dieser Situation bedarf jedoch einer besonderen Erfahrung und Sorgfalt.
Abstract
Liver surgery has developed to a standardized and safe procedure within abdominal surgery. In experienced centres postoperative mortality reached nowadays less than 5 % and morbidity less than 30 %. Knowledge of the intrahepatic anatomy and technical skills are the main factors, which contribute to these results. Postoperative liver insufficiency is the most common reason for significant postoperative disturbance. Therefore measurement of volume and function of the future liver remnant is an important issue. The volume of the future liver remnant can be easily calculated with CT or MRI. Estimation of the function of the future liver remnant is still based on the experience of the surgeon, since available liver function tests are failing to predict function of the future liver remnant. In cases of normal liver quality the volume of the future liver remnant should be larger than 0.5 % of body weight. This limit will be reached only by performing extended right resections. Both, portal vein ligation and embolisation are able to increase the remnant liver volume prior resection. These tools are also helpful in patients with impaired liver quality due to fibrosis, cirrhosis, fatty change, cholestasis, or status post chemotherapy. The indication in this situation is based on individual situations and needs special experience and carefulness.
Schlüsselwörter
Leberchirurgie - Anatomie - Leberresektion - Funktionsreserve - Leberregeneration - Pfortaderembolisation
Key words
Liver surgery - anatomy - hepatic resection - functional reserve - liver regeneration - portal vein embolisation
Literatur
- 1 Couinaud C. Surgical Anatomy of the liver revisited. Paris 1989
- 2 Rex H. Beiträge zur Morphologie der Säugerleber. Morph Jahrb. 1888; 14 517
- 3 Makuuchi M. et al . The inferior right hepatic vein: ultrasonic demonstration. Radiology. 1983; 148 213-217
- 4 Nonami T. et al . Blood loss and ICG clearance as best prognostic markers of post-hepatectomy liver failure. Hepatogastroenterology. 1999; 46 1669-1672
- 5 Hwang E H. et al . Preoperative assessment of residual hepatic functional reserve using 99mTc-DTPA-galactosyl-human serum albumin dynamic SPECT. J Nucl Med. 1999; 40 1644-1651
- 6 Behrns K E. et al . Hepatic steatosis as a potential risk factor for major hepatic resection. J Gastrointest Surg. 1998; 2 292-298
- 7 Selzner M, Clavien P A. Fatty liver in liver transplantation and surgery. Semin Liver Dis. 2001; 21 105-113
- 8 Pocard M. et al . Effects of preoperative chemotherapy on liver function tests after hepatectomy. Hepatogastroenterology. 2001; 48 1406-1408
- 9 Brunken C. et al . [Is resection of colorectal liver metastases still justified in very elderly patients?]. Chirurg. 1998; 69 1334-1339
- 10 Su C H. et al . Factors influencing postoperative morbidity, mortality, and survival after resection for hilar cholangiocarcinoma. Ann Surg. 1996; 223 384-394
- 11 Heinemann A. et al . Standard liver volume in the Caucasian population. Liver Transpl Surg. 1999; 5 366-368
- 12 Leelaudomlipi S. et al . Volumetric analysis of liver segments in 155 living donors. Liver Transpl. 2002; 8 612-614
- 13 Broering D C, Sterneck M, Rogiers X. Living donor liver transplantation. J Hepatol. 2003; 38 (Suppl 1) 119-135
- 14 Shoup M. et al . Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg. 2003; 7 325-330
- 15 Mueller L. et al . The induction of the immediate-early-genes Egr-1, PAI-1 and PRL-1 during liver regeneration in surgical models is related to increased portal flow. J Hepatol. 2002; 37 606-612
- 16 Farges O, Denys A. [Portal vein embolization prior to hepatectomy. Techniques, indications and results]. Ann Chir. 2001; 126 836-844
- 17 Farges O. et al . Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg. 2003; 237 208-217
- 18 Broering D C. et al . Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant. J Gastrointest Surg. 2002; 6 905-913
- 19 Imamura H. et al . Preoperative portal vein embolization: an audit of 84 patients. Hepatology. 1999; 29 1099-1105
- 20 Mueller L. et al . Sustained function in atrophying liver tissue after portal branch ligation in the rat. J Surg Res. 2003; 114 146-155
- 21 Nagino M. et al . Right trisegment portal vein embolization for biliary tract carcinoma: technique and clinical utility. Surgery. 2000; 127 155-160
- 22 Kokudo N. et al . Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization. Hepatology. 2001; 34 267-272
- 23 Barbaro B. et al . Preoperative right portal vein embolization in patients with metastatic liver disease. Metastatic liver volumes after RPVE. Acta Radiol. 2003; 44 98-102
- 24 Azoulay D. et al . Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization. Ann Surg. 2000; 231 480-486
- 25 Belghiti J. et al . Continuous versus intermittent portal triad clamping for liver resection: a controlled study. Ann Surg. 1999; 229 369-375
- 26 Clavien P A. et al . Protective effects of ischemic preconditioning for liver resection performed under inflow occlusion in humans. Ann Surg. 2000; 232 155-162
- 27 Clavien P A. et al . A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg. 2003; 238 843-850
- 28 Hardy K J, McClure D N, Subwongcharoen S. Ischaemic preconditioning of the liver: a preliminary study. Aust N Z J Surg. 1996; 66 707-710
- 29 Belghiti J. et al . Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study. Ann Surg. 1996; 224 155-161
- 30 Cherqui D. et al . Hepatic vascular exclusion with preservation of the caval flow for liver resections. Ann Surg. 1999; 230 24-30
- 31 Torzilli G. et al . Liver resection without total vascular exclusion: hazardous or beneficial? An analysis of our experience. Ann Surg. 2001; 233 167-175
- 32 Jones R M, Moulton C E, Hardy K J. Central venous pressure and its effect on blood loss during liver resection. Br J Surg. 1998; 85 1058-1060
- 33 Chen H, Merchant N B, Didolkar M S. Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anesthesia improves morbidity and mortality. J Gastrointest Surg. 2000; 4 162-167
- 34 Broering D C. et al . Vessel loop-guided technique for parenchymal transection in living donor or in situ split-liver procurement. Liver Transpl Surg. 1998; 4 241
Prof. Dr. med. Dr. h. c. Xavier Rogiers
Universitätsklinikum Hamburg Eppendorf · Klinik für Hepatobiliäre Chirurgie und Viszerale Transplantation
Martinistraße 52
20246 Hamburg
Phone: + 49/40/4 28 03-61 36
Fax: + 49/40/4 28 03-34 31
Email: rogiers@uke.uni-hamburg.de