Surgical approach for hepatectomy
Executive Summary
The selection of a surgical approach for hepatectomy is a critical decision-making process intended to maximize patient safety and ensure optimal surgeon comfort. While several techniques exist, the choice is governed by patient morphology, the specific site of the lesions, the nature of the intended operation, and the surgeon's preference.
Critical Takeaways:
The Right Subcostal Incision remains the most widely performed approach due to its versatility for nearly all types of hepatic resection.
The "Mercedes" Incision (Bilateral subcostal with midline extension) provides excellent exposure but carries a significantly higher risk of postoperative incisional hernia, particularly in high-risk populations (obese, aged, or those with ascites).
Patient Morphology Matters: Midline incisions are efficient but may offer inadequate exposure in overweight patients or those with increased anteroposterior distances. Conversely, subcostal incisions may be limited in thin patients with long xipho-umbilical distances.
Specialized Approaches: The Makuuchi (J) incision and the Modified Makuuchi (L) incision offer targeted exposure while aiming to reduce hernia risks or preserve abdominal wall innervation.
The Trans-diaphragmatic Approach is a niche technique reserved for cirrhotic patients requiring limited resections of the hepatic dome (segments VII and VIII) to avoid the risks of laparotomy and potential liver failure.
1. Patient Installation and Preparation
Standardized positioning is applicable across all abdominal incisions used for hepatic surgery. Proper installation is the first step toward achieving adequate exposure and ensuring patient safety.
Positioning: The patient is placed in a recumbent position. Arms are either spread apart to allow access for anesthesiologists or the right arm is tucked alongside the patient.
Exposure Enhancements:
A transverse cushion (gel or rolled drape) is placed at the level of the bottom of the scapulas to expose the epigastric area.
Alternatively, the cushion may be placed under the right flank to enhance exposure of the right liver's posterior aspect and the right border of the vena cava.
Instrumentation: Subcostal retractors are attached to two posts placed above each shoulder. Surgeons must ensure there is no direct contact between the patient’s shoulders and these posts once the retractors are deployed.
2. Analysis of Abdominal Incisions
2.1 Right Subcostal Incision
The right subcostal incision is the standard approach for most hepatic surgeries.
Procedure: The incision is made 2 to 3 cm (two finger-breadths) below the right costal margin. It is vital to incise muscular planes exactly in line with the skin incision to prevent muscle length loss due to retraction.
Advantages: High versatility; it can be extended cephalad or to the left as needed.
Disadvantages: In thin patients with a long xipho-umbilical distance, exposure of the right subdiaphragmatic region can be restricted.
Closure: Requires two or three layers of slowly absorbable continuous sutures. Skin closure must be exceptionally tight to mitigate risks associated with postoperative ascites.
2.2 Bilateral Subcostal with Midline Cephalad Extension ("Mercedes")
This approach involves extending the right subcostal incision across the midline and cephalad.
Exposure: Provides superior access; sometimes requires resection of the xiphoid process to further enhance exposure.
Risks: The junction between the midline and transversal incisions is a frequent site for incisional hernias.
Clinical Guidance: This approach should be avoided in patients with high hernia risk factors, such as obesity, advanced age, or expected postoperative ascites. A simple cephalad extension is often preferable to the full "Mercedes" pattern.
2.3 Midline Incision
The midline incision is prized for its simplicity and speed.
Advantages: Rapid opening and closing, reducing overall operative duration.
Disadvantages: Historically associated with higher pain levels and pulmonary complications, though recent meta-analyses suggest these differences may not be statistically significant regarding analgesic consumption.
Contraindications: It does not provide adequate exposure for the right subcostal region in overweight patients or those with a deep anteroposterior distance.
Technical Note: Fascial closure is best performed with slowly absorbable running sutures, which are associated with fewer hernias than interrupted sutures.
3. Specialized and Targeted Incisions
4. Trans-diaphragmatic Thoracic and Thoracoabdominal Approaches
Accessing segments VII and VIII (the hepatic dome) through the abdomen typically requires extensive liver mobilization, which can be hazardous in cirrhotic patients.
The Thoracic Approach: An anterolateral thoracotomy is performed in the 7th or 8th costal interspace. The diaphragm is divided peripherally (approx. 3 cm from the ribs) to avoid injuring the phrenic nerve.
Indications:
Cirrhotic patients requiring limited resection of the dome to avoid postoperative liver failure caused by dividing portal collateral circulation.
Patients with a history of antecedent laparotomy.
Limitations:
Does not allow for full exploration of the abdominal cavity or the liver.
Prevents the ability to clamp the hepatic pedicle if needed.
Requires the patient to have satisfactory respiratory function.
5. Conclusion and Clinical Decision-Making
The selection of the surgical approach remains a subjective decision that must be grounded in objective preoperative data. The document concludes that the final strategy should be determined through:
Physical Examination: Assessing the patient in the supine position.
Imaging Analysis: Reviewing abdominopelvic CT scans to determine the morphology of the liver and the distance between the abdominal wall and the organ.
Intraoperative Confirmation: Re-evaluating the approach once the patient is positioned on the table with supports in place.
Surgeons are cautioned to balance the need for exposure with the long-term risks of incisional hernias and pulmonary complications.
