Anatomical resection of segment VIII (SVIII) is one of the most difficult hepatectomies to perform. Although it is the best choice of surgical treatment for tumors located at SVIII, its feasibility can be compromised when the right hepatic vein (RHV) must be resected en bloc with SVIII. Herein we describe a case of a cirrhotic patient that was submitted to segmentectomy VIII in bloc with the main trunk of the RHV, due to hepatocellular carcinoma. The resection could only be performed because a well developed inferior right hepatic vein (IRHV) was present. Anatomical variations of the liver vascularization should be used by liver surgeons to improve surgical results.
Right hepatectomy is the procedure of choice for most patients with normal liver function and hepatic tumors located in the right liver, especially those in close contact to the right hepatic vein (RHV). Parenchyma-sparing resection may be required, however, in patients with impaired liver function and this is common in patients with cirrhosis and hepatocellular carcinoma (HCC).
For tumors confined to segment VIII (SVIII) of the liver, the procedure of segmentectomy VIII offers a chance of anatomically resecting the tumor while preserving most of the liver tissue. This procedure, however, can be really challenging when the tumor is to close to the RHV.
Up to 21% of patients have a large inferior right hepatic vein (IRHV) that drains the inferior segments of the right hemiliver [
Herein we describe a case of isolated segmentectomy VIII due to HCC in a cirrhotic patient, in which the presence of an IRHV enabled the section of the RHV without harming the drainage of inferior segments.
A 66-year-old woman was admitted to our hospital with an abdominal ultrasonography showing a 2 cm nodule in SVIII of the liver. She had been previously diagnosed with Hepatitis B, but received no further treatment. Laboratory tests revealed AST 34 U/L, ALT 28 U/L, total bilirubin 0.8 mg/dL, INR 1.1 and albumin 4.5 g/dL, which demonstrated a minor liver disfunction. As she had no ascites or encephalopathy, she was classified as Child-Pugh’s grade A. Alpha-fetoprotein level was 845 ng/mL. MRI confirmed a 2.5 tumor touching and compressing the main trunk of RHV (Figure
T2 weighted Magnetic Resonance image showing a tumor (arrow) compressing the RHV (arrow head).
T1 weighted Magnetic Resonance image showing inferior right hepatic vein (arrow).
Surgery was performed by bilateral subcostal laparotomy. Structures of the hepatic pedicle were dissected. Right portal vein (RPV) and right hepatic artery (RHA) were isolated. Retrohepatic inferior vena cava was dissected. RHV and IRHV were encircled (Figure
Retrohepatic inferior vena cava. RHV (arrow head) and inferior right hepatic vein (arrow) are encircled.
Final aspect of surgery. Divided RHV (arrow head) and portal pedicle (arrow) can be seen.
On post-operative (PO) period, AST, ALT, total bilirubin and INR raised up to 288 U/L, 254 U/L, 0.7 mg/dL and 1.62, respectively. On PO day 6, patient presented fever and abdominal pain. CT scan revealed fluid collection at right subphrenic space, which was confirmed as a biloma after percutaneous drainage. Patient was discharge on PO day 16 after 10 days of antibiotic therapy. She had no further complications and is doing well, with no signs of HCC relapse, after 18 months.
Patients with large or deeply located liver tumors in SVIII are normally submitted to right hepatectomy or extended right hepatectomy to guarantee an oncological resection of the tumor. However, these major resections may not be tolerated by patients with poor liver reserve, which is often seen in HCC associated to cirrhosis. As HCC tends to metastasize via the portal vein [
Among segmentectomies, isolated resection of SVIII is the most challenging and complex liver resections to perform. This segment is surrounded by the RHV laterally, the middle hepatic vein medially, and the anterior branch of the RPV inferiorly. Moreover, the absence of anatomic landmarks on the liver surface makes it difficult to determine the precise extent of resection. All these circumstances render an isolated resection of SVIII technically demanding, but still feasible to be done. Surgical techniques have already been described to provide an anatomical and secure resection of SVIII [
In particular cases, as the one described here, the tumor may be in close contact to the RHV and its resection together with the tumor is necessary. For these cases, drainage of the right liver can be seriously compromised, unless a variant drainage system of the hepatic veins is present. Fang et al. [
In the case herein reported, we performed the segmentectomy VIII associated to RHV resection because a IRHV was identified. If such anatomical variation was not present, this patient would have been elected for liver transplant, a much more aggressive treatment.
Machado et al. [
In conclusion, every patient eligible for a liver surgery must have his liver anatomy evaluated. Liver surgeons should be prepared to use anatomy variations in favor of their patients. Inferior right hepatic vein is a useful variation for isolated resection of SVIII, when the RHV must be sacrificed.
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