A method is described for one-stage complete hepatectomy in dogs with preservation of the inferior vena cava. The method can be done rapidly with minimal blood loss and has a low operative mortality. The maximum survival time compares favorably with other methods of hepatectomy. © 1959

Benvenuto, R

Bernhard, VM

Cortes, N

Starzl, TE

PubMed

D-Scholarship@Pitt

h i\;E\\. 3IETllOU 11'Olt ON]<-STAGIS IIEI'ATISCTOPIIY k'Olt J)OUS T. E. STAHXI., 3 1)., 1'11.1).,* V. 31. BICI~NIIAI~D, AI.I). ** 1t. BENVENUTO, hl.l).,  , i sn  N. COI~TES, K U . ,  CIIIC,\C;O, ILL. (Fvottr tltc 1)cpctrtrno~ts of S z~rgwy ,  Nortlatocstcrn Tlitivcr~sity Sclrool of Bfedicinc, nnrl 17. 8. Vc3tcrnws Administration Rcscarclt 11ospilnl) 0 NE of the traditional ~ilctllods for in~cstigation of the function of various viscera has been by analysis of tlic eoascqucnccs of rernoval of thc organ OY orgilns ill qncstion. Altllough this h;ls generally bccn a simple matter tcchni- (*;lily, tlic cstirpative approacli to the problc~n o f  l~cpatic function in t h a  dog has provccl to 11c rn~usually troul)lcsonic. Tlic anatomic basis for this is the close approsi~nation of the subdiapliragmatic inferior vena cava to t11c liver. This rclationship is so intimate that a scglncnt of vcna cava is rcscctcd in all popular mctliotls of total hcpatcctomy and i t  is commonly thought that re- inoval of tlie liver is not othci7vise pos~ible.~ Employing this principle, i t  is then . n&cssary to pl'ovide a mechanism for both portal and inferior caval venous re- tlui?~. This has bccn done with multiple-staged proccdnres designed to initially proniote collateral venous %r in single-stage operations by the inter- position of gla.. or plastic cannulae into thc resccted cam1 segment with drainage of thc portal system into the vena cava more i n f e r i ~ r l y . ~ ~  7* lo All presently eniployed methods of hepatectomy have serious disadvantages. The operative moitality is high. 3lultiple-staged methods require long intervals bct~vcen operations, the final operation is bloody due to the presence of ad- hesions, aricl the state of earal and portal drainage is likely to be inadequate in the preparation finally obtained. The use of prosthetic cannulae in single- stage techniques introduces other hazards of air embolus, hemorrhage and clot fo~wation, or defibi-ination in the cannula. I n  this laboratory, considerable experience has accumulated with a single- stage total l~epatectdrny in which no prosthetic devices are used and in which the inferior vena cava is preserved. The operation has a mortality of less than 10 per cent. ~Iaximum survival time conipares favorably with any other method. IIETHODS Sixty mongrcl dogs, weighing 10 to 30 kilograms weTe used. Until the day of surgery the animals were on standard kennel rations. In  56 cases, sodium 1)entobarbital anesthesia was uscd because of the requirements of the experiment for which hepatectomy was done. I n  4 animals used for study of maximam Aided by Grant  No. A-3176 from the United States Public Health Servlce, National Insti- tutes of Health. Bethesda. Md. Received for publication July 20. 1959. 'Markle Scholar. **Present address: Department of Surgery. Marquette University School of Medlclne. Milwaukee, Wis. . snrvil-a1 tinlc, ctllcr i~i~cstl~csia by Cacc 111;lslr wils e~~~l)loycd.  Endotracl~c;ll in- tul)ntio~l ~ v n s  not Ilrccssary since t l ~ c  plcul'nl ci~vitj. wi~s ncvcr cntcrcd. I'osl- opcrativcly, a glncosc infusion \\.;IS givcli nt illc rirtc of 0.3 to 1 Gm. per Itilo- ~ I . ~ I I I I  pcr hour. Isotonic salinc \\,as gi\rrn i ~ t  t11c r i ~ t ~  of 4 10 8 C.V. pcr kiIog~.il~~l r I .  Thc intravenous iilf'usions wcrc tlclivcrrd wit11 a constant inferior -- lu111p to ihc dogs ancsthctizcd with soclium l~c~itobi~vbital, nd intc~-mittcntly --\-with n sMngc  to tlic aili~lials operated upon 1111dcr ctllcr ancstllcsia. Tn ahol~t half of tllc nnimill+Qod tmnsfnsions of 200 to ROO C.C. wcrc givcn, eitlicr S C V C ~ A ~  110111's 1)cEore operaticnl-01' i ~ t  he t i ~ n c  of surgcly. Thc animals stndicrl for l~rnsilnu~il survival wcrc allo~vcil com~dctc frccdoin of a large room. Asirlc fro111 thc intmvenons infusions, and onc postoperative dose of pcncillin, no other therapy was givcn. Arterial a~zd venous pressures wcrc studiod with inductance nlanometeia wliicl~ hncl n frcqncncy response in exccw of 30 cyclcs pcr second. Tlie operation was done undcr clean rather than sterile conditions. Fig. 1.-Total llepatectomy in dog. Portacaval anastomosis has been completed, and the portal triad ligated and divided. A noncrushing clamp h a s  been applied to the inferior vena cava above the entrance of the adrenal veins. DESCRIPTIOX OF TECHNIQUE The abdonlcn is entered through a long upper midline incision (Fig. 1, inset). The inferior veila cava is looped with an umbilical tape, above the ciltrancc of 'tllc adrenal vcins, to facilitate subscqucnt manipulation. Tlie portal triad is siirlilarly cncirclcd. A long (at least 1 cni.) sidc-to-side pol.tncaral ani~stolnosis is tllen perfomcd, using m ~ l e r n  vascular teclinic~ncs, as previously described." l1 Next the ligattures around the portal triad are tied, and the triad is cut (Fig. 1). The inferior vena cava is then occluded with a noncrushing clamp above the level of the adrenal veins (Fig. 1). Srrrcrry STr\ll%I,, HI.:KNIIr\ltD, UENVENUrl'O, AND CORTES 1959 Tlic lia~id is ~ i c s t  placcd ovcr tlic do~nc of tllc livcr and with gcntlc dowll- \r;~r(i triictiol~ tlic nlcscntcrics connccti~ig tlic livcr lobcs to thc diapl~ragn~ zirc cut. IYIicn this is coiilplctccl n fiiigcr can bc insinu:ltcd around thc cava in the Sl)ilcc I)ct\rccn tlic diaphragli and tlie livcr. Tlle livcr is thcn retracted in- fcrior1.v. iiiitl n noncrnsliing cli~lnp is p1;icccl across tlic inferior vcna cava bc- t\r('t.~t t lie doi~lc of thc livcr ancl di:~l)l~ri~g~il (F g. 2 ) .  T ~ I C  Iivcr has IIOW l)cc11 coulplctcl>- tlcvi1scnli~rizct1, i ~ i i i l  thc s l~ort  scglnclit oC inl'crior vcna crt~ii into \vliicli the licpiltic vcins empty is trappcd bct\t~cca t l ~ c  two nonerushing cla~~ips. It is now possible, in s bloodless ficld, to dis~cct he livcr from thc inferior \.ellit cava. This is begun superiorly (Fig. 2 ) .  Vicwcd from bclow, tllc largc~st hcpi~tic vcin is locatcd at 2 o'clocli and is tlic first to I N  cncountcrccl (Pig. 2 ) .  It is oftc~i  casicst to cut boldly into this vcsz;cl and colnplctc its isolation from \vitlii~l the lunicn. Tlic livcr is thcn pcclcd inferiorly using s11al.p and blunt tlisscction, nild as other hcpatic vcins arc cilcountcrcd thcy arc isolatccl and ligiitccl. Bctwccn G and 8 liepatic vcins arc found in all. After the last vein is ticd, a flinisy vein of gastrohcpatic omcntum is tlie only remaining intact stiwcture. This is ligated and the spcri~ilcn removed. Fig. 2.-After occlusion of the suprahepatic vena cava the liver is removed; hepatic vein8 are ligated as encountered. The iiifeiior Pott's clamp is then removed. If any bleeding areas are en- countered on tlie inferior vena cava, these are repaired with arterial silk or ligated. 7Vhen hemostasis is complete the superior clamp is removed, and portal and inferior caval venous drainage is re-established (Fig. 3 ) .  The operating time, from skin to slrin, ranges from,60 to 90 minutes. The measured blood loss is ordinarily betwceli 50 and 200 c.c. * RESULTS Operative Mortality.-I-Iepatcctomy was attcmptcd on 60 dogs. Two animals dicd of hemorrhage during the portacaval anastomosis, and a third succumbed 2 hours postoperatively from intra-abdominal blecding. All other animals were used for study. The survival then in teims of the achievement of l'os/op( ~ . (~ t ivc  Z ~ c l t ~ ~ ~ i o ~ ~ . - ~ \ l l  i111i111als op(>~*iitrvl 111)on I I I I (~ (T  ct11(!1* a~~(lstl~t:sia \V()]<C ] ) I . O I I I { ~ ~ ~ ~  ; I I I ( ~  ~II)I)C~IIT><I to rl~~til-r\ly ~ I O I - I I I ~ I ~ .  A t  v;11,yi11g ti111(~s, ~ I W I I I  1,; to :Xi I I O I I I , ~ ,  r30111n tlcvrlol,ctl \ v l ~ i t * l l  wils 110 loiigc~r rcspollsivc to sugar atl- ~~l in is t~ . ;~ t io l~ .  ,\I1 (logs stutlicrl longcl. ~ , I I ; I IL  24 110111-s ~ i~ ;~~~ i l ' o s t c i l  H C C ~ I I ~ ~ ~ I I - . ~  l)lccdiug, citllcr i'roln t l ~ c  incisiol~, 01. witllil~ thc aI)dolncn, or  both. Until this dc~cluplllcllt t11~ ;ulinlals ~urin;~tctl I'l.c\cl~~cl~tly i111d Ili~d slow ~ U I H C R .  Al't~l' 1 1 1 ~  ollsct of tlic blcctlillg ~ P I I ~ C I I C , ~ ,  i111llrii1 t i1~1 ~)rofound tncllycardja occnl~ed ant1 wcrc i'ollo\vcti within a few l~onrs by tlcath. ~ l f a x i n ~ u l , ~  Survival Tiwte.-Thc 4 anilnals studied for inaximum survival lived 17, 29, 32, and 42 liours for an avcrngc of 30 ]lours. Fig..3 -Operative field after completion of hepateetomy. +-. - \ The E'fect of the Operatton on the Splanchnic and Systet~tic Circulation.- During the operation there is only one time when the circulatory dynamics of the portal vein and infelior.vena cava are not essentially normal. Tl~is  is during the 15 or 20 minutes while the liver is actually being removed, a t  ~11 ich  tilnc the inferior vena cava is occluded both above and bclow the liver. Since a t  this stage the portal vein has been drained into tile vena cava more inferiorly, thc portal and venous systems have been converted into a confluent venous pool, and there is concomitant obstruction of the splanclinic venous re- tuin. Espcriments were conducted in 3 animals to study the iinlnediatc effect of this occlusion on vascular pressures. Shown in Fig. 4 are the changes in the aortic blood pressure and the inferior vena caval pressure in a representative experiment. Since the portaeaval systems are in wide communication through 111,' ~ I I I I I I ~ .  1I1, l  l;111,11' I I I ; I ~  OISO 1 ) ~  (*ol~si(lrr~il ;I 1)01't:11 ] ) ~ P S S I I ~ ( ~ .  111 ~ I I C  C1iLSC sIlo\\.lr. ;I I ' ; r l l  i l l  i~rl( 'ri;~l 1)lQcss~il*c- o *cril*~~c~l to SO 111111. l l g  s).sloli~, (+oi~~(*i(l(>llf ~ v i t l i  ;L risr i l l  tllc portnc*ilv:~l pI.cssilrc lo 350 IIIIII. si~lil~e. 011cc csti~l)lisllc~tl, 1 1 1 ~  v:1\;(*11li1'1. I ) IY>S~III -CS r c l l~ i~ i l~  I-C ; I  t ively s1;11)Ic lint i l 1 I IC  ci~\,al cl:u111)s arc ~*clcasctl, l'ollo\\-il~: \\l~icli thcrc is p ~ ~ o n ~ p t  i*cstori~tioii of tllc prc-existing Iic~~~otlynarnic st:~tc cli'ig. 4 ) .  ,\lt l~ol~gll it was ortlinarily ncccssary to obstruct tlic portacaval system for ol1l.v 15 or 20 ~~~ i i iu t c s ,  i t  was desirable to know how long tliis occlusion could be niaiiitc~incd ~vitli snrvival. I n  5 dogs obstruction was imposed for one hour. In 1111 anilnals tllcrc was pron~pt  rccovcry after tlie clarnps were rcmovrd. - 5 ' +  Clamps 10 15 Clamps applied released Minutes During LiverRemovai Fig. 4.-I'ressurcs in the arterial and portacaral systems during hepateetomy. See text for explanation. a l t ~ f o l ) s ~  Fi~trZitlgs.-Autol)sy IV;IS ~)crforl~cCI 011 most of thc nninials in this scii-ic.; niid on all dogs studied for m n s i m ~ ~ ~ n  survival. Thrombosis of'the nnas- tornosis, portal yein, or iiifcrior vena cava was not found in any case. In  dogs follo~vctl ess tho11 2Q h o u i ~ ,  1.clativcly small ailloulitfi of blood-stained fluid were fonlicl in tllc al)doaicii. Ani~nals follo~ved for longer than this had large amo~uits oC nonclottcd blood in tlic al~domen-sometiilics as much as 1,000 c.c. The bo\vrl was gl-ossly nolmlnl in all c~wcs, and histologic sections made as late as 42 hours ~~ostol~crativcly were normal (Fig. 5) .  Tllc dcscribcd mctlioil reprcsclits ' a  ~eadical ilcp;il~tnrc froni thc usnal ~nctllotls of licl,ntcctoiny, all of which rescct a scgillcllt of tlic infcrior vcna cavil. Tlle only rc31)ort in wliicll pi-eservation of thc inferior vcna cava 11ns bccn i1cs~ril)cd ~ v a s  tliat of Iilrank and tlaco1~.3 Tllcse autliors first pcrfornicd an end- to-siclc portacaval sliuilt (necessitating tcmporaiy complete occlusion of the . portal vein). Tlicy then incticulously dissccteil and ligated the licpatic veins. Because this was not clone in a bloodless ficlcl, the operation was tedious (3 to 5 lioui*;) and bloody (requiring massive tlxnsfusion). Although 3 dogs survived . ;urg~~~.y,  t l ~ r '  i ~ l~ t l~o rq  I+(~(*OIII I I ICII (~( \~  t l ~ ; ~ t  tlit'ir 111(1111o11 101 1)c s ~ i l ~ ~ ~ i l ~ i l e ~ l  f01' th  ~bOllv~~lll i O l l i 1 ~  ~ ~ ~ ~ ~ ~ l l l i ( ~ l l ~ ~ ~  O r  I 1 ~ ' ~ ) i l ~ ~ ' ( ' I O i l l ~ .  Tllc ortlcl. in \vllic*l~ tlic tecl~nici~l s c.1)~ ;II.(> c.iti*ricd out will1 t l ~ c  prcsc>111 111ct110tl dchp~.\ cs flirt I I C V  C O I I I I ~ I C I ~ ~ .  I 1  I I I S  I ) (YI I I  I < I I O \ V I ~  l'oi. a 101ig t i~tte tI1i1t (+on~l)lctc o c.I~~.;ioil of tllc porti~l vc>ili (.;III bc cloilc s:~l'clly in clogs for ollly a few ~iii~iutc.;.~ ,\cute. occlusion ol' thc il~l'rrior vclia cava ahovc t l ~ c  rcnal veins, i~ltliougll cvc111uall~- l ' i ~ t i ~ l ,  clan I)c tolcriitctl for I I I ~ L I ~ Y  I I ~ I I Y S . ' ~ ~  " T ~ I C  difforehl~ce in rcsl'o~lsc to aci~tc ligittio~i in t l ~ c  two systcn~s is appilrcntly cluc to ;I grc:~tclr rnpilcity of tlic occlutlcti i~ll'cl-ior vcna c;ivi~ to sncldcnly utilize collatclsal (*11;111- ncls. \\'itli tlic prcscnt mctliod tllc ljortal a11c1 caval systc~nx arc first l)ror~gl~t illto comi~i~u~icatioli tlirougll the. anaston~osis and whrn the central (1rain;lgc of 1)oth vi~sculill. beds is conconunitnntly occluded, all collatcrals arc avililat)lc to citlicr systcai. The protective cffcct of this ~nctliocl was shown in tlw ~)rcsrnt, , study, in \vllirli it \\.as sliown that colnbiricd po~.tacaval obstruction could 1)c tolcratcd for 11luc11 longer pcrioils (up  to 2 Iionrs) than portal ohst~mction alone. Fig. .i.-Photomicrograph of intestine from dog which survived 4 2  hours after hepatectomy. The surgical proficiency necessary to pcrforrn this operation is no greater than in other techniques of hepatcctorny. Tlle only step that requires uiiusnal cart is the formation of the portacaval anastomosis. 13ecause of the elimination of many objectionable features of otller methods, this has proved to he for us thc lnost satisfactory method of total liepateetomy. .\ 111ctllot1 is clcse~.ibctl for one-stage, c o ~ ~ ~ p l d c  h c l ~ n t c c l o ~ l i y  in dogs mi t l i  ~ ) ~ ' c l h c r v ; ~ t  i on  of t i i c  i n f c r i o r  r c l i ; ~  earn. T l l c  nictl iotl  c a n  be donc rapidly with 1nii1i111;ll 1)lootl loss  nncl lias n low opc~.i~tivc mortality. The maximum s u i ~ i v a l  1 i l l l t~ ~ ~ O l I 1 ~ 1 ~ 1 t ~ ( ~ s  Sil~Ori1IlI)-  lvit l l  01 11(\1' l l l ( % ~ l O ( ~ ~  0t I ~ ~ ] ~ ~ I ~ c c ~ o I I I ~ .  I1ISl"I':I<ICSclCs 1 ~ I I I I : I I ,  1 ,  I I  ' o l e  1 I . :  (::IIIS~ of l)ent,h in Acute I'ortnl Obstruction, Tr .  Am. C;:is~ro.~~nterol. 11.36: l;Hi, l!I:!:i. 2. I'iror, \V. ,\I., nnd Stinson, E., . I T . :  Total  Extirpnt,ion of Dog Liver in One Stnge, 111111. . lol~ns Ilol~li ins llnsp. 44: 1:\8, 1!l3!). . 1 1 i  I .  1 .  1 I : o l  S, 1 .  One Slngc Hepnt,ectorny in Dog Preserving Inferior \-t>~l:i (':~vn, - \ I I I .  .I. I'l~ysir>I, 168: 156, 1!152. 4. F r c c i ~ ~ n ~ ~ .  8.: (~o~n l~nr i so i l  f 15ll'ccts of I lcpnter ton~y ant1 of Cotnlnon Rile Duct Ob- st ruct ion on Ser111n l'hosphnt nse of Adult  I)ogs, Am. d .  Physiol. 164: 792,. 1951. 3. Frec~:11n11. S.: St~tclics on Eck I'istulas i n  I>ogs: Simple Technique f o r  Prepnrntion of l'ort:~cirv:rl A I I ~ I S ~ O I ~ I O R ~ S  \Yith i\i(l  of Clmnp, Surg. Gynec. 8; Ohst. 87: 735, 194'3. . r i 1 1 1 v .  1 .  1 .  I I .  F. . licnloval of 1,iver of I)orr: I':xneri~nentnl S l~ re i rn l  . , r. - ' I ' P I ~ ~ I I I ~ ~ I I P ,  S I . I~( ;EI~\-  31: !lOO, I !le52. 7. 1,cvccn. IF. 11.. nntl I,c\vis. I,.: Silnulifietl One Starre Henntcctomv f o r  Ex~er i rnen ta l  S ~ ~ r g e r y ,  AIIII.  Surg. 139: 195, 19%. S. 3In11n. 1.'. ('.: Slltdics in thc l ' l ~~s io logy  of the l i v e r .  I. Techniqite nntl General J*;n'vc.ts of Rcnlovnl, Am. . I .  AI .  Sc. 161: Xi, 11121. 9. JI:~rlio\\ i tz.  .T.: Eslrerln~entxl Surgery, I%nlti~nore,  1!151, Willinms 8; Wilkins Co. 10. Jlnrltnwitz, .T., Lotto, IV., Arel~ibnlil, J., and I)ownie, H. G.: Hepatectomy; Simple One Stnqc 3lcthocI in Dog, A. It. A. Arch. Surg. 64: 766, 1952. 11. JIeycr, \V. H., ant1 Starzl, T. E.: The Reverse Eclc Fistula, SURGERY 46: 760, 1959. 1 .  1 0 I l i  1 .  1. :  The Phenolsulphonphthalein Output Af ter  Ligation of t he  Vena Cava :111t1 Ilennl V c ~ n s ,  1-rol. 8; Cutnn. Rev. 33: 294, 1!12!). IS. 11-arrcn, R., and  Rhonds, J .  E.: Hepatic Origin of Prothromhin: Observations After  Totnl Hepatectomy in  Dog, Am. J. M. 8c. 198: 1!13, 1939. 14. \Tl~ittenl,erger, .T. T., nnd Huggins, C.: Ligation of t he  Inferior Vena Cava, Arch. Surg. 41: 1334, 1940. 

A new method for one-stage hepatectomy for dogs

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A new method for one-stage hepatectomy for dogs

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