I crossed the East River and went to Sloan Kettring to see how Dr. Blumgart does “complicated hepatectomies”. A few of you may be interested in the following:
The first case: a giant central-posterior tumor occupying the dome of the liver -compressing the IVC -splaying the right and middle/left hepatic veins.
The operation: extended left hepatectomy.
Operation time: 3 hours
Blood loss: 50 cc.
Technical “secrets” of hepatectomy
1. Keep the patient very dry- the CVP -0. Virtually- no IV fluid given intra-operatively.
2. Keep the patient head down to avoid air emboli
3. Complete liver mobilization- having the liver “hanging” on its inflow and outflow structures only.
4. Use of endo-GIA to transect the left/middle hepatic vein trunk at the IVC junction.
5. Clips and endo-GIA to control “minor” and caudate brunches of IVC
6. Endo-GIA to transect the left hilar structures.
7. Division of parenchyma using tissue fracture with an artery-clamp- exposed minor structures-clipped; exposed major structures controlled with endo-GIA.
8. During parenchyma division- Pringle maneuver -5 minutes on/ 1 minute off.
9. Raw surface of liver fried with ABC (Argon beam coagulator)
10. No drains!
According to Blumgart- the secret is knowing anatomy and keeping the patient DRY. CUSA is waste of time. The endo-GIA safes time!
Watching Blumgart ‘s hepatectomy reminded me Arthur Rubinstein playing on the piano.