Abstracts
1999 Digestive Disease Week

# 2121 SAFE ISOLATED RESECTION OF THE CAUDATE LOBE (CL) FOR LARGE BENIGN HEPATIC TUMORS: THE ROLE OF TOTAL VASCULAR ISOLATION (TVI)
Menahem Ben-Haim, D Likholatnikov, S Emre, T Fishbein, P Sheiner, The Mount Sinai Med Ctr, New York, New York, NY; C M Miller, Mount Sinai Med Ctr, New York, NY; M E Schwartz, The Mount Sinai Med Ctr, New York, New York, NY

Introduction: Complete isolated resection of the CL of the liver is still considered as a challenging surgical procedure due to the deep posterior location and the proximity to the porta hepatis and the retro hepatic vena cava (IVC). In most of the reported series the indication for CL resection was a malignant tumor and the resection was combined with additional hepatectomy. The present study summarizes our experience with isolated CL resections for large benign tumors.
Material and Methods: patients: Of 38 CL resections which were performed since 1990, 7 were for benign lesions (FNH-3, Hemangioma-2, Angiomyolipoma-1 and inflammatory pseudo tumor-1). Of these, 6 were isolated complete CL resection and 1 included left hepatectomy. Technique: A chevron incision with a vertical midline extension was the standard incision. Exposure of the CL was achieved via the lesser sac by division the gastrohepatic ligament (left sided approach) in 6 cases and with right sided approach, by mobilization of the right lobe in one case. Total vascular isolation (TVI) of the hepatic circulation during the dissection of the CL from the IVC and the parenchymal separation was applied in 5 cases. When applied, TVI included infra and supra hepatic occlusion of the IVC as well as Pringle maneuver. Method: We retrospectively reviewed the imaging studies, the operative and anesthesiology reports and the hospitalization records. We summarized the principles of technique and the operative results and compared them to the other series and case reports that were published in the English literature.
Results: Patients: There were 6 female patients and 1 male. The mean age was 48 (range 27-68). Only one patient had underlining liver disease (chronic hepatitis B). Clinical characteristics: The clinical presentation was with abdominal pain (4), abnormal liver function tests (2) or early satiety (1). In 3 cases a guided biopsy was performed prior to surgery. Operative findings: The mean tumor diameter was 10 cm (range 7-18). In 4 cases there was a replaced (2) or an accessory (2) left hepatic artery. Operative results: One case was complicated with massive bleeding (28 units of PRBC), required prolonged operating time (10 hours) and had a complicated postoperative course. This case represents the complexity and the risks of CL resection and will be discussed separately. The mean operating time for the other 6 cases was 2 hours and 45 minutes (range 2:25-3:00). The mean length of TVI was 12 minutes (range 7-22). All the patients tolerated the TVI periods. The mean estimated blood loss (EBL) was 315 cc (range 100-500), no one of the patients required blood transfusion and the mean decrease of the hematocrit from the preoperative level was 5.8% (range 1.5-10.6). There were no intraoperative or postoperative complications, nor any sequelae of the liver ischemia during the TVI. The mean hospital stay was 6 days (range 5-7).
Conclusion: Bleeding is the main risk of CL resection. However, with the experience which was gained with liver transplantation and with selective application of TVI, isolated CL resection appear to be a safe procedure and can be used for resection of large benign tumors of the CL in almost a "bloodless" fashion.

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