By D. Jack. Valdosta State University.

Now dissect along tion because lacerating a tumor-invaded portal vein bifur- the lateral and posterior walls of the common hepatic duct cation produces hemorrhage that is difficult to correct if near the cystic stump and elevate the hepatic duct from the one side of the laceration consists of tumor cheap zenegra 100 mg mastercard erectile dysfunction hypogonadism. Try to continue the dissection along dissection order zenegra 100mg overnight delivery impotence of organic nature, pay attention also to the common hepatic and the anterior wall of the portal vein toward the tumor so a the right hepatic arteries that course behind the tumor best buy zenegra erectile dysfunction pump side effects. If there are no signs of gross invasion purchase discount zenegra online impotence massage, identify the lying portal veins and hepatic arteries, continue the dissec- anterior wall of the tumor and try to palpate the Ring cathe- tion along the posterior wall of the tumor. The right and left ters if they have been placed in the right and the left hepatic hepatic ducts and even secondary branches can often be ducts prior to operation. It is crucial times difficult to determine the proximal extent of the tumor that this be accurately assessed during the surgical planning by palpation. If preoperative catheters have been placed, stage, so that formal hepatectomy can be utilized to get an palpate the right and left ducts for the presence of the cath- adequate proximal margin if necessary. Proceed if the tumor is deemed suitable for local exci- ultrasonography may be a useful adjunct. Although some adjacent hepatic frozen section examination of the proximal portions of the parenchyma may be left attached to the duct during blunt right and left ducts in the specimen to determine if the tumor dissection, it may be necessary to perform a major hepatic has been completely removed. Insert Silastic tumor, determine whether removing a reasonable additional tubes into each severed duct by one of the techniques length of duct is feasible. Perform an identi- 73 and bring the closed end of jejunum to the hilus of the cal maneuver to pass the other Silastic tube that exits from liver. Make an incision in the antimesenteric border of the the liver through a puncture wound in the left upper quadrant jejunum equal to the diameter of the open left hepatic duct. Perform the same type of anastomosis between the Place a third closed-suction drain at the hilus of the liver near right hepatic duct and a second incision in the jejunum. Close the abdominal inci- each Silastic catheter through the anastomosis into the jeju- sion in routine fashion. If no Ring catheters were placed before surgery, pass a small Intubation of Hepatic Duct Without Silastic tube across each biliary enteric anastomosis as a Resecting Tumor stent and bring these tubes out through a jejunostomy. Incision Drainage and Closure Make a midline incision from the xiphoid to a point 4–5 cm At the site where the Silastic tube enters the left hepatic duct below the umbilicus. If the an identical maneuver at the point where the second tube patient has previously undergone percutaneous transhepatic enters the anterior surface of the right lobe of the liver. Then pass each tube down into the jejunum for a hepatic duct and try to establish a channel leading into the distance of at least 6 cm (Fig. After the channel has been established, jejunojejunostomy for completing the Roux-en-Y anastomo- dilate the passageway by sequentially passing No. If this channel cannot be established, try It is helpful to keep the hole in Glisson’s capsule as small as to identify the left hepatic duct just above the tumor. If the accomplished this, incise the duct and pass a Silastic tube patient has already undergone preoperative transhepatic through the duct and out the parenchyma of the liver on the catheterization of the hepatic duct and if the point at which anterior surface of the left lobe. It is necessary to anastomose this catheter penetrates the liver capsule is in a satisfactory a Roux-en-Y limb of jejunum to this opening in the left location, one may suture a urologic filiform to the end of the hepatic duct. Urologic filiform followers may then be accommodate two Silastic tubes, and a Roux-en-Y hepatico- attached to the end of the filiform so the path of the catheter jejunostomy to the divided right and left hepatic ducts may can be dilated about 6 mm. By withdrawing the follower, the punched in the Silastic tube prior to its insertion. These holes Silastic tube catheter can be brought through the liver with should be situated above and below the site of the tumor, so minimal trauma and then out through the skin. A convenient source of this Silastic Bakes bile duct dilator through the cut end of the right or left multiperforated tubing is a round Jackson-Pratt drain. Pass the dilator through the duct until it reaches Bring the Silastic catheters out through puncture wounds a point about 1. Then insert closed-suction drains into priate location on the anterior surface of the liver. The tip of the sites from which the catheters exit from the right and left the dilator can frequently be felt under the capsule of the hepatic lobes. Then make a tiny incision in the capsule and push the metal dilator through the hepatic parenchyma. Suture the tip of the 10 F straight rubber catheter to the Bakes dilator Postoperative Care (Fig. This step may be simplified if a small hole has been drilled in the tip of the Bakes dilator to accept the Attach the Silastic catheters to plastic bags for gravity drain- suture. Leave them in place until there is no bile drainage along eter is led into the hepatic duct at the hilus of the liver. Then occlude the Silastic insert a Silastic tube, 6 mm in outer diameter, into the flared catheters with a stopcock. Instruct the patient to irrigate each open end of the French catheter and suture it securely in this catheter twice daily with 25 ml of sterile saline. By drawing the catheter out of the suture fixing the catheter to the skin must be replaced hepatic duct at the hepatic hilus, the Silastic tube moves to approximately every 4–6 weeks. Cholangitis generally replaced by passing a sterile guidewire through the Silastic does not occur unless something obstructs the drainage of tube; the Silastic tube is then removed with sterile tech- bile. If the ducts draining only one lobe of the liver have been nique and replaced with another tube of the same type. If the patient develops cholangitis, it may of a tumor at the bifurcation of the hepatic duct that occludes be necessary to replace the tube earlier than 3 months. Prescribe an H2-blocker or proton pump inhibitor Silastic tubes at intervals of 2–3 months prevents most cases intravenously to lower the incidence of postoperative gastric of postoperative cholangitis. Maintain this regimen until the patient has Bile may leak around the Silastic tube early if the puncture resumed a regular diet. If leakage occurs late during the postoperative radioactive pellets into the Silastic catheters in such fashion course, attempt to replace the tube around which the bile is that a large dose of radiation can be administered precisely to leaking with a tube of somewhat larger diameter. The range of radiation occurs during the immediate postoperative course, check the is limited to a precise, shallow depth. Liver transplantation for Klatskin’s tumor: contraindi- cedures that divert bile from the duodenum. Multidisciplinary manage- ment of hilar cholangiocarcinoma (Klatskin tumor): extended resection is associated with improved survival. Chassin† Indications Prolonged vascular inflow occlusion leading to refractory liver ischemia Isolated liver metastases Injury to the diaphragm, inferior vena cava, or intestine Symptomatic benign liver lesions (especially after prior gastric, hepatobiliary, or colon Primary hepatic malignancies surgery) In conjunction with bile duct resection for selected cases of proximal bile duct carcinoma (see also Chap. Each delineates a plane (termed a hepatic scissura) that Preoperative Preparation divides the liver into functional anatomic units (Fig. The terms left and right liver are used Provide adequate blood and blood product support. The location of this plane can be approx- the liver and attempt to improve nutritional parameters. In modern terminology, a right hepatic lobectomy con- Pitfalls and Danger Points sists of removing all of the right liver, and left hepatic lobectomy removes the entire left liver. Hemorrhage from hepatic or portal veins or hepatic arteries The portal pedicles contain major branches of the hepatic Air embolism from hepatic venous injury artery, portal vein, and bile ducts running together. These ped- Injury to the bile ducts, with postoperative obstruction or icles interdigitate with the hepatic veins. The territory served fistula by the portal pedicles and their major branches define the sec- Portal or hepatic vein compromise with subsequent tors and segments of the liver (Fig. Segmental hepatic venous drainage is variable and ana- Department of Surgery, Roy J. A continuation of peritoneum The specific resection strategy (enucleation versus wedge termed the cystic plate covers the right pedicle, and the left versus formal anatomic resection) depends on the size, loca- pedicle is invested by the umbilical plate. This peritoneum tion, and relation to the tumor of the major afferent and fuses with Glisson’s capsule, and the falciform ligament efferent vasculature and bile ducts. Wedge Adequate exposure of this area requires upward mobilization resections are typically subsegmental and performed with- of segment 4 and incision of Glisson’s capsule. These nonanatomic resections generally are undertaken for peripheral liver masses that are not adjacent to the hilus or hepatic veins. Extent of Resection Wedge resections are easiest for small (<4 cm) tumors aris- ing within anterior liver segments 3–6. Formal anatomic The need to achieve a clean resection with an adequate mar- resection should be considered for large or deeply seated gin must always be balanced against the need to preserve an lesions or those with indistinct margins, such as hepatic adequate mass of functioning liver parenchyma. This resection liver has a remarkable capacity for regeneration, patients may be a standard right or left anatomic lobectomy, or it without underlying liver disease can tolerate resection of up may be tailored along segmental boundaries in such a man- to six of the eight liver segments. The situation is far differ- ner as to maximize residual functioning hepatic mass and ent when resection is contemplated in the setting of acute or preserve vital vascular and ductal structures to the liver chronic liver disease. Hence patients with known chronic liver disease or resection with a margin of normal liver. Ideally, a 1- to 2-cm cirrhosis are best evaluated in centers performing orthotopic margin is preferred to reduce the risk of recurrence. Use preoperative imaging studies to approach, or malignant thromboses extending into the main exclude patients with multicentric tumor arising in both portal vein or inferior vena cava. Additional intraopera- is preferred for malignancies unless the malignancy is small tive findings that preclude resection are peritoneal metasta- and located peripherally. Intraoperative ultrasonography is a ses, extensive regional lymph node involvement, unexpected useful adjunct. The parenchyma is then divided, and the bile ducts are divided only when the Resection of a single liver segment or multiple contiguous surgeon has ascertained the precise anatomy and ensured segments requires identification and ligation of the segmen- that drainage to the remnant is preserved. Resection along intraopera- tively defined anatomic boundaries is the major difference Parenchymal Transection between nonanatomic wedge resections and anatomic seg- mental resections. In general, anatomic resections are prefer- Embedded in the soft liver parenchyma are vascular and duc- able for primary malignancies because they remove tal structures of greater mechanical strength. Most methods segmental intraportal metastases and enhance preservation of parenchymal transection use this difference in tissue of function in adjacent segments in cirrhotic livers. Conceptually, the surgeon Resection of segments 2 and 3 is commonly termed left simply disrupts the parenchyma along the planned transec- lateral lobectomy.

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One should not exert too much pressure on the bell of the stethoscope purchase zenegra 100mg on line impotence use it or lose it, lest it should obliterate the artery and cause an artificial bruit order zenegra with a visa erectile dysfunction in diabetes treatment. A bruit is also heard on the renal artery in case of hypertension due to renal artery stenosis buy 100mg zenegra amex erectile dysfunction doctor in miami. Blood pressure of both the arms are measured to exclude affection of subclavian discount zenegra 100 mg with mastercard impotence jokes, brachiocephalic or axillary artery. This is done by inflating a sphygmomanometer cuff around the limb to 250 mm Hg for 5 minutes. Then the cuff is deflated and the time of appearance of red flush in the skin Fig. It is 1 to 2 seconds in case of normal limb and it will be delayed in case of arterial occlusive disease and it may never appear in case of severely ischaemic limb. Atherosclerosis is a generalized disease and the patient must be examined thoroughly to exclude ischaemic heart disease, cerebro-vascular disease, hypertension, renal artery stenosis etc. In embolic manifestation, the heart is examined for presence of cardiac murmur, which may indicate certain lesion to cause embolus formation. Estimation of serum P-lipoprotein, triglyceride and cholesterol should be performed when atherosclerosis is suspected. The common femoral artery is used for aortoiliac, renal, mesenteric and femoropopliteal arteriography, whereas the brachial artery is used for subclavian, vertebral, carotid and thoracic angiography. The needle is now withdrawn and a flexible guide wire is threaded through the cannula. The cannula is withdrawn and a polythene catheter is passed over the guide wire into the artery for a distance. Series of X-ray exposures are made to see particularly the whole length of the arterial tree, the origins and the adjacent part of its branches. In selective angiogram the tip of the catheter is introduced into the corresponding artery to delineate the artery and its branches precisely. Abdominal aorta (translumbar route) may be chosen for aortoiliac and femoropopliteal arteriography when the femoral arteries are occluded or the retrograde method has failed to produce necessary information. In patients with occlusive lesion, abnormal signals can be obtained distal to the block and will be lost entirely over the site of the block. The second and third sounds are absent when the flow signals are detected just below the stenotic lesion where high velocity flow is present, a single high-pitched continuous sound is present indicating turbulent flow. This simple apparatus can be used to measure blood pressure at the ankle and at the arm. Normally the ankle systolic blood pressure is greater than the brachial (arm) systolic blood pressure by 5 to 15 mm Hg. If this pressure index becomes less than one it indicates some degree of arterial occlusion. Recently Technetium 99 has become the isotope of choice though the technique remains essentially the same. More recently intravenous injection of isotope has been used to get a direct arterial visualization. Two electrodes are placed diametrically opposite to each other in contact with the arterial wall. The electrodes on the surface of the artery pick up an electromotive force induced in the blood by its motion through the magnetic field and feed it back to suitable electronic amplification. But the greatest disadvantage of this technique is that the artery has to be exposed. Many of these patients are diabetic, though they may not show increased level of sugar in the blood. Later on organic changes develop and sympathectomy does not do much good to the patient. So, importance of finding out the degree of vasospasm cannot be overemphasized to assess the value of sympathectomy. Any rise of skin temperature is recorded and is compared with the rise of mouth temperature. Venous outflow from a limb is briefly arrested while allowing arterial inflow to measure the volume change in the limb which is proportional to the arterial inflow. But it has rarely been found suitable for screening method for surgery, as the surgeon is more interested to know the site of the arterial block rather than to measure the blood flow as such. Recently segmental plethysmography has been introduced by placing venous occlusion cuffs around the thigh, calf and ankle. The cuffs are inflated to 65 mm Hg and the pulsation is the quantitative measure of the arterial diseases. In embolism, a sudden decrease in the movement of its needle is obtained at the level of arterial occlusion. In thromboangiitis obliterans, if no pulsation is obtained in the leg, amputation should be performed in the thigh. The affected part becomes dry, shrivelled, hard, mummified and discoloured from disintegration of haemoglobin. Due to infection and putrefaction the affected part becomes oedematous with blebs. The term ‘Pregangrene’ is used to describe the changes in the tissue to indicate that its blood supply is so precarious that it will soon be inadequate to keep the tissue alive. Syringomyelia, tabes dorsalis, peripheral neuritis, leprosy, caries spine, fracture-dislocation of spine etc. Various special investigations as stated above will help the clinician to diagnose the condition and the level of the block. It is the inflammatory reaction in the arterial wall with involvement of the neighbouring vein and nerve, terminating in thrombosis of the artery. In lower extremity the disease generally occurs beyond popliteal artery, starting in tibial arteries extending to the vessels of the foot. So far as aetiology is concerned this disease has a striking association with cigarette smoking. An autoimmune aetiology has been postulated and familial predisposition has been reported. The pedal arteries are involved first and the patients complain of pain while walking at the arch of the foot (foot claudication), somewhat less often at the calf of the leg, but never at the thigh or buttock (which is common in atherosclerosis). Gradually postural colour changes appear followed by trophic changes and eventually ulceration and gangrene of one or more digits and finally of the entire foot or hand may ensue. It is differentiated from senile gangrene by the age, by its association with superficial phlebitis and pitting oedema. Characteristic arteriographic appearance of this disease is the smooth and normal appearance of larger arteries combined with extensive occlusion of the smaller arteries alongwith extensive collateral circulation. Presence of localized tenderness at the site of embolus and complete disappearance of pulse below this level are the pathognomonic features of this disease. The heart when examined carefully often gives an indication of the source of the embolus. It may be caused by (i) cervical rib, (ii) scalenus anticus muscle, (iii) costoclavicular syndrome, (iv) pectoralis minor syndrome, (v) wide first thoracic rib, and (vi) fracture of the first rib or clavicle. Neurologic symptoms are pain, paraesthesia and numbness in the fingers and hand in the ulnar nerve distribution. The symptoms gradually appear due to sagging down of the shoulder girdle with the advent of puberty. Sometimes symptoms appear later in life due to weakness of the muscles of the shoulder girdle. Presence of cervical rib does not always reveal symptoms or brings the patient to the surgeon. Symptoms of the cervical rib are mainly caused by angulation of the subclavian artery over the cervical rib and by the pressure irritation of the lowest trunk of the brachial plexus which contains the sympathetic nerve fibres to the upper limb. These symptoms will only appear when the muscles of the shoulder girdle will become weak and both the artery and the nerve trunk will be compressed on the cervical rib. When the hand is elevated it looks pale and it becomes blue on prolonged dependent position due to cyanotic congestion. Numbness of the fingers is complained of and the radial pulse becomes feeble on the affected side. X-ray often reveals the cervical rib, though sometimes a fibrous band in its place causes the symptoms like cervical rib and will not be seen by X-ray. The scalenus anticus syndrome is one in which the clinical pictures very much resemble those of the cervical rib. Here the pull of the scalenus anterior muscle, which compresses the subclavian artery and the lower trunk of the brachial plexus, is responsible for the symptoms. Negroes, people of Central Africa, Central America and the East are more prone to be affected. It usually affects the little toe, sometimes the fourth and rarely the third, second or the great toe. Though it is rare in upper limbs yet cases are on the record when the terminal phalanx of the little finger has been involved. The disease starts as a linear groove in the skin on the inner and plantar side of the root of the toe. Frequently the involvement is bilateral affecting both the feet simultaneously or one after the other. The groove gradually deepens and extends round the whole circumference of the toe. The distal part becomes swollen as if the root of the toe has been tied with a ligature. The affected area becomes ischaemic and very much swollen and ultimately undergoes gangrenous changes. The onset is sudden accompanied by pain in the wound, swelling, fever, vomiting and toxaemia. Gradually the whole limb becomes swollen and tense with crepitation on palpation over the muscles.

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