Liver Surgery Flashcards
What are the roles of the liver?
Metabolism
Detoxification
Coagulation factors
Anti- coagulations
Think about what pre-operative and peri-operative measures may be required when operating on the liver. (6)
- Coagulation profile
- Blood typing /cross matching
- Biochem - monitor glucose
- ABx - one study 60% of healthy livers cultured
- Stabilising - IVFT +/- oncotic
- Maintain perfusion - remove ascites/pre O2
Low albumin can affect what drugs?
Protein bound
Epiploic foramen, from the surgical view:
A) What is seen dorsally?
B) What is seen ventrally?
C) What is seen dorsocranially?
A) Vena Cava
B) Coeliac a
C) Portal vein
What is the pringle manoeuvre?
Digital pressure, correctly applied, hooking the index finger cranially through the epiploic foramen and compressing against the thumb, to occlude both the hepatic artery and portal vein, can prevent blood flow into the liver for up to 20 minutes in the dog
Which side of the liver does the Vena cava run through?
Right
What attaches the liver to the diaphragm and splits into right and left sided triangular ligaments?
Coronary ligaments
What covers entire surface of the liver with the exception of the porta of the liver?
Peritoneal covering
What is the hilus where the vessels, nerves and ducts enter or exit. Nerves and arteries enter dorsally; hepatic ducts leave ventrally; portal vein enters between these;
Porta of the ligament
What attaches caudate lobe to the right kidney;
Hepatorenal ligament
What lies between the quadrate and right medial liver lobe and terminates into the common bile duct via the cystic duct?
Gall bladder
Hepatic artery is responsible for what:
A) % blood flow?
B) % O2?
A) 20
B) 50
What is an opening in the omental bursa bordered dorsally by the vena cava, ventrally by the portal vein, located medially to the caudate liver lobe and to the right of the midline?
Epiploic foramen
Portal vein is responsible for what %:
A) Blood flow?
B) O2
A) 80
B) 50
What is The right border of the lesser omentum, containing the portal vein, bile ducts and hepatic artery, and forming the ventral border of the epiploic foramen.?
Hepatoduodenal lig
When operating on a dog’s liver, from a surgeon’s view, is the portal vein above or below the hepatic ducts at the porta of the liver?
Below
What lobe is the most accessible lobe for sampling?
Left lateral
What are the 3 reasons we perform liver biopsies?
For histopathology analysis to assess diffuse liver disease or a focal lesion;
To quantify copper, zinc or iron levels;
For bacterial or fungal culture, PCR or FISH (molecular techniques to identify bacteria that cannot be cultured).
Why is liver haemorrhage fatal?
At rest, the liver receives around 30% of the cardiac output.
FNA of liver:
A) morbidity?
B) Tissue architecture?
C) What needle?
D) Sample storage?
A) Low
B) Not retained
C) 20-25g; 1-3inch
D) On slide
Core biopsy of liver:
A) What is needed first?
B) Percutaenous, what needle?
C) How much tissue obtained?
D) Sample storage?
E) How common is haemorrhage?
A) Coag
B) Tru cut needle or smaller
C) 5-20mg
D) Histopath in formalin
E) 50%
FNA of liver - to aspirate or not?
No aspiration pressure should be used
Why should you NOT use sprung core biopsies in cats?
reverberations can cause vagally-induced severe bradycardia and death.
Trucut biopses are best suited to focal or diffuse lesions?
Focal
What is used to collect surgical samples of the liver? (2)
Guillotine suture
6mm baker biopsy punch
Operating on the liver is different to operating on other body tissues because (3)
Liver tissue is friable;
Ligation of blood vessels and bile ducts is very difficult once cut as they retract into the tissue;
Over-zealous packing to control haemostasis may inadvertently cause necrosis and ischaemia.
Guillotine Sutures:
A) Which area of the liver?
B) How does this work?
A) Peripheral liver
B) Sterile laparotomy pads soaked in warm saline are used to pack around the site. A loop of absorbable suture is placed around the lobe and tied securely. Sharp dissection to remove distal liver
Biopsy punch:
A) Which samples can be obtained?
B) What size?
C) How to help haemostasis?
D) Avoid what thickness penetration?
A) Central
B) 6mm Baker
C) Haemostatic agent e.g. Lyotypt
D) > half
Benefits of laparoscopic liver biopsy? (6)
A much larger tissue sample can be obtained (45 mg);
Much less invasive than coeliotomy;
Multiple liver lobes can be sampled;
Focal lesions can be accurately sampled;
Other structures can be examined;
A third port may allow access for haemostatic devices.
How much liver can be removed in humans?
70%
Liver regeneration occurs immediately after liver resection and liver mass regenerate in what time frame?
A few months
Which of these are possible indications for liver lobectomy? (3)
Focal neoplasia
Trauma
Abscess
Liver lobectomy:
What ligament is excised?
Fatty falciform lig.
Liver lobectomy:
How to increase cranial quadrant exposure? (2)
Caudal medial sternotomy or diaphragmatic myotomy
Partial lobectomy:
How to dissect the capsule and parenchyma?
The capsule is transected with a sharp scalpel blade.
Blunt dissection of the parenchyma using a blunt end of a scalpel blade. Digital pressure can be used to fracture the parenchyma (“Finger Fracture”) but may lead to increased blood loss.
On the right side, what is adhered and requires careful dissection to isolate the hepatic veins individually? Which lobes are affected? (2)
Vena cava
Right lateral, caudate
T or F
Be aware that, particularly in cats, staples alone are often found not to provide sufficient haemostasis.
True
An encircling suture or a stapler can be placed at the base of which lobes? (2) Why?
The left medial and left lateral lobes maintain their separation
