1. 1. SurgicalManagementofHepatobiliary andPancreaticDisorders PostonDAngelicaAdam www.informahealthcare.com Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK 52 Vanderbilt Avenue, New York, NY 10017, USA Surgical Management of Hepatobiliary and Pancreatic Disorders Second Edition Edited by Graeme J. Poston, Michael DAngelica, and Ren Adam About the book Hepato-Pancreato-Biliary (HPB) surgery is now firmly established within the repertoire of modern general surgery. This new edition has been completely rewritten by world-leading surgeons to reflect the considerable advances made in the surgical management of HPB disorders since the highly successful first edition. This new edition includes: An in-depth coverage of benign and malignant disorders of the liver, pancreas, and bile ducts and gallbladder A comprehensive section on anatomy, imaging, and surgical technique Over 20 new chapters, including a complete account of pediatric HPB disorders Almost 300 high-resolution images, many in full color Surgical Management of Hepatobiliary and Pancreatic Disorders, Second Edition, comprehensively covers the full spectrum of common HPB diseases and associated surgical techniques to assist not only the general surgeon in regular practice, but also surgical trainees and those in related specialties of oncology, radiology, gastroenterology, and anesthesia. About the Editors Graeme j. Poston, MS, FRCS (Eng), FRCS (Ed), is Director of Surgery and Hepatobiliary Surgeon,UniversityHospitalAintree,Liverpool,UK.HeisthePresidentoftheAssociation of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS), President- Elect of the European Society of Surgical Oncology (ESSO), Past President of the British Association of Surgical Oncology (BASO), and author of numerous publications and national/international guidelines relating to the practice of HPB surgery. Michael DAngelica, MD, is an Associate Attending at Memorial Sloan-Kettering Cancer Center and an Associate Professor at Cornell University/Weill Medical Center. He is currently the Program Chairman of the American Hepato-Pancreato-Biliary Association and a writing member of the National Comprehensive Cancer Network (NCCN) practice guidelines for hepatobiliary malignancy. Ren Adam, MD, PHD, is Hepatobiliary Surgeon and Professor of Surgery, Hpital Paul Brousse, Universit Paris-Sud, Villejuif, France. Edited by Graeme J. Poston Michael DAngelica Ren Adam Second Edition With a Foreword by Yuji Nimura, MD, President of the Aichi Cancer Center, Japan, and Past President of the IHPBA This book demonstrates the wisdom of the new knowledge and technical skills of these diverse disciplines where cooperative efforts contribute toward the benefit of the patients with HPB disorders. Also Available Hepatocellular Carcinoma: A Practical Approach Edited by Bandar Al Knawy, K. Rajendra Reddy and Luigi Bolondi ISBN: 9780415480802 e-ISBN: 9780203092880 Improved Outcomes in Colon and Rectal Surgery Edited by Charles B. Whitlow, David E. Beck, David A. Margolin, Terry C. Hicks and Alan E. Timmcke ISBN: 9781420071528 e-ISBN: 9781420071535 Textbook of Surgical Oncology Edited by Graeme J. Poston, R. Daniel Beauchamp, and Theo J. M. Rogers ISBN: 9781841845074 e-ISBN: 9780203003220 Surgical Management of Hepatobiliary and Pancreatic Disorders Second Edition
2. 2. Surgical Management of Hepatobiliary and Pancreatic Disorders
3. 3. Surgical Management of Hepatobiliary and Pancreatic Disorders Second Edition Edited by Graeme J. Poston MS, FRCS (ENG), FRCS (ED) Centre for Digestive Diseases University Hospital Aintree and Department of Surgery The Royal Liverpool University Hospitals Liverpool, UK Michael DAngelica MD Weill Medical College of Cornell University and Memorial Sloan-Kettering Cancer Center New York, New York, USA and Ren Adam MD, PHD AP-HP Hpital Paul Brousse Centre Hpato-Biliaire Villejuif, France
4. 4. First published in 2003 by M. Dunitz Ltd, United Kingdom This edition published in 2010 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK. Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th floor, New York, NY 10017, USA. 2011 Informa UK Ltd, except as otherwise indicated. No claim to original U.S. Government works. Reprinted material is quoted with permission.Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, unless with the prior written permission of the pub- lisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence per- mitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP, UK, or the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA (http://www.copyright.com/ or telephone 978- 750-8400). Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. This book contains information from reputable sources and although reasonable efforts have been made to publish accurate infor- mation, the publisher makes no warranties (either express or implied) as to the accuracy or fitness for a particular purpose of the information or advice contained herein. The publisher wishes to make it clear that any views or opinions expressed in this book by individual authors or contributors are their personal views and opinions and do not necessarily reflect the views/opinions of the publisher. Any information or guidance contained in this book is intended for use solely by medical professionals strictly as a supplement to the medical professionals own judgement, knowledge of the patients medical history, relevant manufacturers instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be independently verified. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as appropriately to advise and treat patients. Save for death or personal injury caused by the publishers negligence and to the fullest extent otherwise permitted by law, neither the publisher nor any person engaged or employed by the publisher shall be responsible or liable for any loss, injury or damage caused to any person or property arising in any way from the use of this book. A CIP record for this book is available from the British Library. ISBN-13: 978-1-84184-693-4 Orders may be sent to: Informa Healthcare, Sheepen Place, Colchester, Essex CO3 3LP, UK Telephone: +44 (0)20 7017 5540 Email: CSDhealthcarebooks@informa.com Website: http://informahealthcarebooks.com/ For corporate sales please contact: CorporateBooksIHC@informa.com For foreign rights please contact: RightsIHC@informa.com For reprint permissions please contact: PermissionsIHC@informa.com Typeset by Exeter Premedia Services Printed and bound in the United Kingdom
5. 5. v List of contributors vii Foreword x Preface xi I ANATOMY/IMAGING/SURGICAL TECHNIQUE 1 Surgical anatomy of the liver and bile ducts 1 Robert Jones and Graeme J. Poston 2 Anatomy of the pancreas 17 Margo Shoup and Jason W. Smith 3 Hepatic resection 24 Ajay V. Maker and Michael DAngelica 4 Ultrasound for HPB disorders 36 Duan Li and Lucy Hann 5 Liver surgery in elderly patients 46 Gerardo Sarno and Graeme J. Poston 6 Small solitary hepatic metastases: when and how? 53 David L. Bartlett and Yuman Fong 7 Managing complications of hepatectomy 63 Fenella K. S. Welsh, Timothy G. John, and Myrddin Rees 8 Pancreatic resection 73 Thilo Hackert, Moritz Wente, and Markus W. Bchler 9 Surgical complications of pancreatectomy 81 Steven C. Katz and Murray F. Brennan 10 Laparoscopy in HPB surgery 89 Nicholas ORourke and Richard Bryant 11 Cross-sectional imaging for HPB disorders (MRI and CT) 100 Lawrence H. Schwartz II LIVER A. Malignant i. Metastases 12 Liver metastases: detection and imaging 109 Valrie Vilgrain, Ludovic Trinquart, and Bernard Van Beers 13 Surgery for metastatic colorectal cancer 118 Ren Adam and E. Hoti 14 Chemotherapy for metastatic colorectal cancer 135 Derek G. Power and Nancy E. Kemeny 15 Multimodal approaches to the management of colorectal liver metastases 148 Gerardo Sarno and Graeme J. Poston 16 Management of neuroendocrine tumor hepatic metastasis 154 Kaori Ito 17 Noncolorectal, nonneuroendocrine metastases 166 C. Kahlert, R. DeMatteo, and J. Weitz 18 Chemotherapy-associated hepatotoxicity 173 Martin Palavecino, Daria Zorzi, and Jean-Nicolas Vauthey 19 Thermal ablation of liver metastases 180 Samir Pathak and Graeme J. Poston ii. Primary 20 Resection for hepatocellular carcinoma 192 Rajesh Satchidanand, Stephen W. Fenwick, and Hassan Z. Malik 21 Treatment of laparoscopically discovered gallbladder cancer 197 Jason K. Sicklick, David L. Bartlett, and Yuman Fong 22 Liver transplantation for HCC: Asian perspectives 208 Shin Hwang, Sung-Gyu Lee, Vanessa de Villa, and Chung Mao Lo 23 Non-surgical treatment of hepatocellular carcinoma 216 Ghassan K. Abou-Alfa and Karen T. Brown 24 Resection of intrahepatic cholangiocarcinoma 223 Junichi Arita, Norihiro Kokudo, and Masatoshi Makuuchi 25 Transplantation for hilar cholangiocarcinoma 229 Julie K. Heimbach, Charles B. Rosen, and David M. Nagorney 26 Rare vascular liver tumors 233 Jan P. Lerut, Eliano Bonaccorsi-Riani, Giuseppe Orlando, Vincent Karam, Ren Adam, and the ELITA-ELTR Registry B. Benign 27 Management of recurrent pyogenic cholangitis 242 W. Y. Lau and C. K. Leow 28 Liver abscess: amebic, pyogenic, and fungal 253 Purvi Y. Parikh and Henry A. Pitt 29 Benign solid tumors of the adult liver 261 Mark Duxbury and O. James Garden 30 Liver trauma 271 Timothy G. John, Myrddin Rees, and Fenella K. Welsh Contents
6. 6. vi CONTENTS 31 Portal hypertension 280 Michael D. Johnson and J. Michael Henderson 32 Liver transplantation for acute and chronic liver failure 288 Vincent Kah Hume Wong and J. Peter A. Lodge 33 Benign cystic disease of the liver 301 Stephen W. Fenwick and Dowmitra Dasgupta 34 Management of hydatid disease of the liver 308 Adriano Tocchi 35 Surgical management of primary sclerosing cholangitis 324 Jason A. Breaux and Steven A. Ahrendt III BILE DUCTS AND GALLBLADDER A. Malignant 36 Management of advanced gallbladder cancer 329 Hiromichi Ito and William R. Jarnagin 37 Extrahepatic cholangiocarcinoma 333 Yuji Nimura 38 Endoscopic management of malignant biliary obstruction 343 Nick Stern and Richard Sturgess B. Benign 39 Choledochal cyst detected in adulthood 354 Bilal Al-Sarireh and Hassan Malik 40 Bile duct injuries and benign biliary strictures 360 Steven M. Strasberg 41 Gallstones and common bile duct stonessurgical and non-surgical approaches 373 Matthew P. Dearing and Michael Rhodes IV PANCREAS A. Malignant 42 Adenocarcinoma of the pancreas 380 Andr L. Mihaljevic, Jrg Kleeff, and Helmut Friess 43 Palliation of pancreas cancer 401 Michael G. House and Keith D. Lillemoe 44 Cystic tumors of the pancreas 407 Peter J. Allen and Murray F. Brennan 45 Neuroendocrine pancreatic tumors 414 Stephen N. Hochwald and Kevin Conlon 46 Rare tumors of the pancreas 432 Jooyeun Chung, Lisa J. Harris, Hamid Abdollahi, and Charles J. Yeo B. Benign 47 Acute pancreatitis 439 C. Ross Carter, A. Peter Wysocki, and Colin J. McKay 48 Chronic pancreatitis 451 Jakob R. Izbicki, Oliver Mann, Asad Kutup, and Kai A. Bachmann 49 Pancreatic injury 463 Demetrios Demetriades, Beat Schnriger, and Galinos Barmparas 50 Pancreas transplantation 470 Khalid Khawaja V PEDIATRIC HPB DISORDERS 51 Pediatric HPB disorders 478 Maureen McEvoy and Michael P. La Quaglia Index 489
7. 7. vii Ghassan K.Abou-Alfa MD Assistant Attending, Memorial Sloan-Kettering Cancer Center, and Assistant Professor, Weill Medical College at Cornell University, New York, New York, USA Hamid Abdollahi MD Senior Resident (General Surgery), Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA Ren Adam MD, PhD AP-HP Hpital Paul Brousse, Centre Hpato-Biliaire, Inserm, Unit 785, and Universit Paris-Sud, UMR-S 785, Villejuif, France Steven A. Ahrendt MD Associate Professor of Surgery, University of Pittsburgh Medical Center, UPMC Passavant Cancer Center, Pittsburgh, Pennsylvania, USA Peter J.Allen MD Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Bilal Al-Sarireh MBBCh, FRS, PhD Consultant Hepatopancreatobiliary and Laparoscopic Surgeon, Swansea University, and Department of Surgery, Morristown Hospital, Swansea, UK Junichi Arita MD, PhD Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan Kai A. Bachmann Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Galinos Barmparas Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California, USA David L. Bartlett Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, and National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA Eliano Bonaccorsi-Riani Th. STARZL Abdominal Transplant Unit, Cliniques Universitaires St Luc Universit catholique de Louvain, Department of Abdominal and Transplantation Surgery, Brussels, Belgium Jason A. Breaux MD Surgical Oncology Fellow, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania, USA Murray F. Brennan Benno C. Schmidt Clinical Chair in Oncology, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Karen T. Brown MD Attending Radiologist, Memorial Sloan-Kettering Cancer Center, and Professor of Clinical Radiology, Weill Medical College at Cornell University, New York, New York, USA Richard Bryant MBBS, FRACS Royal Brisbane Hospital, Brisbane, Queensland, Australia Markus W. Bchler Department of General Surgery, University of Heidelberg, Heidelberg, Germany C. Ross Carter West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, Scotland, UK Jooyeun Chung MD Department of Surgery, The Methodist Hospital, Houston, Texas, USA Kevin Conlon Professor of Surgery, University of Dublin, Trinity College Dublin, and Professorial Surgical Unit, Education Centre, AMNCH, Dublin, Ireland Michael DAngelica MD Weill Medical College of Cornell University and Memorial Sloan-Kettering Cancer Center, New York, New York, USA Dowmitra Dasgupta MD, FRCS Consultant Hepato-Pancreatico-Biliary Surgeon, Department of Upper GI Surgery, Castle Hill Hospital, Cottingham, UK Matthew P. Dearing Department of Surgery, Norfolk & Norwich University Hospital, Norwich, UK R. DeMatteo Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Demetrios Demetriades Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California, USA Mark Duxbury Clinical Surgery, University of Edinburgh Royal Infirmary, Edinburgh, UK Stephen W. Fenwick MD, FRCS Consultant Hepatobiliary Surgeon, North Western Hepatobiliary Unit, University Hospital Aintree, Lower Lane, Liverpool, UK Yuman Fong MD Hepatobiliary Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Helmut Friess Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universitt Mnchen, Munich, Germany O. James Garden Regius Professor of Clinical Surgery, Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary, Edinburgh, UK Thilo Hackert Department of Surgery, University of Heidelberg, Heidelberg, Germany Lisa J. Harris MD Senior Resident (General Surgery), Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA J. Michael Henderson Chief Quality Officer, Cleveland Clinic, Cleveland, Ohio, USA Stephen N. Hochwald MD Chief, Division of Surgical Oncology, University of Florida, Gainesville, Florida, USA Michael G. House MD Assistant Professor, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA List of contributors
8. 8. viii LIST OF CONTRIBUTORS Lucy Hann MD Professor of Radiology, Weill Cornell Medical Center, and Director of Ultrasound Memorial Sloan-Kettering Cancer Center, New York, New York, USA Julie K. Heimbach Mayo Clinic, Rochester, Minnesota, USA Steven N. Hochwald University of Florida Medical School, Box 100286, Gainesville, FL 326100286, USA E. Hoti AP-HP Hpital Paul Brousse, Centre Hpato-Biliaire, Villejuif, France, and Liver Transplant Unit, Saint Vincents University Hospital, Dublin, Ireland Shin Hwang Professor, Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea Hiromichi Ito MD Department of Surgery, Michigan State University, Lansing, Michigan, USA Kaori Ito MD Department of Surgery, Michigan State University, Lansing, Michigan, USA Jakob R. Izbicki FACS Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany William R. Jarnagin MD Hepatobiliary Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Timothy G. John MD, FRCSEd (Gen) Hepatobiliary Unit, Basingstoke and North Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK Michael D. Johnson MD Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA Robert Jones MB, ChB, MRCS Clinical Fellow, North Western Hepatobiliary Centre, Aintree University Hospital, Liverpool, UK C. Kahlert Department of Surgery, University of Heidelberg, Heidelberg, Germany Vincent Karam Centre Hpatobiliaire, Hpital Paul Brousse, Villejuif, France Steven C. Katz MD Director of Surgical Immunotherapy, Roger Williams Medical Center, Providence, Rhode Island, USA Khalid Khwaja MD Director of Kidney and Pancreas Transplantation, Senior Staff Surgeon, Lahey Clinic, Burlington, Massachusetts, USA Nancy E. Kemeny MD Memorial Sloan-Kettering Cancer Center, New York, New York, USA Jrg Kleeff Department of Surgery, Klinikum rechts der Isar, Technische Universitt Mnchen, Munich, Germany Norihiro Kokudo MD, PhD Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan Asad Kutup Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany W.Y. Lau Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, SAR C. K. Leow Mount Elizabeth Medical Centre, Singapore, Singapore Keith D. Lillemoe MD Jay L. Grosfeld Professor and Chairman, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA Sung-Gyu Lee Professor, Division of Hepatobiliary Surgery and Liver Transplanta- tion, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea Michael P. La Quaglia MD Department of Surgery, Pediatric Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Jan P. Lerut MD, PhD, FACS Th. STARZL Abdominal Transplant Unit, Cliniques Universitaires St Luc Universit catholique de Louvain, Department of Abdominal and Transplantation Surgery, Brussels, Belgium Duan Li MD Assistant Attending Radiologist, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Chung Mao Lo Professor, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China J. Peter A. Lodge MD, FRCS Professor and Clinical Director, HPB & Transplant Unit, St. James University Hospital, Leeds, UK Ajay V. Maker MD Director of Surgical Oncology, Creticos Cancer CenterAdvocate Illinois Masonic Medical Center; Departments of Surgery and Microbiology/Immunology, University of Illinois at Chicago, Chicago, Illinois, USA Masatoshi Makuuchi MD, PhD Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan Hassan Malik MD, FRCS Hepatobiliary Unit, Department of Surgery, University Hospital Aintree, Liverpool, UK Oliver Mann Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Maureen McEvoy MD Department of Surgery, Pediatric Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Colin J. McKay West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, Scotland, UK Andr L. Mihaljevic Department of Surgery, Klinikum rechts der Isar, Technische Universitt Mnchen, Munich, Germany David M. Nagorney Mayo Clinic, Rochester, Minnesota, USA Yuji Nimura MD President, Aichi Cancer Center, Chikusaku, Nagoya, Japan Giuseppe Orlando Th. STARZL Abdominal Transplant Unit, Cliniques Universitaires St Luc Universit catholique de Louvain, Department of Abdominal and Transplantation Surgery, Brussels, Belgium
9. 9. ix LIST OF CONTRIBUTORS Nicholas ORourke MBBS, FRACS Royal Brisbane Hospital, Brisbane, Queensland, Australia Martin Palavecino MD Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA Purvi Y. Parikh MD Department of Surgery, Albany Medical College, Albany, New York, USA Samir Pathak MD, ChB, MSC, MRCS Clinical Fellow, North Western Hepatobiliary Centre, Aintree University Hospital, Liverpool, UK Henry A. Pitt MD Indiana University, Indianapolis, Indiana, USA Graeme J. Poston MS, FRCS (Eng), FRCS (Ed) Centre for Digestive Diseases, University Hospital Aintree, and Department of Surgery, The Royal Liverpool University Hospitals, Liverpool, UK Derek G. Power MD Memorial Sloan-Kettering Cancer Center, New York, New York, USA Myrddin Rees MS, FRCS, FRCS (Ed) Hepatobiliary Unit, Basingstoke and North Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK Michael Rhodes Department of Surgery, Norfolk & Norwich University Hospital, Norwich, UK Charles B. Rosen Mayo Clinic, Rochester, Minnesota, USA Gerardo Sarno MD Clinical Fellow, North Western Hepatobiliary Centre, Aintree University Hospital, Liverpool, UK Rajesh Satchidanand MD, FRCS Clinical Fellow, North Western Hepatobiliary Centre, Aintree University Hospital, Liverpool, UK Beat Schnriger Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California, USA Lawrence H. Schwartz Department of Radiology, Columbia University College of Physicians and Surgeons, and Radiologist-in-Chief, New YorkPresbyterian Hospital/ Columbia University Medical Center, New York, New York, USA Margo Shoup MD, FACS Chief, Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA Jason K. Sicklick Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA Steven M. Strasberg MD, FRCS(C), FACS, FRCS (Ed) Pruett Professor of Surgery and Head Hepato-Pancreato-Biliary and Gastrointestinal Surgery, Washington University in Saint Louis and Barnes-Jewish Hospital, Saint Louis, Missouri, USA Jason W. Smith MD Chief Resident, Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA Nick Stern Consultant Gastroenterologist, Digestive Diseases Department, University Hospital Aintree, Liverpool, UK Richard Sturgess Consultant Gastroenterologist and Clinical Director, Digestive Diseases Department, University Hospital Aintree, Liverpool, UK Adriano Tocchi Head of 1st Department of Surgery and Chief of the Gastro-intestinal and Hepato-biliary Surgical Service, University of Rome Sapienza Medical School, Rome, Italy Ludovic Trinquart Department of Radiology, Assistance-Publique Hpitaux de Paris, Hpital Beaujon, Clichy, France Bernard Van Beers Department of Radiology, Assistance-Publique Hpitaux de Paris, Hpital Beaujon, Clichy; Universit Paris; and Centre de recherche biomdicale Bichat-Beaujon, Paris, France Jean-Nicolas Vauthey MD Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA Valrie Vilgrain Department of Radiology, Assistance-Publique Hpitaux de Paris, Hpital Beaujon, Clichy; Universit Paris; and Centre de recherche biomdicale Bichat-Beaujon, Paris, France Vanessa de Villa Assistant Professor, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China J.Weitz MD Department of Surgery, University of Heidelberg, Heidelberg, Germany Fenella K. S.Welsh MA, MD, FRCS (Gen Surg) Hepatobiliary Unit, Basingstoke and North Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK Moritz Wente Department of Surgery, University of Heidelberg, Heidelberg, Germany Vincent Kah Hume Wong MBCB, MRCS Research Fellow in Hepatopancreatobiliary & Transplant Surgery, HPB & Transplant Unit, St. James University Hospital, Leeds, UK A. Peter Wysocki Department of Surgery, Logan Hospital, Meadowbrook, Queensland, Australia Charles J.Yeo MD The Samuel D. Gross Professor and Chair, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA Daria Zorzi MD Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
10. 10. x As recent progress in hepato-pancreato-biliary (HPB) surgery has been evident since the first edition of this book was pub- lished eight years ago, Dr. Graeme Poston, Dr. Mike DAngelica, and Dr. Ren Adam, internationally recognized authorities in HPB surgery, have attempted to rewrite the sec- ond edition, joined by selected numerous worldwide special- ists renowned as expert authors in each field to present a current view of the surgical and non-surgical management of benign and malignant HPB disorders. This book demonstrates the wisdom of the new knowledge and technical skills of these diverse disciplines where cooperative efforts contribute toward the benefit of the patients with HPB disorders. The general surgeon will find this volume to be a useful source of current thoughts on how to manage the diverse HPB diseases. Yuji Nimura MD President, Aichi Cancer Center Professor Emeritus, Nagoya University Graduate School of Medicine Past President, International Hepato-Pancreato-Biliary Association (IHPBA) Foreword
11. 11. xi Preface Hepato-pancreato-biliary (HPB) surgery is now firmly established within the repertoire of modern general surgery. Indeed, in many major tertiary centers there are now specific teams for both pancreatic and liver surgery. However, in most hospitals outside these major centers the day-to-day manage- ment and decision-making for patients with these disorders remains the remit of the general surgeon. Following the launch of the highly successful first edition of this book eight years ago there have been considerable advances in the surgical management of HPB disorders. Many of these relate to related specialties (radiology, oncology, gas- troenterology, and anesthesia) and also directly to surgery (liver transplantation, caval bypass and replacement, laparo- scopic surgery to name but a few). As such the second edition has been completely rewritten from scratch. As with the first edition, the purpose of this edition is twofold. First, it is intended to cover the spectrum of common HPB diseases that will confront the general surgeon in his or her regular practice. Second, we hope that this work will be sufficiently comprehensive to cover the broad spectrum of HPB surgery for candidates coming to examinations at the completion of surgical training. We are indebted to the many international contributors for their perseverance and patience over the gestation of this proj- ect, which is greatly appreciated. Lastly, we are grateful to our publishers, Informa Healthcare, for their help during the preparation of this project. Graeme J. Poston Michael DAngelica Ren Adam September 2010
12. 12. 1 lobar anatomy (2). The first successful elective liver resection was performed two years later by von Langenbuch, who excised a portion of the left lobe of the liver containing an adenoma in 1888 (9). He had to reopen the abdomen several hours after the operation because of reactionary hemorrhage, but was able to ligate the bleeding vessels and return the over- sewn liver to the abdomen. Two years later in 1890, the Baltimore surgeon McLane Tiffany reported the successful removal of a benign liver tumor (10), and the following year Lucke described the successful resection of a cancerous growth of the liver (11). Surgery was now becoming a recognized treatment for liver pathology. Advances in surgery closely mirrored increased understanding of the functional anatomy of the liver (1214). The first attempt to define the functional anatomy of the liver, which could possibly guide current surgical practice, was made by Cantlie in 1898, while working in Hong Kong. He dis- sected the livers of executed prisoners (15) and making vascu- lar casts, he demonstrated that the main division between the right and left lobe in fact extended from approximately the gallbladder fossa, to the right side of the IVC, posterosuperi- orly. Cantlies line, therefore, follow a line drawn from the gall- bladder fossa, along the middle hepatic vein, to the IVC (Figs. 1.2 and 1.3) (3). In 1911, Wendel reported the first case of right lobectomy for a primary tumor (16), however this procedure did not follow the precise anatomical plane described by Cantlie. In 1939, while working in Paris, the Vietnamese surgeon Ton That Tung described the venous drainage of the liver in rela- tion to the true lobar anatomy (Fig. 1.4) (17). The first ana- tomically correct description of a left lateral segmentectomy was made by Raven in 1948 while resecting metastatic colon cancer (18). Four years later, Lortat-Jacob and Robert finally described a similar approach to the true right hepatic lobec- tomy, based on the anatomical principles described by Cantlie (Fig. 1.6) (19). Healey and Schroy were the first to demonstrate in 1953 that the right lobe was further divided into an anterior and a pos- terior sector (20). They also showed that the left lobe was divided into a medial and lateral sector by the line of the falci- form ligament and umbilical vein (Fig. 1.5). Understanding of the functional anatomy of the liver continued to develop, and in 1957, Goldsmith and Woodburne described a number of anatomical planes through the liver parenchyma that followed this functional anatomy. Their paper finally defined true right lobectomy (right hepatectomy), left lobectomy (left hepatec- tomy), and left lateral segmentectomy (Fig. 1.6) (21). appreciation of segmental anatomy Probably the most important anatomical contribution to modern liver surgery comes from the work of the late Claude The success of any surgical intervention on the liver and bile ducts is totally dependent on a thorough working knowledge of their anatomy. As the number of patients undergoing hepa- tobiliary surgery is increasing, good understanding of the anatomy of this area is increasingly important for any surgeon with an interest in the gastrointestinal tract. Command of this anatomy is also essential for the successful interpretation of functional imaging of hepatobiliary anatomy. When operating on the liver and biliary tree, the surgeon has to obey three basic tenets. Remove all pathologically involved tissue. Preserve the maximal amount of functioning non- pathological liver tissue. Perform safe resection, while ensuring adequate blood supply to the remaining hepatic parenchyma. Historically, the liver was described according to its mor- phological appearance (1,2). However, these three tenets have altered the approach to surgery, and the liver is now consid- ered from a functional and therefore surgical perspective. morphological anatomy Historically, when viewed at laparotomy, the liver appears divided into a larger right lobe, and a smaller left lobe by the umbilical fissure and falciform ligament (Figs. 1.1 and 1.2) (3). Situated on the inferior surface of the right lobe is the transverse hilar fissure, which constitutes the posterior limit of the right lobe. The quadrate lobe was defined as the portion of the right lobe lying anterior to this transverse hilar fissure and to the right of the umbilical fissure, its other margin being defined by the gallbladder fossa. The caudate lobe, which is anatomically and functionally separate from the rest of the liver, lies posterior to the hilum, between the portal vein and the inferior vena cava (IVC) (4). This historical anatomical approach does not consider the vasculature or biliary drainage of the liver and is of only lim- ited use when planning surgical resection. early application of the functional anatomy Isolated liver wounds, usually as a result of military action, had been successfully treated since the early seventeenth century (5,7), but the first attempt at resection of a liver tumor was not made until 1886, when the French surgeon Luis excised a solid liver tumor by ligating and cutting through a pedunculated left lobe adenoma. Attempts to suture the sev- ered pedicle were unsuccessful, and the stump was returned to the peritoneal cavity. Not surprisingly, the patient succumbed some six hours later (8). In 1888, Rex reported a new arrangement of the right and left lobes of the liver and further refined our understanding of 1 Surgical anatomy of the liver and bile ducts Robert Jones and Graeme J. Poston
13. 13. 2 SURGICAL MANAGEMENT OF HEPATOBILIARY AND PANCREATIC DISORDERS IVC Cantlie's line Middle hepatic vein lying among Cantlie's line Gallbladder IVC Figure 1.3 Cantlies line. IVC Right lobe Left lobe IVC Right free border of lesser omentum Figure 1.1 Morphological anatomy. Cantlie's line Gallbladder Quadrate lobe Umbilical ssure Transverse hilar ssure Gastrohepatic omentum Caudate lobeIVCCommon bile duct, hepatic artery and portal vein Figure 1.2 Anatomical features. Couinaud, who in 1957 produced a huge number of vasculo- biliary casts of the liver (23,24). Couinaud was able to demon- strate that the liver appeared to consist of eight anatomical segments,each of which could potentially be separately resected without affecting the physiological viability of the other seg- ments. Couinaud redefined the caudate lobe as segment 1 and Goldsmith and Woodburnes left lobe as segments 2 and 3. The quadrate lobe was termed segment 4, and more recently has been subdivided by further studies of its portal blood supply into 4A (superiorly) and 4B (inferiorly). The right liver consists of segments 5 (anteroinferiorly), 6 (posteroinferiorly), 7 (pos- terosuperiorly), and 8 (anterosuperiorly) (Fig. 1.7). Couinaud later suggested a further clarification, in which the caudate lobe to the left of the IVC remained segment 1, with that to the right being redefined as segment 9 (25). Resections based on these anatomical segments enable the surgeon to safely operate following the three central tenets described above; remove all pathologically involved tissue, preserve the maximal amount of nonpathological liver tissue, and perform safe resection, while ensuring an adequate blood supply (inflow and outflow), and therefore viability, to the remaining hepatic parenchyma. The description of Couinaud is the most complete and exact, and also the most useful for the operating surgeon, and therefore it is this description that will be used throughout this book. segmental anatomy of the liver These anatomical studies of the functional anatomy of the liver allow us to define hepatic segments based upon both the distribution of the portal pedicles and the drainage of the hepatic veins (Fig. 1.5). The three main hepatic veins (right, middle, and left) divide the liver into four sectors, each of which receives a portal pedicle containing branches of the hepatic artery, hepatic duct, and portal vein; thus producing an alternation between hepatic veins and portal pedicles. These four sectors, demarcated by the hepatic veins, are the portal sectors, each sector therefore receiving an independent portal supply. For the same reason, the scissurae containing the hepatic veins are termed the portal scissurae while the scis- surae containing portal pedicles are the hepatic scissurae (Fig. 1.5). Thus, the liver is divided by the main portal scissura along the line of the middle hepatic vein into two discrete hemilivers, along the line previously described by Cantlie (15). We therefore refer to these hemilivers as right and left livers, rather than right and left lobes, to avoid confusion with the anatomical lobes, particularly since there is no visible surface marking that permits individualization of the true lobes. As described by Cantlie, the main portal scissura runs poste- riorly from the middle of the gallbladder fossa to the right side of the IVC (Fig. 1.5). Therefore, the right and left livers, demar- cated by the main portal scissura, are independent in terms of their portal and arterial vascularization and their biliary drainage. These right and left livers are both further divided into two by the other two portal scissurae, delineated by the right and left hepatic veins. Goldsmith and Woodburne refer to these further divisions as segments (21), but for the rest of this book, we will use the more generally accepted nomenclature of Couinaud, which refers to these divisions assectors(23). The
14. 14. 3 SURGICAL ANATOMY OF THE LIVER AND BILE DUCTS Left heptic vein Caudate hepatic veins (variable) IVC IVC Gallbladder, note that the middle vein may lie supercially in the gallbladder fossa Right hepatic vein Middle hepatic vein (usually enters left vein before IVC) Right inferior hepatic vein (variable) Right liver Left liver Figure 1.4 Venous drainage of the liver. IVC Middle hepatic vein in main portal scissura following Cantlie's line Left hepatic vein in left portal scissura Lateral segment of left lobe Falciform ligament Medial segment of left lobe Portal veinRight anterior sector Right posterior sector Right hepatic vein in right portal scissura Right liver Left liver 7 8 6 5 1 4 3 2 Figure 1.5 Functional sectoral anatomy and relationship to hepatic scissurae. right liver is divided by the right portal scissura (right portal vein) into an anteromedial (or anterior) sector containing segments 5 inferiorly and 8 superiorly, and a posterolateral (or posterior) sector containing segments 6 inferiorly and 7 supe- riorly (Fig. 1.5). When the liver lies in its normal position within the upper abdominal cavity, the right posterolateral sector lies directly behind the right anteromedial sector, and this scissura is therefore almost in the coronal plane. Therefore in the clinical setting (particularly when imaging the liver), it is better to speak of these anterior and posterior sectors (Fig. 1.5). The exact location of the right portal scissura is imprecise, because it has no external landmarks. According to Couinaud (23), it extends from the edge of the liver at the mid- dle point between the back of the liver and the right side of the gallbladder bed along the right hepatic vein posteriorly to the confluence of the right hepatic vein and the IVC (2628). The venous drainage of the right liver is variable in that, in addition to the right and middle hepatic veins, there are often a number of smaller hepatic veins draining directly into the IVC from segments 6 and 7. Not infrequently (6368%) seg- ment 6 drains directly into the IVC through a distinct inferior right hepatic vein, larger than these other venous tributaries to the IVC, which can be a significant bonus in the preservation of residual hepatic function when undertaking extended left hepatectomies (Fig. 1.4) (29,30). The left portal scissura, along the left hepatic vein, divides the left liver into two sectors: an anterior sector containing segments 3 and 4 and a posterior sector containing segment 2
15. 15. 4 SURGICAL MANAGEMENT OF HEPATOBILIARY AND PANCREATIC DISORDERS 7 8 5 6 4 1 2 3 7 8 5 6 4 1 2 3 (A) (B) Figure 1.7 Functional division of the liver and of the liver segments according to Couinauds nomenclature (A) as seen in the patient and (B) in the ex vivo position. Figure 1.6 Formal hepatectomies: (A) right hepatectomy; (B) left hepatectomy; (C) left lateral segmentectomy; (D) extended left hepatectomy; (E) extended right hepatectomy. (A) (B) (C) (D) (E)
16. 16. 5 SURGICAL ANATOMY OF THE LIVER AND BILE DUCTS as they will leave behind devascularized residual liver and will also probably not adequately excise all the pathologically involved parenchyma. The usual anatomical hepatectomies can be considered in two groups: right and left hepatectomies in which the line of transection is the main portal scissura separating the right and left livers along the middle hepatic vein, and right and left hepatectomies in which the line of transection commences in the umbilical fissure. For some time the latter definition, initially proposed by Goldsmith and Woodburne (21), has been the accepted conven- tion. We would encourage the use of the former definition, as segment 4 (quadrate lobe) is anatomically part of the left liver (Fig. 1.9), and this convention was adopted universally at the 2000 Brisbane Congress of the IHPBA (Brisbane Convention), and will be used hereafter in this book. Using this functional approach to liver anatomy, we can define numerous potential liver resections based upon the order (first, second, third) of the hepatic divisions (main portal scissura, anterior and poste- rior right portal scissurae, left portal scissura) (28). With regard to the first order division, right hepatectomy or hemihepatectomy (removal of the right liver/hemiliver) there- fore consists of the resection of segments 5 to 8 (stipulating segment 1). Left hepatectomy or hemihepatectomy (removal of the left hemiliver or liver) is the removal of segments 24 (stipulating segment 1) (Fig. 1.6). In certain pathologies (multiple liver metastases or large tumors transgressing the main portal scissura) hepatectomies can be extended to include adjacent segments and sectors of the other liver.There- fore extended right hepatectomy (right trisegmentectomy or extended right hemihepatectomy) will also include resection of segment 4 (stipulating segment 1), taking portal struc- tures to the right of the falciform ligament (Fig. 1.6). Similarly, extended left hepatectomy (left trisegmentectomy or extended left hemihepatectomy) would include resection of segments 5 and 8 en bloc with segments 2 to 4 (stipulating segment 1) (Fig. 1.6). When discussing second order divisions, individual sectors can be resected in isolation or in adjacent pairs depending upon the distribution of pathology. Therefore right anterior sectionectomy refers to the en bloc resection of segments 5 and 8 (between the main portal scissura (middle hepatic vein) and right portal scissura (right portal vein) on their pedicle of the anterior division of the right portal vein). Right posterior sectionectomy (previously referred to as right posterior or lat- eral sectorectomy) is the contiguous resection of segments 6 and 7, posterior to the right portal scissura (on the pedicle of the posterior division of the right portal vein) (Fig. 1.8). On the left side, isolated excision of segment 4 can be described as left median sectionectomy, although it is also legitimate to refer to it as resection segment 4 or segmentectomy 4. One area of confusion in these definitions of hepatectomies comes in the simultaneous resection of segments 2 and 3 (Fig. 1.10). Goldsmith and Woodburne originally described this procedure as a left hepatic lobectomy (21). Describing this as left lateral segmentectomy is technically wrong since the true left lateral segment (and sector) comprises no more than segment 2 (excision of which in isolation can therefore be (Fig. 1.5). It is important to note that the left portal scissura does not follow the umbilical fissure; this portal scissura contains a hepatic vein and the umbilical fissure contains a portal pedicle. Therefore the left portal scissura lies poste- rior to the ligamentum teres, inside the left lobe of the liver (Fig. 1.5). The middle hepatic vein (defining the main portal scissura) usually enters the left hepatic vein some 1 to 2 cm before the left hepatic vein joins the IVC (Fig. 1.4) (30). Occasionally the middle and left hepatic veins enter the IVC separately, and in 2 out of 34 of Couinauds casts, the middle vein and left veins joined at more than 2.5 cm from the IVC (30). Such an anom- aly must be detected and excluded during isolated resection of segment 4, since if it is not seen, and the last 2 cm of the left vein is damaged, segments 2 and 3 will be needlessly sacrificed (and in the case of extended right hepatectomy, threaten future remnant liver viability). The caudate lobe (segments 1 and 9) is the dorsal portion of the liver, lying posteriorly and surrounding the retrohepatic IVC. It lies directly between the portal vein (anteriorly) and the IVC (posteriorly). The main bulk of the caudate lobe lies to the left of the IVC, with its left and inferior margins being free in the lesser omental bursa (Fig.1.2).The gastrohepatic (lesser) omentum separates the caudate from segments 2 and 3 of the left liver. The left portion of the caudate lobe lies inferior to the right between the left portal vein and the IVC, as the caudate process. This process then fuses inferiorly with segment 6 of the right liver. The amount of caudate lobe that lies on the right side is variable, but usually small. The anterior surface of the caudate lobe lies within the hepatic parenchyma against the posterior intrahepatic surface of segment 4, demarcated by an oblique plane slanting from the left portal vein to the left hepatic vein. The caudate lobe must be considered functionally as an iso- lated autonomous segment, since its vascularization is inde- pendent of the portal division and of the three main hepatic veins. It receives a variable arterial and portal blood supply from both the right and left portal structures, although the right caudate lobe consistently receives an arterial supply from the right posterior artery. Biliary drainage is likewise into both the right and left hepatic ducts. However, the left dorsal duct can also join the segment 2 duct. The small hepatic veins of the caudate lobe drain directly into the IVC. This independent functional isolation of the caudate lobe is clinically important in BuddChiari syndrome; if all three main hepatic veins are obliterated, the only functioning hepatic venous drainage is through the caudate lobe, which therefore undergoes compen- satory hyperplasia. anatomical classification of hepatectomies Hepatic resections can be classified as anatomical and nonanatomical. Anatomical hepatectomies (hepatectomies reglees) are defined by resection of a portion of liver paren- chyma defined by the functional anatomy. These resections are called left or right hepatectomies, sectorectomies, and seg- mentectomies. Nonanatomical hepatectomies involve resec- tion of a portion of hepatic parenchyma not limited by anatomicalscissurae.Suchresectionsareusuallyinappropriate,
17. 17. 6 SURGICAL MANAGEMENT OF HEPATOBILIARY AND PANCREATIC DISORDERS described as left lateral or posterior sectorectomy). It is now accepted convention that resection of segments 2 and 3 is regarded as a left lateral sectionectomy (but can also legiti- mately be referred to as bisegmentectomy 23). With regard to the third order divisions, resection is now at the level of the individual hepatic segment(s). Therefore these resections are referred to as segmentectomy (classified according to the segment being removed: 19). Similarly, segments 5 and 6 can be resected en bloc (and this used to be described as a right inferior hepatectomy) and this should now be described as bisegmentectomy 56. If there is a significant right inferior hepatic vein draining segments 5 and 6, then segments 7 and 8 can be resected with the right hepatic vein (bisegmentectomy 78) (Fig. 1.8). surgical approach to the caudate lobe This resection (segmentectomy 1 or 9, or 1 and 9 en bloc) is initially achieved by dissection of the coronary ligament up to the right of the IVC, being careful to avoid the right hepatic vein. The falciform ligament is then dissected to the IVC, the Figure 1.8 Other hepatic sectorectomies: (A) right posterior sectorectomy; (B) right anterior sectorectomy; (C) left medial sectorectomy (segments 4A and 4B); (D) right inferior hepatectomy; (E) right superior hepatectomy. (A) (B) (C) (E) (D) lesser omentum being incised close to the liver. Opening the left coronary ligament allows ligation of the inferior phrenic vein. The caudate veins running directly to the IVC are now exposed and can be divided between ligatures as they run up the back of the caudate lobe. After the hilar plate is lowered to expose the right and left portal pedicles, the portal inflow to both the right and left caudate segments can be identified, ligated, and divided. The caudate lobe is now isolated and the main portal fissure is divided to separate segments 4, 7, and 8. Note that the caudate segment 1s not defined macroscopically from segment 6. the biliary tract Accurate biliary exposure and precise dissection are the two most important steps in any biliary operative procedure and are both totally dependent on a thorough anatomical under- standing of these structures. Several authors have described the anatomy of the biliary tract (17,22,23), but unfortunately the surgical implications have been incompletely described and continue to be misunderstood by many surgeons.
18. 18. 7 SURGICAL ANATOMY OF THE LIVER AND BILE DUCTS intrahepatic biliary anatomy The right liver and left liver are respectively drained by the right and the left hepatic ducts. The caudate lobe (segments 1 and 9) is drained by several ducts joining both the right and left hepatic ducts (20). The intrahepatic ducts are tributaries of the corresponding hepatic ducts, which form part of the major portal tracts invaginating Glissons capsule at the hilus and penetrating the liver parenchyma (Fig. 1.11). There is vari- ation in the anatomy of all three components of the portal triad structures (hepatic ducts, hepatic arteries, and portal vein), but it is the portal vein that shows the least anatomical variability. In particular, the left portal vein tends to be consis- tent in location (23). Bile ducts are usually located above the portal vein whereas the corresponding artery will lie below. Each branch of the intrahepatic portal vein corresponds to one or two intrahepatic bile ducts, which converge outside the liver to form the right and left hepatic ducts, in turn joining to form the common hepatic duct. The left hepatic duct drains segments 2, 3, and 4, which con- stitute the left liver. The duct draining segment 3 is found a lit- tle behind the left horn of the umbilical recess, from where it passes directly posteriorly to join the segment 2 duct to the left of the main portal branch to segment 2. At this point, the left branch of the portal vein turns forward and caudally in the recessus of Rex (23) (Figs. 1.12 and 1.13). As the duct draining segment 3 begins its posterior course it lies superficially in the umbilical fissure, often immediately under Glissons capsule.As such it is usually easily accessible at surgery to allow a biliary enteric (segment 3 hepaticojejunostomy) anastomosis for bili- ary drainage if such access is not possible at the porta hepatis. The left hepatic duct then passes beneath the left liver at the posterior base of segment 4, lying just above and behind the left branch of the portal vein.After the left duct crosses the anterior edge of that vein it joins the right hepatic duct to form the com- mon duct at the hepatic ductal confluence. In this transverse portion, where it lies below the liver parenchyma, it receives one to three small branches from segment 4 (23). The right hepatic duct (Fig. 1.14) drains segments 5 to 8 and arises from the convergence of the two main sectoral (anterior 5 and 8, and posterior 6 and 7) tributaries. The right posterior sectoral duct runs almost horizontally (26) and comprises the confluence of the ducts from segments 6 and 7 (Fig. 1.15). The right posterior duct joins the right anterior sectoral duct (formed by the confluence of the ducts from segments 5 and 8) Figure 1.9 Completion of segment 4 resection with portal bifurcation lying inferiorly in front of the inferior vena cava. Figure 1.10 Left lateral segmentectomy immediately prior to division of the portal structure lying inferiorly and the left hepatic vein lying superiorly. Figure 1.11 Exposing the hilar plate by raising the inferior surface of segment 4B, thus demonstrating the condensation of Glissons capsule, which will cover the extra hepatic confluence of the right and left hepatic ducts. Figure 1.12 Exposing the recessus of Rex by distraction of the falciform liga- ment to demonstrate the bifurcation of segment 3 and segment 4 bile ducts.
19. 19. 8 SURGICAL MANAGEMENT OF HEPATOBILIARY AND PANCREATIC DISORDERS as it descends vertically (26). This right anterior sectoral duct lies to the left of the right anterior sectoral branch of the intra- hepatic portal vein as it ascends within the parenchyma (Fig. 1.15). The junction of the two main right biliary ducts usually occurs immediately above the right branch of the por- tal vein (23). The right hepatic duct is considerably shorter than its counterpart on the left, which it joins to form the com- mon hepatic duct in front of the right portal vein (Fig. 1.15). The caudate lobe (segments 1 and 9) has its own separate biliary drainage. This segment comprises two anatomically and functionally distinct portions, a caudate lobe proper (which consists of a right and left part) located at the posterior aspect of the liver, and a caudate process passing behind the portal structures to fuse with segment 6 of the right liver. In nearly half of individuals, three separate bile ducts drain these distinct parts, while in a quarter of individuals, there is a com- mon biliary duct between the right portion of the caudate lobe proper and the caudate process, while the left part of the cau- date lobe is drained by an independent duct. However, the site of drainage of these ducts is variable. Most authors advocate en bloc resection of the caudate lobe during resection of hilar cholangiocarcinoma (31), since the tumor usually infiltrates these ducts draining the caudate lobe. Certainly these authors have demonstrated that in 88% of cases of hilar cholangiocar- cinoma coming to resection there is histological evidence of tumor infiltration of the caudate lobe along these ducts. extrahepatic biliary anatomy The detail of this section will be confined to the upper part of the extrahepatic biliary tree, above the common bile duct, since the common bile duct is also covered in chapter 2. The right and left hepatic ducts converge at the right of the hilum of the liver, anterior to the portal venous bifurcation and over- lying the origin of the right portal vein. The biliary confluence Figure 1.15 Biliary and vascular anatomy of the right liver.Note the horizontal course of the posterior sectoral duct and the vertical course of the anterior sectoral duct. Anterior sectoral duct 8 5 Posterior sectoral duct 7 CHD PV HA LHA LPV LHD 6 Figure 1.13 Biliary and vascular anatomy of the left liver. Note the position of segment 3 duct above the corresponding vein and its relationship to the reces- sus of Rex. 4 2 3 RPV RHD RHA CHD 4 (ant.) Recessus of Rex HAPV Figure 1.14 Demonstration of the right hepatic duct lying within the gallblad- der fossa.
20. 20. 9 SURGICAL ANATOMY OF THE LIVER AND BILE DUCTS is separated from the posterior aspect of the base of segment 4 by a fusion of connective tissue investing from Glissons cap- sule to form the fibrous hilar plate. This hilar plate has no vas- cular interposition and, when opened behind the posterior aspect of the base of segment 4, will display the extrahepatic confluence of the right and left hepatic ducts (Fig. 1.16). The main bile duct is divided into its upper part, the com- mon hepatic duct, and lower part, the common bile duct, by the entry of the cystic duct from the gallbladder. This point of confluence of hepatic and cystic ducts to form the common bile duct is widely variable, and any surgeon performing the operation of cholecystectomy has a duty of care to their patient to be fully aware of this anatomic variability (lest they mistake the common bile duct, or less frequently the common or right hepatic ducts for the cystic duct, resulting in catastrophic con- sequences for the patient). The main bile duct normally has a diameter of up to 6 mm and passes downward anterior to the portal vein in the right free border of the lesser omentum. The bile duct is closely related to the hepatic artery as it runs upwards on its left side before dividing into its left and right branches, the right hepatic artery usually passing posteriorly to the bile duct. The cystic artery, which usually arises from the right hepatic artery, crosses the common hepatic duct as fre- quently anteriorly as it does posteriorly (Figs. 1.17 and 1.18). Calots triangle was originally defined by the common hepatic duct lying medially, inferiorly by the cystic duct and superiorly by the cystic artery (32). However, the usually accepted surgical definition of this triangle has been modified to that of the cholecystectomy triangle, which defines the upper border as the inferior surface of the liver (and therefore contains the cystic artery) (33). The junction of the cystic duct and common hepatic duct varies widely and may even occur behind the pancreas. The retropancreatic portion of the bile duct approaches the duodenum obliquely, accompanied by the terminal part of the duct of Wirsung (see chap. 2). These two ducts join to enter the duodenum through the sphincter of Oddi at the papilla of Vater (34,35). gallbladder and cystic duct The gallbladder lies within the cystic fossa on the underside of the liver in the main liver scissura, thereby defining the junc- tion between the right and left hemilivers. It is separated from the hepatic parenchyma by the cystic plate, which is an exten- sion of connective tissue from the hilar plate (described previ- ously). The anatomical relationship of the gallbladder to the liver ranges from hanging by a loose peritoneal reflection to being deeply embedded within the liver parenchyma. The gall- bladder varies in size and consists of a neck, body, and fundus, which usually reaches the free edge of the liver, still closely applied to the cystic plate. Large gallstones impacting within the neck of the gallbladder may create a Hartmanns pouch (33), and inflammation secondary to this can obscure the ana- tomical plane between the gallbladder and the common hepatic duct (thus obliterating the cholecystectomy triangle). This degree of inflammation can make dissection during cho- lecystectomy difficult, increasing the risk of damage to the common hepatic duct (36). Other structures similarly threat- ened during this dissection as part of cholecystectomy for RHD RHA RPV Cystic artery Cystic duct Gallbladder CBD Superior mesenteric artery and vein Splenic vein Gastroduodenal artery Retroduodenal artery HA CHD LHA LHD LPV Figure 1.17 Anterior aspect of biliary anatomy. Note the hepatic duct conflu- ence anterior to the right hepatic artery and origin of the right portal vein. Note also the course of the cystic artery, arising from the right hepatic artery and passing posteriorly to the common hepatic duct. Figure 1.16 Demonstration of the relationship between the posterior aspect of the base of segment 4 and the biliary confluence. Note the extension of Glis- sons capsule to invest the portal structures at the hilum (hilar plate) and extending over the hepatic surface of the gallbladder (cystic plate). Exposure of the extrahepatic left hepatic duct is achieved by incising the hilar plate at the base of segment 4 medially as far as the umbilical fissure. Cystic plate Hilar plate Line of incision of hilar plate to expose left hepatic duct Umbilical ssure Lig.teres Glisson's capsule Segment 4
21. 21. 10 SURGICAL MANAGEMENT OF HEPATOBILIARY AND PANCREATIC DISORDERS The cystic duct arises from the neck of the gallbladder and in 80% of people descends to join the common hepatic duct in its supraduodenal course. Its length varies widely but its luminal diameter is usually between 1 and 3 mm. The mucosa of the cystic duct is arranged in spiral folds (valves of Heister) (33). In a small number of cases, the cystic duct joins the right hepatic duct or occasionally a right hepatic sectoral duct. The gallbladder receives its blood supply by the cystic artery, the anatomy of which varies widely (Fig. 1.18). The most com- mon variant arises directly from the right hepatic artery, then dividing into an anterior and posterior branch. The venous drainage of the gallbladder is directly through the gallbladder fossa to the portal vein in segment 5 (Fig. 1.19). biliary anomalies The biliary anatomy described above, comprising a right and left hepatic duct joining to form a common hepatic duct occurs in between 57% (23) and 72% (8) of cases. This vari- ance may be explained by Couinauds (23) description of a triple confluence of right posterior sectoral duct, right ante- rior sectoral duct, and left hepatic duct in 12% of cases, which Healey and Schroy do not describe. There are many other abnormalities in biliary anatomy. Couinaud described a right sectoral duct joining the main bile duct in 20% of individuals (right anterior sectoral in 16%, right posterior sectoral in 4%). In addition, a right sectoral duct (posterior in 5%, anterior in 1%) may join the left hepatic duct in 6% of cases. In 3% of cases, there is an absence of a defined hepatic duct confluence with all the sectoral ducts joining separately and in 2% the right posterior sectoral duct may join the neck of the gallbladder or be entered by the cystic duct (23) (Fig. 1.20). Similarly, there are common variations of the intrahepatic biliary anatomy. Healey and Schroy (20) describe the classical intrahepatic biliary arrangement outlined above in 67% of Figure 1.18 The eight most common variations in the anatomy of the arterial supply (cystic artery) to the gallbladder. (A) (B) (C) (D) (E) (F) (G) (H) chronic cholecystitis include the right hepatic artery (in up to 50% of cholecystectomy bile duct injuries, so rendering the upper bile duct ischemic with ramifications for the timing of bile duct repair), the right hepatic duct, and in exceptional cir- cumstances, a low-lying middle hepatic vein lying superficially just below the gallbladder fossa. Figure 1.19 (A) Venous drainage of the gallbladder. (B) The lymphatic drainage of the gallbladder towards the coeliac axis. (A) (B)
22. 22. 11 SURGICAL ANATOMY OF THE LIVER AND BILE DUCTS cases, with ectopic drainage of segment 5 in 9%, segment 6 in 14%, and segment 8 in 20% of the cases. In addition, they describe a subvesical duct in 20% to 50% of the cases (8,37). This subvesical duct may lie deeply embedded in the cystic plate and can join either the common or right hepatic ducts. This duct does not drain any specific area of the liver and never communicates with the gallbladder, but may be damaged dur- ing cholecystectomy and therefore contribute to postoperative biliary leak. On the left side, the commonest anomaly is a com- mon union of ducts of segments 3 and 4 (25% of cases), and in only 2% does the segment 4 duct independently join the common hepatic duct (Fig. 1.21). Gross described a number of anomalies of the accessory biliary apparatus in 1936 (38). These include bilobed and Figure 1.20 Main variations of the hepatic duct confluence. (A) (C) (D) (E) (F) ra rp Ih 57% ra rp Ih 2% ra rp Ih 20% C1 16% ra rp Ih 6% D1 5% (B) ra rp Ih 12% ra rp Ih C2 4% ra rp Ih D2 1% ra rp 1 2 3 4 3% E1 2% ra rp 1 2 34 E2 1% duplicated gallbladder (39,40), septum and diverticulum of the gallbladder, and variations in cystic duct anatomy includ- ing a double cystic duct (41). More rare is agenesis of the gall- bladder (42,43) (Fig. 1.22). Furthermore, the gallbladder may be abnormally positioned, either lying deep within the liver parenchyma or lying under the left liver (44). The union of the cystic duct with the common hepatic duct may be angular, parallel, or spiral. The most frequent union is angular (75%) (45), while the cystic duct may run parallel with the hepatic duct in 20%, both encased in connective tissue. In 5% of cases, the cystic duct may approach the hepatic duct in a spiral fashion, usually passing posteriorly to the common hepatic duct before entering on its left side (Fig. 1.23). the arterial blood supply of the bile ducts The hepatic artery usually arises as one of the three named branches of the coeliac trunk, along with the left gastric and splenic arteries (Fig. 1.24). The first named branch of the hepatic artery is the gastroduodenal artery and either of these arteries may then give rise to the right gastric and retroduode- nal arteries (Fig. 1.24). The hepatic artery then divides into right (giving rise to the cystic artery) and left hepatic arteries. This arrangement holds true for 50% of cases. In nearly 25% of cases, the right hepatic artery arises sepa- rately from the superior mesenteric artery, indicative of the joint fore- and mid-gut origin of the liver (Fig. 1.25). In the remaining 25% of cases, the left hepatic artery arises from the left gastric artery. Occasionally, other variations will occur. These variations will be readily apparent to an experienced surgeon at operation. The authors do not advocate preopera- tive angiography to delineate these anomalies prior to routine hepatectomy. The extrahepatic biliary system receives a rich arterial blood supply (46), which is divided into three sections. The hilar sec- tion receives arterioles directly from their related hepatic arter- ies and these form a rich plexus with arterioles from the supraduodenal section.The blood supply of the supraduodenal section is predominantly axial. Most vessels to this section arise from the retroduodenal, right hepatic, cystic, gastroduodenal, and retroportal artery.Usually,eight small arteries,each 0.3 mm in diameter, supply the supraduodenal section. The most important of these vessels run along the lateral borders of the duct and are referred to as the 3 oclock and 9 oclock arteries. Of the arteries supplying the supraduodenal section, 60% run upward from the major inferior vessels while 38% run down- ward from the right hepatic artery. Only 2% are nonaxial, aris- ing directly from the main trunk of the hepatic artery as it runs parallel to the bile duct. The retropancreatic section of the bile duct receives its blood supply from the retroduodenal artery. The veins draining the bile duct mirror the arteries and also drain the gallbladder. This venous drainage does not enter the portal vein directly but seems to have its own portal venous pathway to the liver parenchyma (47). It has been proposed that arterial damage during cholecys- tectomy may result in ischemia leading to postoperative stric- ture of the bile duct (47), although it seems unlikely that ischemia is the major mechanism in the causation of bile duct stricture after cholecystectomy.
23. 23. 12 SURGICAL MANAGEMENT OF HEPATOBILIARY AND PANCREATIC DISORDERS Contraindications to this approach include patients with a very deep hilum, which is displaced upward and rotated later- ally (36), and those patients who have undergone removal or atrophy of either the right or left livers resulting in hilar rota- tion. In this situation, the bile duct may come to lie behind the portal vein. When approaching the segment 3 duct (segment 3 hepati- cojejunostomy), follow the round ligament (in which runs the remnant of the obliterated umbilical veins) through the umbilical fissure to the point where it connects with the left branch of the portal vein within the recessus of Rex. This junction may sometimes be deeply embedded within the parenchyma of the fissure. The bile ducts of the left liver are located above the left branch of the portal vein, whereas the corresponding arteries lie below the portal vein. Dissection of the round ligament on its left side allows exposure of either the anatomy of biliary exposure Although intraoperative ultrasound has made easier the loca- tion of dilated intrahepatic biliary radicals, surgical exposure of the extrahepatic biliary confluence and the segment 3 duct demands knowledge of precise anatomical landmarks. Biliary enteric anastomosis necessitates precise bile duct exposure to facilitate the construction of a mucosa to mucosa apposition (36,4850). To expose the extrahepatic biliary confluence, the base of the quadrate lobe (segment 4) is lifted upward and Glissons cap- sule is incised at its base (see Fig. 1.16) (51). This technique is also sometimes referred to aslowering the hilar plate.In only 1% of cases is this made difficult by any vascular imposition between the hilar plate and the inferior aspect of the liver. This maneuver will expose considerably more of the left hepatic duct than the right, which runs a shorter extrahepatic course. Figure 1.21 Variations of the intrahepatic biliary anatomy. a 67% b 1% c 1% d 25% e 1% f 1% g 4% 2 2 2 2 2 2 2 3 3 3 3 3 3 3 (D) seg IV 7 7 5 5 6 6 80% 20% (C) seg VIII 8 8 8 8 7 7 7 7 5 5 5 5 86% 10% 2% 2% (B) seg VI 8 8 87 7 7 6 6 6 91% 4%5% (A) seg V
24. 24. 13 SURGICAL ANATOMY OF THE LIVER AND BILE DUCTS liver split to the left of the umbilical fissure in order to widen the fissure to achieve adequate access to the biliary system. Access to the right liver system is less readily achieved than to the left as the anatomy is more imprecise. However, intraop- erative ultrasonography greatly enhances the ability of the sur- geon to locat e these ducts at surgery. The ideal approach on the right side is to the segment 5 duct (52), which runs on the left side of its corresponding portal vein (23). The duct is exposed by splitting the liver over a short distance to the right of the gallbladder fossa, commencing at the right side of the porta hepatis. The segment 5 duct should lie relatively superfi- cially on the left aspect of the portal vein to that segment. radiological anatomy of the liver Accurate preoperative localization of liver pathology using radiological techniques is of increasing importance, as any potential resection depends largely on the segmental loca- lization. Imaging is generally performed using ultrasound, computed tomography (CT), and magnetic resonance (MR). Ultrasound is excellent for imaging bile ducts, cysts, abscesses, and tumors. Hepatic circulation can also be accu- rately assessed using a Doppler technique. Ultrasound is also the imaging modality of choice for the biliary tree. However, the accuracy of ultrasound imaging is very operator depen- dent, and fine detail can be limited. Examination is limited by body habitus, and can be restricted by overlying bowel gas. CT scanning is an excellent method of assessing the liver parenchyma. It is able to identify a variety of different patholo- gies, and CT with IV contrast is the most commonly used method of imaging liver metastases. MR is excellent for the imaging and characterizing primary liver tumors, and is useful for the identification of hemangiomas, which can resemble metastases on CT scanning. Methods for defining segmental anatomy on ultrasound, CT, and MR images follow the anatomical landmarks previ- ously described (53). These methods generally involve using three vertical planes along the lines of the main hepatic veins to divide the liver into its four sectors, with a transverse scis- sura along the portal vein further subdividing these four sec- tors to give the eight Couinaud segments. These anatomical landmarks are generally easily identifiable on standard imag- ing. The middle hepatic vein, left hepatic vein, and ligamen- tum teres provide good landmarks for dividing the left liver into its four segments. The right hepatic vein can usually be clearly seen dividing the right liver into its two sectors. hepatic veins In an oblique ultrasonic view, the three hepatic veins join the IVC to form a characteristic W, with its base on the IVC. A similar view can be seen on CT scan. These veins are usually easily seen: the left hepatic vein separating segment 2 from seg- ments 3 and 4, the middle hepatic vein separating segment 4 from 5 and 8, and the right hepatic vein separating 5 and 8 from 6 and 7. portal system The portal supply to the left lobe, when viewed obliquely, can be seen as a side-on H, with the left portal vein giving its the pedicle or anterior branch of the duct from segment 3. This dissection is achieved by mobilizing the round ligament and pulling it downwards, thereby freeing it from the depths of the umbilical fissure. This procedure usually requires the preliminary division of the bridge of liver tissue that runs between the inferior parts of segments 3 and 4. The umbilical fissure is then opened and with downward traction of the ligamentum teres an anterior branch of the segment 3 duct is exposed on its left side. Sometimes it may be necessary to perform a superficial liver split to gain access to this duct. In the usual situation of chronic biliary obstruction with dilatation of the intrahepatic bile ducts, the segment 3 duct is generally easily located above the left branch of the portal vein. However, in the situation of left liver hypertrophy, it may be necessary to perform a more extensive 1 2 3 (A) 1 12 (B) (C) 1 2 (D) Figure 1.22 Main variations in gallbladder and cystic duct anatomy: (A) bilobed gallbladder; (B) septum of gallbladder; (C) diverticulum of gall- bladder; (D) variations in cystic duct anatomy. (A) 75% (B) 20% (C) 5% Figure 1.23 Different types of union of the cystic duct and common hepatic duct: (A) angular (75%); (B) parallel (20%); (C) spiral (5%).
25. 25. 14 SURGICAL MANAGEMENT OF HEPATOBILIARY AND PANCREATIC DISORDERS branch to segment 2, before dividing into the terminal branches to 3 and 4. The portal supply to the right lobe also demonstrates a side- onHin the oblique view. The right branch of the portal vein forms the cross bar of the H, with the branches to segment 5 to 8 forming the arms. gallbladder, ligamentum venosum, and falciform ligament Radiological landmarks of these structures are fallible (Figs. 1.261.28). Significant variations in intrahepatic vascu- lar anatomy may result in incorrect identification of lesion location. A study by Rieker et al. looked at CT scans of patients who underwent liver resection. The location of the lesion was Left branch of the hepatic artery Hepatic artery 3 o'clock artery Common hepatic artery Gastroduodenal artery Right branch of the hepatic artery 9 o'clock artery Retroduodenal artery (A) Common hepatic Left gastric Aorta Celiac trunk Splenic M.H. artery L.H. artery R.H. artery Cystic Proper hepatic Supraduodenal Gastroduodenal Right gastric (B) Figure 1.24 (A) The biliary duct blood supply; (B) conventional arterial anatomy of the liver (50%). key points A full understanding of the lobar, sectoral, and seg- mental anatomy of the liver and biliary system is an essential prerequisite for successful liver surgery. The surgeon must appreciate the wide variation in extrahepatic biliary anatomy. identified using the landmarks outlined above. The scans were then reviewed, with the lesion being attributed to the nearest portal branch. Sixteen percent of lesions had a different seg- mental location if the portal branch was used instead of the conventional technique (Fig. 1.29) (54).
26. 26. 15 SURGICAL ANATOMY OF THE LIVER AND BILE DUCTS Figure 1.25 Variations in anatomy of hepatic arterial supply. (A) (B) (C) (D) (E) (F) Figure 1.26 Portal phase CT scan through porta hepatis showing the left portal vein (L) lying centrally and the anterior (RA) and posterior (RP) divisions of the right portal vein (R). Figure 1.27 CT scan of upper liver in venous phase showing the left, middle and right hepatic veins draining into the inferior vena cava (IVC). IVC 24a 8 7 Figure 1.28 CT scan of the liver in portal phase showing the left portal vein passing anteriorly between segments 3 and 4 within the recessus of Rex. Figure 1.29 Percutaneous direct portogram showing the relationships of the anterior (RAPV) and posterior (RPPV) to the main (MPV) and left (LPV) portal veins. RAPV RPPV LPV MPV
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28. 28. 17 tributary ducts coming off at near right angles and that this duct opened into the duodenum, and he saw that there were occasionally two ducts in the gland (1). It was Santorini who finally concluded that, in the normal condition, there existed two ducts with the smaller of the two emptying into the duo- denum by way of a small papilla approximately 2 cm nearer to the stomach than the major duct and this smaller duct bears his name (5). The smaller duct is patent all the way to the duo- denum in only 60% of specimens and the duct of Wirsung represents the larger of the two; however, in about 10% of specimens, the duct of Santorini is the main drainage for the pancreas. Also in about 10% of cases, the two ducts are not in communication with each other (1) (Fig. 2.2). The paren- chyma of the pancreas consists of small lobules divided by connective tissue. These lobules are centered around the main tributary ducts that run to the main pancreatic duct. Smaller branches off of these tributaries define further septated regions within the lobules of pancreatic tissue. The main branches of the pancreatic duct tend to meet the main duct on its superior and inferior aspect. The diameter of the main pancreatic duct is reported to be between 2.6 and 4.8 mm in the head, 2.0 and 4.0 mm in the body, and 0.9 and 2.4 mm in the tail (3). The duct runs in a relatively superficial position in the tail and after traversing the neck of the pancreas it dives deep into the paren- chyma as it crosses the head and is near the dorsal surface of the pancreas as it nears the confluence with the common bile duct (CBD) and the duodenum (1). The lower portion of the CBD lies in contact with the head of the pancreas for between 2 and 7 cm and 40% of the time it lies in a groove between the surface of the pancreas and the duodenum. In the remainder of cases, it lies within the paren- chyma of the pancreas (7). During embryological develop- ment,the lower duct of Wirsung arises in the ventral pancreatic bud adjacent to the early hepatic duct. Therefore, the associa- tion of the duct of Wirsung with the CBD is a consistent fea- ture of the ductal anatomy of the pancreas (1). The duct of Wirsung and the CBD unite 6 to 8 mm within the papilla and form a common channel, which is slightly dilated and referred to as the ampulla of Vater. In just over 10% of cases, the two ducts do not form a short common channel and instead enter the duodenum independently on the papilla (5). arterial anatomy of the pancreas The pancreas enjoys an abundant arterial blood supply that draws from both the celiac axis and the superior mesenteric artery (SMA). The pancreas is supplied from the celiac axis by the superior pancreaticoduodenal artery from the gastroduo- denal artery (GDA), and the dorsal pancreatic and pancreatica magna arteries from the splenic artery (Fig. 2.3). The distal and inferior borders of the pancreas are supplied by the caudal and inferior pancreatic arteries, which are formed by topography of the pancreas The shape and size of the pancreas are highly variable but in general it has a roughly trapezoidal shape and lies in the retro- peritoneum of the upper abdomen (1). It is a finely lobular structure with a tan to dull yellow color that reaches from the medial concavity of the duodenum up and to the left termi- nating at the hilum of the spleen. The volume of the pancreas increases rapidly during childhood, plateaus from 20 to 60 years, and then steadily decreases; however, the percentage of parenchyma versus fat in the pancreas continues to increase during life slowly replacing functional tissue (2) (Fig. 2.1). The pancreas is divided into three major regions, the head and uncinate, the neck, and the body and tail (3). The head is the most medial portion of the gland. It is the widest and thickest part, having the most globular ultrastructure and is cradled in the concavity of the duodenum lying just to the right of the second lumbar vertebra (1). There is an inferior projection to the head of the pancreas that lies posterior to the superior mesenteric vessels, which makes up the uncinate pro- cess. The head and uncinate are intimately associated with the duodenum, sharing an abundant network of anastomosing vessels. The posterior surface of the head of the pancreas is in apposition to the inferior vena cava, aorta, right spermatic and ovarian vessels, and right renal vessels and separated from them by the avascular fusion fascia of Treitz (4). The ante- rior surface is covered by the transverse colon and its mesentery (5,6). The neck of the pancreas is 2 to 3 cm in length and overlies the confluence of the superior mesenteric vein (SMV) and splenic vein by which it is grooved. It is related superiorly to the pylorus and first portion of the duodenum (3,4). The body of the pancreas extends from body of the second lumbar vertebra over the left kidney and begins to taper into the tail as it reaches the hilum of the spleen. The prismatic shape of the pancreas flattens in the tail. The splenic vein runs the length of the pancreas on the posterior surface, while the artery courses along the superior edge of the body. The body of the pancreas lies over the aorta and the left renal pedicle and kidney and is separated from these structure