Background: The objective was to analyze the multi-institucional experience with a novel next-generation modelling 3D software for personalised surgery decision-making in perihiliarchonagiocarcinoma (pCCA). Methods: Between September 2017 and January 2021, patients who underwent pCCA staging using anovel 3D preoperative planning system were included (Figure). To assess the agreement between surgicalspecimens, CT scans or MRI and 3D model, a Bland-Altman analysis was used. Anatomical vascularvariations were alsoanalysed. The reliability of the questionnaire to characterise the experience of hepatobiliary surgeons was calculated using Cronbach's alpha. Results: A total of 41 patients were evaluated. An improvement in the interpretation of vascular and biliary anatomy was detailed with a mean Likert score of 4.72 ± 0.46 and 4.77 ± 0.42, respectively.Theunderstanding of the biliary and vascular anatomy together with preoperative planning reached a higherscore of 0.88 and 0.83, respectively (Table). Teaching students, residents and better patient communication waspositively valued with a mean of 4.77 ± 0.42, 4.72 ± 0.46 and 4.44 ± 0.70, respectively.The averagedifference between 2D and intraoperative findings according tumour size (3.60 ± 3.75 mm,limits ofagreement of-14.97 to 22.15) was higher than with 3D (-2.52 ± 1.35 mm, limits of agreement of-9.21to 4.17). In 36.6% of the cases, the Michels classification was insufficient to correctly classify the variations in the hepatic artery. Conclusions: Next generation modelling3D software improvessurgical planning in pCCA andfacilitates the identification of the relationship between the lesion and vascular structures.

Introduction: The first variant reported was Tourniquet-ALPPS (T-ALPPS), which occludes the intrahepatic circulation by means of a tourniquet around the liver. Methods: We present a modification of our surgical technique, T-ALPPS, named “partial Tourniquet-ALPPS” (pT-ALPPS) which avoids the pass of the tourniquet by hanging maneuver and the right extraglissionan approach. The first Stage of this variant is easier, quicker and less risky compared to ALPPS, p-ALPPS or T- ALPPS. Results: In our HBP unit 65 T-ALPPS have been performed. Since February 2017 we underwent a prospective study comparing T-ALPPS with pT-ALPPS, including 6 patients with colorectal liver metastases (CRLM) in each group. The first case of pT-ALPPS, was performed in a patient with bilobar metastases and one of them was located in segment, in front of the inferior vena cava thus the tourniquet could not be passed by hanging maneuver. After clearing the future liver remnant (FLR) of CRLM, we ligate the right portal vein. Considering that the ventral portion of the liver to the right portal pedicle is a non-vascularized area, and with the aid of intraoperative ultrasonography, an Adson clamp was passed through the liver parenchyma. This clamp emerged between the right and middle hepatic vein. A tourniquet was then passed and knotted under ultrasound control. In Stage 2, we used the tourniquet as hanging maneuver for right hepatectomy or right trisectionectomy depending on its location. Conclusion: In selected patients P-T-ALPPS is an accessible technique easier than T-ALPPS as the clamp passes through an avascular area.

Purpose: Standardization in experimental animal models plays a crucial role in preclinical studies by providing useful information on the type and extent of liver disease. However, it is necessary to combine these determinations with functional dynamics imaging and testing techniques to implement a non-invasive protocol for liver evaluation. Method: Six healthy SD rats were followed for 4 weeks. The aim was to determine hepatic function, perfusion and parenchyma attenuation with biochemical blood parameters, indocyanine green, ultrasound and computed tomography. Results: Indocyanine green clearance 5 and 10 minutes after its injection was 80.12% and 96.59%, respectively. Hepatic perfusion evaluation with the high-frequency ultrasound was related to cardiovascular hemodynamic and renal perfusion. Portal area, hepatic artery resistance index and average between hepatic artery and porta was 3.41 ± 0.62 mm 2 , 0.57 ± 0.04 mm 2 /s and 4.82 ± 0.96 mm 2 /s, respectively. Heart rate, cardiac output, left renal artery diammetre and renal blood flow were 331.01 ± 22.22 bpm, 75.58 ± 8.72 mL/min, 0.88 ± 0.04 mm 2 and 13.65 ± 1.95 mm 2 /s. CT-scan hepatic average volume for each rat were 21.08±3.32, 17.57±2.76, 14.87±2.83 and 13.67±2.45 cm 3 with an average attenuation coefficient of 113.51±18.08, 129,19±7.18, 141,47±1.95 y 151,67±1.2 HU. Conclusion: Indocyanine green and high-frequency ultrasound could be used in rats as a suitable marker of liver function. Computed tomography help to characterize liver parenchyma, and could be a potential tool for early detection and linear follow-up of patients. Further studies in rats with liver disease are necessary to verify the usefulness of these parameters.Table 1Indocyanine Green plasma clearance (ICG) rateICG plasma concentration (μg/mL)Min 1Min 5Min 10Rat 1128.1±55.61819.45±2.285.41±3.32Rat 2161.47±65.8228.58±9.235.75±3.60Rat 3160.63±27.6833.14±6.957.44±0.52Rat 4189.16±51.0538.13±2.863.47±0.05Rat 5165.91±23.9147.51±8.822.90±0.76Rat 6130.65±10.2119.24±3.546.91±0.99Average ICG Concentration (μg/mL)155.99±23.1131.01±11.015.31±1.82Average Clearance %0.0080.1296.59 Open table in a new tab μg/mL: microgram/mililitre

Next-generation three-dimensional modelling software for personalized surgery allows spatially accurate depiction of the hepatic and vasculature anatomy based on the complexity and individual variation in each patient, and could facilitate decision-making about preoperative strategy in perihilar cholangiocarcinoma.

Purpose: Resection of the posterior superior segments has been considered one of the most difficult procedures due to difficult access. Our aim is to prove that, in spite of all the disadvantages, such as poor visualization, difficult instrumentation, and greater complexity in bleeding control, the laparoscopic approach is a feasible way to resect these liver segments. Methods: A systematic search strategy was performed using a combination of terms and standardized index numbers: (laparoscopic liver surgery) AND (posterior superior segments) AND (segment 7) AND (segment 8). Results: A total of 13 hospital series and 6 clinical cases that exclusively analyzed the segments 7 and/or 8 were included in this review. The most frequent indication was metastasis (55.4%), followed by hepatocellular carcinoma (28.7%). The average size of the lesions ranged from 13 to 39 mm. The mean surgical times were between 105 and 420 minutes. Six groups conducted the pringle maneuver in 8-84% of patients. Blood losses ranged from 50-550 ml with a conversion rate between 0-42.9%. Major complications ranged from 0-10.86% with average stays between 2 and 12 days. The resection margin was negative in 90-100% of the resections. The intrahepatic glissonian approach to segment 7 consists on locating G7 by ultrasound and identification of the right hepatic vein. Once G7 is ligated, resection begins from the demarcation that occurs between S6 and S7 to expose the full length of the right hepatic vein. In case of the intrahepatic glissonian approach to segment 8, the approach begins taking as reference the middle hepatic vein. The dissection should continue in this direction more deeply until reaching the root of the G8. Glissonean branches from segment 7 or 8 can be isolated extrahepatically from the hilum of the liver. It is possible through an avascular plane to dissect the right anterior and posterior pedicles in the hepatic hilum until the corresponding G7 and G8 branches are isolated near their origins. Segmental pedicles to segment 7 can be approached after dissecting the liver in the Rouviere groove, while segments 8 first need to locate the G5 and G8 branches that branch from the right anterior pedicle to later isolate G8 exclusively. Conclusions: The accumulated experience of the different groups in minimally liver surgery invasive treatment have facilitated resection of tumors in segments 7 and 8 with similar and even better results than open surgery.

Purpose: Hepatic cysts are formations of liquid content with multiple histological types that differ from each other due to their etiology, symptoms, and clinical management. Specifically, simple cysts are commonly asymptomatic and only require clinical observation. In particular, jaundice is a very rare clinic in these patients. Our goal is to show a case of a simple hepatic cyst that caused jaundice and needed surgery in order to emphasize how infrequent the case is. Methods: We present a descriptive study based on a case of a simple liver cyst that required surgery through a laparoscopic approach. Results: A 79-year-old woman had consulted to the Emergency room due to jaundice for 15 days. The blood test that was carried out showed elevated total bilirubin (12mg/dL) and transaminases levels with a cholestatic pattern, without alterations in the hemogram or elevation of acute phase reactants. An abdominal computerized tomography (CT) and a cholangioresonance revealed dilation of the intrahepatic bile duct secondary to a large cystic lesion in the right lobe of the liver, which measured approximately 10 centimetres. She underwent laparoscopic surgery, unroofing the cyst and the following day the patient was discharged from hospital without jaundice or any surgery complication. Finally, the anatomopathological study demonstrated a simple hepatic cyst, so the woman did not require more periodic controls. Conclusion: Simple liver cysts rarely cause symptoms and only require clinical observation. However, it is very important to perform an adequate anamnesis and carry out the necessary complementary tests to confirm such a diagnosis, since they can be confused with other liver cysts. Some examples might be a hydatid cyst or even a cystadenoma, which has the capacity to become malignant and require more aggresive management. In these patients, if surgery is needed, laparoscopy is a suitable approach, as allows the total resection of the lesion and provides an early postoperatory recovery.

Purpose: Tumoral affection of the hepatic veins represents a surgical challenge due to the technical difficulty and the hemodynamic disorders that occur during the surgery. Despite left renal vein (LVR) graft is not a widely used option, we want to show that hepatic veins resection and autologins LVR for hepatic vein reconstruction is possible without increased morbidity and impairment of renal function. Methods: This is a retrospective study on a prospective database of 1750 liver resections performed from July 1985 to March 2020 at Virgen de la Arrixaca University Hospital, Murcia. Patients undergoing a resection of hepatic vein(s) with hepatic vascular exclusion and LRV placement were selected. Our study was reviewed by an ethics committee. We also describe the hemodynamic management and surgical technique, from the initial staging and hepatic transection, to the LRV graft preparation (Figure 1d-e), the total hepatic vascular occlusion (clamping right portal vein and cannualting left porta: Figure 1f), the tumor resection and graft placement (Figure 1g), and in the end, the hepatic reperfusion. Results: Four patients underwent left hepatectomy with vascular reconstruction using LVR for tumor invasion of the confluence of hepatic veins (Table 1). Median lesion size was 40 mm [interquartile range (IQR), 35-62]. Liver lesions involved right hepatic veins and the origin of middle and left hepatic veins in all cases. The median blood loss was 500 ml (IQR, 300-1500), median surgical time was 360 min (IQR, 255-465), perfusion time with cold ischemia was 67 min (IQR, 60.5-77.5) and warm ischemia time was 63.5 min (59-77). The median length of the graft was 4.5 cm (IQR, 3.1-5.2) and the grafts remained patent during the follow-up with no signs of thrombosis. Three of the 6 patients presented a complication and none of them exceeded a Dindo-Clavien grade IIIb, with a median hospital stay of 15 days (IQR, 12-21). Median follow-up was 97 months (IQR, 27-113). One of the three patients currently alive had a lung recurrence (case 3) and the patient who died, did it disease-free due to a cerebral hemorrhage (case 2). Conclusions: VRI grafts for the reconstruction of a hepatic vein are a safe alternative when hepatic resection is the only curative alternative. In addition, the use of in situ liver perfusion reduces ischemic damage to the liver without the need for a veno-venous bypass with adequate hemodynamic control.EP031_Table 1NºDiag-nosisGenderAgePrevious chemoNº of lesionsSize (cm)Blood losses (ml)Surgical time (min)Compli-cations (Clavien)Warm ischemia (min)ICU length of stay (days)Hospital stay (days)Tumor recurrenceSurvival time (months)1CRLMM53Xelox1401500240No77415NoAlive (118)2CRLMF60Folfox + Cetuximab240; 20300420No60511NoDeath (90)3BCLMF53Anthracycline170500300Pleural effusion (IIIa)62715YesAlive (98)4CRLMM40Folfiri + Cetuximab134500480Intraabdominal collection (IIIA)72524NoAlive (6) Open table in a new tab

We have read with interest the case published by Plua-Muñiz as an example of how endovascular treatment may be an acceptable and safe option even in an emerging situation as long as swift action is taken and the patient is stabilized previously. Hepatic artery aneurysms are an infrequent entity and their management is a great challenge. In the following letter we show our point of view and what the literature says about its management.