Liver sutures and resection methods
Special liver sutures are used to stop bleeding and securely approximate the wound edges. Kuznetsov-Pensky suture is applied as a double U-shaped stitch, with knots tied on both the upper and lower surfaces of the organ. As an alternative, the Oppel mattress suture is used.
Liver resection is performed in two main ways:
- With preliminary vascular ligation: the liver edge is brought out into the wound, stitched with a blunt needle along the line of the intended wedge resection, the segment is excised, and the defect is closed with a series of mattress sutures.
- Without preliminary ligation: the parenchyma is temporarily compressed with fingers, excised in a wedge shape, and the gaping vessels are grasped with clamps and ligated. The wound surfaces are sutured with interrupted catgut stitches while simultaneously fixing the omentum on a pedicle.
Depending on the extent, procedures are divided into atypical (marginal, wedge, transverse) and typical anatomical. In typical operations (segmental resections, lobectomies, right- and left-sided hemihepatectomies), the intraorgan structure is strictly taken into account, and the elements of Glisson's capsule and hepatic veins are ligated beforehand. In atypical ones, the suture is placed parallel to the interlobar fissure, keeping 1.0–1.5 cm away from the resected area.
Organ-sparing surgeries on the gallbladder
Cholecystotomy involves opening the lumen, removing calculi, and tight closure of the wall. It is performed extremely rarely, usually as an incidental finding of calculous cholecystitis during another operation, and requires absolutely free patency of all bile ducts.
Cholecystostomy (Cholecystostomia) is the creation of an external fistula. It is indicated for debilitated patients with acute cholecystitis (when the risk of radical surgery is high) or in the presence of a dense infiltrate, as well as in unresectable obstructive jaundice. There are two types of drainage: "close" (the fundus is sutured to the abdominal wall) and "interrupted" (a tube is inserted into the lumen, and the space is walled off with packs).
The patient is placed supine with a roll under the XII rib. Access is an oblique incision in the right upper quadrant. The gallbladder fundus is brought out, a wide seromuscular purse-string suture is placed with silk, punctured with a thick needle, and the lumen is opened. After removing the stones, a drainage tube is inserted, the first purse-string is tightened, and it is invaginated with a second one.
The most critical step is marsupialization. Starting 0.5 cm away from the second purse-string, the serosa is sutured with interrupted stitches, first to the peritoneum, then to the aponeurosis. It is strictly forbidden to fix the wall to the skin, otherwise a permanent lip-like fistula will form. If the common bile duct is patent, the fistula closes spontaneously after the drainage is removed.
Cholecystectomy and biliodigestive anastomoses
Cholecystectomy (Cholecystectomia) is the complete removal of the gallbladder. It is indicated for chronic recurrent cholecystitis, destructive forms (phlegmonous, gangrenous, perforation), and cancer.
There are two technical approaches:
- From the fundus: a technically simpler option.
- From the neck (retrograde): more complex to perform, as it requires careful isolation of structures. The surgeon dissects the anterior leaf of the hepatoduodenal ligament, visualizes the common hepatic and common bile ducts, and the right branch of the proper hepatic artery. The cystic duct and artery are ligated and divided, after which the gallbladder is bluntly dissected from its bed. This method reliably prevents the displacement of calculi into the common bile duct.
In cases of unresectable cancer of the pancreatic head, palliative biliodigestive anastomoses are performed:
- Cholecystojejunostomy: connection to the jejunum (the loop is routed retrocolically). It must be supplemented with an enteroenterostomy or the use of an isolated Roux-en-Y loop to prevent reflux of intestinal contents.
- Cholecystoduodenostomy: connection to the duodenum using a two-layer suture (inner catgut, outer silk).
Briefly: answers to topical questions
What types of hemostatic liver sutures exist?
The following types of hemostatic liver sutures exist:
- Kuznetsov-Pensky suture — application of a double U-shaped stitch with a blunt needle through the entire thickness of the tissue, with knots tied on the upper and lower surfaces of the liver.
- Oppel suture — an alternative option of an interrupted or mattress stitch capturing the tissue.
- Mattress sutures — simple and reliable stitches that are often passed through the omentum on a pedicle to prevent suture cut-through.
What anatomical structures must be isolated in the hepatoduodenal ligament during cholecystectomy from the neck?
During cholecystectomy from the neck, the following anatomical structures must be isolated in the hepatoduodenal ligament:
- Common hepatic duct (ductus hepaticus communis) — visualized after dissecting the anterior leaf of the ligament.
- Common bile duct (ductus choledochus) — isolated to locate the entry site of the cystic duct.
- Right branch of the proper hepatic artery (r. dexter a. hepaticae propriae) — visualized for safe manipulation.
- Cystic artery (a. cystica) — isolated above the entry site of the cystic duct for subsequent ligation.
- Cystic duct (ductus cysticus) — isolated before gallbladder removal for ligation and transection.
What surgical approaches to the liver and biliary tract exist?
The following open surgical approaches to the biliary tract are used:
- Oblique incisions in the right upper quadrant — parallel to the costal margin, according to Fedorov or Kocher.
- Upper midline approach.
- Bilateral subcostal approach.
Minimally invasive methods are also used: ultrasound-guided percutaneous cholecystostomy and ultrasound-guided percutaneous transhepatic biliary drainage.
What types of palliative biliodigestive anastomoses are used in surgery?
The following biliodigestive anastomoses are used in surgery:
- Cholecystojejunostomy — connection of the gallbladder to the jejunum. The intestinal loop is routed retrocolically; an additional enteroenterostomy is mandatory to prevent reflux of contents into the gallbladder.
- Cholecystoduodenostomy — connection of the gallbladder to the duodenum, applied with a two-layer suture.
- Hepatoduodenostomy — mentioned as an example of a bypass anastomosis.
- Hepaticoenterostomy — creation of an anastomosis using a "long" intestinal loop brought out preperitoneally.
To memorize the fixation layers in cholecystostomy, use the rule "PA": Peritoneum, then Aponeurosis. Skin is excluded to avoid forming a lip-like fistula.
Class and exam questions
What is the difference between typical and atypical liver resection?
A typical resection is performed strictly along anatomical boundaries with preliminary ligation of the vessels of Glisson's capsule and veins. An atypical one (wedge, marginal) is performed without regard to segmental structure, guided by intraorgan architectonics and the location of the lesion.
Why is cholecystectomy from the neck considered safer for the ducts?
During isolation from the neck, the cystic duct is ligated first. This eliminates the risk of squeezing stones from the gallbladder into the common bile duct during surgical manipulations.
Why is an additional entero-enteroanastomosis required in cholecystojejunostomy?
It is necessary to prevent reflux of jejunal contents into the gallbladder and biliary tract, which can lead to severe infectious complications.
What else to study on this topic
- Topographic anatomy of the hepatoduodenal ligament
- Technique of applying the Kuznetsov-Pensky hemostatic suture
- Features of creating an isolated Roux-en-Y intestinal loop
- Surgical anatomy of Glisson's capsule and hepatic veins
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