No abstract

Anatomical central hepatectomy is technically demanding and is often excessive. It has an increased risk for insufficient remnant liver volume, especially in case of P8 dorsal pedicle for segment 7 and/or P5 dorsal for segment 6, and/or abnormal background liver. On the contrary, limited central hepatectomy (LCH) for centrally located tumors, based on preserving the P8 dorsal and some of P5 and P4 pedicles (depending on tumor placement) is conservative, and therefore has a low risk for insufficient remnant liver volume. It is less technically demanding, when compared to anatomical central hepatectomy. The right side of the resection plane is driven along the P8 dorsal pedicle intersecting the P8 ventral pedicle and as few of the P5 pedicles as possible. The left side of the resection plane is established according to tumor placement anywhere in between the Cantlie's plane and the falciform ligament. The video presents 5 cases that support the conclusion that LCH may be standardized, with good results, especially when using intraoperative ultrasound guidance.

This technical paper introduces a novel organ preservation system based on isochoric (constant volume) supercooling. The system is designed to enhance the stability of the metastable supercooling state, offering potential long-term preservation of large biological organs at subfreezing temperatures without the need for cryoprotectant additives. Detailed technical designs and usage protocols are provided for researchers interested in exploring this field. The paper also presents a control system based on the thermodynamics of isochoric freezing, utilizing pressure monitoring for process control. Sham experiments were performed using whole pig liver sourced from a local food supplier to evaluate the system’s ability to sustain supercooling without ice nucleation for extended periods. The results demonstrated sustained supercooling without ice nucleation in pig liver tissue for 24 and 48 h. These findings suggest the potential of this technology for large-volume, cryoprotectant-free organ preservation with real-time control over the preservation process. The simplicity of the isochoric supercooling device and the design details provided in the paper are expected to serve as encouragement for other researchers in the field to pursue further research on isochoric supercooling. However, final evidence that these preserved organs can be successfully transplanted is still lacking.

Background: Liver resection (LR) is the standard treatment for most focal liver lesions. Intraoperative ultrasound (IOUS) improves their diagnosis and guides the liver resection. The present paper analyses our experience in IOUS guided LR, reviewing the indications, surgical techniques, and the short-term results. Material and Method: 198 LRs guided by IOUS in 186 patients operated in our center between January 2013 and December 2017 were included in a combined prospective and retrospective study. The median age of the patients was 60 years (mean 57, range 16-79), with a male/female ratio of 109/77, and adult/pediatric patient ratio of 185/1. Results: Malignant lesions were the main indication for IOUS guided LR (164 LRs; 82.8%); among these, colorectal liver metastases were the main indication (66 LRs; 33.3%), followed by hepatocellular carcinoma (44 cases, 22.2%). The mean number of tumors was 3 (range 1-16), and the median diameter of the largest tumor was 40 mm (mean 51; range 3-240). IOUS found new lesions in 22.3% of cases operated for liver metastases (46 LRs), and changed the surgical strategy in 41.9% of cases (83 LRs). Major resection rate was 18.2% (36 LRs); anatomical LRs were performed in 18 cases (9.1%). The median operative time was 330 minutes (mean 334; range 90-920). The median blood loss was 700 ml (mean 900; range 250-9500), with a transfusion rate of 54.8% (108 LRs). Overall and major complication rates were 46.5% (92 LRs) and 7.6% (15 LRs), respectively, while the mortality rate was 2% (4 pts). Conclusion: IOUS should be fully integrated in the modern liver surgery, providing improved diagnosis and optimal resection guidance, increasing resectability and surgical safety, with low perioperative morbidity and mortality.

Liver resection for malignant tumors should respect oncological margins while ensuring safety and improving the quality of life, therefore tumor staging, underlying liver disease and performance status should all be attentively assessed in the decision process. The concept of parenchyma-sparing liver surgery is nowadays used as an alternative to major hepatectomies to address deeply located lesions with intricate topography by means of complex multiplanar parenchyma-sparing liver resections, preferably under the guidance of intraoperative ultrasound. Regenerative liver surgery evolved as a liver growth induction method to increase resectability by stimulating the hypertrophy of the parenchyma intended to remain after resection (referred to as future liver remnant), achievable by portal vein embolization and liver venous deprivation as interventional approaches, and portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy as surgical techniques. Interestingly, although both strategies have the same conceptual origin, they eventually became caught in the never-ending parenchyma-sparing liver surgery vs. regenerative liver surgery debate. However, these strategies are both valid and must both be mastered and used to increase resectability. In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors. In addition, liver volume-manipulating regenerative surgery should be employed when resectability needs to be extended beyond the possibilities of parenchyma-sparing liver surgery.