How we do it—the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery

Abstract

Purpose Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects. Methods All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1–8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity. Results Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred. Conclusions The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

Portomesenteric Reconstruction during Whipple Procedure Using Autologous Left Renal Vein Patch Graft in a Patient with a Gastric Cancer Recurrence

“…There are several vascular reconstruction techniques, and the optimal method is the one that provides the most significant opportunity for a safe R0/R1 resection of the tumor. Various types of grafts have been described for venous reconstruction; however, the decision for the optimal type depends on several factors, such as the vessel lumen, the type of vascular reconstruction (patch plastic or a tube substitute), the septic contamination of the operative field, the accessibility of the graft, and the surgeon's experience [ 26 ].…”

“…The PPPs graft is readily available, operation time is not significantly prolonged, and there is no need for additional surgical procedures as in the case of harvesting another autologous vessel. In addition, there is no graft size limitation [ 26 ].…”

Inferior vena cava reconstruction with non‐fascial autologous peritoneum: Retrospective study and literature review

“…We adopted the Clavien–Dindo classification and Karnofsky performance scale to define the complications and functional status of patients in the postoperative period 6 . We used Radulova's criteria to define IVC patency 7 …”

“…1,2,47 Other authors have recommended lifelong anticoagulant treatment for reconstructions using synthetic materials or temporarily (up to 6 months) using autologous human materials. 7,32,37 However, a study in 2021 found no difference in thrombosis between patients who received anticoagulant or antiaggregant therapy and those who did not. 23 The ultimate goal was to find a completely nonthrombogenic material.…”

“…However, it should be noted that the anterior fascia of the rectus muscle provides primary strength for abdominal closure; therefore, harvesting the posterior fascia should not compromise wall integrity. 4,7,36,37 This potential risk is completely overcome using NFAP. Carcinomatosis is the only contraindication for the use of AP.…”