Surgical Approach for the Resection of Tumour-involved Common Hepatic Artery during Pancreaticoduodenectomy

Abstract

Introduction: Polycystic liver disease (PLD) is characterised by the presence of multiple fluid-filled liver cysts, >10 cysts. According to Gigot, type 3 (severe) is multiple cysts occupying >75% of TLV. Treatment options are limited, including surgical like aspiration-sclerotherapy, fenestration, hepatectomy, liver transplantation, and medical options such as somatostatin analogs. However, the efficacy of these treatments remains uncertain except liver transplantation which is curative especially in severe variety. Case: 32 year old female with a BMI of 26 presented with history of abdominal pain and swelling since 5 years with post prandial fullness. Preoperative evaluation with CT scan showed Gigot Type 3 PLD. She opted for all treatments except transplant. Right-extended hepatectomy and fenestration of cyst in seg 2,3(remnant volume 21%) was done in this patient. Intra-operatively the liver was so large that mobilisation was difficult leading to compression of the heart leading to hypotension every time liver was pushed. Routine outflow control was not feasible. 10 mins Intermittent dissection and 10 mins intermittent stoppage gave time to anesthesist for proper resuscitation. Careful parenchymal transection along the cantles line using the Belghiti technique prevented blood loss since the portal tracts are completely distorted. Some cyst were decompressed along with wall cauterisation to prevent postoperative ascites and in some tetracycline was injected as a sclerosant to prevent recurrence. Conclusion: Severe PLD is very rare. Extended hepatectomy and fenestrations are good palliative options for relieving patients symptoms. Few technical improvisations during hepatectomy along with energy devices can help HPB surgeons achieve these feats.