Professional Documents
Culture Documents
*y
ABDUL-HAMZA 3HNAIN
B. V.
M.
1961
MASTER OP SCIENCE
Approved by:
''HiQjfP
Major Professor
(J
i-0
Ri
)f(7
SS
TABLE OF CONTENTS
Page
INTRODUCTION
1 3 5 8 8
in.
HISTORICAL REVIEW
Portocaval Shunt
the Dog
....
11 12
14-
Simplified Hepatectomy
One-stage Hepatectomy Two-stage Hepatectomy in Rabbits
14-
18
21 21
....
...
23 25
26
28 32
33
Partial Hepatectomy
36
39
4.3
SUMMARY
APPENDIX REFERENCES
46
62
INTRODUCTION
Surgery began as a handicraft.
In ancient times it was
Today's
ment of disease.
Subsequent advances
Extensive research
New
Secords
today many standard operative procedures are utilized throughout the world.
These procedures
niques.
(1) carbohydrate
the blood, and (10) the formation of vitamin A and the storage
of vitamins A and D.
were used and those which are still heing used in medical
HISTORICAL REVIEW
One of the earliest methods employed in investigations of
was performed by Bock and Hoffman (1874-) when they excluded the
liver from the circulation by ligation of the hepatic veins.
In this tech-
nique the portal blood was shunted to the vena cava by side-toside anastomosis of these vessels and ligation of the portal
which the aorta and vena cava were ligated above the diaphragm
through an incision in the chest.
He was studying changes in
the blood sugar and wanted to exclude the liver from a circula-
In
4 1/2 hours.
A thorough knowledge of the anatomy of the liver is essential in research concerning this organ.
The liver of the dog has 4 lobes, the left, quadrate, right and the caudate lobes.
divided into medial and lateral sublobes while the caudate lobe
is composed of the caudate and papillary processes and a con-
The small visible functional divisions of the liver are the hepatic lobules. The central vein is found in the center
the liver.
fibers from the vagus and by sympathetic fibers from the celiac
plexus.
Two branches arise from the ventral vagal trunk and
They
Alexander
(194-0)
lobes, has been termed the "main liver", and the smaller por-
region the hepatic artery and the portal trunk are in close
apposition.
The superior
SURGICAL TECHNIQUES
Bile Fistula
about the common bile duct, and the duct divided between the
ligatures.
stay sutures.
Eooper
and Whipple stated that care should be taken to insure the tube
It can
obstructive jaundice.
side-to-side anastomosis with the vena cava, the common mesenteric vein was chosen for the anastomosis.
the splenic vein close to its union with the common mesenteric
vein, and on the portal vein just cranial to its juction with
10
approximately 1/2 inch long and 1/8 inch wide, was excised.
The elliptical shape of the excision prevented excessive closure
caudal end.
of the incision in the mesenteric vein was sutured to the wall of the vena cava using a continuous suture (Pig. 1-C)
.
The
traction suture was removed, and the upper margin of the incision was sutured in the same method as the lower margin.
clamps were then removed starting with the Pott's clamp.
All
The
following surgery the animal was still fairly comfortable; however, ascites reoccurred whenever meat or meat by-products
11
Rabbits
rabbit
'
liver was conducive to the type of experiment perThe liver masses are unequal in size, with the larger
formed.
and the right anterior lobe which includes the gall bladder.
The "main mass" is 3 times as large as the smaller, or "lobe
In addition the small vein arising from the portal trunk at the
level of the ligature, was ligated and cut away from the
caudate lobe.
bile duct and hepatic artery while ligating the portal trunk.
The operation was performed on rabbits weighing from
14-00 gm.
Following surgery an
occasional animal was lost from a fatal necrotic process, however the majority of animals recovered without complication and
12
Three-stage Hepatectomy
between the portal vein and the vena cava in the manner of the
Eck fistula, except that the vena cava was ligated instead of
the portal vein. The ligature was applied immediately anterior The procedure resulted in
route.
before its entrance to the liver and after its anastomosis with
artery and the vena cava just below the diaphragm, along with
15
Mann's statement
"as
ful".
He further
It-
Simplified Hepatectomy
Markowitz and Soskin (1927) described a simplified method
for hepatectomy of dogs.
The procedure consisted of partially
The result of
Markowitz, Mann
and Ballman (1928) used this technique while studying the gly-
One-stage Hepatectomy
Initial experiments
15
:..-.':;:
Lo
After this initial success they proceeded with the onestage hepatectomy on dogs.
liedium-sized, well conditioned dogs,
the open method with no preanesthetic. The abdominal cavity was opened by a longitudinal incision
With careful
16
and the diaphragm a tunnel was made under the vena cava.
ligature was passed through the tunnel and Drought into place
Anteri-
When excessive
was ligated between the liver and the hemostat, and was then
3-C).
foreward 2 to
3 cm.
(Fig. 3-D).
17
cannula filled with saline was slipped into the incised vessel
and passed upward until it met the obstruction caused hy the
diaphragmatic ligature.
tightly around the end of the cannula lying within the hepatic
vena cava so as to prevent bleeding around the cannula and to
help hold it in place.
The open ends of the cannula were
A ligature
The
with one tie was placed near the open end of the vessel.
removed, the portal blood flowed through the cannula into the
vena cava.
the cork was removed from the lower end of the cannula which
The previously
cannula in place.
18
The
silk suture.
Animals
could walk, bark, run, void, defecate and drink water after
the vena cava and the portal vein were exposed from the right
side of the abdomen.
Breakage
19
Subse-
quently a method was devised in which the veins were approached from the left side without exposing the liver thus leaving
the right side free from adhesions for the second operation.
to the
A silk ligature,
end tapered and at a right angle to the main shaft was placed
beside the portal vein, and the two were ligated together.
The
junction with the portal vein as was the small vein arising on
the caudal surface of the pylorus and leading into the portal
vein at a point
1 cm.
pancreatico-duodenal vein.
20
adrenal vein.
layer of sutures.
rapid.
was generally allowed to elapse between the preliminary and the second operation.
It was, however, possible for the
including in the tie the portal vein, bile duct, and hepatic
artery.
The vena cava was ligated just cephalad to the right
adrenal gland, and again just cephalad to its union with the
hepatic vein from the "main liver" severed between the ligatures.
cut between the liver and the tie which was placed about it. The hepatic ligaments to the diaphragm and the peritoneum in
The small
21
At this point in
hepatectomy in rats.
The
Thus
65% to 75% of the total liver was removed, leaving only the
22
The abdomen
abdominal muscles were closed in the first layer and the skin
in the second layer.
No special postoperative care was employed, except that
suture about 2 mm. above the point where the vessels separated
A hemostat was
ture and the hemostat along with the attached hepatic ligaments.
the lobes to be removed, and was tied; the lobes were dissected
25
that this was the only practical method for use in such small
animals
artery was ligated close to the aorta and then stripped away
from the renal vein (Fig. 5-A).
The renal vein was then
ligated at the point of exit from the kidney and the kidney
excised.
A small thin-
24
microscope the ligature was removed from the free end of the
renal vein, the vein was cuffed over the glass sleeve and tied
structures in the hepatic pedicle and ligated at the point of their entrance into the liver.
portal vein.
wall of the portal vein between the two ligatures and the glass
sleeve with the everted free end of the renal vein was intro-
the portal vein was brought into contact with the intima of the renal vein while the glass sleeve remained entirely extra-
vascular in position.
the portal vein and the cuffed end of the glass sleeve.
min-
5 to 17 hours in a series of 12
When the
25
indefinite period with a complete porto-caval shunt. mental animals used in this study were normal rats.
Experi-
thetic.
costal space.
relatively permanent, easily applied, sterilizable and uniformly prevented thrombosis within the cannula.
The technique used by Firor and Stinson was followed
catheter was inserted into the chest cavity, the lungs were
26
The
muscles and the skin were closed with continuous silk suture.
The residual air in the chest was then aspirated through the
was closed with a continuous suture of braided silk through all layers except the skin. suture of fine silk.
The suggested advantages of this modification to Firor's The skin was closed with a continuous
method were:
(4-)
the thoracotomy
sidered impossible.
An intratracheal
27
All liga-
portal vein was anastomosed to an oval opening in the ventrolateral wall of the vena cava just above the lumbo-adrenal
veins.
The anastomosis was facilitated by partial occlusion
Congestion of
ligated or sutured flush with the caval wall following amputation of the individual lobes (Pig. 6-3) was removed.
This procedure was attempted on 4 dogs.
.
28
A plastic T-tube
Accord-
easier to intro-
A right thoracoabdominal incision was utilized since adequate exposure could not be easily obtained with an abdominal
incision.
between two clamps down to the vena cava, and all bleeders were
ligated.
into the wound, and the abdominal viscera were packed to the left of the duodenal mesentery, thus providing a barrier to
29
The
vena cava was exposed and its adventitia stripped away from
the segment extending from the right kidney to the liver hilus. The adrenal veins were ligated and divided carefully at their
left adrenal vein of small dogs, but for large dogs the surgery
plastic T-tube, one around the narrow arm and the other on the
the liver and around the vena cava was tightened, and a non-
50
direction to the point at which the side arm reached the limits
of the incision in the vein.
liver was tightened about the vena cava and the main trunk of
the cannula (Fig. 7-A)
.
second ligature was tightened about the vena cava and the short
segment of the cannula.
The short segment of the cannula was
trunk of the cannula and the vena cava to allow the blood to
circulate through the cannula and the vena cava (Fig. 7-B).
The entire procedure normally required no more than 3 to 4
cm.
The
cm.
The portal vein was ligated at the liver hilus and The side arm
of the cannula was inserted into the lumen of the portal .vein
31
were removed, and the portal venous blood allowed to flow into
the vena cava through the cannula.
3 to
the animal.
A cleavage
plane was established between the diaphragm and the liver and
the vena cava by means of blunt dissection.
A heavy silk
ligature was passed beneath the vena cava through this tunnel.
The ends of the ligature material were placed within a Eumel
dog's circulation.
32
development of shock.
The value of the procedure was that blood circulation
tributary ligated.
above the entrance of the right renal vein and up to the liver
hilus.
An elliptical opening
33
Following
portal vein was then anastomosed to the vena cava over the
elliptical opening.
2,
3/8
of
The roentgeno,
50 Ma.
1/20
Partial Hepatectomy
Sigel (1963) described a modified technique of partial
hepatectomy on dogs.
34
The left division consisted of the lateral lobe The central division sometimes
union between the lobes of the right division and the remainder
of the liver. It constitutes an ideal location for transect-
hepatic veins, and bile ducts of the left and central division
ligation and division and yet allow the structures of the right
division to be preserved.
The hepatic duct was dissected from its bed to a point
immediately above the entry of the bile duct from the right
division and was ligated and divided.
The hepatic artery was
55
Following division of
the bile duct and hepatic artery, the portal vein located
the liver the portal vein provides a large branch for the right
At this point
the lobes of the right division appeared red and were turgid
in consistency, whereas the lobes of the left and central divisions and the papillary process were dark and flaccid.
left triangular ligament was incised with care to avoid the left phrenic vein and small vessel usually located in the free edge of the ligament.
vein from the left division is too short and too wide to be
safely ligated.
After dissection
back; of the
larger hepatic
The vein was
divided and the stump was closed with a continuous 4-0 arterial
silk suture.
The hepatic vein from the central division was
36
ligated.
was then incised and the liver tissue to he resected was ele-
In their experiments
37
In the
anesthesia was used for both the recipient and the donor animals.
and the hepatic artery and its proximal tree were isolated.
Since the hepatic artery was usually too small to ensure reliable patency following an anastomosis, a segment of the aorta
'
33
transected and fixed over a Blakemore-Lord cuff, in preparation for a nonsuture anastomosis to the subcardiac vena cava
of the donor.
posterior to the liver which was also ligated, the portal vein,
the aorta below and above the celiac artery, and the sub-
preparation was usually used thus allowing the superior mesenteric artery to be used for a shunt.
3y use of the shunt in
liver.
39
between
4-
tolerance to anoxia.
week later.
4-0
less
The
The inferior vena cava posterior to the liver, and the portal
The
cracked ice and saline and the abdomen temporarily closed with
towel clips.
The left common carotid artery was then pre-
and divided at a point 1 cm. caudal to the left renal vein. The left common iliac artery was isolated, ligated, and divided
in preparation for placement of the liver graft in the pelvis.
The abdomen of the donor animal was reopened. The hepatic
41
units of
>.,;.'
.Line
As soon
the left common carotid artery of the donor animal and pre-
incised.
phrenic veins.
through the liver while the last anastomosis was being made.
The liver grafts were without blood flow for 30 to 40 minutes.
A cholecystoduodenostomy was made to provide internal biliary drainage for the graft.
The abdominal cavity was closed after
42
original livers were In 10 of the recipient animals the 1 week after implantation.
_
cage and mainEther anesthesia was induced in an air-tight semiclosed system. tained via an endotracheal tube using a
the level A right thoracoabdominal incision was made at
of the 10th intercostal space.
vena cava. She radially to allow exposure of the inferior to free the phrenic veins were clamped, divided, and iigated The portal vein was inferior vena cava from the diaphragm.
anastomosis to anastomosed to the vena cava by end-to-side The remaining
gastro-hepatic structures in the "porta hepatis" and the The inferior vena cava omentum were then Iigated and divided.
expose the hepatic was isolated by blunt dissection in order to The liver was removed, veins which were Iigated and divided.
43
operations were technically successful were studied to determine the clinical course and the survival of these animals.
for more than 24 hours and 19 of these lived for more than 7
days.
of these died during the following week; 1 died during the 4th
days and that retained their own livers, 3 died during the
second week, 2 died during the 3rd week, 2 died during the 4th
cerning the liver reveals that the several difficulties encountered in manipulating this organ are attributable in part to
its anatomical peculiarities and its many functions.
The main
44
liver functions.
The most important surgical procedures contributing to our
The portocaval
Several surgical techniques are used in performing hepatectomy which is a common procedure in medical research and
Hepatectomy is of value in
Partial hepatectomy techniques were used to study hypertrophy of the remaining part of the liver.
,
45
performed on dogs.
this procedure.
the-
graft.
problem was solved by utilizing either the hypothermic technique or an arterial shunt.
future investigations involving the liver and requiring
surgical procedures will require increasingly refined tech-
APPS20IX
PLA'l'E I
'
4-7
"the
portocaval
shunt
..portal vein
-Bulldog clamp
posterior vena
cava
_splenio vein
-slit
Pott's clamp
..Bulldog clamp
common mesenteric
right renal _ _ vein
3
vein
malting an
portal vein.
PIAIEE II
48
portal vain
traction suture
_coa2iOii
neseaxteno vein
sutures
PIA'l'E
III
4-9
-/_,.
'
portal voxn
.
>-w._ __ _
_ _ Bulldog clcjap
Say
raotion suture
coiiaion
mesenteric vein
Pott
'
clamp
Sten-C suturing
the shunt
P1A.2E IV
50
third ligature
area in which the hepatic veins enter
first ligature
vena cava
PIAl'E
51
Vuiibo-adrenal vein
cava
right kidney
vena L_ . a _ _
]
cava
/""fTlSl- 4
adrenal
*K
:-i
PXAIE VI
52
liver
ligature
\~1 ipC&/^
!
Kelly olamp
mosq,uito artery
6C\//--^>}J\
*\ V
forceps
-
portal
,
viral
~=7
T"
liver
sNt
&'"////
(Ky/^J/
kJC
//
//
tsortal vein
iuoscuito forceps
ligature
lunfoo-adrenal vein
-^
_"^i
^^s ^Sv
j
Kelly
*,
clamp
-_
-*
V
_
_L
vena cava
Step-C. Dividing the portal vein and clamping of the vena cava
_ liver
mosq.uito forceps
f\\
A.
u
1
vena cava
_J
right renal vein
"^
1^:
i
Ke:
Step-D. Incision into the vena cava for the insertion of the
cannula
PLA'l'r:
VII
53
->->.
liver
vena cava
cannula
yuosquito forceps
-.ligature
lgaturo
7^.
~-
portal vein
Kelly clamp
liver
vena cava
cannula
ligature
_ _ _
_;
portal vein
lumQO-adrenal vein___
right renal vein _ _
the vena cava and the side arm into the portal vein
EDAffli
VIII
5*
liver
_
_ _ _ _
_ _
pyloric vain
pancreaticoduodenal vein
,__ superior
t.
it j
'
glass rods
portal vein
phrenico abdominal vein
_ vena cava
PLATi'l
EC
55
hepateotomy
vona cava
..
aorta
- adrenal gland
- left
~ ""gonadal vein
kidney
__-. vena
cava
vein
-
__
__
vena cava
*ir*-
renal vein
PIAIB X
56
xivor
vena cava
glass sleeve
renal vein
jnosq.ui.to aomos
ua. c
vv^l-gastro-splenie vein
'
//
II
^w
j$lk
\
I
Step-D. Insertion of the glass sleeve into the portal vein and
PIATE XI
57
3?ifl.6.schai3iatio
__
lumbo-adrcnal vein
right renal vein
Pott a clamp
'
diaphragm
hepatic veins
41
liver
cava
vena
,
-aortal vein
Step-B. dissection of the hepatic tissue from the vena cava exposing the hepatic veins which --are sutured flush with the vena cava
PIA2E XII
58
J'ig. 7.
liver
ligature
homo3tats
side arm of the cannula
jlio rt
clamp
right adrenal vein
liver
-c-
P1AIE XIII
59
.liver
\L_Jr
Vsi
__
portal vein
vena cava
A aastroduodenal
_ -astrO-splenic
.o-V)t _^._r-i right
vein vein
-rmft.! renal
vein
cannula
^>^i^T,~ diaphragm
LjT^s --"^.
Rumel tourniquet
.
p'f^
.
_ aorta
liver
<5^J f-~
PyV^y -C
v
hemoBtat
common hapati c artery
_ portal vein
vena cava
PIAIE XIV
60
Fig. 8. ochematic drawings of the arterial shunt and the blood vessel anastomoses for the homotransplantation technique
of the liver
liver
recipient's aorta
clamps
recipient's aorta
Step-A. Creation of the temporary shunt between the recipient's aorta and the donor's arterial tree
...cholecystostomy tube
..gall bladder -donor vena cava _ common bile duct stump
artiepatic artery
PIAffiE
XV
61
Pis. 9.. Schematic drawing of i'homford method of homotransplantation of the liver showing the hlood vessel anastomoses
Lp.
-recipient
- .
** -
'
left renal
'X - -
_
Vi
cholecystoduodenostomy
-N -liver
'
//
\V
\Si
hepatic artery
-left
.
\\-
62
REFERENCES
Drury, D. R. and Bruce, M. C, 1936, A QuantitaArch.. tive Study of Coll Growth in Regenerating Liver. Path. 22:653-673,
l.
.';.,
Clay, R. C. and Ratnoff, 0. D. , 1929, Modified One-stage Bull. Johns Hopkins Hospital 88(5): Het>atectomy in Dog.
457-568.
Drury, 3. R. , 1927, Total Surgical Removal of the Liver in Rabbits. J. Exp. Med. 49:759-764-. Firor, W. M. and Stenson, E. 1928, Total Extirpation of the Johns Hopkins Hospital. Jog's Liver in One-stage. Bull. 44:138-148.
,
Frank, H. A. and Jacob, S. W. , 1952, One-stage Hepatectomy in Am. J. Physiol. the Dog, Preserving the Inferior Vena Cava. 168(1): 156-158.
Goodrich, S. Welch, H. Kelson, J., Beecher, T. and Welch, S. Surgery 1956, Homotransplantation of the Canine Liver. 39(2): 244-251.
,
Higgins,
G. H. and Anderson, R. M. 1931, Experimental Pathology of the Liver; 1. Restoration of the Liver of the White Rat Follovang Partial Surgical Removal. Arch. Path.. 12:186-202.
,
Hooper, C. W. and Whipple, 1916, Bile Pigment Metabolism; 1. Bile Pigment Output and Diet Studies; Am. J. Physiol. 40:332-348.
Keefe, F. Mason, M. M. and Boria, T. 1961, Use of Portocaval Shunt in the Treatment of Ascites in a Dog. J. A. V. M. A. 138:200-203,
Surgery 50:668-672.
Lichtenstein, I. L. Draplcin, H. and State, D. 1956, A Technique for the Reversible Exclusion of the Liver in Dog. Surgery 40:503-509.
,
Mackay, R. C. J., 1961, Post-surgical Adhesions in the Abdomen of the Dog. A". Z. Vet. J. 9:18-19.
Mann, F. C. 1921, Studies in the Physiology of the Liver; 1. Technic and General Effects of Removal. Am. J. Med. Science 161:37-42.
,
63
Mann, P. 0. Liver.
1927, A Simplified Technique for Markowitz, J. and Soskin, S. Hepatectomy. Proc. Soc. Exp. Biol, and tied. 25:71928, The GlyMarkowitz, J., Mann, F. C. and Bollman, J. L. cogenic Function of Skeletal Muscle in the Dehepatized Dog, with Special Reference to the Hole of Insulin Therein. Am. J. Physiol. 87:566-58$.
,
1964, Surgery Markowitz, J., Archibald, J., and Downie, H. G. Experimental Surgery 5th Ed. pp. 507-562. of the liver,
,
Am.
J.
Anatomy of the Dog, Ed. 1964, Liver. Miller, M. E. 706. U. B. Saunders Company.
, ,
1,
pp. 699-
Sicular, A., Burrows, L. Paronetto, P., Horowitz, P. E. 19&5, Immunologic Observations Hark, A. E. and Popper, H. Transplantation on Homo grafts, 1. The Canine Liver. 3(5):503-317.
,
1903, She Influence of Ablation Pavy, P. U. and Siau, R. L. J. of the Liver on the Sugar Contents of the Blood. Physiol. 29:375-381.
,
1946, One-stage Functional Reinhardt, W. 0. and Bazell, A. H. Hepatectomy in the Rat. Proc. Soc. Exp. Biol, and Med. 62:270-271.
,
Reus, P. and Larimore, L. 3., 1920, Relation of the Portal J. Exp. Med. 21:609-632. Blood to Liver Maintenance.
Sicular, A., Paronetto, P., Kark, A. E. , Burrows, L. and Popuer, E. 1963, Rejection of the Transplanted Dog Liver Proc. Soc. Exp. in the Absence of Hepatic Insufficiency. Biol, and Med. 112:760-764.
,
Arch. Surg.
Soskin, 8. and Canada, T. 1930, Further Experiences with the Simplified Technic for Hepatectomy. J. Lab and Clin. Med. 16:332-385.
,
64
Starzl,
Rowland, J. 2., Kirkpatrick, Marchioro, I. L. |T. E. Rifkind, D. and Waddell, W. R. Wilson, li. IS. C. C. H. Immunosuppression after Experimental and Clinical 1964, Homotransolantation of the Liver. Annals of Surgery
, ,
160(3) 4-11-439.
:
Thomford, U. R.
Shortes, R. G. and Hallenbeck, G. A., 1965, Homotransplantation of the Canine Liver. Arch. Surg. 90(4):525-538.
,
DESIGN AND TECHNIQUES OE SURGICAL PROCEDURES RELATED TO MEDICAL RESEARCH AND INVOLVING THE LIVER
by
ABDUL-HAMZA SHNAIN
B. V.
M.
S.
MASTER OE SCIENCE
Research involving the liver has resulted in the development of numerous surgical procedures, some of which have many
techniques.
described 2 techniques.
shunting the portal blood into the inferior vena cava while
the reverse Eck fistula consisted of shunting the vena cava
Hooper and Whipple (1916) performed bile fistula by inserting rubber tubing into the gall bladder then ligating the common
bile duct.
Rous, et al.
(1920) performed partial functional hepatec-
collateral circulation.
blood from the portal vein and the infrahepatic vena cava
through the hepatic vena cava; and then removing the liver.
technique
Clay and Eatnoff (1951) performed hepatectomy in one-stage by using a modification of the method of Piror and Stinson.
Frank and Jacob (1951) hepatectomized dogs without injuring the vena cava.
Lichtenstein (1956) devised a method of reversible exclusion of the liver utilizing the Humel tourniquet to control the
Either
The
hypothermic method to eliminate the activity of the intrahepatic saprophytes during interruption of the circulation in
the donor's liver was used.
Solutions to these