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Comparative surgical resection of the ligamentum teres hepatis in a cadaveric model and a patient with ovarian cancer

Authors:
Ilker Selcuk at Ankara City Hospital-Bilkent
Ilker Selcuk
  • Ankara City Hospital-Bilkent
Zehra Öztürk at Artvin Coruh Universitesi
Zehra Öztürk
Nurian Ohri
Nurian Ohri
Nurian Ohri
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Bertan Akar
Bertan Akar
Bertan Akar
  • This person is not on ResearchGate, or hasn't claimed this research yet.
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Abstract

Resection of all tumor implants with the aim of maximal cytoreduction is the main predictor of overall survival in ovarian carcinoma. However, there are high risk sites of tumor recurrence, and the perihepatic region, especially the point where the ligamentum teres hepatis enters the liver parenchyma under the hepatic bridge (pont hepatique), is one of them. This video demonstrates the resection of the ligamentum teres hepatis both in a cadaveric model and in a patient with ovarian cancer. © 2019 by the Turkish-German Gynecological Education and Research Foundation.
Available via license: CC BY-NC-ND
Content may be subject to copyright.
©Copyright 2019 by the Turkish-German Gynecological Education and Research Foundation - Available online at www.jtgga.org
Journal of the Turkish-German Gynecological Association published by Galenos Publishing House.
62 Video Article
Introduction
The falciform ligament divides the liver into the right and left
lobes on the antero-superior part of portoumbilical fissure
where the ligamentum teres hepatis (umbilical ligament of
liver/round ligament of liver) attaches to the visceral surface.
Due to the distribution pattern of the portal vein and hepatic
veins, the liver is divided into eight functional segments (1).
The umbilical fissure exists between liver segments III and IVb,
and the umbilical ligament lies there. The liver parenchyma
over this structure varies in thickness, and in some patients
the umbilical ligament will be completely visible, which allows
broad exposure until its entrance into the liver. Paul Sugarbaker
defined this parenchyma surrounding the umbilical ligament
as the ‘pont hepatique/hepatic bridge,’ which creates a tunnel
(2,3).
Mucinous ovarian or gastrointestinal carcinoma, appendiceal
carcinoma, mesothelioma or a serous ovarian cancer may have
a widely disseminated recurrence on the peritoneal surfaces.
The complicated surgical anatomy of the liver and perihepatic
tissues limits the easy detection of tumor implants; eventually,
good exposure of the abdominal cavity is needed to excise all
the visible tumor implants, especially on high-risk fields such as
the end part of the ligamentum teres hepatis under the hepatic
bridge (4).
There is no risk of injuring any structures while cutting the
hepatic bridge. However, if the ligament is deeply attached to
the bottom of the liver parenchyma, while dissecting the end
point, care should be taken not to damage the left hepatic
artery or the left hepatic duct over the hepatoduodenal
ligament, which is covered by the peritoneal lining of lesser sac
(3,5). Routine resection of the ligamentum teres hepatis may
increase morbidity (6); however, in patients with peritoneal
carcinomatosis, the base of the ligamentum teres hepatis
should be observed under the hepatic bridge because it is a
continuation of peritoneal tissue.
Received: 16 October, 2018 Accepted: 21 December, 2018
DOI: 10.4274/jtgga.galenos.2018.2018.0135
Address for Correspondence: İlker Selçuk
Phone: +90 312 306 50 00 e.mail: ilkerselcukmd@hotmail.com ORCID ID: orcid.org/0000-0003-0499-5722
Abstract
Resection of all tumor implants with the aim of maximal cytoreduction is the main predictor of overall survival in ovarian carcinoma. However,
there are high risk sites of tumor recurrence, and the perihepatic region, especially the point where the ligamentum teres hepatis enters the liver
parenchyma under the hepatic bridge (pont hepatique), is one of them. This video demonstrates the resection of the ligamentum teres hepatis
both in a cadaveric model and in a patient with ovarian cancer. (J Turk Ger Gynecol Assoc 2019; 20: 62-3)
Keywords: Pont hepatique, umbilical ligament, liver, ovarian cancer, cytoreduction
1Department of Gynecologic Oncology, Health Sciences University, Ankara Zekai Tahir Burak Woman’s Health Training and
Research Hospital, Ankara, Turkey
2Department of General Surgery, Division of Surgical Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
3Department of Obstetrics and Gynecology, Bahçeşehir University Faculty of Medicine, İstanbul, Turkey
4Department of Obstetrics and Gynecology, Okan University, WM Medical Park Hospital, Kocaeli, Turkey
İlker Selçuk1, Zehra Öztürk Başarır1, Nurian Ohri2, Bertan Akar3, Eray Çalışkan4, Tayfun Güngör1
Comparative surgical resection of the ligamentum
teres hepatis in a cadaveric model and a patient with
ovarian cancer
63
J Turk Ger Gynecol Assoc 2019; 20: 62-3
This video consists a cadaveric surgical demonstration of
ligamentum teres hepatis resection over the portoumbilical
fissure and a live patient video of 56 years old woman who
had a recurrent high-grade serous ovarian cancer with
widespread peritoneal implants. There were tumor implants at
the perihepatic region on the umbilical ligament, which were
resected.
Acknowledgement: Thanks to University of Health Sciences,
Ankara Zekai Tahir Burak Woman’s Health Training and
Research Hospital and Bahçeşehir University Radical and
Reconstructive Abdominal Surgery Cadaveric Course for
contributions.
Conflict of Interest: No conflict of interest was declared by the
authors.
Financial Disclosure: The authors declared that this study has
received no financial support.
References
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anatomic structure in cytoreductive surgery. J Surg Oncol 2010;
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3. Sugarbaker PH. The hepatic bridge. Eur J Surg Oncol 2018; 44: 1083-
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E, et al. Is cholecystectomy and removal of the round ligament of
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Selçuk et al.
Comparative resection of ligamentum teres hepatis
Figure 1. Localization of the pont hepatique and hepatic
segmentation with the anatomic structures of the falciform
ligament and ligamentum teres hepatis
Figure 2. Cut end of the ligamentum teres hepatis over the
liver parenchyma superior to hepatoduodenal ligament
(choledoc, portal vein and hepatic artery)
Figure 3. Tumor implants at the ligamentum teres hepatis
and pont hepatique
... Sappey's and Burrow's veins are shown in Figure 21 [62][63][64][65]. In some cases, metastatic cancer at the base of the round ligament of the liver could be a reason for suboptimal debulking during ovarian cancer surgery [68][69][70][71]. Moreover, recurrences at the ligamentum teres have also been described [72]. ...
... Particular attention should be paid to the preparation of the ligament base. There is a risk of injury to the left portal vein, the left hepatic artery, and the left bile duct (Figures 22 and 23) [68][69][70][71]. In some cases, metastatic cancer at the base of the round ligament of the liver could be a reason for suboptimal debulking during ovarian cancer surgery [68][69][70][71]. ...
... There is a risk of injury to the left portal vein, the left hepatic artery, and the left bile duct (Figures 22 and 23) [68][69][70][71]. In some cases, metastatic cancer at the base of the round ligament of the liver could be a reason for suboptimal debulking during ovarian cancer surgery [68][69][70][71]. Moreover, recurrences at the ligamentum teres have also been described [72]. ...
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Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery
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Is cholecystectomy and removal of the round ligament of the liver a necessary step in cytoreductive surgery and HIPEC, for peritoneal carcinomatosis?
Article
Full-text available
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The Hepatic Bridge
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Division of the pont hepatique of the liver in cytoreductive surgery for peritoneal malignancy
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Pont hepatique (hepatic bridge), an important anatomic structure in cytoreductive surgery
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The Porta Hepatis as a Site of Recurrence of Mucinous Appendiceal Neoplasms Treated by Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy
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A successful new treatment for a particular disease may change the natural history of that disease as patients go on to longer survival. The goal of this study was to investigate the porta hepatis as a site of recurrence of appendiceal mucinous neoplasms. A prospective database on patients with peritoneal dissemination of mucinous appendiceal neoplasms has been maintained for 21 years. In patients with complete cytoreduction, disease progression/recurrence in and around the porta hepatis has been noted as a new manifestation of this disease. In 710 patients treated for mucinous appendiceal cancer with a complete cytoreduction, 140 developed recurrent disease. Seven patients (5%) had disease recurrence in and around the porta hepatis. Four of the seven had biliary obstruction and three had masses within the liver hilum not causing bile duct obstruction. Four of the seven patients were successfully palliated by surgical procedures within the liver and biliary tree. Two patients were successfully palliated using a biliary stent and one patient was not treated. Progression of mucinous neoplasms within the porta hepatis may be related to imperfect cytoreduction technique. Reoperative surgical treatment and biliary stents were beneficial in some of these patients.
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Hepatic surgical anatomy
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