Surgery is really interesting and challenging to our minds and skills. General Surgery agglutinates several different procedures which give the surgeon the opportunity to perform different surgeries and apply different techniques. Learning one technique from one particular procedure is what gives the surgeon background to use that technique and knowledge in another procedure. This is what gives the surgeon the ability to evolve. Knowledge is not a straight, encapsulated and well-defined line; knowledge has several ramifications which all come together to build a strong, safe and consistent path for the surgeon.
They used autologous falciform ligament from recipient to create a new middle hepatic vein.
A recent Linkedin® publication by Prof. Dr. Eduardo Fernandes from Rio de Janeiro, Brazil, got my attention. This great surgical team from Adventist Hospital is leader in hepatic transplant in South America, and this publication is a proof of that fame. During a living donor liver transplant (the right liver from donor) they used autologous falciform ligament from recipient to create a new middle hepatic vein to reconstruct V5 and V8, allowing a good blood drainage to the inferior vena cava. It was one of the first cases Prof. Dr. Eduardo Fernandes performed, and for me it was completely new. Although I am not doing transplant, this technique can be of good help in other fields of general surgery, namely abdominal procedures like oncologic resections. The fantastic pictures were taken by Prof. Dr. Eduardo Fernandes and his team during that procedure. Great idea, great skills.
Another interesting paper comes from Spain. Dr. María Galofré-Recasens from the General Surgery Department of “Hospital Universitari Mútua Terrassa”, Barcelona, reported the use of the falciform ligament for vascular reconstruction during pancreas resection. To achieve R0 resection in a cancer of the pancreatic body with involvement of gastric antrum and splenoportal confluence (without vein occlusion or vessels encasement), an en bloc resection was conducted (pancreas, spleen, gastric antrum) resecting a lateral segment of the portal vein. A falciform ligament patch was successfully used for portal vein reconstruction. Pathology confirmed free margins. One-month later portal vein was patent. According to the authors there are several options for vascular reconstruction using autologous grafts. Autologous vein grafts include saphenous vein, femoral vein, external iliac vein, jugular vein and umbilical vein. Another option is peritoneum which is a non-thrombogenic graft described for the first time in 1965 by Kurbangaleev. Dr. María Galofré-Recasens also present the falciform ligament as a recent option with advantages over the peritoneum. The falciform ligament is easier to obtain, can be used on both sides because it has a double membrane which also provides greater strength.
A falciform ligament patch was successfully used to reconstruct the portal vein during a pancreatic cancer surgery.
Dr. Alpergola et al. from France tell us that parietal peritoneal flap is a safe option for vascular reconstruction by having some advantages over other materials, namely a low risk of infection, no need for anticoagulation, easily available, low cost and easy to adapt to vascular defect dimension. It can be used both as a tubular graft or as patch. Although there is a lack of experience using autologous peritoneum flap for vascular reconstruction, it can be used in transplant, trauma, oncologic surgery with vascular resection, as well as other cases of abdominal surgery where a major vein was resected or severely injured. Neither randomized trials nor consistent case series are available, but the authors conducted a systematic review to analyze results. In my point of view, besides being easily available a major advantage of this method is the low risk of infection in cases where synthetic material should be avoided, like trauma, contaminated or dirty abdominal surgery, and cases of high risk of deiscence of an intestinal anastomosis. Nowadays there seems to be a shift towards not defining as a contraindication for surgery a major vein involvement by a tumor. Venous resection and reconstruction are being increasingly used to achieve R0 resections in those difficult cases. On the contrary, arterial involvement still continues to be a contraindication due to the high mortality and complications rates, mainly in pancreatic cancer. Does vascular resection because of cancer involvement has positive impact in survival? I will try to explore this topic in a future post, since I still have some doubts about both IVC and portal vein resections for oncologic proposes. Are they good for the surgeon or for the patient?
Parietal peritoneal flap is a safe option for vascular reconstruction. It has a low risk of infection and is easily available.
These three publications (falciform ligament for venous vascular reconstruction in hepatic transplant, falciform ligament for venous reconstruction in pancreatic cancer surgery, peritoneal flap for venous reconstruction in abdominal cancer surgery) all give the surgeon tools to evolve, tools that can be used in several fields of abdominal surgery, tools that can be used to solve an incidental vascular injury during surgery, tools that can be used somewhere no one has ever thought. Learning from different procedures gives the surgeon more options and skills to be a better surgeon, whatever preferred area he has.
Knowledge is never too much. Do not limit yourself in knowledge nor let anyone pose a limit to your growth as a surgeon. There are no limits for a skillful and versatile surgeon.
Thank you to Prof. Dr. Eduardo Fernandes for letting me use the fantastic pictures.
Link to articles:
Dr. Carlos Eduardo Costa Almeida
General Surgery
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