PMC4643337_01
Axial views of a contrast enhanced CT scan of the liver revealing a large heterogenous tumour in the right hepatic lobe (Asterix). Yellow arrows point to an area of tumour that breaches Glisson's capsule.
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Contrast enhanced CT scan revealed a large heterogenous tumour in the right hepatic lobe measuring 10 x 12 x 15 centimetres in maximal diameter (Fig. 1, Fig. 2).
The peritoneum has been entered to reveal the anterior surface of the liver. Yellow arrows demonstrate the tumour with a bossellated surface. The right hepatic artery and portal vein have already been ligated (not visible in this figure), resulting in ischemic change to the right liver as indicated by the broken black line.
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The tumour had a bossellated surface (Fig. 3) and was adherent to the diaphragm.
In preparation for a hanging manoeuvre, a large vascular clamp is passed anterior to the duodenum (D) and used to develop the avascular space anterior to the inferior vena cava (IVC). The plane is developed along the plane of Cantlie's line from the IVC to the gallbladder (GB). Multiple vessel loops are seen encircling the main portal vein (blue sling), hepatic artery proper (red sling) and the common bile duct (yellow sling).
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The avascular space anterior to the inferior vena cava was developed from the lower border of the liver to the supra-hepatic space (Fig. 4).
A large bore nasogastric tube has been passed along the avascular space anterior to the IVC and used to carry out a hanging manoeuvre that will facilitate parenchymal transection.
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A large bore nasogastric tube was advanced into the avascular space and used to elevate the liver and facilitate anterior parenchymal transection without prior mobilization (Fig. 5).
Parenchymal transection is completed as indicated by black arrows. This allowed controlled mobilization of the right liver down to the point at which the tumour invades into the diaphragm (marked by yellow arrows).
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Hemostasis was ensured and this allowed controlled mobilization of the right liver to the point at which the tumour invaded the diaphragm (Fig. 6).
Complete resection of the right lobe demanded en bloc resection of the diaphragm. The margins of the resected diaphragm are held open by multiple artery forceps to reveal the pleural space.
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Complete removal demanded en-bloc resection of the diaphragm (Fig. 7).
A high power (x20) view of the malignant cells demonstrating the poorly differentiated, bizarre multi-nucleated giant cells. These cells are poorly differentiated and possess indistinct cell margins, large irregular nucleoli and prominent chromatin.
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These bizarre cells spread along the hepatic sinusoids in sheets as they invaded into the adjacent hepatocytes (Fig. 9).