Choice of surgical approach for liver surgery

Objective. The radical method of treating focal liver pathology is currently surgical. Despite the widespread use of endoscopic techniques, laparotomic access in liver surgery is often the only possible one. More than 70 types of accesses are known, used in various interventions on this organ, which are divided into oblique transverse, longitudinal, oblique longitudinal, transverse extended and combined. In the Tomsk Zonal Hepatology Center, an abdominal wall incision in the epigastrium to the anterior axillary line with the intersection of the right rectus muscle closer to the tendinous bridge of the second segment was developed and introduced into clinical practice, which can be extended if necessary by crossing the costal arch. The access was named after the authors’ surnames – Merzlikin– Paramonova. There is no information in the literature on the comparative effectiveness of various surgical approaches in liver pathology.

Purpose of the study: to compare the Merzlikin–Paramonova approach with other, most frequently used ones, in terms of their degree of trauma, accessibility for visualization of the organ in accordance with the criteria of A.Yu. Sozon-Yaroshevich, presented to approaches for liver surgery.

Material and methods. For anatomical and physiological justification of the access, autopsy studies of cadaveric material were performed, during which anthropometric measurements were taken. An analysis of immediate and remote results of surgical treatment of 321 patients with focal liver lesions was conducted, the main ones being hemangiomas, alveococcosis, and echinococcosis. They underwent liver resections of various volumes, supplemented by cryodestruction of the organ stump.

Results. The choice of surgical access was determined by the nature of the pathological process (malignant, benign), its prevalence, involvement of large vessels and bile ducts of the liver porta. Sectional studies have shown that with the Merzlikin-Paramonova access, the innervation and blood supply of the epigastric zone is maximally preserved. Its main parameters correspond to the assessment criteria of A.Yu. Sozon-Yaroshevich. Analysis of the results of surgical interventions using this access showed that postoperative hernias formed only in 3 people (3.87%), all patients had no restrictions on physical and social activity, pain.

Conclusion. The Merzlikin–Paramonova approach is low-traumatic due to the preservation of innervation and muscular structure of the anterior abdominal wall, as a result of which it is physiological, which allows to obtain good results in the late postoperative period. This approach allows to perform a complete revision of the operated organ and to perform the necessary volume of surgery, in the postoperative period to reduce the number of postoperative complications.

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