Comparison between musicians and nonmusicians on tests of EF.
\r\n\tComputational fluid dynamics is composed of turbulence and modeling, turbulent heat transfer, fluid-solid interaction, chemical reactions and combustion, the finite volume method for unsteady flows, sports engineering problem and simulations - Aerodynamics, fluid dynamics, biomechanics, blood flow.
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His research interest lies in computational fluid dynamics, experimental heat transfer enhancement, solar energy, renewable energy, etc.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"233630",title:"Dr.",name:"Suvanjan",middleName:null,surname:"Bhattacharyya",slug:"suvanjan-bhattacharyya",fullName:"Suvanjan Bhattacharyya",profilePictureURL:"https://mts.intechopen.com/storage/users/233630/images/system/233630.png",biography:"Dr. Suvanjan Bhattacharyya is currently working as an Assistant Professor in the Department of Mechanical Engineering of BITS Pilani, Pilani Campus, India. Dr. Bhattacharyya completed his post-doctoral research at the Department of Mechanical and Aeronautical Engineering, University of Pretoria, South Africa. Dr. Bhattacharyya completed his Ph.D. in Mechanical Engineering from Jadavpur University, Kolkata, India and with the collaboration of Duesseldorf University of Applied Sciences, Germany. He received his Master’s degree from the Indian Institute of Engineering, Science and Technology, India (Formerly known as Bengal Engineering and Science University), on Heat-Power Engineering.\nHis research interest lies in computational fluid dynamics in fluid flow and heat transfer, specializing on laminar, turbulent, transition, steady, unsteady separated flows and convective heat transfer, experimental heat transfer enhancement, solar energy and renewable energy. He is the author and co-author of 107 papers in high ranked journals and prestigious conference proceedings. He has bagged the best paper award in a number of international conferences as well. 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Children respond to music starting in their very earliest moments and music is thought to predate speech evolutionarily [1]. Music is a powerful driver of cognitive and neurological development involving the use of nearly every cognitive faculty. Furthermore, it is well known that music engages the appetitive/rewarding neurochemical systems of the brain [2]. The impact of music throughout development is an area of interest across multiple disciplines. Both music and language allow us to communicate through sound, and both require the ability to process and produce precise sounds. The same abilities that allow us to sing and discern emotion from a melody, allows us to discern meaning from words [1]. Music is a highly complex cognitive activity. A musician must coordinate fine motor movements in order to reproduce a memorized series of sounds while receiving auditory, somatosensory, and visual feedback. Becoming an expert musician requires years of dedicated practice. Music has been proposed as an intervention for cognitive and neurological development because of the breadth and depth of the faculties exercised in this activity [3, 4]. It is not just those functions directly recruited to produce music that are impacted by it. Executive functions (EFs) are cognitive abilities that organize and direct the deployment of other cognitive processes and they also benefit from musical training.
EF includes abilities such as working memory, cognitive flexibility, and behavioral inhibition. Working memory is task-oriented memory that allows people to remember what they are doing and to recall relevant information that allows for task completion. Working memory is involved in accomplishing most tests of EF, as participants must at a minimum remember the rules of the task. One task that measures working memory ability is the Tower of Hanoi (ToH). ToH requires participants to move pieces of a tower across a set of three spaces. The rules of the game are such that this manoeuver takes a minimum of fifteen moves to complete. In order to avoid errors and complete the task in as few moves as possible, participants must keep the rules in mind and think through multiple moves ahead [5]. Working memory is a fundamental EF that allows for the planning and execution of this goal-oriented task. Cognitive flexibility or task switching is an element of EF that requires a person to move back and forth between several tasks successfully. These are the abilities that allow for multitasking. Cognitive flexibility can be measured using a tool like the Wisconsin Card Sorting Task (WCST) wherein participants complete multiple similar tasks back to back. Researchers measure how seamlessly participants transition to the new task by tracking the errors they make which would have been correct in the previous task [6]. This ability to rapidly switch between tasks is required for successful navigation of a world where many complicated jobs and separate priorities are competing for attention. Inhibition is the ability to resist doing something natural or instinctual and instead engage in some effortful activity. Being able to inhibit a behavior successfully allows one to sort out irrelevant information and remain focused on a given task. Inhibition also allows people to pause and consider other skills that can be used to solve the problems that are important to them. It is no surprise then, that inhibition is critical for academic success. Bull and Scerif [7] studied seven to nine-year olds and discovered that inhibition predicted a child’s mathematical ability independent of their intelligence and reading ability. Objective tests of inhibition often ask participants to respond to one type of stimulus while introducing some other competing stimulus that the participant must ignore. A popular test of inhibition is the Stroop Colour Word Task (SCWT). Here stimuli are presented in pairs and participants are asked to respond to the less salient stimulus. In the classic SCWT, participants are presented with words that denote a color that are printed in different colors (i.e. “green” printed in green ink) and asked to respond to the color of the ink rather than reading the word. When these stimuli are congruent the task is simple, but when they do not match (i.e. “green” printed in red ink) inhibition is required, leading to increased response time and a higher error rate [8].
Better EF is associated with improved outcomes in school and life, and so has been a focus of research in the last decade [9]. Researchers have looked into training EF, particularly inhibition, to improve school performance in children. For example, kindergarten children trained for a month on tasks that promote inhibitory control such as a modified SCWT, achieved a grade one performance level after the training [10]. Another way to enhance inhibitory control and thus academic achievement is through musical training. Short-term musical interventions of a few months to a year have been found to be effective in raising children’s EF and verbal intelligence [11, 12, 14]. Children engaged with music have higher intelligence and better inhibitory control than age-matched children without musical training [13, 14, 15]. Therefore, inhibitory control interventions are important means to enhance academic performance.
A great deal of research has focused on adult musicians and demonstrates a variety of behavioral and neurological benefits associated with this long-term musical training. Adult musicians show improved EFs compared with nonmusicians in working memory and particularly in inhibitory control [16, 17]. Beyond behavioral research, the brains of long-time musicians have been found to be structurally and functionally distinct from the brains of nonmusicians [18, 19]. These changes are thought to underlie the cognitive benefits found to be associated with musical training.
A gap in the literature is the understanding of how musical training affects cognitive function in adolescence. Adolescence is the period between childhood and adulthood, beginning at the onset of puberty around 11 years of age, and continuing until adulthood [20]. Adolescence is an important period of development; physically, socially, and cognitively. Adolescence and early childhood are both periods of high neuroplasticity and rapid cognitive development. These two windows of elevated neuroplasticity provide opportunities to help youth cultivate the faculties which they will carry with them into adulthood. Because musical training has been so thoroughly demonstrated to enhance cognitive development in early childhood it is worth asking whether musical training in adolescence is also effective in increasing EF skills. Weintraub et al. [21] found evidence for two developmental windows in childhood and adolescence while assessing the cognitive battery included in the NIH Toolbox for the assessment of Neurological and Cognitive Function. They found that in measures of memory, and general EF there was a sharp increase in proficiency between the ages of 3 and 6. A second smaller spike in executive function development occurs starting at 12 years old and continuing until early adulthood at age 25.
The current study investigates the association between musical training and EF in adolescence. Given the previously discussed benefits of musical training on cognitive function in children and adults, we wondered if musical training has the same positive associations with EF development in adolescents? We know that even short musical interventions can have significant impacts on a child’s EF, and that child musicians engaged in extracurricular musical training show improved EF across a variety of domains [11, 12]. It is possible that these benefits wash out by the adolescent years, as children without musical training may catch up through other activities. However, if music does have a uniquely strong ability to train EFs as indicated by the existing literature, adolescent musicians will continue to exhibit improved cognitive abilities.
Forty adolescents (21 females, 19 males) between the ages of 14–18 were recruited from local middle- and high-schools in Lethbridge Alberta. Participants self-identified as right-handed, and were healthy, with no history of neurological impairment. Participants were not told the purpose of the study, but were told about each of the tasks they would complete before giving consent. Parental consent was obtained for participants younger than 18 before they arrived for testing.
Each participant completed a music self-report questionnaire, and three tests of EF: the ToH (working memory), WCST (cognitive flexibility), and SCWT (inhibition). The entire experiment took between 35 and 45 min to complete.
Four square blocks were stacked on each other, on the first of three marked spaces (see Figure 1). Participants began the task centered on the second space, with both hands on the table. They were asked to move the tower of blocks to the third space, stacked in the same order that they began. Participants were only allowed to move one block at a time, and could only stack blocks on top of larger blocks. Participants’ hands were filmed while completing this task. Total moves to complete the task were recorded. Completing the task requires a minimum of fifteen moves, and anything lower than twenty is consider good performance.
Tower of Hanoi: this task measures planning and working memory. Participants moved blocks from the left space to the right, according to a set of specific rules. Completing the ToH requires a minimum of 15 moves. Move to complete is the measure of EF in this task.
This study used a computerized version available on PsyToolkit (
Wisconsin Card Sort Task: participants clicked on the cards at the top in order to match with the card at the bottom. Cards could match based on the number, color, or type of shapes on the card, and this rule changed throughout the session.
This experiment utilized a computerized version of the Stroop available at expfactory.github.io [23]. Participants were instructed to identify the color of words printed on the screen as red, blue, or green, by pressing buttons on the keyboard (Figure 3). Each trial began after a 500 ms fixation and words were presented on the screen for 1500 ms or until participants responded. Participants completed 23 practice trials, followed by 96 measured trials. Forty-eight of these trials were congruent, meaning the color of the word matched the printed meaning of the word, (e.g. “Red” in red ink). Forty-eight were incongruent, meaning the color of the word did not match its printed meaning, (e.g. “Green” in red ink). Errors were recorded for both the congruent and incongruent conditions (Figure 3).
Stroop Color Word Task: participants responded to a series of words by pressing a key corresponding to the color that the word was printed in. Each word appeared on the screen for 1500 ms. A fixation mark appeared on the screen for 500 ms before each trial. Trials were categorized as congruent and incongruent, and errors were recorded for each condition.
Participants completed a self-report questionnaire detailing their musical training. Each participant reported whether they were currently playing any instruments or singing a vocal part. They reported each of those instruments and gave the time spent practicing each week, and the years spent practicing that instrument. They then repeated the exercise for any musical experience they had in the past and subsequently abandoned. Finally, participants were asked to rank their knowledge of music theory, ability to read music, and general musical aptitude on a five-point Likert scale (1–5), where 1 was no ability and 5 was exceptional.
For the purposes of this study, we considered participants to be musicians if they had at least three years of musical training, and a minimum of five hundred reported lifetime hours engaged in musical training. This eliminated participants who had only just begun engaging with music, and allowed this study to focus on the long-term impacts of musical training.
In order to test the hypothesis that teenagers with a history of musical training would have higher executive function than those without, a series of Welch nonparametric T-tests were conducted. This test was chosen because it does not assume normalcy, and is more robust to dependency between multiple comparisons. Musician status was used as the independent variable and number of moves to complete the ToH as well as errors in the WCST and the SCWT were dependent variables. In order to account for multiple comparisons Bonferroni correction was used. SCWT errors were found to be significantly different between musicians and nonmusicians (see Table 1). Musicians were found to commit significantly fewer errors than nonmusicians.
Variable | Orientation | Musician mean | Musician SE | Non-musician mean | Non-musician SE | t Statistic | p-Value |
---|---|---|---|---|---|---|---|
Tower of Hanoi (moves to complete) | Lower for better EF | 32.889 | 3.53 | 26.684 | 3.47 | −1.2717 | 0.5593 |
WCS errors (preservation errors) | Lower for better EF | 7.750 | 0.770 | 9.500 | 1.09 | 1.2744 | 0.2124 |
Stroop errors (total errors) | Lower for better EF | 4.389 | 0.759 | 9.737 | 1.40 | 3.3774 | 0.0022* |
Comparison between musicians and nonmusicians on tests of EF.
Adjusted for Bonferroni correction.
Musicians make significantly fewer errors in the Stroop Task than nonmusicians. Welch Pairwise two tailed T-tests.
In order to examine whether increased musical training time, or self-reported musical ability was associated with executive function, a Pearson’s Product-Moment Correlation analysis was performed. This analysis allowed us to treat musicianship as a continuous variable, and to evaluate whether increased musical training time was associated with better EF in the absence of any categories. Musical training time correlated with SCWT Errors; the more musical experience a participant reported, the fewer errors on the SCWT, (r(40) = −.405; p = 0.01).
While music has been demonstrated to have positive associations with EF in childhood and adulthood, the impact that music has on EF throughout adolescence is less well understood. Two research questions were investigated: (1) Does musical training have the same positive associations with EF in adolescence as it does in young children? (2) Is there a relationship between time spent on musical training and adolescent EF? The results of this study showed a positive association of musical training with a key contributor to EF: inhibition. Inhibition, as measured by the SCWT, was the only domain of EF in which adolescents with musical training differed from nonmusicians. Furthermore, the results of the SCWT showed a positive correlation with lifetime musical training (i.e. total number of lifetime practice hours); the more hours engaged in practice, the better the behavioral inhibition in adolescence. Once again, the SCWT was the only measure of EF associated with musical training, indicating that spending more time engaged in musical training results in greater improvements to inhibition. Taken together, these results indicate a unique relationship between musical training and inhibitory control.
During the SCWT participants are asked to parse an incoming stream of information and control their responses in a nonintuitive fashion. This is a central skill set for a musician attempting to properly respond to input from the current sounds, the sheet music, their fellow bandmates, and the sensorimotor feedback that comes with performing a piece of music. Musicians must inhibit a large number of possible responses to these stimuli in order to select the actions that will create the music they wish to produce. Mastering behavioral inhibition to generate the perfect performance is one feature that makes music so rewarding. Imagine a saxophone player attempting to sight read a new melody. The musician reads each oncoming note moments before they have to play it, just like a participant reads the next word in the SCWT as it flashes on the screen. The musician’s fingers move to carefully practiced positions, each one unique to the note, just like a participant during the SCWT taps the correct key, unique to the color.
The fact that adolescent musicians in this sample did not show any improvement in the areas of working memory and cognitive flexibility, was somewhat surprising given the results of other studies. A meta-analysis including 18 studies showed improved working memory in children with musical training [24]. Bhide et al. [25] showed that short-term musical training improved working memory in a population of 6 and 7-year-olds who were struggling with reading. The children were engaged in 19 sessions over two months, during which they were given rhythm training. At the end of the two months children were shown to perform significantly better on a digit span backwards test of working memory. Zuk et al. [15] found that working memory and cognitive flexibility was better in both preadolescent children and in adults with musical training. Puzzling, they report that musical training had no influence on inhibitory control in either group. This is in stark contrast to the finding of the present study in which inhibition was found to be most influenced by musical training. Our finding is consistent with other studies in children and adult musicians which have shown that improvement in inhibition is the most reliable effect that musical training has on EF across a variety of tasks, and throughout the lifespan. Children’s inhibition improves in response to musical interventions and long-term private music education [3, 12, 14, 15]. Adult musicians have improved inhibition that persists into old age [17, 26, 27]. The current study demonstrates that the relationship between musical training and inhibitory control is not disrupted throughout the tumultuous developmental years of adolescence.
Inhibition may be improved by the dedication required for musical training and thereby lead children to be more effective in developing their cognitive abilities. There is evidence that musical training in children improves inhibition more than other equivalent forms of artistic training. Moreno and colleagues showed that twenty days of musical training was sufficient to improve performance of kindergarten children on a visual Go-No Go task. The children were trained on pitch, tempo, melody, voice, and other basic concepts, using a computer program that focused on listening tasks. These children outperformed an active control group receiving an equivalent fine arts training [3, 12]. This result suggests that there is something especially important about music in the development of inhibition. Furthermore, it appears that musical training is an effective intervention for training inhibitory control. In fact, musical interventions are commonly used to enhance behavior in children with developmental delays, ADHD, and even autism [28, 29]. This form of therapy is also used in people with brain injury and neurodegenerative disorders [30, 31]. Perhaps the common element here is that musical interventions improve inhibitory control which in turn improves behavioral outcomes.
The benefits to inhibition have been shown to persist in adults with a history of musical training. Bialystok and Depage [32] showed that musicians performed better on an auditory Stroop test of inhibition than those with no musical training. This result was confirmed by D’Souza, et al. [27] using a full battery of inhibition tests, including the visual Stroop, a flanker task, and an auditory stop signal test. Musicians showed a significant advantage on each of these measurements compared with adult nonmusicians. These improvements continue even as people age. In a study of professional musicians older than age 50 [26], musicians were found to outperform nonmusicians in a full battery of inhibition tasks. This battery included an auditory Stroop task, a go-no-go task, a distracted reading task and a Simon task (in which a color appeared on one side of the screen, and participants had to hit a matching button which was on the same side as the color in congruent trials and on the opposite side in incongruent trials). Music practice can thus be beneficial throughout life.
It is possible that certain kinds of musical practice improve inhibition better than others. Bialystok and Depage [32] did not find any difference between vocalists and instrumentalists in their study, however recent findings have suggested that there may be differences between different kinds of musical training. For example, percussionists who must keep careful track of time may have better inhibition than other musicians. A study compared inhibition abilities between vocalists, percussionists, and nonmusicians between the ages of 18 and 35 [33]. The authors found that percussionists outperformed both vocalists and nonmusicians in inhibitory control. This finding further supports the notion that musical training which involves more inhibitory control improves this EF.
The current study has a number of limitations. A relatively small sample size meant that subdivisions between different types of musicians were inappropriate. This study only accepted participants in mid and late adolescence, making developmental inferences more difficult. The correlational nature of this study makes it impossible to make determinations about cause and effect. Finally, the uncertainty about the relationship between various EF’s, and overlap in how these functions are measured is a general problem in this field which this study did not address. Future research could be designed in such a way that tackles these issues and allows for a more thorough understanding of adolescent EF.
Few studies have explicitly examined distinctions between forms of musical training, and this should be a priority for future research investigating relationships between musical training and cognitive abilities. A study directly examining the differences between vocalists and percussionists in EF found that percussionists out-performed vocalists, and nonmusicians in the area of inhibition [33]. Previous research has shown no difference in inhibition between vocalists and instrumentalists, which only serves to make the enhanced abilities of percussionists even more interesting [32]. The timing of musical training is another factor which might lead to distinct outcomes. Early musical training has been shown to increase the volume of the corpus callosum in the brain whereas later training does not [34]. An implication of this finding is that musical training will have a larger effect if it occurs within early development. These findings indicate that some subdivisions by age of musical training and by musical speciality may be important to the EF differences observed here. This study was unable to account for these potential distinctions due to the limited sample size.
Extra-curricular musical training means practicing for hours every week. While other children may take a break, or not have an opportunity to engage in a cognitive exercise after school, music students are translating dots on a page into music in the air. This extra period of instruction and practice may itself be the cause of the improved cognition observed across the board in musicians. It is also true that musical instruction costs money. This means that the average musician may be of higher socioeconomic status, which could be a potential confound when interpreting the current results. Intervention studies, where music lessons can be provided regardless of economic status, and musical training that can be compared against equally challenging programs are needed to address these issues.
While this study does establish a relationship between inhibition and musical training in adolescents, it is unclear whether musical involvement in the adolescent years is truly responsible for this improvement. It is possible that childhood musical training contributes in important ways to the effect observed here. Similarly, it is possible that adolescents with stronger inhibitory skills are more likely to continue engaging in musical training even as they gain more independence in the mid adolescent years. In order to address this issue, it would be necessary to give adolescents musical interventions in the style that has been used to improve childhood EF.
The current study examined the relationship between musical training and EF in mid to late adolescence. Musical training was found to be associated with better inhibition, as measured by the SCWT but not working memory or cognitive flexibility. Future research should focus on determining causality, and accessing whether it is feasible to use music to improve inhibitory control in adolescents.
The evolution of hepatic resection from an imprecise removal of portions of the liver often associated with a mortality rate of up to 20% to a routine and controlled anatomic procedure with operative risk less than 5%, represents a major advance in modern surgery. This accomplishment has been made thanks to better understanding of the liver vascular and biliary anatomy, recognition of the functional reserve of the liver and the potential for regeneration, advances is surgical technique as well as anesthesia and perioperative care. These factors, along with the improvement of prolonged survival following hepatic resection for colorectal metastases, hepatocellular and cholangiocarcinoma have led to an expansion of liver surgery.
\nIn this chapter, we will give the evolution of the technique used for the standard open right hepatectomy. In addition, we will describe on detail our technique employed for right hepatectomy focusing on:
Indications
Preoperative preparation
Specific technical aspects
It was the work from our center conducted by Bismuth [1] which introduced to the English speaking word, the segmental approach to liver surgery, which in turn was based on the anatomical description of the liver by Couinaud [2]. The two liver lobes are divided into four segments with defined blood inflow and outflow as well as biliary drainage. The fibrous Glissonian sheath surrounds the branches of the segmental structures, whereas the hepatic veins lie between the pairs of the liver segments [3, 4].
\nFor further details on liver anatomy of interest for surgeons performing liver surgery the reader is referred to the chapter on liver anatomy on this book.
\nCurrently, hepatic and right liver resections may be required in a wide variety of conditions, including pathological processes which are limited to the respective right side of the liver. Partial right hepatectomy in the treatment of primary (benign or malignant) liver tumors, biliary tract tumors and secondary malignant tumors are the most common indications. Partial right hepatic resections may also be necessary in the management of complex cystic diseases, benign biliary stenoses, some hepatic trauma, and more recently in liver transplantation with live donors. Total hepatectomies are reserved for situations of liver uptake in cadaveric donors and hepatic replacement in the hepatic transplant recipient.
\nThe modern era of anatomic resection dates as far back as 1950s, when Lortat-Jacob [5] reported the technique of right hepatectomy by performing an initial dissection, ligation and division of the right hepatic artery, portal vein and right hepatic vein, followed by parenchyma transection with intrahepatic isolation of the vessels. Although, this technique is advantageous as it reduces the bleeding during the parenchyma transection in addition to displaying the demarcation line between healthy and ischemic parenchyma, it is associated with serious complications such as major bleeding and air embolism (if the right hepatic vein is injured during the dissection of its non-parenchymal route). For this reason, Lortat-Jacobs’ original technique [5], was later modified by preceding the portal and hepatic vein dissection by supra- and infra-hepatic caval control. This technique has, however, two drawbacks: firstly, the already mentioned risk of trauma to the hepatic vein, and secondly, the possibility of devascularization of parts of remaining liver in cases of anatomical variations. In addition, during a right hepatectomy, the extrahepatic ligation of the right pedicle is associated with a risk of ligation of the biliary convergence situated anterior to the origin of the right portal branch.
\nIn contrast, these complications are less frequent with the technique described by Tung and Quang [6] which entails an initial parenchymal dissection with intrahepatic control of the vessels.
\nAlthough, other techniques have been described, generally most liver surgeons use a combination of these techniques often applied in accordance to case specifics.
\nThe technique we use, first described by Bismuth [7], consists of an initial hilar dissection to control the arterial and portal components without touching the biliary duct (Figure 1).
\nControl of the arterial and portal components without touching the biliary duct.
The control of right hepatic vein can also be done at this stage, however, this is not essential and should be avoided if difficulties are anticipated. This technique has the advantage of preceding the parenchymal section by the selective control of the right arterioportal and right hepatic components (as in the technique described by Lortat-Jacob) [5] and tie the vessels in the hepatic parenchyma (as in the technique described by Ton That Tung) [6].
\nBefore any decision to perform a major surgical procedure could be made there is a need for a thorough pre-operative evaluation of the patients focused on the general physical status as related to the requirements of the planed operative procedure. All factors needed for a proper evaluation of the risk and possible gain from the patient’s point of view should be taken into account. In this aspect liver resection does not differ from any other major surgical resection. However, there are factors that are specific to liver resection: the risk for massive intraoperative hemorrhage and postoperative functional hepatic insufficiency. The preoperative evaluation of the functional capacity of the remaining liver is difficult and there are no strict and objective rules and specific knowledge and experience is required. In general, to determine the indications for surgery and the possible course of the prognosis following the surgical treatment, evaluation of liver cell integrity, excretory, and metabolic performance as well as the expected temporary ischemia and the effects of the anesthesia are all of importance [8]. Risk factors should be taken into account particularly fibrosis/cirrhosis or small future remnant volume and the question whether resection safety can be increased by portal vein embolization (PVE) should be examined preoperatively [9].
\nAlso, the preoperative evaluation should aim at clarifying the following questions:
The extent of the pathological lesions.
Detailed evaluation of the pathological lesions within the hepatic parenchyma and the relationship with important structures such as vascular and biliary components.
In this regard, a three phase spiral computerized tomography (CT) and a magnetic resonance (MR) can be of a significant help. However, further information and accuracy with great clinical benefit during the preoperative evaluation is obtained from 3D CT or MR reconstruction, vascular reconstruction as well liver volume measurements.
\nThe patient is placed on supine position. The right arm is placed along the body wrapped in a drape whose ends pass under the back of the patient. The left arm is stretched at 90°. For anesthesiological monitoring, central venous lines and an arterial pressure sensor are placed. A gastric tube may be used to decompress the stomach.
\nMedian incision with right transverse extension (modified Makuuchi incision).
The surgical field usually extends from the lower half of the chest to the pubic symphysis. The patient’s head is turned to the right and fixed on this position by Elastoplast® tape in order to expose the left jugular triangle. The site of the abdominal incision is marked and the entire operative field is then covered. For large tumors requiring a thoracoabdominal incision or median sternotomy, the entire chest is included in the surgical field.
\nAn optimal surgical approach is a prerequisite for safe, controlled liver resection. For right hepatic resection, we use almost exclusively an abdominal approach. This involves a median incision with right transverse extension (Figure 2).
\nDepending on the case, the incision usually can be extended cranial over the xiphoid process. A bicostal incision may provide a very good exposure suitable for almost all types of standard hepatectomies.
\nExtension of the incision into the chest is exceptional, however, in extreme cases the incision can be extended further by a partial sternotomy, giving an excellent exposure of the suprahepatic vena cava. Similarly, a thoraco-phreno-laparotomy is used rarely for very large tumors of the right lobe or the upper right lobe preventing the mobilization and control of the suprahepatic vena cava.
\nThis step involves a complete exploration of the abdominal cavity paying special attention to the liver in order to identify possible undiagnosed lesions which could constitute a contraindication to liver resection. In general, it is possible to perform this step via a limited right subcostal incision. The first part of the exploration involves a manual palpation which is focused on the left liver, porta hepatis (in particular the lower posterior aspect) and the coeliac region. Division of the ligamentum teres and the falciform ligament along the anterior surface of the liver facilitates the exploration. The elevation of the ligamentum teres helps to expose the inferior surface of the liver and the area of the hilus as well as umbilical fissure. Performing this step (elevation of the ligamentum teres) helps to identify and better estimate lesions which can be potentially missed or underevaluated. Exploration should also include the inferior quadrants of the abdomen looking for adenopathy, peritoneal carcinomatosis or any lesion indicating colonic recurrence. Frozen section biopsies should be done for suspected lesions.
\nThe second part of the exploration involves performing an ultrasound (US) examination of the liver. The US helps to identify previously undetected lesions and to clearly delineate anatomical landmarks in the relation to the tumor [10]. The intraoperative US is particularly beneficial for deep seated lesions <10 mm in diameter as identification of these lesions may influence the surgeon to change the strategy and/or tip the balance against a curative resection. In addition, US may identify anatomical variations that may make the resection more difficult, such as accessory hepatic veins or common origins of the portal pedicles [11]. Finally, ultrasound is an indispensable aid when the anatomy is altered by a previous hepatectomy. If the exploration (manual and by US) is negative, the incision is enlarged to start the mobilization of the liver.
\nFollowing the division of the ligamentum teres, the posterosuperior remaining part of the falciform ligament is incised and divided as far back as the suprahepatic IVC. The space between the right hepatic vein (RHV) and middle hepatic vein (MHV) is dissected 2 or 3 cm in the caudal direction. In a similar fashion, the perihepatic attachments (right and when required left coronary ligament) are divided. This begins from the right lateral side and continues to the inferior peritoneal reflection exposed by retracting the right lobe anterosuperiorly. During this stage it is important to stay in close contact to the liver surface so to avoid entering the retroperitoneum. Failure to do so may result on profuse bleeding from severed retroperitoneal veins, which at times can be very dilated, particularly in patients with portal hypertension. Similarly, after dividing the upper lamina of the coronary ligament, care should be taken not to enter the thickness of the diaphragm as it can cause bleeding which often requires a time consuming hemostasis. In addition, adhesions between liver and diaphragm when present should not be digitally dissected (especially with a cirrhotic liver) as this approach is associated with a real risk of liver decapsulation leading to massive bleeding.
\nMultiple short Spigelian veins between the IVC and posterior surface of the liver are ligated and divided as the liver is retracted anteriorly and laterally to the left. If an inferior right hepatic vein/s are present (>5 mm) it is crucial to ligate and divide them as they are a potential source of major bleeding. During this stage, one often encounters a band of ligamentous tissue extending from the liver to the right lateral aspect of the vena cava and in some patients this represents a small bridge of liver parenchyma. Regardless the nature, this too requires ligation and division as most of the time this band contains one or two veins.
\nAfter the right liver is fully mobilized, the space between the RHV and the MHV in the anteromedian surface of the vena cava is carefully dissected using a right angle forceps through which a tape is passed around to control the root of the RHV. Having achieved this, laparotomy pads are placed behind the liver to enhance the exposure of the right lobe necessary for the parenchyma resection.
\nIt is not unusual that during mobilization to find right lobe tumors attached to the diaphragm. The surgeon should either separate these attachments or in some cases resect a segment of the diaphragm which can be subsequently repaired. Tumor attachment/s to the diaphragm should not be considered as distal metastatic lesions and should not influence the surgeon to abandon the planed resection.
\nAfter cholecystectomy, the right lateral aspect of the hepatoduodenal ligament is incised longitudinally just posterior to the bile duct, followed by a hilar dissection to identify and achieve control of the right hepatic artery (RHA) and right portal vein (RPV). The right hepatic artery is identified during the cholecystectomy. Anomalies such as having a right hepatic artery originating from the superior mesenteric artery or posterior location in the hepatoduodenal ligament should always be kept in mind if injuries are to be prevented. Ideally, these possibilities should be excluded during the preoperative work-up by CT angiography imaging. The artery is traced to its left sufficiently to identify with certainty its junction with the proper hepatic artery after which the right branch is controlled.
\nThe next step involves the exposure of the portal vein. Using gently a blunt right angle forceps, the trunk of portal vein is dissected anteriorly and posteriorly and a traction tape is passed around this vessel. Dissection is then continued into the hilum of the liver to expose the bifurcation of the portal vein, where the right branch is freed up and controlled by a vascular tape. During this step, one should be careful to avoid two possible complications. First, the left portal vein tends to pass directly away from the operator and care must be taken not to injure it. Second, the possibility of small tributaries from the right portal branch to the caudate lobe should always be kept in mind as failure to do so may lead to cumbersome bleeding from such very fine veins. Hilar dissection is completed by tracing the common bile duct into the hilum where the right and left branches are seen. Insertion of a small catheter through the cystic duct stump and up into the left and right ducts can be useful to identify these structures as a preparation step for eventual division (during the parenchyma transection).
\nAn initial occlusion of RHA and RPV with bulldog clamps will reveal a demarcation line on the liver surface that corresponds to the transection plane, which is marked with electrocautery. The isolation and clampage of the right arterial and portal branches is advantageous as it allows selective clamping without inducing ischemia in the contralateral site of the liver [12, 13, 14].
\nOne important point to remember is that at the end of this step the surgeon has two options. First, as described above to dissect and control the vascular components (right hepatic and portal branch) followed by parenchyma transection. Second, to dissect, ligate and divide the vascular components before commencing the parenchymal transection. The choice will depend on the case particulars and on the surgeons’ preference.
\nAfter selectively controlling the right lobe inflow and outflow, transection of the parenchyma is commenced along the marked line running from an anteroinferior to posterosuperior direction near the diaphragmatic hiatus of the IVC for early exposure of the middle hepatic vein. The transection is done using either a Kelly clamp or ultrasonic dissector with selective occlusion of the vascular inflow (RHA and RPV). While the ultrasonic dissector is highly effective for exposure of the periportal pedicles, care must be taken with this instrument when dissecting in close contact to the hepatic veins whose walls are extremely fragile. In addition, one should be always aware of the location of the tumor to achieve a negative histologic margin. When the resection is performed in a fibrous or cirrhotic liver, using a small Kelly clamp (kellyclasie) to carry out the transection may be preferable. As parenchymal division proceeds, pedicles including the larger branches originating from the hepatic veins are tied with silk 4.0. We do not use metal clips or absorbable material to achieve the hemostasis in transection surface of the remaining parenchyma. In our experience, the clips can easily be removed/dislodged during manipulations, by vigorous suction or when the liver becomes very congested or edematous leading to unnecessary bleeding and time delay to control it.
\nCare must be taken to preserve the middle hepatic vein by carefully ligating its branches to the anterosuperior and anteroinferior segments of the right lobe and by preserving the venous drainage of the medial segment of the left lobe. The parenchyma is divided in an anteroposterior direction until the anterior surface of the IVC is exposed. Before the specimen is removed it is necessary to divide the right portal pedicle and right hepatic vein. The right hepatic artery already controlled is double ligated with nonabsorbable suture (Cardionyl® 4.0), whereas the portal vein is sutured transversely with Cardionyl® 5.0 in order to prevent stricture of the remnant portal trunk. At this stage, the right biliary duct as the only remaining anatomical structure of the pedicle is in turn divided and closed with PDS 6.0. The right hepatic vein as the last structure holding the specimen, clearly exposed by a combined approach (extrahepatic dissection above the liver and laterally along the vena cava as well as medially by the parenchymal transection) is double clamped using DeBakey clamps and divided leaving sufficient length to perform a secure closure with Prolene® 4.0, or it may be divided using a vascular stapler. Alternatively, the right hepatic vein can be controlled and divided intrahepatically during the parenchyma transection. However, extrahepatic control reduces blood loss as the liver is divided and is very important maneuver for tumors close to the vena cava. Following the removal of the specimen, it is important to check for possible bile leaks by injecting methylene blue either via the cystic duct stump or the stump of the right bile duct before closing it. Bile leaks on the resection surface are easily visualized and selectively closed by using monofilament sutures. With the described technique for the parenchymal transection, the cut surface is usually dry, however, when required the hemostasis is achieved by gentle manual compression combined sometimes with application of biological fibrin glues.
\nFollowing resection, torsion of the mobilized left lobe may occur which can potentially lead to either kinking of the vessels in the hilum or the left hepatic vein. By refixing the falciform ligament this complication can be prevented. In addition, the diaphragmatic veins, vena cava, the surface of the parenchyma, hepatic artery and the integrity of the bile duct are checked before abdominal closure.
\nIn 2001 Belghiti described a technique termed the “liver hanging manoeuvre” (LHM). In this procedure, the liver is lifted by a tape passed between the anterior surface of the vena cava and the liver, thereby providing effective vascular control, in order to make the anterior approach safer and easier [15].
\nThe classic technique was first described to facilitate right hepatectomy by the anterior approach. In this first variant of the procedure, the anterior aspect of the suprahepatic IVC is exposed and the space between the right hepatic vein (RHV) and the middle hepatic vein (MHV) is dissected along the IVC axis for 2–3 cm, and when the dissection is complete, the hepatic parenchyma is looped up with a tape.
\nDuring the parenchymal transection, continuous upwards traction is applied on the tape by holding both its ends together. The tape ensures the safety of the underlying major vascular structures during transaction in a manner akin to dissecting on the finger to protect an important underlying structure. The tape elevates the liver, making it easier to transect, and constantly guides the surgeon towards the correct plane, thereby enabling a vertical transaction along the shortest possible route. The traction on the tape can also be regulated to provide control in instances of venous bleeding to help identify the vessel.
\nIn “up to down” technique, the classic technique is modified in order to increase its security that no major bleeding occurs during the maneuver [16]. The entire blind dissection of the RHIVC tunnel is performed in a craniocaudal direction in order to avoid the possible risk of RHV or MHV injury by the clamp inserted caudally. The maneuver is begun between the RHV and MHV, this space usually does not contain SHVs [17], and can be safely dissected for 3–4 cm downwards with a right-angled vascular clamp without any risk. The long axis of the RHIVC does not always represent a straight perpendicular line, but may take a straight-oblique or slightly curved course [17]. For this reason the dissection should be performed along a right oblique axis rather than in vertical direction to reduce the risk of injury to the caudate processus vein.
\nDrainage is carried out by silicone drains. Two drains are brought out on the lower edge of the surgical incision, one placed on the right subdiaphragmatic space near the resected surface, whereas the second drain whose end lies in the foramen of Winslow is placed under the liver. In general, we believe that hepatectomies should be drained as this measure reduces the risk of postoperative hematoma formation or bile collection.
\nThe patient is kept in ICU for a minimum of 12 h in order to begin monitoring potential postoperative complications (Table 1).
\n\n
| \n
Potential postoperative complications of right hepatectomy.
The adoption of a specific technique for right hepatectomy is related to the preference of the surgeon and for each specific situation, however, it is desirable that surgeons are familiar with various techniques available to perform the operation. An obvious example is the resection of large tumors of the right lobe in these cases and it is desirable, but impossible, to maintain the conventional mode of hepatic resection with mobilization of the wolf right prior to transection. Another example is the ability to promptly apply occlusion of vascular influx, or even total vascular exclusion, in case of bleeding during hepatectomy.
\nThe surgical risks associated with hepatic resection are now smaller, especially in specialized centers and high volume liver operations.
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\n\nOur end-to-end publishing service frees our authors and editors to focus on what matters: research. We empower them to shape their fields and connect with the global scientific community.
\n\n"In developing countries until now, advancement in science has been very limited, because insufficient economic resources are dedicated to science and education. These limitations are more marked when the scientists are women. In order to develop science in the poorest countries and decrease the gender gap that exists in scientific fields, Open Access networks like IntechOpen are essential. Free access to scientific research could contribute to ameliorating difficult life conditions and breaking down barriers." Marquidia Pacheco, National Institute for Nuclear Research (ININ), Mexico
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