pendekatan diagnostik transtorakal untuk tumor hepar

7/22/2019 Pendekatan Diagnostik Transtorakal Untuk Tumor Hepar

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Transthoracic Approach for Liver Tumors

N. Golsea, C. Ducerfa, A. Rodeb, C. Gouillat b,

J. Baulieuxa, J. -Y. Mabruta

Journal of Visceral Surgery (2012) 149, e11e22

Pendekatan DiagnostikTranstorakal untuk Tumor

Hepar

RITA HAPSARI META OCTAVIANI

ISNIN ANANG MARHANA

Departemen Pulmonologi dan Ilmu Kedokteran Respirasi

FK-UNAIR - RSUD Dr. Soetomo Surabaya

2014


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PENDAHULUAN

Tindakan Intervensi pada Tumor

Hepar :

Pembedahan konvensional

Thoraco phreno laparotomy(TPL)

Hanging tecnique anterior(thoraco-abdominal)


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Tindakan Intervensi pada Tumor Hepar :

prosedur terbuka thoracotomy

teknik pembedahan invasif minimal denganbantuan video (thoracoscopy)

Ablasi radiofrekuensi transcutaneous denganCT guided


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pada kasus yang jarang,

pendekatan transtorakaldapat menjadi pilihan

yang berguna untuk

manajemen lesi yang

terletak pada puncak

hepar (hepatic dome),

atau yang berkaitan

dengan pertemuanantara vena cava dan

hepar (cavo-hepatic)

pada pasien tertentu.http://web.uni-

plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Cha ter%2019 %20Liver.htm
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htmhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2019_%20Liver.htm


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Pembedahan konvensional

http://richardgwyn.wordpress.com/2011/07/14/the-liver-transplant/

Kelemahan dari tindakan pembedahankonvensional adalah perdarahan hebat

dan bekas luka operasi yang luas.

Pembedahan konvensional/laparotomy

tetap dilakukan bila ukuran lesi tumor

luas.
http://richardgwyn.wordpress.com/2011/07/14/the-liver-transplant/http://richardgwyn.wordpress.com/2011/07/14/the-liver-transplant/http://richardgwyn.wordpress.com/2011/07/14/the-liver-transplant/http://richardgwyn.wordpress.com/2011/07/14/the-liver-transplant/http://richardgwyn.wordpress.com/2011/07/14/the-liver-transplant/http://richardgwyn.wordpress.com/2011/07/14/the-liver-transplant/


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Hanging tecnique anterior(thoraco-abdominal)

manajemenpembedahan pada

tumor dengan ukuran

besar di bagian kanan

liver, tumor liverterletak jauh didalam

abdomen, atau

dengan maksud untuk

meningkatkanpendekatan ke

pertemuan

cavohepatic.http://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspx
http://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspxhttp://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspxhttp://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspxhttp://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspxhttp://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspxhttp://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspxhttp://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspxhttp://www.medivisuals.com/thoraco-abdominalapproach-305296-03xg.aspx


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Ablasi radiofrekuensi transcutaneousdengan CT guided

http://healthinfoispower.files.wordpress.com/2008/06/rf_spine_intro01.jpg

khusus untuk lesi yang

tidak mungkin dijangkau

melalui rute perkutan

biasa (blindarea,tumor yang lemah

secara echogenis.

Teknik invasif minimal

dan relatif masih baruuntuk terapi tumor solid,

dapat pula diberikan

pada penderita Non

Small Cell Ca Paru yang
http://healthinfoispower.files.wordpress.com/2008/06/rf_spine_intro01.jpghttp://healthinfoispower.files.wordpress.com/2008/06/rf_spine_intro01.jpg


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THORACOSCOPY

http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-

assisted-thoracic-surgery-rats-
http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-http://www.intechopen.com/books/current-concepts-in-general-thoracic-surgery/robot-assisted-thoracic-surgery-rats-


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THORACOSCOPY

Trokar harus diposisikan dengan tujuan untukmemungkinkan triangulasi yang adekuat

Secara horizontal, trokar harus ditempatkan pada

garis axilla yang berbeda (anterior, middle dan

posterior)

Secara vertikal, perlu untuk dilakukan pada beberapa

rongga antar costa yang berbeda: ruang antara ke 3-


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FOCUSED TUMOR ABLATION

Radiologiintervensionaluntuk tumor hatimencakupcryotheraphydan

radiofrekuensi

Untuk herniadiafragmatis

setelah dilakukancryoatau thermalinjurypadadiafragma setelahdilakukan ablasitumor perkutan.


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Indikasi Pendekatan Diagnostik Transtorakal

Hepato CelullarCarcinoma

colorectal hepaticmetastase

Metastase hepar

di dome hepar


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PENDEKATAN DIAGNOSTIK

TRANSTORAKALTidak MengubahRekomendasiTatalaksana

batasreseksi/pengangkatanyang aman

Reseksi dilakukansecara anatomis (formalsegmental resection)

atau memiliki freedisease marginsebesar1-2 cm di HCC, dantumor free marginsebesar 0,5-1 cm.

Hanya alternatifatas pendekatanoperatif

Melihat lokasi tumorhepar yang terlalu dalamtau terletak di puncakhepar

Tidak bolehmelanggar aturancarsinologi hepar

tatalaksana terhadaptumor hepar primerataupun tumor heparmetastase dapatmenggunakanpertimbangan

pendekatan transtorakal


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Kelebihan Pendekatan DiagnostikTranstorakal

jangkauan langsung ke lesi di puncakhepar

berguna dalam hal reseksi hati minor,focuses radiofrequency ablationmaupun cryo theraphy ablation

Pembedahan tunggal pada lesi tumorganda metastase hati dan paru


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Aspek Teknis

Phrenotomy

phrenotomy peripheral, jaringan otot harus dijagapada saat penempatan costodiaphragmaticuntukmemfasilitasi rekonstruksi diaphragmaticpada

saaat akhir dari operasi dilakukan pemasanganchest tube drainage/thoracic catheter.

Laparotomy yang dilakukan ke toraks

perluasan pembedahan perut (subcosta, medianatau insisi berbentuk J) ke bagian thoraks untukmengantisiapasi kesulitan dalam prosespembedahan


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Aspek Teknis

Thoracotomy

mengakses puncak hepar untuk melakukanfocalized tumor ablation: secara trans-diaphragmaticatau kontak secara langsung

dengan liver melaluiphrenotomyyangsingkat/pendek.

Thoracoscopy

Pasien posisi lateral decubitussebelah kirisetelah dilakukan bronchial intubation.Sesuai prosedur yang dilakukan

(pengangkatan tumor atau focal desruction),


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Konsekuensi fungsional dari

thoracotomy danthoracoscopy pada thoracicapproach adalah :

Atelektasis Infeksi sekunder


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Batasan KontraindikasiThoracic Approach

(1)Paru tunggal

resiko gagal napas ketika

operasi dilakukan melalui

bagian paru lainnya,akses ke lubang paru

setelah dilakukan

pneumonectomy bersifat

kompleks resiko infeksi

sekunder.

(2)Operasi thoracic

sebelumnya atau efusi

pleura

menyebabkan kesulitan

ketika dilakukan

pelepasan adhesi pleura

dan resiko luka padaparu terutama ketika rute

perkutanatau

thoracoscopicdigunakan.


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Hasil Akhir

Pendekatan diagnostik

dan terapi trans-abdominaltetapmerupakan standardalam melakukan

operasi hati

rute thoracictetapmerupakan pilihan

tindakan bagi pasientertentu dengan lesi

pada puncak hati


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APPENDIX


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Histopatologi

Pendekatan thoracic merupakan opsi pendekatan

yang dapat dilakukan pada seluruh tipe histologitumor hati.

HCC dan colorectal hepatic metasetase (CRHM)menunjukkan indikasi mayor yang disebutkan

dalam literatur

Metastase hepar dari tumor primer misalnya Ca

Mammae, Ca Pankreas


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Thoracoscopy Pasien posisi

lateraldecubitussebelah

kiri setelah dilakukan

bronchial intubation.

Bergantung pada

prosedur yang dilakukan

pengangkatan hepar atau

focal desruction, tiga

sampai dengan lima trokar

dimasukkan. Penempatan

trokar sesuaihttp://riverviewcardiacsurgery.com/diagnostics/vats-thoracoscopy/
http://riverviewcardiacsurgery.com/diagnostics/vats-thoracoscopy/http://riverviewcardiacsurgery.com/diagnostics/vats-thoracoscopy/http://riverviewcardiacsurgery.com/diagnostics/vats-thoracoscopy/http://riverviewcardiacsurgery.com/diagnostics/vats-thoracoscopy/


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Tusman G, Bohm SH, Warner DO, Sprung J. Atelectasis and perioperative pulmonary complication in high-risk patients. Curr Opin Anesthesiol. 2012; 25: 1-10. Availablefrom www.co-anesthesiology.com


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Atelektasis pasca operasi

penutupan saluran napas akibat penurunan functional

residual capacity(FRC) dipengaruhi oleh fungsi dinding

dada yang tidak normal akibat hilangnya aktivitas

koordinasi normal otot pernapasan.

Penurunan volume dan kapasitas paru menyebabkan

abnormalitas ventilasi dan pertukaran gas regional serta

mengakibatkan atelektasis.

kompresi jaringan paru mekanis selama tindakan

operasi


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Atelektasis absorpsi pasien

dengan ventilasi oksigen

100%.

pemberian oksigen 100%,

nitrogen di alveoli didorong

keluar dan digantikan oleh

oksigen.

oksigen sangat mudah larut

dalam darah dan berdifusi

sangat cepat ke dalamvaskuler paru. Karena terlalu

cepat proses ini terjadi maka

akibatnya adalah gas yang

tersisa di alveoli tidak cukup

untuk mempertahankan

Atelektasis pasca operasi

http://www2.hawaii.edu/~yzuo/research1-surfactant.html

University of Hawaii at Manoa

2540 Dole St - Holmes Hall 302

Honolulu HI 96822

pendekatan diagnostik transtorakal untuk tumor hepar

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