Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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2. DISSECTION

Inferior to the liver edge, divide the falciform ligament between clamps and tie with heavy silk suture. Cut the sutures at the caudal divided ligament. Place a hemostat on the uncut cephalad end of the divided ligament for use in manipulating the liver during dissection.

You will discover the need for a constant balance between retracting the liver cephalad and retracting caudad. Using this tether, you may restore some caudal exposure while the selfretaining retractor suspends the liver toward the diaphragm.

Using electrocautery, the filmy, avascular falciform ligament is incised beginning at its attachment to the anterior abdominal wall and continuing in a cephalad and dorsal direction until the point of convergence of this ligament meets the left and right triangular ligaments (Figure 45-4). The hepatic veins are visualized at the superior extent of this dissection. Carefully divide the peritoneal surface to clearly define the right and middle hepatic veins. We favor placing a vessel loop around the right and middle hepatic veins at this juncture

(Figure 45-5).

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Divide the anterior and posterior leaflets of the right triangular ligament using electrocautery. It is usually best to first extend the incision of the anterior leaflet from the right lateral margin to the midline. At this point, gentle blunt dissection will separate the diaphragmatic attachments, better revealing the posterior leaflet and facilitating division of this structure. In this fashion, the liver is mobilized to the midline, as well as in a caudal direction (Figure 45-6).

At the most posterior and medial extent of this dissection, the vena cava is seen, and the small tributaries between the posterior surface of the liver and the vena cava can be visualized. We delay division of these vessels until we have fully dissected the hepatoduodenal ligament. The umbilical tape is used as a tourniquet surrounding the liver parenchyma from the posterior to the anterior surface in the anticipated line of resection. On occasion, this maneuver may be useful to control parenchymal bleeding during division of the right liver (see Figure 45-6).

The right hepatic and middle hepatic veins will be visible at the superior extent of dissection in the midline. Dissect and place a vessel loop around the right hepatic vein at this time for later division. Because the liver may be displaced either to the left or to the right compared with classic orientation, one must confirm that the vein encircled is in fact the right hepatic vein (see Figure 45-5).

Dissect the peritoneum overlying the hepatoduodenal ligament in a transverse direction. After dividing the typically filmy gastrohepatic or lesser omentum medial to the ligament, it should be possible to pass your finger or an instrument into the foramen of Winslow and completely encircle the structures contained in the hepatoduodenal ligament (Figure 45-7).

Pass an umbilical tape around the ligament and, using the hooked instrument with a section of rubber tubing, create a Rummel loop. This safety measure is performed to permit complete inflow occlusion, which may be necessary to control undue hemorrhage if encountered during the procedure. Place a hemostat on the two loose ends of umbilical tape (see Figure 45-7).

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Remove the gallbladder (Figure 45-8).

At approximately the mid-portion of the hepatoduodenal ligament, dissect and isolate the common bile duct laterally; the proper hepatic artery is located on the medial edge of the ligament. Place a 1⁄4-inch Penrose drain around the bile duct and a vessel loop around

the artery, and use traction laterally and medially on these two structures to reveal the portal vein, positioned between and posterior to these two parallel structures. Gently tease the filmy adhesions to isolate all three structures toward the hilum (Figure 45-9).

Follow the common bile duct, hepatic artery, and portal vein toward the hilum of the liver, and then isolate and encircle the right branch of each structure. Each of these will follow a course directed toward the cystic plate, deep to the gallbladder bed (see Figure 45-9).

By retracting the liver to the left, you expose the vena cava. Identify, ligate, and divide multiple small tributaries between the vena cava and the right lobe of the liver, permitting full mobilization of the right liver.

Interrupt vascular inflow to the right liver by dividing the right hepatic artery between clamps and suture ligating (see Figure 45-9).

Divide the right branch of the portal vein between clamps. With the clamp in place, a continuous running closure is performed with 5-0 Prolene, beginning at one corner. At the opposite corner, lock the suture. Remove the clamp and place a second layer of continuous suture back to the original corner and tie. Vascular staples may be substituted (see Figure 45-9).

Divide and suture ligate the right branch of the hepatic duct using absorbable suture (see Figure 45-9).