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Distended gallbladder
1
2
Greater curvature
of stomach
4
Suction
SI
Placing the posterior
row of sutures
SI
5
SI
3
SI
Incision
SI
6
SI
SI
Biopsy of liver
A
1
S3
8
7
a
b
2
1
c
2
b
3
b
c
5
a
Gallbladder
4
Stomach
233
d
d
PLATE
108
SURGICAL ANATOMY OF LIVER e liver is divided into eight major sub-
segments or areas (including the caudate lobe), with the principal line (Cantlie’s line) of division between the right and le sides extending cephalad and
obliquely from the middle of the gallbladder fossa to the center of the inferior
vena cava between the right and le main hepatic veins (figure 1, a–aʹ).
e true anatomic le lobe thus de ned is divided into medial and lateral
segments approximately along the line of the falciform or round ligament,
and each of these segments is then subdivided into a superior (cephalad) area
and an inferior (caudad) area (figure 2). In contrast, the right lobe is divided
into anterior and posterior segments by a plane from the anteroinferior edge
of the liver that extends both superiorly and posteriorly. is cleavage is similar to the oblique ssure above the right lower lobe of the lung, and it is
roughly parallel to it. ese segments of the right hepatic lobe are then split
into superior and inferior areas similar to those on the le (figure 2).
Although the segmentation of the liver appears straightforward, successful segmentectomy or lobectomy depends upon a thorough understanding
of the di erence between the portal vein, biliary duct, and hepatic artery distribution as opposed to the hepatic vein drainage. In general, the portal triad
structures bifurcate in a serial manner and ultimately lead directly into each
of the eight areas. e speci c exception to this rule is the paraumbilicalis
of the le hepatic branch of the portal vein, as this structure straddles the
division between the le inferior medial and lateral segments. us, it lies
roughly under the round ligament (figure 1, 7). e superior and inferior
areas of the le lateral lobe have a portal venous supply from either end of the
paraumbilicalis (figure 1, 9, and 10); however, special note should be made
of the paired medial supply to the superior and inferior areas of the medial
segment (figure 1, 8, and 12). It is equally important at this point to examine
the biliary and arterial supply of this area (figure 6). e main le hepatic
duct and artery proceed with the expected bifurcations out through the superior and inferior divisions of the le lateral segment; however, the le medial
segment duct and artery (figure 6, 13) do not divide and send a large branch
to the superior and inferior areas, but rather send long, paired structures out
in each direction from the junction of the two areas (figure 6, 12, and 13).
A R L
In contrast, the portal triad distribution to the right hepatic lobe is by
a straightforward arborization with major divisions rst into anterior and
posterior segments, followed by secondary divisions into superior and inferior subsegmental vessels (figure 1, 2 through 5). Interestingly, the caudate
lobe straddles the major right and le cleavage plane and simply receives
its portal supply directly from the right and le main branches of the portal
vein, hepatic arteries, and biliary ducts. Its venous return, however, is usually a single caudate lobe hepatic vein that enters the inferior vena cava on
its le side just distal to the main hepatic veins (
e hepatic veins, in general, run between the hepatic segments in a
manner analogous to the pulmonary veins. e right hepatic vein lies in
the major cle between the anterior and posterior segments on that side
(figure 1, 14). e le hepatic vein (figure 1, 15) drains predominantly
the lateral segment, while the middle hepatic vein (figure 1, 16) crosses
between the le medial segment and the right lobe. It is imperative to know
that this middle vein is variable where it joins the main le hepatic vein
within a few centimeters of the junction with the vena cava and that this
vein has two major tributaries that cross over into the right anterior inferior
and the le medial inferior areas (figure 1, 17). Appropriate preservation
of these channels is, of course, important in speci c segmental resections,
as hepatic venous occlusion results in necrosis of the entire area(s) involved.
e two common variations in the termination of the middle hepatic vein
are shown here in Plate and in Plate , where it has an entrance into
the cava that is separate from the le hepatic vein.
e remaining gures demonstrate the four most common hepatic resections, whose speci c details are covered in the operative text (Plates
through ). Of speci c note are the “danger points” along the paraumbilicalis of the le branch of the portal vein (figures 3, 4, and 5). It is in these
areas that the surgeon must be certain of the integrity of the hepatic venous
drainage before dividing any major venous branches. Also shown is the use
of interlocking full-thickness mattress sutures for hemostasis in the partial
and total le lateral segmentectomies, a common technique (figure 3), as
is the nger-fracture technique. ■
figure 1, 11).
234
Venous structures of the liver
1
Right lobe
1. Portal vein
2. Right anterior inferior portal vein
3. Right anterior superior portal vein
4. Right posterior inferior portal vein
5. Right posterior superior portal vein
A’
Left lobe
Right
2
6. Left branch of portal vein
7. Parumbilicalis of portal vein
8. Left medial inferior portal veins
9. Left lateral inferior portal vein
10. Left lateral superior portal vein
11. Caudate lobe veins (portal and hepatic)
12. Left medial superior portal veins
13. Inferior vena cava
14. Right hepatic vein
15. Left hepatic vein
16. Middle hepatic vein
17. Left middle inferior hepatic vein
18. Left middle superior hepatic vein
19. Left lateral inferior hepatic vein
20. Left lateral superior hepatic vein
21. Round ligament
22. Gallbladder
23. Anatomic line of division between
left and right lobesa
Left
Superior
Inferior
Lesion
A
Superior
Lateral
3
Medial
Inferior
Anterior
Segments of the liver
Lesion
Posterior
Lesion
5
Danger
Left lateral segmentectomy
(segments 2 and 3)
Danger
4
Danger
Biliary ducts and hepatic arteries
Left hepatectomy
(segments 2, 3, 4, +/-1)
Right hepatectomy
(segments 5, 6, 7, 8, +/-1)
6
1. Common hepatic duct
2. Right hepatic duct
3. Posterior segmental duct
4. Anterior segmental duct
5. Anterior superior duct
6. Anterior inferior duct
7. Posterior superior duct
8. Posterior inferior duct
9. Caudate process duct
10. Caudate lobe duct (right and left)
11. Left hepatic duct
12. Medial superior ducts
13. Medial inferior ducts
14. Lateral segmental duct
15. Medial segmental duct
16. Lateral inferior duct
17. Lateral superior duct
18. Gallbladder
19. Hepatic artery
20. Left hepatic artery
21. Right hepatic artery
22. Cystic artery
235
PLATE
109
L E H T
(N R)
INDICATIONS A persistent rise in the carcinoembryonic antigen (CEA)
level measured every to months during the postoperative years following
resection of a colorectal malignancy is an indication for a thorough search
for a possible recurrence. e original operation and pathologic reports are
reviewed because they may provide a clue as to where the recurrence is
located. However, the liver is the chief organ to be investigated by imaging
scans (CT, MRI, PET-CT), abdominal echograms, and liver function studies as well as a complete survey of the colorectal system by colonoscopy.
Evidence of metastases to the lungs or di use involvement of the abdomen
or bone generally contraindicates surgical intervention, but local excision
is usually considered in a good risk patient with a de nite steady increase
in the CEA level. Further, a hepatic lobectomy may be considered for a
metastasis too large for local excision. Radio immuno-guided detection of
recurrent malignancy may be useful in localizing metastasis which otherwise would be missed as well as providing evidence of complete resection
of the tumor. e -year survival rates following the removal of hepatic
metastases tend to be encouraging. e patient should be fully informed of
the reasons for the “second look” exploration as well as the uncertainty of
being cured of recurrence of malignancy.
PREOPERATIVE PREPARATION Multivitamins and adequate caloric
intake are urged during the days of preoperative investigation. Antibiotics
are given.
ANESTHESIA A general intratracheal anesthetic is given. Catheters are
placed in both arms for replacement of uid and blood products if required.
POSITION e patient is placed supine on the operating table in a slightly
reverse Trendelenburg position.
OPERATIVE PREPARATION e skin is prepared over the chest and abdo-
men down to the pubis.
INCISION AND EXPOSURE An extended or bilateral subcostal incision
can provide excellent exposure. Alternatively a liberal midline incision
beginning over the xiphoid may be used.
DETAILS OF PROCEDURE e peritoneum, the small and large intestines,
the cul de sac, mesentery, and omentum are all inspected for evidence of
metastases. e major concern will be the liver, especially if preoperative
studies indicate probable liver involvement. If only one or two very small
metastases are found in readily accessible locations, they can be excised or
destroyed by cauterization. Di use multiple metastases should be considered to contraindicate extensive attempts at surgical excision of many sites
of recurrence.
e liver is carefully inspected and palpated bimanually. In addition, the
use of hand-held intraoperative ultrasound is very useful in the search for
deep metastases. Su cient mobilization of the liver is advisable to visualize
the dome and posterior aspects of the liver. e falciform and triangular
ligaments are divided to ensure direct vision of all aspects of the liver. Fixation of the liver with tumor invading into the diaphragm posteriorly is a
relative contraindication for excision.
e size and location of the metastases as well as the age and general
condition of the patient are factors to be considered in determining whether
local excision or lobectomy are to be performed. A metastasis tends to be
spherical but usually is not so deep as it is wide. Local excision is usually
performed when more than one metastatic nodule is present in the liver or
both lobes are involved, and in the presence of a recurrence a er a previous
resection of more than one or more metastases.
When the metastatic nodule is near the margin of the le lobe of the
liver, a wedge resection is easily performed (figure 1). A safety zone of
at least or preferably cm is outlined with an electrocautery around the
metastatic nodule, since at least cm of normal liver should be excised with
the lesion.
Distal to the cautery line and parallel to it, a series of deeply placed mattress sutures of catgut on slightly curved large thin needles are placed in
the liver tissue to provide hemostasis (figure 2). ese catgut sutures are
carefully tied to compress the liver tissue without lacerating the surface of
the liver.
One or more traction sutures (A) may be placed in the safety zone
between the tumor and the line of compression sutures. e traction
sutures should never be placed through the tumor, since seeding may take
place. Such sutures are valuable in li ing up the tumor as the dissection
progresses (figure 3). Traction on these sutures helps in keeping a safe distance from the metastasis as the tumor nodule is retracted upward. Every
precaution is taken to ensure a safe zone of normal liver tissue beyond the
neoplasm, especially in the deepest portion of the resection. e electrocautery or laser may be used for the division of the liver tissue as well as
to control bleeding. Many surgeons use the Cavitron Ultrasonic Surgical
Aspirator (CUSA) ultrasonic instrument for dissection, while others nd
the Argon beam electrocoagulator very useful for obtaining hemostasis.
Any visible vessels or bile ducts may be clipped (figure 4). However,
most liver surgeons prefer individual ligation of vessels and ducts. e
pathologist must evaluate the completeness of the resection before closure.
Sometimes several metastases of various sizes may be excised in a similar
fashion. Some prefer to pack the cavity le by the excision for a few minutes
with Surgicel gauze saturated with a chemotherapeutic chemical. Blood loss
is rarely a troublesome factor in the excision of liver metastases, unless the
lesion is located rather deep and near a sizable blood vessel in an unusual
location. e risk of excising such lesions must be carefully weighed against
the potential gain of their removal. In such instances, anatomic resection
with pedicle control may be a safer option.
CLOSURE If the eld is dry, drainage is not necessary (figure 5), other-
wise, Silastic closed-system suction drains are inserted in the area. If bile is
noted to escape into the liver tissue, an e ort should be made to ligate the
area of drainage and consider closed suction drainage.
When the margins of the metastasis are questionable, additional liver
tissue is excised for study by the pathologist.
POSTOPERATIVE CARE Patients with proven metastases should be consid-
ered candidates for chemotherapy. e CEA levels are measured every two or
three months, and the patient is surveyed for evidence of other recurrences.
Measurements should be continued inde nitely, although the interval between
tests can be lengthened a er several years if the CEA level and CT scans as well
as other evaluation procedures remain within a normal range. ■
236
Falciform
ligament
1
2
Cautery
Lesion
Mattress
sutures
Traction
suture
3
Metal clip
4
A
Ligature
A
applier
5
237
PLATE
110
R H
(S , , , ± S )
INDICATIONS e successful local excision of benign liver tumors has fos-
tered a more aggressive surgical approach to the excision of hepatic metastases of colorectal malignancies. During the rst or more years a er the
removal of a colorectal tumor, carcinoembryonic antigen (CEA) levels
are measured every months. When the CEA level begins to rise, recurrence
must be considered. In the absence of proof of metastasis or recurrence in the
rectum, colon, lung, or peritoneal cavity, a search is made for hepatic metastases. Imaging by CT, MRI, or PET scans is performed. Hepatic angiography
is usually not necessary and has been replaced by CT or MRI with coronal
reconstruction to de ne regional anatomy. Any evidence of liver metastases
requires an evaluation of the number, size, and location of the metastases.
It is hoped that none or only one or two solitary metastases will be veri ed in locations easily accessible to the surgeon. e age and general condition of the patient, as well as the size, number, and locations of metastases,
are considered in making a decision to attempt curative resection. Given
the sensitivity of modern imaging, “blind” abdominal exploration for rising CEA in the absence of radiographic abnormalities is discouraged. e
patient should be fully informed and should participate in making a decision to reoperate. e patient should be made aware that a major portion of
the liver may need to be excised. A residual of percent or more of normal
liver tissue remaining in the le lobe is essential for survival.
PREOPERATIVE PREPARATION Perioperative antibiotics are given, and
any blood de ciency is corrected. Studies should have ruled out metastases
to the lungs and general peritoneal cavity insofar as possible.
ANESTHESIA A general anesthetic that has minimal potential to harm the
liver is required.
POSITION e patient is placed at on the table in a modest reverse Tren-
delenburg position.
OPERATIVE PREPARATION e skin of the thorax and abdomen is pre-
pared, since the incision may extend from over the lower sternum to below
the umbilicus. Appropriate catheters are placed to provide ready access for
the administration of blood, uids, and medications and central venous
pressures should be monitored.
INCISION AND EXPOSURE A long right subcostal incision that extends
across the midline as a bilateral subcostal incision with a midline extension
to the xiphoid provides excellent exposure. Alternatively, a liberal midline
incision extending from well above the xiphoid to or below the umbilicus
may be used.
DETAILS OF PROCEDURE e extent of tumor involvement in the right
lobe is veri ed by inspection of a bimanual palpation (figure 1). e angio-
grams and imaging scans available in the operative room are reviewed to
recon rm the location of the lesion. In patients with colorectal metastases,
it is essential to palpate and visualize the pouch of Douglas for metastases as
well as the entire colon, small bowel, mesentery, omentum, and peritoneum.
If there is suspicion of intraperitoneal spread, many surgeons will rst view
the peritoneal space with a diagnostic laparoscopy. Multiple seeding would
cancel the procedure, although some prefer to excise or cauterize an occasional small metastasis and proceed with the liver section. e extent and
location of all hepatic metastases is noted using ultrasound directly on the
liver surface. Understanding the relationship of lesions in question with
major vascular structures is essential to minimizing blood loss.
e liver is mobilized by dividing the falciform and right triangular ligaments as well as freeing the liver posteriorly from the diaphragm (figure 2).
Some surgeons prefer not to cut the triangular ligament, as it provides stabilization and support for the le lobe. e cystic artery and cystic duct are
ligated, and the gallbladder removed, since the gallbladder bed is the dividing line between the le and right lobes of the liver. e right hepatic duct is
easier to visualize a er removal of the gallbladder. A clear exposure of the right
hepatic duct is essential to avoid interference with the area of bifurcation supplying the le hepatic duct.
e right hepatic duct is divided under clear vision and double-sutured
with one or more trans xing sutures (figure 3). A er the right duct is
divided, the variable arterial supply is exposed. e surgeon should at this
time review imaging, alert to the possibility that the right hepatic artery
may arise from the superior mesenteric artery. e right hepatic artery is
ligated and divided (figure 4). e le hepatic artery must be visualized
to be certain it has not been obstructed or compromised in any way. Variations in the arterial blood supply between the right and le lobes of the liver
should be remembered by the surgeon during the dissection in this area.
e right and le branches of the portal vein are clearly exposed before
the right branch of the portal vein is doubly clamped with straight Cooley
vascular clamps. Both ends of the portal vein are oversewn with a continuous - nonabsorbable suture. For additional security, the end of the
proximal vein may be doubly closed with horizontal mattress sutures
(figure 5a). Alternatively, the right portal vein may be divided using a
vascular stapler figure 5b).
Special attention must be given to taking down the hilar plate, followed
by freeing up the le hepatic duct, the le hepatic artery, and the le branch
of the portal vein from the undersurface of the overlying liver. ese vessels enter the liver near the falciform ligament. A er the vessels and other
structures are gently dissected away from the liver, a logical area is exposed
for the division between the right lobe and the medial segment of the le
lobe of the liver.
CONTINUES
238
Right hepatic vein
1
3
Right
triangular
ligament
Left hepatic vein
2
4
Left
triangular
ligament
Falciform
ligament
Ligated
right hepatic
artery
Cystic artery
Loop about
common
hepatic duct
5a
Cystic duct
5b
239
PLATE
111
R H
(S , , , ± S )
DETAILS OF PROCEDURE e right hepatic lobe is freed
up from the diaphragm and rotated medially away from the diaphragm,
exposing the small hepatic veins communicating with the inferior vena
cava. ese small vessels are carefully and securely ligated (figure 6a).
e cava ligament must be divided to expose the inferior border of the
right hepatic vein. Caution must be executed as an accessory right hepatic
vein may traverse this ligament and drain into the inferior vena cava (IVC)
(figure 6b). e major right hepatic vein is exposed.
A loop is passed around the large right hepatic vein, and the liver tissue
gently pushed away to permit the application of two curved Cooley vascular clamps to the vein. Su cient vein must extend beyond the vascular
clamps in order to secure the open ends. A er the vein has been divided,
two rows of nonabsorbable vascular sutures are used to secure the ends
of the right hepatic vein (figure 7a). Alternatively a vascular stapler may
be used (figure 7b).
e concave line of demarcation following the color change subsequent
to ligation of the blood supply may be super cially outlined with a cautery. Starting at the inferior border of the line of demarcation, deeply placed
mattress sutures are inserted to control bleeding. e mattress sutures must
be tied to compress the liver substance but not to crush it, thus leading to
more bleeding. A er three or four mattress sutures are placed on either side
of the lower end of the zone of demarcation, the liver tissue is divided with
an ultrasound dissector, laser, or electrocautery unit (figure 8). Larger
vessels and branches from the middle hepatic vein may require double ligation. Surface coagulation may be obtained with an argon beam electrocau-
tery device. Alternatively, the hepatic parenchyma can be transected using
multiple applications of an endoscopic cutting linear stapler with vascular
loads. is approach should only be used a er clear mapping of the internal vascular anatomy using the ultrasound probe. A er all bleeding and
bile leakage has been controlled (figure 9), the omentum may be brought
up to cover the raw surface of the le lobe. Su cient sutures are taken to
secure the omentum in place.
e pathologist examines the specimen to determine adequate clear
margin. e structures going into the le lobe are inspected to ensure that
no structures are obstructed by angulation.
e falciform ligament is reapproximated to ensure stability of the le
liver lobe. Closed system Silastic suction drainage may be used.
CLOSURE Routine surgical closure procedures are followed with place-
ment of closed suction catheters.
POSTOPERATIVE CARE Daily blood and liver function studies should be
carried out. Signi cant blood loss from drains may require replacement.
Meticulous attention must be paid to minimizing infectious risks. Leakage
of uid from the wound should not be tolerated and aggressively corrected.
If there is a bile leak of greater than mL/day, then an endoscopic biliary
start should be considered. If there is an ascites leak, the wound should be
revised. Long-term follow-up should include frequent examinations with
periodic liver function tests and CEA assays for patients with colon cancer.
Rising abnormal values will signal the need for complete reevaluation, as
described under Indications. ■
240
6a
Right
hepatic
vein
Ligature on
caval branches
Right hepatic
vein
Danger
6b
7a
Inferior
vena cava
Divided oversewn
right hepatic vein
Line of
resection vs
line of color
demarcation
Vascular clamps
8
on right
hepatic vein
Right
hepatic vein
7b
Ligated minor
vessels and ducts
Residual
portal
structures
9
241
PLATE
112
L H
(S , , ± S )
INDICATIONS ere are a number of indications for removal of all or part
of the le lobe of the liver. e most common indication is evidence of one
or more metastases from a previously resected colorectal cancer. e diagnosis is supported by a rising carcinoembryonic antigen (CEA) level during
repeated postoperative evaluations. Liver function studies are performed
and evaluated. Imaging scans verify the location, size, and probable number of metastases. e initial operative notes and the pathologist’s report
should be carefully studied for evidence of metastasis at the time of the initial operation. Studies to identify abdominal and lung metastases, including
colonoscopy, must be negative. A period of delay may be chosen to reassess
the trend of the CEA levels and CT scans, as well as to evaluate the risk of
a second-look procedure in an elderly patient. PET/CT to identify occult
intra and extrahepatic disease should be undertaken.
PREOPERATIVE PREPARATION An informative discussion with the
patient and the family is part of the preoperative preparation. Antibiotics
are given and cross-matched blood is made available. Intravenous catheters
are inserted in both arms for the administration of uids and blood products, and central venous pressure is monitored.
ANESTHESIA A general anesthetic with the minimum of potential for
injuring the liver is given.
OPERATIVE PREPARATION e skin is prepared over the entire abdomen
and the chest since a sternotomy may be required.
INCISION AND EXPOSURE Various incisions have been used, but the
bilateral subcostal incision with midline extension to the xiphoid provides
excellent exposure. Extra assistants may be needed, unless special selfretaining retractors are available to retract the le costal margin. Alternatively, a long midline incision that can be extended with a median sternotomy can be used.
DETAILS OF PROCEDURE e abdominal cavity is carefully inspected for
evidence of pinpoint or large metastases in the pouch of Douglas, colon,
mesentery, small bowel, omentum, or peritoneum. Any suspicious areas are
excised for frozen section examination. e liver surface is inspected for
evidence of metastases, followed by bimanual palpation to verify the diagnostic procedures suggesting metastasis in the le lobe of the liver. Metastases deep within the le lobe rather than super cially are best evaluated
with a hand-held ultrasound probe. Metastases readily seen on the surface
of the le lobe can be locally excised with a -cm margin. Metastases near
the inferior liver margin can be removed by wedge incision.
e incision is outlined extending into the bed of the gallbladder. e
le hepatic vein is the major vessel in the dome of the le lobe (figure 1).
When the tumor is located deep in the le lobe, the le lobe is mobilized by
division of the falciform and coronary ligaments (figure 2).
Since the median margin of the le lobe extends into the gallbladder
bed, a cholecystectomy is performed a er ligation and division of the cystic
artery and cystic duct. Removal of the gallbladder improves the exposure
for the identi cation of the major hepatic ducts and vessels to be divided
and ligated (figure 3).
e hilar plate or bridge of the liver, if present, is divided to enhance
the exposure of the structures entering the le lobe. e le hepatic duct is
freed up for the su cient distance to allow passage of a right-angle clamp.
e duct is doubly ligated and then divided (figure 4). e division of the
le hepatic duct exposes the underlying le hepatic artery, which usually
arises from the common hepatic artery. e surgeon should seek out the
presence of aberrant arterial anatomy. e most common variation is the
abnormal origin of the le hepatic artery from the le gastric artery. In this
case, the le hepatic artery will run through the pars condensa in the lesser
omentum.
e le hepatic artery is gently freed up a short distance from its point
of origin and doubly tied with - nonabsorbable sutures proximally
(figure 5). e area of the arterial bifurcation is inspected to be certain
the blood supply to the right lobe is intact and then the artery is divided
between the ligatures.
CONTINUES
242
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