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14.6 Haemostasis ontheRaw Surface oftheRemnant Liver
Fig. 14.28 Kousnetzoff and Pensky technique
149
Fig. 14.29 Wendel technique
150
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Fig. 14.30 Auvray chain ligature
14 Liver Transection Techniques andHaemostasis ontheRaw Surface oftheRemnant Liver
Fig. 14.31 Suturing techniques after Wedge resection of the liver
14.6 Haemostasis ontheRaw Surface oftheRemnant Liver
151
Fig. 14.32 Using both hands to compress on the edges of the lacerated
liver to decrease bleeding
152
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14 Liver Transection Techniques andHaemostasis ontheRaw Surface oftheRemnant Liver
Fig. 14.33 Suturing liver lacerations using. (a) Simple stitches. (b) Horizontal mattress sutures
14.6 Haemostasis ontheRaw Surface oftheRemnant Liver
153
Fig. 14.34 In difcult cases of lacerated liver, suturing of laceration over a guard of Surgicel
Fig. 14.35 Interlocking stitches to reinforce the laceration edge followed by simple sutures to approximate the lacerated edges
154
c
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14 Liver Transection Techniques andHaemostasis ontheRaw Surface oftheRemnant Liver
ab
def h
Fig. 14.36 Robinson and Butcher suturing technique
Further Reading
Castaldo ET, Pinson W. Chapter 24: Techniques of liver transection.
In: Lau WY, editor. Hepatocellular carcinoma. Singapore: World
Scientic; 2008. p.529–49.
Jiao LR, Habib NA.Chapter 25: Radiofrequency-assisted liver resec-
tion. In: Lau WY, editor. Hepatocellular carcinoma. Singapore:
World Scientic; 2008. p.441–567.
Lau WY. The history of liver surgery. Roy Coll Surg Edinb.
1997;42:303–9.
Xia F, Lau WY, Mak S, Bie P. Modied conventional clamp-crushing
technique in liver parenchymal transection. Hepatobiliary Pancreat
Dis Int. 2012;11:442–5.
Different Approaches toLiver Resection
15
With better understanding of surgical anatomy, physiology
and regeneration of the liver, and with improvements in technical developments in liver resection, alternative methods of
approaches to liver resection evolved.
To make things simple, there are only ve steps in liver
resection before the resected specimen can be removed from
the patient, and they are mobilisation of the liver by division
of ligaments, interruption of the vasculo-biliary inow, liver
parenchymal transection, interruption of the venous outow
from the short hepatic veins and from the main hepatic veins.
Obviously, adequate haemostasis is required before the abdomen is closed. The alternative approaches in liver resection
involve the combination of these ve steps in different orders.
To complicate matters, the interruption of the vasculo- biliary
inow can be at a different site and level from the actual ligation and division of the vasculo-biliary inow branches (e.g.
Pringle’s manoeuvre at porta hepatis with intrahepatic division of the individual branches). Similarly, the outow control can be at a site and level different from the division and
ligation of the hepatic veins (e.g. extrahepatic control of the
right hepatic vein with a vascular sling coupled with intrahepatic division and ligation of the vein). Furthermore, the alternative approaches also involve the division and ligation of the
Glissonian pedicle with all its portal triads together, or the
individual ligation and division of the hepatic arterial branch,
the portal venous branch and the biliary branch separately.
right hepatic duct are ligated and divided extrahepatically
(Fig.15.1). The right liver is then dissected from the inferior
vena cava. Short hepatic veins that drain from the right liver
into the inferior vena cava are ligated and divided (Fig.15.2a,
b). The hepato-caval ligament is then divided between
clamps and ligated. The right hepatic vein is dissected extrahepatically (see Sect. 13.6.1) divided and sutured (Fig.15.2c).
A line of demarcation is seen marking the devascularised
right liver from the left liver (Fig.15.3). Liver parenchymal
transection can then be done, transecting the liver on the
right border of the middle hepatic vein. Occasionally, the
transection line of a right hepatectomy can be along the left
border of the middle hepatic vein. Under this situation, care
must be taken to preserve the segment 4 branch or the liver
segment 4 would become congested (see Fig.15.4).
The segment 8 and segment 5 branches of the middle
hepatic vein need to be ligated intrahepatically and divided.
Blood loss during parenchymal transection can be
decreased by the use of Pringle’s manoeuvre and a low central venous pressure (see Chap. 12). Instead of using low central venous pressure, the trunk of the middle and the left
hepatic veins can also be controlled with a clamp extrahepati-
15.1 Conventional Approach
This is the approach used by Lortart-Jacob and Robert for
their rst successful right hepatectomy reported in 1953.
15.1.1 Right Hepatectomy
This approach starts with mobilisation of the right liver by
division of the falciform, coronary and right triangular ligaments. The right hepatic artery, the right portal vein and the
© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House Co. Ltd. 2021
W. Y. Lau, Applied Anatomy in Liver Resection and Liver Transplantation, https://doi.org/10.1007/978-981-16-0800-1_15
Fig. 15.1 Dissection and slinging of the right hepatic artery (red
sling), right portal vein (blue sling) and right hepatic duct (yellow sling)
155
156
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15 Dierent Approaches toLiver Resection
a
b
c
Fig. 15.2 (a) Short hepatic veins and right hepatic vein from the right liver draining into the inferior vena cava. (b) Isolation of a short hepatic
vein prior to ligation and division. (c) Isolation of the right hepatic vein before ligation and division
cally to prevent blood loss during parenchymal transection
(selective hepatic vascular exclusion). The dissection of the
trunk of the middle and left hepatic veins can be facilitated by
the division of the ligamentum venosum near to its termination at the trunk of the hepatic veins (see Sect. 13.6.1). Once
the ligamentum venosum is divided, the trunk can be dissected and looped with a vascular sling (see Sect. 6.10).
15.1.2 Left Hepatectomy
The procedure is similar to right hepatectomy with mobilisation
of the left liver by division of the falciform and left triangular
ligaments. Extrahepatic branch of the hepatic artery, left portal
Fig. 15.3 Line of demarcation between right and left livers after the
division of blood inow and outow to right liver
vein and left hepatic duct are divided and ligated extrahepatically. The trunk of the middle and left hepatic veins are isolated
MHV
RHV
sacrificing middle hepatic vein
Cantlie’
15.2 Parenchymal Transection withEarly Intrahepatic Control ofGlissonian Sheath
157
and slung. Parenchymal transection is along the plane demarcated by the ischaemic left liver along a plane on the left side of
the middle hepatic vein. The left hepatic vein is ligated intrahepatically. Again, blood loss can be reduced by using Pringle’s
manoeuvre plus either low central venous pressure or selective
hepatic vascular exclusion by clamping the right hepatic vein as
well. Please note that there is no short hepatic vein that drains
from the left liver (segments 2, 3, 4) to the inferior vena cava.
15.1.3 Extended Right Hepatectomy (Right
Trisectionectomy)
This is similar to carrying out right hepatectomy with the
exception that the hepatic arterial, portal venous and bile
ducts branches to segment 4 are also divided extrahepatically, and the right and middle hepatic veins are divided,
leaving behind the portal triad supplying the left lateral section and the left hepatic vein.
15.1.4 Extended Left Hepatectomy (Left
Trisectionectomy)
This is similar to carrying out left hepatectomy, with the
exception that the hepatic arterial, portal venous and bile
duct to the right posterior section, and the right hepatic vein
LHV
Sg 8 br
are preserved, and the additional resection of the right anterior section. If the right inferior hepatic vein is large (see
Sect. 7.4) this vein should be preserved, or the venous drainage to segment 6 can be affected.
15.2 Parenchymal Transection withEarly
Intrahepatic Control ofGlissonian
Sheath
15.2.1 Anterior Approach
This approach starts off with liver parenchymal transection
of the liver. This procedure is commonly accompanied by
temporary control of the portal triad using Pringle’s manoeuvre and low central venous pressure. Occasionally, liver
parenchymal transection can proceed with minimal blood
loss using some of the technical devices described in Chap.
14 without Pringle’s manoeuvre. Vascular inow control can
soon follow parenchymal transection by early intrahepatic
approach to, and control of, the hepatic pedicle structures
which are contained within the Glissonian sheath (Fig.15.5).
Further parenchymal transection and intrahepatic control of
vessels follow until the parenchymal transection is complete.
This is then followed by ligation and division of the hepatic
venous branches, which include one or two of the major
hepatic veins and the short hepatic veins (Fig. 15.6).
Mobilisation of the falciform, coronary and triangular ligaments completes the resection and removal of the specimen.
The benecial effects of the anterior approach are there is
less blood loss compared with the conventional approach,
there is less chance of disseminating the tumour as a result of
less manipulation on the tumour, there is less compromised
blood ow to the remnant liver as a result of less kinking of
the remnant liver during mobilisation, and there is less
chance of rupturing the tumour when the tumour is large.
Sg 4 br
Sg 5 br
b
a
transection line of right hepatectomy
preserving middle hepatic vein
transection line of right hepatectomy
Fig. 15.4 Line of parenchymal transection for right hepatectomy
s line
Right hepatic
pedicle
Fig. 15.5 Right hepatectomy using the anterior approach
158
Right hepatic vein
Right hepatic vein
15 Dierent Approaches toLiver Resection
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Inferior vena cava
iddle
Middle
epatic vein
hepatic vein
Fig. 15.7 Belghiti’s liver hanging technique transecting the liver at the
mid plane
Fig. 15.6 Right hepatectomy using the anterior approach. Please note
the completion of parenchymal transection before control of the venous
structures (the right hepatic vein and the short hepatic veins) at the
black of the liver
There are some limitations to the anterior approach. Some
patients with a large tumour compressing a major hepatic
vein can develop venous collaterals. In these patients, parenchymal transection without prior mobilisation of the liver is
associated with massive bleeding from the venous collaterals. In such situation, after inow clamping, the outow
should be resumed by mobilisation of the liver with an upper
traction on the liver to facilitate venous ow into the inferior
vena cava.
Nagasue in 1985 advocated the additional clamping of the
hepatic vein draining the part of the liver being resected,
claiming there to be less blood loss during resection than
when the Pringle’s manoeuvre is used in isolation. However,
this procedure requires early mobilisation of the liver, thus
defeats the original purpose of the anterior approach: parenchymal transection to get early inow occlusion, then further
parenchymal transection, followed by outow occlusion and
mobilisation of the ligaments.
15.2.1.1 Belghiti’s Liver Hanging Technique
Belghiti proposed a liver hanging technique to facilitate the
anterior approach.
The idea is to put a sling between the back of the liver and
the front of the inferior vena cava at the ‘avascular tunnel’
(see Sect. 3.3) right at the back of the midplane of the liver
(Fig.15.7).
Intraoperative ultrasound is used to conrm the absence
of tumour inltration and abnormal short hepatic veins at the
10–11 O’clock position of the anterior surface of the retrohe-
patic inferior vena cava. After opening the anterior leaf of the
coronary ligament and the anterior part of the right triangular
ligament (to expose the anterior and left sides of the right
hepatic vein), the fossa located between the right hepatic
vein and the middle hepatic vein is dissected 3–4cm downwards with a right-angled dissector (Fig. 15.7). For caudal
retrohepatic dissection, the caudal edge of the caudate lobe is
lifted from the inferior vena cava (Fig. 15.8a), and small
short hepatic veins are divided and ligated up to the level of
the inferior right hepatic vein. A long, tight, curved aortic
clamp is inserted behind the caudate lobe just to the left side
of the inferior right hepatic vein and is passed cranially along
the anterior surface of the inferior vena cava between the 10
and 11 O’clock positions, identifying the position of the
clamp tip by ultrasonography. By successfully opening and
closing the clamp, the clamp is directed towards the previously dissected space between the right hepatic vein and the
middle hepatic vein, while the clamp tip reaches suprahepatically (Fig.15.8b). A 10mm-wide soft silicon multitubular drain is seized with the clamp and pulled down through
the retrohepatic space (Fig.15.8c). When the right hepatectomy includes the middle hepatic vein, the tap is switched
from the right to the left side of the middle hepatic vein; this
allows safer dissection of the middle hepatic vein near the
vena cava conuence. The caudate lobe is divided to place
the tap near the right portal pedicle. The tap pulls up the liver,
thus facilitated the anterior approach by pulling the liver tissue away from the inferior vena cava and protecting it from
injury during transection (see Fig.15.8d).
The Belghiti’s hanging technique has a success rate of
80–92%. Adhesions between the liver and the inferior vena
cava and direct tumour involvement are the main causes of
failure. In 4–6% of cases, major bleeding happens because of
torn short hepatic veins.
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