considered. The main portal vein was not invaded; the right hepatic artery was not invaded. The left lobe of the liver was signicantly atrophied with a compensatory proliferation of the right lobe (Figs.16.33 and 16.34). After admission, the patient underwent percutaneous transhepatic cholangial drainage (PTCD) of the right liver, with drainage time of 6 days, and the total serum bilirubin was reduced to

3D Outcome Three-dimensional reconstruction showed that the middle hepatic artery was invaded, while the left and right hepatic arteries were not. The right hepatic artery originated from the superior mesenteric artery. The left branch, bifurca­tion, and right branch of the portal vein were invaded, and the main portal vein was not affected (Figs.16.35 and 16.36). The tumor was a Bismuth IVb type, and left hepatectomy com­bined with the right portal vein resection was initially planned.

mass was found in the hilum, with extensive involvement on both sides, and atrophy of the left lobe of the liver. The hilar part of the liver had enlarged lymph nodes with a hard tex­ture. The common hepatic artery sheath was opened, and the enlarged lymph nodes around the common hepatic artery were dissected and separated. The gastroduodenal artery, proper hepatic artery, and left hepatic artery were dissected successively to the proximal end; the right hepatic artery was dissected along the right margin of the hepatic duodenal ligament, and the surrounding connective tissue was dis­sected from the main portal vein to the hepatic portal. The distal end of the common bile duct was cut off close to the pancreas, and the bile duct was pulled away to the hilum of liver. The tumor was mainly located in the left hepatic duct, invading the left branch of the portal vein, bifurcation, and main portal vein, which exceeded the evaluation results of preoperative imaging and three-dimensional reconstruction. However, the extent of invasion of the right portal vein branch was not clear. Due to the deep position of the right portal vein branch, the proximal invasion of the hepatic por­tal vein could not be determined by the anatomy of the hepatic portal vein. Combined with CT images, the splitting of the middle hepatic ssure and the opening of the hepatic portal plate were considered to determine the resectability after further exploration. Partial hepatic parenchyma was separated from the side of the hepatic portal, and the hepatic portal plate was opened. The right hepatic duct was sepa­rated from the normal texture of the bile duct, and two bile duct openings could be seen at the broken end, which were right anterior and right posterior bile duct openings, respec­tively. Under the immediate circumstance, it could be observed that the origin of the right branch of the portal vein, the bifurcation, the left branch, and main trunk of the right portal vein were invaded by tumors, but the resection and reconstruction could be completed. It was decided to combine left hepatectomy with portal vein resection and reconstruction (Figs.16.37, 16.38, 16.39, and 16.40). Postoperative pathological diagnosis: bile duct adenocarci­noma, grade II–III, mass size 1.8cm × 1.5cm × 1.5 cm, inltration of hepatic parenchyma and hepatic adipose brous connective tissue, invasion of the hepatic duct, nerve invasion, and intravascular tumor thrombus. No residual tumors were found in the incised margin of the liver. No tumor involvement was found at the cutting edge of the hepatic duct and right anterior bile duct. Tumor tissue can be seen at the portal vein pedicle. Tumor metastasis was found in lymph nodes (adjacent to the right hepatic artery and common hepatic artery). No metastasis was found in the lymph nodes of group 13 (0/1).

anterior lobectomy + caudate lobectomy + left portal vein branch resection and reconstruction, the reserved liver vol­ume can reach 73.3%. However, should this procedure be performed, there would be two liver transections, bilateral choledochointestinal anastomosis, more frequent intraopera­tive bleeding, and a higher incidence of postoperative com­plications, all of which would increase the difculty of surgery. Through three-dimensional visualization, it was shown that the patient had an anatomic variation of the portal vein, that is, the right anterior portal vein was originated from the left portal vein; the bifurcation and course of right hepatic were lower and farther away from the tumor; the middle hepatic vein was slender, the right hepatic vein was thick and there were branches of the right posterior inferior hepatic vein. Thanks to the identication of the above­mentioned anatomical variations and the measurement of liver volume, we believed that the combined resection of hepatic SIII could simplify the surgical procedures to the greatest extent and conform to the principle of complete tumor resection while retaining sufcient functional liver volume.

Although expanding the scope of liver parenchyma resec­tion can improve the rate of radical resection, the incidence of postoperative complications and mortality is higher. Also, in the case of hilar cholangiocarcinoma without microvascu­lar invasion, some scholars advocate small-scale hepatec-

was pulled laterally to expose the portal vein behind the bile duct, and the surrounding tissue was cleaned proximally to the bifurcation of the portal vein. Through careful anatomy to form the skeletal area of the hilar area during operation, the actual invasion range of the tumor was further deter­mined, and the resectability was claried. If the bile duct cannot be clearly separated from the breakpoint outside the liver, the liver parenchyma can be cut along the median s­sure, and the hepatic portal plate can be opened to explore the extent of proximal tumor invasion fully.