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142 Atlas of Gastrointestinal Surgery: Liver
Left hepatic v.
looped
As with right-sided
major resections, the out-
flow should be controlled
extrahepatically when possi-
ble (2). It is often more diffi-
2
cult to fully control the left
hepatic vein owing to its proximity
to the middle vein. While preferable
to achieve extrahepatic venous isolation,
it is not essential, and cavalier dissection in
this area should be avoided.
As with right hepatectomies, the hilar dissection begins
with removal of the gall bladder. The left hepatic
artery and left portal vein can be ligated separately (3).
Left portal v.
Left hepatic a.
Cystic a.
and duct
3
Left portal pedicle
Left Hepatectomy 143
Hepatotomies
5
Left hepatic v.
4
Each hilar structure can be divided and ligated, or a
pedicle ligation/stapling can be done (4). For left hepa-
tectomy, the relatively long distance from the bifurcation
to the umbilical fissure and the capacity to identify and
lower the hilar plate below segment 4b facilitates an en
bloc hilar pedicle technique. Following control of the
left inflow, the left hepatic vein can then be divided
using a vascular stapler (5).
144 Atlas of Gastrointestinal Surgery: Liver
Devascularized
left lobe
Dividing
parenchyma with
dissector device
The transection line for left hepatectomy is similar to that of
right hepatectomy, based on the line of demarcation and location of the middle hepatic vein on IOUS. Here, however, the
transection line is immediately to the left (ipsilateral) to the
middle vein (1). As with other hepatectomies, the method
of parenchymal transection can vary, including ultrasonic
6
dissection, crush clamp, or preablative transection.
Depicted here is the use of a saline-enhanced cautery
dissector device (6). Larger pedicles and vessels are
divided using a vascular stapler (7). As with other
major resections, techniques to minimize blood loss,
including maintenance of low central venous pressure
and selected temporary total inflow occlusion
should be considered.
7
Application of
stapler to
intrahepatic
pedicle
Left Hepatectomy 145
Management of the liver surface after the completion of the resection is similar to that of other liver resections (8).
Directed suture ligature of major bleeding points, careful inspection for bile leaks, and electrosurgical control of minor bleeding with argon beam coagulation should be employed. Reimaging of the liver with IOUS can be helpful to confirm adequate hepatic vascular flow in the remnant liver, but resuspension is not required with left hepatectomy. Fibrin sealant can
be applied to the resection surface in order to further aid in hemostasis and reduce the risk of postoperative bile leak. As
with other resections, placement of drains in the perihepatic space is not recommended in most cases.
L. hepatic v.
Caudate lobe
L. portal pedicle
8
Extended Left Hepatectomy
(Trisectorectomy)
Operative Indications:
The indication for an extended left hepatectomy is when complete resection of a tumor requires removal of all or part of
the right anterior sector (segments 5 and 8) along with the left liver (segments 2, 3, and 4) (1). As with other major
resections, this can be done with or without combined caudate resection. Unlike extended right resections, the remnant
liver volume following extended left hepatectomy (the remnant of segments 6 and 7) is almost always sufficient.
Preoperative liver volumetric assessment leading to a need for preoperative portal vein embolization to expand the remnant
volume is almost never required.
Middle hepatic v.
R. anterior pedicle
L. hepatic v.
1
L. portal pedicle
Extended Left Hepatectomy (Trisectorectomy) 147
Operative Technique:
Extended left hepatectomy is performed much like that of a left hepatectomy. As with
all liver resections, the same four basic steps are performed as previously described:
• Exposure and assessment
• Hepatic mobilization and vascular control
• Transection of hepatic parenchyma
• Management of the liver surface, and completion
The type of incision is not different than when performing other liver resections. The assessment phase continues with
a careful evaluation of extrahepatic sites within the abdominal cavity. Assessment of the liver is conducted with careful palpation and visual inspection for (1) additional lesions, (2) quality of the uninvolved liver, and (3) resectability, followed
by methodical intraoperative ultrasonography. As with formal left hepatectomy, particular attention should be paid to
assessment of the anatomy of the left and middle hepatic veins, the left portal pedicle, and proximity of the pathology to
these structures.
The steps for the mobilization are similar to that of the
standard left hepatectomy. The round and falciform
ligaments are divided, along with the left triangular ligament. The gastrohepatic ligament is divided and any accessory or
Middle hepatic v.
and l. hepatic v.
looped together
replaced left hepatic arteries are ligated and divided. Dissection along the
left inferior vena cava below the
caudate lobe or between the caudate and left lateral sector is conducted, depending on whether
the caudate lobe is to be included
in the resection. This assists in the
identification and isolation of the
left and middle hepatic veins. Sharp
dissection of the suprahepatic vena
cava between the middle and right
veins is done to isolate the left and
middle veins (2). IOUS can help iden-
2
148 Atlas of Gastrointestinal Surgery: Liver
tify any aberrant venous anatomy in this area. For extended left hepatectomy, typically both the left and middle veins are
divided. As they often originate from a common trunk, control of both together is often easier than isolation of any one
individually. If it’s not possible to isolate them without a hazardous dissection, control can be achieved during the
parenchymal dissection.
The hilar dissection begins with removal of the gall bladder and ligation of the left hepatic artery and left portal vein.
If complete removal of segments 5 and 8 is necessary along with the left liver, identification and division of the portal vein
to the right anterior sector along with the left portal pedicle allows the identification of the transection plane by visual
demarcation.
Middle and left
hepatic vv.
Right hepatic v.
preserved
Right anterior pedicle
Left portal pedicle
3
Right posterior
pedicle preserved
Extended Left Hepatectomy (Trisectorectomy) 149
For an extended left hepatectomy, the line of transection is between the anterior and posterior right sectors (1). Care
must be taken to not be too close to the right hepatic vein in order to maintain adequate outflow to the liver remnant. For
tumors near the hilum, care must be exercised in order not to injure the main right or posterior right pedicle. In some cases,
partial preservation of the right anterior sector can be achieved, provided that the right anterior portal pedicle is preserved
and adequate tumor margins are achieved. As with other hepatectomies, the method of parenchymal transection can include
ultrasonic dissection, crush clamp, or transection with preablation. Vascular staplers should be utilized for larger vessels. The
resection surface area of the extended left hepatectomy is the largest, compared to the other major hepatectomies.
Temporary total inflow occlusion can be used here, as with other resections, but care must be taken to record the duration of inflow occlusion and consider intermittent release of the clamp every 10 to 15 minutes.
Upon completion of the resection, only the right posterior portal pedicle and right hepatic vein remain (3).
Management of the resection surface and closure is similar to that of other major liver resections. With a large surface area,
care must be taken to carefully control bleeding and identify any potential bile leaks. Resuspension of the liver is not
required, and placement of drains is not necessary.
MINOR RESECTIONS:
Segmental Resection:
Right Posterior Sectorectomy
Operative Indications:
Provided that complete resection of the diseased region can be achieved, anatomic resections of less than a full hemiliver
should be considered. This allows for the preservation of a larger liver remnant and increases the probability of a successful repeat hepatectomy in the future if needed. The decision as to whether such a resection can be achieved is largely based
on the tumor location relative to the vascular structures, particularly the portal pedicles. A right posterior sectorectomy
(6-7 bisegmentectomy, 1) is indicated when a tumor or tumors are in proximity to the right posterior portal pedicle but
R. hepatic v.
R. posterior pedicle
1
Segmental Resection: Right Posterior Sectorectomy 151
resection can spare the main and anterior right branches. Similarly, a right anterior sectorectomy can be performed for tumors
sparing the posterior pedicle. Careful review of the preoperative cross-sectional imaging and IOUS is important when determining when these operations are indicated.
Operative Technique:
The technique of right posterior sectorectomy follows most of the same basic principles employed with all liver resections. The incision and exposure is the same as
that of a right hepatectomy. The right hemiliver is fully mobilized, including division of the round ligament, falciform ligament, and the right triangular ligament.
Dissection along the posterior right liver and vena cava is conducted sharply, and
accessory veins are ligated and divided exposing the retrohepatic ligament just
below the right hepatic vein origin. As with the right hepatectomy, the right
hepatic vein should be looped and controlled. In many cases, the right hepatic
vein will need to be divided with this operation in order to gain adequate tumor
clearance.
The hilar dissection begins with a cholecystectomy. The hilar structures, including the hepatic artery and portal vein, are
identified. For this resection, however, the dissection is extended into the right hilum, identifying the portal pedicle to the
posterior sector. Intraoperative ultrasonography can be helpful in identifying the vascular anatomy, including the length of
the main right portal vein and the location of the sectoral branches. The posterior pedicle can be visualized by retracting
the right portal vein to the left and dissecting the lateral aspect of the portal vein. Care must be taken to avoid disruption
of small branches to the caudate lobe. This can be facilitated, if needed, by looping and applying gentle traction on the
main right portal vein.