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152 Atlas of Gastrointestinal Surgery: Liver
The technique of ligation or stapling of the posterior portal pedicle en mass is preferred, as these structures come together within Glisson’s sheath as they enter the liver parenchyma (2). We have found the proper positioning of the vascular
stapler can be confirmed using IOUS before application, avoiding inadvertent injury to the anterior pedicle. Following division of the posterior portal branch, demarcation of the devascularized posterior sector can be readily seen. It is at this point
that the right hepatic vein can be divided, if necessary. In such cases, segments 5 and 8 of the liver remnant will usually
have adequate venous drainage via the middle hepatic veins.
R. posterior pedicle
divided
2
Devascularized right posterior sector
Segmental Resection: Right Posterior Sectorectomy 153
3
Right
posterior
pedicle
divided
Pringle
maneuver
As with other types of resection, the liver substance can be divided using a variety of methods. The crush clamp technique, the ultrasonic dissector, or preablation devices are all options. Temporary total inflow occlusion (Pringle maneuver)
can be used for this type of resection as well. To perform this, an umbilical tape and Rommel-type tourniquet can be used
(3). Bleeding from the resection surface can be controlled using figure-of-eight sutures applied directly to the bleeding
points, and minor bleeding of the surface can be controlled using argon beam coagulation.
Left Lateral Sectorectomy
Operative Indications:
The left lateral sectorectomy (segments 2 and 3) is the most common bisegmentectomy performed (1). It is employed for
lesions confined to this portion of the liver where there is no tumor encroachment on the falciform ligament or involvement
of the left pedicle at the umbilical fissure. Both benign and malignant tumors in this location may be amenable to this type
of resection.
L. hepatic v.
1
Left Lateral Sectorectomy 155
Operative Technique:
The technique of left lateral sectorectomy follows most of the same basic principles employed with all liver resections. The mobilization is relatively easier than
other anatomic resections because this is a thinner and more mobile part of the
liver. While the incision used for this operation can be any one of the standard
incisions, a more limited subcostal or midline incision is often sufficient. Moreover,
resection of the left lateral segments can be performed using laparoscopic techniques, with or without hand assistance.
The left liver is mobilized by first dividing the round and falciform ligaments. It
is sometimes useful to maintain a long tie on the round ligament in order to maintain traction at the umbilical fissure during the transection. The left triangular ligament is divided (2) and the left lateral sector mobilized with caution so as to not
cause injury to the spleen. In most cases, the gastrohepatic ligament is divided in order to facilitate identification of the left
hepatic vein. An accessory or replaced left hepatic artery is usually ligated and divided when found. As the left hepatic
vein enters segment 2 superiorly, this vessel should be controlled extrahepatically when possible, although it is often more
L. triangular ligament
2
156 Atlas of Gastrointestinal Surgery: Liver
difficult to fully control it due to its proximity to the middle vein. In many cases where the tumor is not close to the left
hepatic vein, extrahepatic isolation is not required and it can be divided with a vascular stapler within the parenchyma.
Sharp dissection along the fissure between the lateral sector and caudate lobe helps to complete the mobilization.
A hilar dissection is not required when performing a left lateral sectorectomy.
Traction on the round ligament can facilitate dissection to the left of the
umbilical fissure in order to identify the portal pedicles to segments 3
and 2. These are divided intraparenchymally using a vascular sta-
pler or clamps and suture ligatures. The liver capsule is scored
Suture on
falciform
ligament
approximately 1 cm to the left side of the falciform ligament
and along the umbilical fissure (3). The parenchymal dis-
section is performed beginning from the inferior edge and
moving superiorly using any one of the parenchymal
transection techniques (4). Linear staplers can be used
3
for the larger vascular branches, including the left
hepatic vein.
Parenchyma
divided
4
Left Lateral Sectorectomy 157
The transection surface is managed with a combination of sutures and thermal coagulation. This surface area is relative-
ly small compared to most other resections (5). Drains are not required.
5
Nonanatomic Resection of Liver
Operative Indications:
In addition to anatomic resections of the liver (eg, major resections, bisegmentectomies), resections that do not rely on
segmental landmarks and often include less than a complete segment can be performed. Sometimes called wedge resections, these are typically done for small lesions or tumors that are relatively near the liver surface (1). It is not uncommon
to perform multiple nonanatomic resections for patients with bilateral tumors, or in some cases combined with anatomic or
major resections on the contralateral side. Patients with primary liver cancer, hepatic metastases, or benign tumors all may
be candidates for these minor resections.
1
Nonanatomic Resection of Liver 159
Operative Technique:
When planning a nonanatomic resection, the surgeon still needs to follow the same
basic principles employed with all liver resections. The exposure of the liver begins
with an incision that allows adequate visualization and manipulation of the liver and
surrounding structures. The most common incision is the right subcostal.The extent
of visualization and mobilization of the liver depends on the location of the planned
resection. Regardless of the location, however, it is still important to fully assess the
extent of disease outside of and within the liver before determining the type of
resection needed. In some cases, a more limited incision may be used to begin, in
order to determine if resectability is feasible. Then, the incision can be enlarged to
that which is necessary for resection.
The assessment phase is done much like that of any hepatectomy. Intraoperative ultrasonography is done to determine
if additional occult tumors are present and if a nonanatomic resection is feasible and safe. Proximity of a tumor to a major
vascular pedicle, which, if taken, would compromise additional liver, is a contraindication to such a resection. Mobilization
of the liver and detachment of any suspensory ligaments depends on the location of the planned resection. Ample mobilization is recommended, in most cases, in order to optimize visualization and gain control as needed during the resection.
Selective isolation of vascular structures, however, is typically not required for these resections.
160 Atlas of Gastrointestinal Surgery: Liver
A variety of techniques can be employed when performing a nonanatomic resection. As with other more major resections,
crushing techniques, dissectors, or precoagulation devices can be used. For smaller resections, standard electrocautery can be
used for transecting the liver (2). When near the inferior liver edge, some surgeons make use of large liver sutures placed prior
to transection. When using this method, large absorbable transparenchymal liver U sutures are placed in an overlapping fashion approximately 1 cm from the margin of resection (3). Electrocautery is used to perform the parenchymal transection (4)
and argon beam coagulation is applied to the surface to achieve complete hemostasis (5).
Surface coagulated
with argon beam
2
Overlapping
sutures
Nonanatomic Resection of Liver 161
3
4
Parenchyma
divided
5
Coagulation of
resected surface