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Ultrasound-Guided Anatomic Resection
oftheLiver
JunichiShindoh, KiyoshiHasegawa,
andMasatoshiMakuuchi
30
Abstract
Anatomic resection of the liver is an important concept to
secure the local tumor control for hepatocellular carcinoma (HCC). For patients with primary, solitary HCC,
systematic removal of the third-order tumor-bearing portal territories has been shown to be associated with longer
time-to-recurrence after surgery and potentially longer
overall survival. Although further clinical studies are
needed to establish an optimal surgical strategy in management of patients with HCC, anatomic resection of the
liver has several clinical advantages, and hepatobiliary
surgeons should be familiar with this technique. In this
chapter, technical details and clinical advantages of
ultrasound- guided anatomic resection of the liver were
reviewed.
30.1 Introduction
Liver resection is the rst-line treatment in selected patients
with primary or metastatic liver tumors. The safety of liver
resection has dramatically improved over the decades with
renements of perioperative management and surgical techniques. However, the most important factors inuencing on
the surgical outcomes are surgeon’s knowledge on anatomy
and basic principles pertaining to the surgical procedure.
For patients with hepatocellular carcinoma (HCC), sys-
tematic removal of the tumor-bearing portal territories, so
J. Shindoh (*)
Hepatobiliary-pancreatic Surgery Division, Department of
Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
e-mail: shindou-tky@umin.ac.jp
K. Hasegawa
Hepatobiliary-pancreatic Surgery Division, Department of Surgery,
Graduate School of Medicine, The University of Tokyo,
Tokyo, Japan
M. Makuuchi
Koto Hospital, Tokyo, Japan
called “anatomic resection”, was proposed in 1980s as a
theoretically optimal surgical procedure to expect eradication of potential micrometastases surrounding tumors [1]. To
date, a number of studies have reported that anatomic resection may prolong the time-to-recurrence after surgery and
potentially improve the overall survival [2–11], with clear
evidence of a decrease in the local recurrence rate [6, 8, 10].
A latest study using a Markov model has further claried that
complete removal of the tumor-bearing portal territory at initial hepatectomy delays both recurrence and post-operative
stage progression of HCC, yielding improved survival of
patients with solitary HCC [11]. Although the optimal choice
of surgical procedure for patients with HCC remains under
debate, given these encouraging clinical outcomes, hepatobiliary surgeons should be familiar with anatomic resection of
the liver as a potentially appropriate surgical procedure in
selected cases. In this chapter, we review the basic principles
and techniques of ultrasound-guided anatomic resection of
the liver.
30.2 Anatomical Principles andDenition
ofAnatomic Resection oftheLiver
Anatomic resection of the liver usually refers to “systematic
removal of various combinations of the third-order portal territories”. According to the Brisbane 2000 terminology of
liver anatomy and resections [12], resection of the rst-order
portal territory is called hemihepatectomy and resection of
the second-order portal area is dened as sectorectomy or
sectionectomy. Couinaud’s segment is dened as the thirdorder division of the liver and monosegmentectomy is classied as anatomic resection. However, Couinaud’s segment
does not always correspond to the third-order portal territory
because segment 2 is classied as the second-order portal
territory, segment 5 or 8 usually consists of two or three
third-order portal territories, and the denition of the caudate
lobe (i.e., segment 1) is much more complex. The basic principles are that complete removal of any combination of third-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_30
241
242
Uncontrollable
2/3 hepatectomy)
1/3 hepatectomy)
J. Shindoh et al.
order portal territories can be classied as anatomic resection
of the liver. Given that segment 5 and 8 usually have two or
more third-order branches including ventral and dorsal
branches [13], ventral/dorsal part of segment 5 or 8, ventral/
dorsal part of the right paramedian sector, or even more complex combination of portal territories [14] can be classied
as anatomic resection of the liver as long as systematic
removal of the corresponding portal territories is secured.
30.3 Surgical Indication
For liver resection of HCC, strict assessment of hepatic functional reserve is needed because HCC usually develops in an
injured liver, and the maximum extent of hepatectomy in
patients with chronic hepatitis or cirrhosis is limited to avoid
postoperative hepatic insufciency, compared to those who
have healthy livers. Liver resection is indicated only for
Child-Pugh class A or B patients with controllable ascites
and serum total bilirubin level of <2.0 mg/dL. Maximum
extent of resection can be determined based on the measurement of indocyanine green retention rate at 15 min (ICGR15) as proposed by Makuuchi etal. [4]. In original criteria
for the maximum extent of resection, up to 2/3 hepatectomy
(right hepatectomy or trisectionectomy) is accepted for
patients with ICG-R15<10%, up to 1/3 hepatectomy (left
hepatectomy or sectorectomy) is indicated for those with
ICG-R15 between 10% and 19%, up to 1/6 hepatectomy
(monosegmentectomy) is tolerated in those with ICG-R15
between 20% and 29%, and only limited partial hepatectomy
or enucleation is indicated for patients with ICG-R15 equal
to or greater than 30% (Fig. 30.1). Following strictly this
algorithm, no operative mortality due to liver failure was
recorded in 1056 consecutive patients at the University of
Tokyo Hospital [15]. More recently, our group has adopted
more sophisticated criteria based on the estimated ICG disappearing rate and precise three-dimensional volumetry of
future liver remnant and it has been reported that the conventional criteria can be expanded safely, avoiding increased
risk of postoperative hepatic insufciency [16, 17].
30.4 Surgical Technique
30.4.1 Exposure
Incision and exposure are key components of the quality of the
exploration of the liver and the safety of hepatectomy. Different
incisions, including the inverted L incision, the inverted-T incision, the bilateral subcostal (chevron) incision, or the right/left
subcostal incisions are used as well as the midline incision to
achieve these objectives. Thoracotomy is sometimes required
for safe exposure and manipulation of paracaval part of the
liver. Meanwhile, recent laparoscopic technique has enabled us
to minimize total length of incision through completing mobilization of the liver before opening the abdominal cavity, even
in major hepatectomy which is not suitable for pure laparoscopic approach (i.e., laparoscopic- assisted hepatectomy).
Ascites
None or controllable
Total bilirubin
<
1,0 mg/dL
=
ICG-R15
<10% 10-19% 20-29% 30-39% 40%–
Right hepatectomy
Trisectionectomy
(up to approx.
Fig. 30.1 Surgical indication criteria (Makuuchi Criteria) for patients with injured liver
Inoperable
1.1-1.5 mg/dL 1.6-1.9 mg/dL >2.0 mg/dL
Limited resection EnucleationInoperable
Left hepatectomy
Sectorectomy
(up to approx.
Segmentectomy
(up to approx.
1/6 hepatectomy)
Limited resection Enucleation
30 Ultrasound-Guided Anatomic Resection oftheLiver
243
30.4.2 Exploration andIntraoperative
Ultrasound
After sufcient exposure of the liver, size, depth, location of
tumors, their correlation to the surrounding vascular structures,
presence/absence of new lesions, and intrahepatic blood ows
are checked by ultrasound with or without contrast enhancement. Final surgical plans were then determined according to
the preoperative data and intraoperative ndings.
30.4.3 Identication ofSegmental Border
ontheLiver Surface
To conrm the segmental border to be transected, positive or
negative staining is then performed. Positive staining (i.e.,
direct staining of the corresponding portal area) is conven-
a
tionally performed by injecting a blue dye (indigocarmine,
Daiichi Sankyo Co., Ltd. Tokyo, Japan) into portal branches
under ultrasound guidance. Tip of the needle is clearly visualized and injected dye can be conrmed as bubbles on ultrasound images. To obtain clear staining, hepatic arteries are
needed to be clamped at the hepatic hilum while staining
portal branches to delay washout of injected dye. Also, injection point and speed should be adjusted not to stain adjacent
portal territories by regurgitation of the dye (Fig. 30.2a).
When a tumor is located at the segmental border, corresponding tumor bearing portal branches should be stained
respectively (Fig. 30.2b). However, when it is difcult to
stain all the portal branches due to presence of multiple
branches (e.g., segment 5) or too small size of branches
which are difcult to be punctured (e.g., segment 1), negative staining can be used as an alternative method to conrm
the segmental border by staining adjacent portal territories.
b
c
Fig. 30.2 Technical details of anatomic resection of the liver (adapted
from Shindoh J, etal. J Hepatol 2016;64(3):594–600 with permission).
(a) Segmental staining under ultrasound guidance. Tip of the needle and
injected dye can be conrmed by ultrasound. (b) Staining of contiguous
tumor-bearing third-order portal branches. When a tumor is located at
the segmental border, corresponding tumor bearing portal branches
should be stained respectively. (c) Anatomic resection of tumor-bearing
segment. Anatomic resection can be achieved by (i) parenchymal tran-
section from the marked segmental border on the liver surface to the
land mark veins, (ii) full exposure of the veins on the cut surface of the
liver, and (iii) ligation of portal pedicles near the root of the segment. T
tumor, P5 segment V portal branch, P8vent ventral branch of segment
VIII portal branch, P8dor dorsal branch of segment VIII portal branch,
P4sup superior branch of segment IV portal branch, LHV left hepatic
vein, MHV middle hepatic vein, UFV umbilical ssure vein, V8i intermediate vein for segment VIII, IVC inferior vena cava
244
J. Shindoh et al.
For sectorectomy/sectionectomy or anatomic resection of
left side of the liver, however, portal staining is not always
necessary because direct ligation or transient clamp of the
corresponding Glissonean pedicle is feasible extrahepatically to visualize demarcation line on the liver surface.
Although these staining methods are relatively easy and
can be applicable in most of the cases in actual clinical settings, it is sometimes difcult to obtain a clear staining on
liver surface especially in patients with severe cirrhosis or
those undergoing repeat hepatectomy requiring extensive
lysis of adhesions. For such instances, diluted ICG solution
can be used as an alternative material for injection when
uorescent imaging technique can be used [18].
30.4.4 Parenchymal Transection
Parenchymal transection is started along the segmental border conrmed on the liver surface. To secure complete
removal of the target part of the liver, the landmark veins are
exposed on the cut surface of the liver and the corresponding
portal branches are ligated at the root of the segment
(Fig. 30.2c). Because the intersegmental planes are not
always at [19], it is important to carry out parenchymal
transection under ultrasound guidance (i) from liver surface
to the landmark veins and (ii) from the exposed landmark
veins to the root of the corresponding portal pedicles.
Figure 30.3 demonstrates a typical preoperative evaluation
and intraoperative ndings of anatomic resection of dorsal
part of segment 8.
30.4.5 Hemostasis andCheck forBile Leak
Injury of landmark veins during parenchymal transection
can be secured by suture or application of brin glue according to the size of injury. Bile leak test [20] should be performed when cholecystectomy is carried out as a part of
procedure because the shape of cut surface is relatively
complex after anatomic resection of the liver and there is an
increased risk of uid collection compared to those after
simple partial hepatectomy.
a b
c d
Fig. 30.3 Example of anatomic resection of dorsal part of segment 8
(Adopted from Takamoto T etal. Am J Surg 2013;206(4):530–538 with
permission). Anatomic resection of dorsal part of segment 8 is planned
(a) and corresponding portal branch was punctured under ultrasound
guidance (b). Stained area visualized on liver surface (d) is very similar
to the preoperative simulation (c). Based on the preoperative threedimensional simulation (e), landmark veins (i.e., right hepatic vein and
its tributary) are exposed on the cut surface of the liver (f)
e
30 Ultrasound-Guided Anatomic Resection oftheLiver
Fig. 30.3 (continued)
245
f
30.5 Clinical Advantages
solitary HCC and it remains inconclusive whether or not the
same scenario can be applied for recurrent lesions, multiple
30.5.1 Technical Advantages
HCCs, or large HCC occupying two or greater Couinaud’s
segments, the reported results suggest that initial selection of
From the practical standpoint, anatomic resection has several
technical advantages. First, because the intersegmental plane
at the watershed of portal territories are usually “avascular”
excluding landmark veins, the risk of bile leak and amount of
blood loss per area of the transection plane may be decreased
surgical procedure may have signicant inuence on subsequent clinical course and survival outcomes of patients with
HCC.Therefore, anatomic resection should be considered as
a choice of surgical maneuver at initial hepatectomy for
patients with solitary HCC.
[7]. Second, postoperative sustained hepatic dysfunction or
disturbance of hepatic regeneration [13, 21, 22] could be
avoided because no ischemic area or congested areas is pres-
30.6 Conclusions
ent after complete removal of a portal territory leaving intersegmental venous branches at the cut surface of the liver.
Third, branch-based volumetry or meticulous surgical planning is feasible and the option of curative surgery can be
proposed based on the objective volumetric data even for
patients with a marginal hepatic functional reserve [23–25].
Technical details and clinical advantages of anatomic resection of the liver for patients with HCC were reviewed in this
chapter. Although further clinical studies are needed to
establish an optimal surgical strategy in management of
patients with HCC, successful anatomic resection of tumorbearing portal territory is reportedly delays long-term stage
progression of HCC and may prolong survival outcomes.
30.5.2 Prognostic Advantages
Given that ultrasound-guided anatomic resection of the liver
consists of various basic techniques required for more com-
Potential prognostic advantage of anatomic resection of the
liver for primary, solitary HCC has been reported in many
studies [2–10]. The University of Tokyo group previously
plex liver surgery, hepatobiliary surgeons need to be familiar
with this procedure in the era of aggressive surgical management of advanced hepatobiliary malignancies.
reported that complete removal of tumor-bearing portal territories decreases the risk of local recurrence and death from
HCC based on a database established under strict quality
control [7] and recent large multi-institutional cohort studies
have yielded similar outcomes [2, 9]. Another recent study
conducted at a Japanese high-volume center has further claried the differences in time-to-interventional failure and
transition rate from the early recurrence stage to advanced
stages according to the choice of surgical maneuver at initial
hepatectomy for solitary HCC [11]. Although these results
were conrmed only in a specic population with primary,
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Parenchyma-sparing Hepatic Resection
forMultiple Metastatic Tumors
BrunoBranciforte, FlavioMilana, andGuidoTorzilli
31
Abstract
Liver surgery is actually asked to deal with high tumor
burden also in case of colorectal metastases. Harming the
most diseased part to hypertrophy the future liver remnant
remains the mainstream. However, ultrasound guidance
has progressively driven to challenge the tumor-vessel
detachment (R1vasc), which has proven to be oncologically suitable in term of local control. This nding has
boosted the suitability of parenchyma sparing surgery
even when tumor burden is extremely high. A further
improvement in this sense has been provided in case of
hepatic vein tumoral stricture or occlusion: indeed, in
these circumstances natural by-pass develop preserving
the outow. Through ultrasound and vessel guidance,
parenchyma sparing surgery has entered the complexity.
From there, a different way of large tissue deprivation: the
meaningful parenchymal sparing major hepatectomies.
31.1 Introduction
Surgical resection is the only potentially curative treatment
for metastatic tumors in the liver. Patients with colorectal
liver metastases (CLMs) are often addressed to multiple
hepatic resections, but initial experiences with major hepatic
resection were associated with a high peri-operative mortality. Preservation of an adequate remnant liver volume after
resection became recognized as one of the most relevant
B. Branciforte · F. Milana
Division of Hepatobiliary and General Surgery, Humanitas Clinical
and Research Center IRCCS, Milan, Italy
G. Torzilli (
Division of Hepatobiliary and General Surgery, Humanitas Clinical
and Research Center IRCCS, Milan, Italy
Department of Biomedical Sciences, Humanitas University,
Milan, Italy
e-mail: guido.torzilli@hunimed.eu
*)
issue in the prevention of post-hepatectomy liver failure
(PHLF), and one of the main cause of post-operative
mortality.
To maximize the safety of liver surgery, and expand the
suitability of the surgical treatment, surgeons tended to
develop operative techniques that limit the extent of parenchymal resection, tailoring the resection to the extent of the
pathology without compromising cancer-specic
outcomes.
A better understanding of intrahepatic anatomy and tumor
biology, as well as advances in imaging technologies,
together with improvement in peri- and intraoperative management, allowed expanding indications and performing
more aggressive and complex procedures.
The parenchyma-sparing surgery (PSS) philosophy is a
part of this perspective and merges the oncologic rules of
surgery with minimal sacrice of liver tissue.
31.2 Multiple Bilobar CLM
Liver surgery represents the standard of treatment for CLMs,
even in patients with multiple and/or bilobar lesions. These
patients are the most complex to treat because a large parenchyma sacrice is often needed. Moreover, in patients with
underlying liver disease (or even in those who have received
multiple cycles of chemotherapy), the risk of developing
post hepatectomy liver failure (PHLF) is even higher [1].
Reducing the risk of PHLF whenever a major removal of
functioning liver tissue was performed has been the main target of many surgeons. In early 2000 Adam etal. proposed a
staged procedure scheduling as rst step a debulking surgery,
limiting the CLM clearance to one side of the organ, and in a
second operation the denitive organ clearance: the so-called
2-stage hepatectomy (TSH) [2]. For improving the efciency
of the approach Jaeck etal. introduced, in between the two
step, a portal vein embolization of the right hemiliver for
inducing hyperthrophy of the left [3]. The main disadvantage
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_31
247
248
ef
bc
RHV
B. Branciforte et al.
a
LHV
d
UP
B
D
MHV
Fig. 31.1 (a) virtual liver cast based on CT images of a patient carrier
of 19 colorectal liver metastases (dark pink); the glissonean branches in
light pink; hepatic veins in dark blue; inferior vena cava in light blue.
(b, c) resection areas (yellow and orange dotted lines) drawn with electrocautery on the liver surface. (d–f) cut surfaces at the end of the tumor
of TSH is the non-negligible risk of drop-out: about onethird of patients do not receive the second hepatectomy
because of disease progression between the 2 stages or inadequate hypertrophy of the future liver remnant (FLR) [4].
More recently, the associated liver partition and portal vein
ligation for staged hepatectomy (ALPPS) has been proposed:
despite, this approach, a sort of fast-track TSH, guarantees a
signicantly lower drop-out rate compared to TSH, surgical
risk and long-term oncological results remain open issues
[5–7]. Finally, liver venous deprivation (LVD) followed by
major hepatectomy is the last release aiming to empower
liver regeneration. Simultaneous occlusion of portal vein
inow and hepatic vein (HV) outow for harming part of the
liver seems safe, and efcient in terms of FLR increase and
consequent drastic limitation of patients’ drop-out [8, 9].
Anyhow, all these solutions boosting the FLR by means of
major vessel amputation reduce the chance of redo surgery in
case of relapses. Indeed, it seems somehow obvious that less
remnant vascular structures offer lower freedom degrees for
nding technical solutions able to clear the organ.
In the last decades, PSS has been increasingly adopted
[10]. However, several authors have limited the application
of their parenchyma-sparing policy to a “cherry-picking surgery” (limited peripheral resection) or anatomic segmentectomy [11]. In presence of supercial lesions, single-session
multiple minor resections are commonly adopted, but in case
of deep-located CLMs, staged hepatectomy still remains the
LHV
Gp2
Gp3
removals; the cut surfaces surrounded by the yellow and orange dotted
lines refer to the previously highlighted resection areas. RHV, Right
Hepatic Vein, MHV Middle Hepatic Vein, LHV Left Hepatic Vein, IVC
Inferior vena cava, Gp glissonean pedicles (numbers refer to the segment fed), UP umbilical portion
preferred option. The authors have extensively demonstrated
the feasibility, safety and efcacy of IOUS-guided PSS for
CLMs [12–17].
In particular, the possibility to resect in a PSS perspective
also deep lesions with complex intrahepatic relations have
been explored, namely with the so-called enhanced onestage hepatectomy (E-OSH) [14, 18] (Fig.31.1). Minimizing
the parenchyma sacrice, and preserving the liver scaffold
were the pillars of an approach devoted to be radical, and
conservative. Increased safety and salvageability in case of
relapse have been the merits of this policy. In particular, salvageability means better long-term disease control: recent
series reported ve-year survival rates after surgery of about
50%, despite up to 70–80% of patients having disease recurrence [19, 20].
Intra-operative ultrasound (IOUS) guidance, tumor vessel
detachment and the presence of communicating veins (CVs)
preserving liver outow whenever detachment is unfeasible,
are the main technical pillars in which advanced PSS relies.
31.2.1 Intraoperative Ultrasound
IOUS, used in hepatic surgery since the early 1980s [21], has
been repeatedly advocated as a useful tool for resection guidance both in primary and secondary metastatic tumors, and
represents the cornerstone of PSS policy [12]. Despite several
31 Parenchyma-sparing Hepatic Resection forMultiple Metastatic Tumors
249
reasons may explain decrease in mortality following major
hepatic resection reached in the last decades [22], a privileged
role should be surely assigned to improved operative techniques which became feasible thanking to IOUS guidance.
Indeed, IOUS makes possible creating complex multiplanar
dissection trajectories during liver resection, then really opening to policies alternative to major hepatectomies [23, 24].
The use of IOUS in liver resections could be divided into
three main phases: (1) liver exploration for disease staging,
(2) planning of the surgical strategy, and (3) surgical maneuvers guidance. Although palpation still plays a fundamental
phase, for deep located lesions IOUS exploration represents
a crucial intraoperative tool, rened on the possibility of contrast enhancement (CE-IOUS). Despite progress in preoperative imaging, adding CE-IOUS to IOUS exploration showed
to modify the operative plan in up to 38% of patients with
CLM, with its ability in recognizing new lesions otherwise
not visible [25].
Moreover, IOUS allows an accurate estimation of the
relationship among the tumor and vessels (both glissonian
pedicles and HVs), which is a fundamental step in dening
the most appropriate surgical strategy. Indeed, the tumorvessel relationship represents a crucial point in parenchymalsparing policy, being informative in discriminating a vascular
contact from a vascular inltration.
31.2.2 Tumor-vessel Detachment
Surgeons have progressively moved from the 1-cm rule to
the 1-mm rule, but negative surgical margin (R0) has been
considered as the standard while R1 resection as an unfavorable surgical result [26]. Nevertheless, vascular wall may
represent a boundary to tumor spread, and vascular detachment could be performed safely. Specically, R1 vascular
(R1vasc) resection is dened as any tumor detachment from
rst/second-order glissonean pedicles (in contact with up to
half of the pedicle circumference) or from HVs (in contact
with up to two-thirds of the vein circumference) within their
last 4cm before hepato-caval conuence [23]. R1vasc corresponds to tumor exposure (0-mm margin) along the
“detachment area” and it has been demonstrated offering
equivalent results to R0 resection in terms of local recurrence
and 5-year survival [17, 27]. R1vasc suitability is the crucial
nding which could make reliable not just the PSS strategy
but the tissue removal preserving the organ scaffold: this
could mean resecting conservatively complex presentation
otherwise affordable just with major hepatectomies or staged
procedure or resulting even unresectable.
To maximize the feasibility of R1vasc resections, IOUSbased criteria have been introduced and validated [12, 13]:
the circumferential extent of the contact represents the main
driver for deciding to spare or not the vessel.
31.2.3 Communicating Veins
in the event of clear vessel wall inltration, vascular resection is mandatory. Liver resection for tumors involving the
major HVs nearby the hepatocaval junction traditionally
requires major anatomical resection with or without venous
reconstruction. HVs, when inltrated, in the majority of
situations could be anyhow spared by means of tangential
resection with direct reconstruction or seldom patching
[17]. In the event this would not be feasible, then in case of
more signicant inltration, despite HVs are sacriced the
drained area of liver parenchyma could be almost always
spared. Indeed, in such conditions which mimics a BuddChiari Syndrome, CVs between major HVs, exist and can
be identied in up to 80% of patients with a tumor at the
hepatocaval conuence [28]. CVs represent an outow
pathway alternative to major HVs, making suitable to preserve liver venous discharge even when a major HV is
resected. This further possibility increases the suitability of
conducting PSS.
Preoperative imaging ndings can suggest CV patency,
by direct visualization or just conrming a uniform enhancement of the liver parenchyma at venous phase for CT or
hepato-specic delayed phase for MRI.Anyhow, CV patency
is denitively detected by IOUS color-ow analysis.
Moreover, HV clamping during surgery may offer additional
data: CV patency can be enhanced, and persistent hepatopetal portal inow, even in the absence of evident CVs, is a
permissive condition for PSS [13, 28]. Their presence guarantees otherwise unfeasible technical solutions, thus leading
ineligible patients undergoing radical surgery and avoiding
major hepatectomies.
31.3 New Procedures
The IOUS indicates the door for entering into the liver, and
the vessel guides the surgeon once inside. Following the
intrahepatic vessels from the surface to the deep warrantees
anyhow an anatomical approach, but with innite trajectories
according to the selected vessel, then innite solutions.
Parenchyma sparing vessel guided hepatectomies (PSVGH)
for sculpturing the organ, implementing the portfolio of surgical options, and increasing the salvageability in case of
relapse by keeping the major in and out-ow intrahepatic
vascular structures [29]. Cornerstone of PSVGH are the following new parenchymal-sparing procedures:
250
B. Branciforte et al.
31.3.1 Systematic Extended Right Posterior
Sectionectomy (SERPS)
Right posterior sectionectomy (S6-7) extended to part of S5
and S8 with section of the right HV (RHV). The outow of
spared S5 and/or S8 is provided by branches of the middle
HV (MHV) (Fig.31.2).
[30]
31.3.1.1 Eligibility Criteria
Patients suitable for SERPS are those with tumors showing:
A. invasion of the RHV close to the hepato-caval conuence
(within 4 cm), with other lesions involving segment 6
and eventually segment 7 (Fig.31.2a).
B. invasion of the RHV close to the hepato-caval conu-
ence (within 4cm), without other lesions involving segment 6, but without inferior RHV (IRHV), and with
hepatofugal portal blood ow at color-ow IOUS in portal branch to segment 6 (P6) when RHV is clamped
(Fig.31.2b).
C. contact with the right anterior glissonean sheat, and a
relation with the right posterior having at least one of the
following features: contact with dilation of bile ducts of
right posterior section, vessel wall invasion, or contact
wider than one-third of pedicle circumference
(Fig.31.2c).
31.3.2.1 Mini-Upper Transversal Hepatectomy
Anatomic or limited resection of S7-8 with section of the
RHV. The outow of S5 and S6 is provided by an IRHV
[31], by branches of the MHV [20] or by CVs between the
RHV and/or left HV (LHV) and the MHV [32].
31.3.2.2 Right Upper Transversal Hepatectomy [33]
Anatomic or limited resection of S7-8-4s with section of the
RHV and the MHV.The outow of S4i-5-6 is provided by the
IRHV and/or CVs only, among the RHV, the MHV and the
LHV.
31.3.2.3 Left Upper Transversal Hepatectomy [24]
Anatomic or limited resection of S2-4s or of S2-4s-8 with
section of the LHV or the LHV and the MHV.The outow of
segments 3-4i-5 is provided by CVs among the RHV, the
MHV and the LHV.
31.3.2.4 Total Upper Transversal Hepatectomy [24, 34]
Anatomic or limited resection of S2-4s-7-8 with section of
the RHV, the MHV and the LHV in presence of an IRHV and
CVs among the liver-side stumps of the HVs, which warrantee the outow of S3-4i-5-6.
Eligibility Criteria
31.3.2 Upper Trasversal Hepatectomy (UTH))
Tumor at caval conuence invading from one to all HVs at
caval conuence in presence of an IRHV, and CVs or just
Transversal hepatectomies for tumors involving more than
one and up to all the HVs at hepato-caval conuence. The
following subtypes can be recognized:
RHV
ab c
T
Fig. 31.2 schemas of patterns eligible for Systematic Extended Right
Posterior Sectionectomy (SERPS); (a) tumor (T) invading the right
hepatic vein (RHV) with others involving segment 6; (b) T invading the
RHV with hepatofugal (white arrows) portal vein blood ow in glissonean pedicles for segments 6 (Gp6) and 7 (Gp7); (c) T in contact with
Gp7
Gp6
RHV
T
CVs. The tumor could lie over the hilar plate with contact but
no invasion of the right and left portal branches, and the seg-
mental portal branches to the antero-inferior segments.
the 2nd order right Gp, but with dilated bile duct draining segment 6
(dB6) and 7 (dB7) indicating the invasion of the Gp of the right poste-
rior section. Green arrow = dissection plane of the SERPS. Yellow
arrow=dissection plane of the right hepatectomy
RHV
dB7
T
dB6