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Right Hemihepatectomy
Christoph Tschuor, Pierre-Alain Clavien
Procedure
Step1
Access, exposure, and exploration
Aer the right subcostal incision, the falciform and round ligaments are divided. e retractor
(e. g., ompson) is installed and the site is exposed (.
the tumor number and size, as well as their location in relation to vascular structures, are evaluated by intraoperative ultrasound. A denitive decision regarding resectability of the lesion is
made (. Fig. 46.1b).
Fig. 46.1a
). e abdomen is explored and
. Fig.46.1
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_46, © Springer-Verlag Berlin Heidelberg 2016
Section III • Liver: Nontransplant Procedures
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Step2
Mobilization of the right lobe
e right lobe is mobilized by dissecting the anterior leaf of the coronary ligament and the right
triangular ligament. erefore the assistant retracts the liver inferiorly and to the le using a gauze
swab. e ompson nger blade retracting the stomach and the duodenum should be removed
during this step of the procedure.
Approaching the cava, the ligament can be exposed using a right angle or a Kelly clamp
(. Fig. 46.2a). Ligaments can be well presented by passing a nger between the diaphragm and
the coronary ligament (
hemostasis from phrenic collaterals.
Next, the Pringle maneuver is prepared as shown in ▶
Clamping, Vascular Exclusion, and Caval Resection in Liver Surgery”. e falciform, round, and
right coronary ligaments are divided and the gallbladder is removed as described in
“Laparoscopic Cholecystectomy, Open Cholecystectomy, and Cholecystostomy”.
. Fig. 46.2b). Care must be taken to protect the phrenic vessel and secure
Chap. 41
, “Techniques of Vascular
▶ Chap. 67,
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. Fig.46.2
Chapter • Right Hemihepatectomy
Step2 (continued)
Step3
First, the suprahepatic vena cava and the right hepatic vein should be identied. . Figure 46.2c
depicts the mobilized liver and the structures that must be identied during the next steps: the
hepatic artery, the portal vein, and the bile duct. An aberrant le hepatic artery (single asterisk) is
found in about 20 % to 25 % of patients. It should be isolated for later possible inow occlusion.
An aberrant right hepatic artery (double asterisk) is present in 10 % to 15 % of patients.
Preparation of the hilar structures and transsection of the right
hepatic artery
e hepatoduodenal ligament is divided from the cystic duct to the le in order to identify the
common hepatic duct and the right branch of the hepatic artery. No attempt is made to visualize
or even secure the right hepatic duct (
To test the patency of the arterial blood supply to the le hemiliver, a “bulldog” is placed on
the right branch of the hepatic artery. e patency of the le branch of the hepatic artery can now
easily be assessed by palpating it through the hepatoduodenal ligament (
an aberrant right hepatic artery from the superior mesenteric artery, posterior and right to the
portal vein (double asterisk in
of the right portal vein.
Once the arterial anatomy is clearly identied, the right branch of the hepatic artery is divided
between ties (.
should be applied.
Fig. 46.3c
). In the presence of an aberrant right hepatic artery, the same maneuver
. Fig. 46.3a).
. Fig. 46.3b). Search for
. Fig. 46.2c) should be routinely performed prior to identication
. Fig.46.3
Section III • Liver: Nontransplant Procedures
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Step4
Transsection of the right portal vein
e bifurcation of the portal vein should be identied. A small branch to the caudate process is
oen present. By ligating it, about 2 cm of length along the right portal vein is obtained, facilitating
a safe ligation of the right portal vein (. Fig. 46.4a).
Once the right branch of the portal vein is freed from the adventitial tissue, a right-angle clamp
is passed around the vein (. Fig. 46.4b).
A vascular clamp (e. g., small Satinsky clamp) is placed distally. e right portal vein is ligated
with 1-0silk (
vein stenosis and subsequent thrombosis. e portal vein on the liver side is controlled through
suture ligation, as a single ligature could slip away and cause bleeding. Now the demarcation line
between the le and right hemiliver can be observed.
An alternative (e. g., in the case of a short right portal vein) is to use a small Satinsky clamp
on the proximal right portal vein and a running Prolene 6-0 suture (.
alternative, a vascular stapler can be used in this position, but usually the small window in the
porta hepatis through which the dissection is performed lends itself more to a suture ligation
than to stapling.
. Fig. 46.4c). e distance to the bifurcation should be about 5 mm to avoid portal
Fig. 46.4d
). As another
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. Fig.46.4
Chapter • Right Hemihepatectomy
Step5
Transsection of short hepatic veins
e short hepatic veins on the right side are divided between ties. Clips should be avoided particularly on the caval side, as the clip can detach once the low central venous pressure (CVP) has
been corrected postoperatively (
. Fig. 46.5).
. Fig.46.5
Section III • Liver: Nontransplant Procedures
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Step6
Transsection of the right hepatic vein
e right hepatic vein is prepared (separated from the mid and le hepatic vein) from the top and
below on the cava by means of a Kelly clamp (. Fig. 46.6a).
A 1-0silk or vessel loop is placed around the right hepatic vein. e transsection can be performed using a vascular stapler (
An alternative technique is to occlude the right hepatic vein with a vascular spoon clamp
and ligate the proximal hepatic side with a 1-0 silk ligature in combination with a large clip
(. Fig. 46.6c). Should bleeding occur despite the combined ligature and clip, it can easily be controlled by putting a nger on the transected right hepatic vein. Continue on the caval side, which
is secured by a running 4-0polypropylene suture. Once the caval side is secured, the bleeding on
the transected proximal hepatic vein can be controlled by a suture ligature.
. Fig. 46.6b).
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. Fig.46.6
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Chapter • Right Hemihepatectomy
Step7
Transsection of the liver parenchyma
Two stay sutures (2-0 silk) are placed at the inferior margin of the liver, one on each side of the
demarcation line. At this point, verify that CVP is low (below 3 mm Hg). If the CVP is higher,
ask the anesthesiologist to correct it and wait. e liver capsule is incised with diathermy a few
millimeters on the ischemic side (
e dissection of the parenchyma is started at the inferior margin between the stay sutures.
e possible techniques for parenchyma dissection are described in
Liver Parenchyma Transection”. e Pringle maneuver for continuous or intermittent inow occlusion is used if needed. e dissection is continued posteriorly, then inferiorly, preserving the
mid hepatic vein.
. Fig. 46.7).
▶ Chap. 44, “Techniques of
. Fig.46.7
e technique using bipolar forceps and Kelly clamp to transect is shown in .
be placed between the cava and the liver to allow liing and better exposure (see also ▶ Chap. 42,
“Hanging Maneuver for Anatomic Hemihepatectomy (Including Living-Donor Liver Transplantation)”).
As an alternative, the le hand of the surgeon can be placed between the liver and the cava.
All identied bile ducts or vessels (> 3 mm) are ligated on the le side and divided. In the hilum,
the right bile duct is divided away from the main conuence above the caudate process.
Fig. 46.8
. A loop can
Section III • Liver: Nontransplant Procedures
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Step7 (continued)
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. Fig.46.8
A gauze swab is placed on the resection surface while slight compression is maintained for a few
minutes in case of diuse bleeding. Each bleeding site on the cut surface should be suture-ligated.
At the end of the procedure, the gauze swab is removed and, together with the resection site,
inspected carefully. Any bile leaks (represented by yellow spots on the gauze swab) are oversewn
by PDS4-0 or 5-0. Some surgeons routinely inject methylene blue in the common bile duct to
identify bile leaks.
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Chapter • Right Hemihepatectomy
Step7 (continued)
In order to prevent rotation of the le hemiliver, the falciform ligament must be reattached
(. Fig. 46.9).
e abdomen is closed without drainage.
. Fig.46.9
Tricks of the Senior Surgeon
Optimal exposure by a retractor is of utmost importance for evaluation, assessment, and suc-
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cess of surgery.
Ask the anesthesiologist early in the procedure for a low CVP; this signicantly reduces over-
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all blood loss.
If you use a ligature to secure the right hepatic vein on the liver side, add a large clip to the
-
ligature–This prevents bleeding! If it bleeds despite the clip, do not panic. Compress the right
hepatic vein with your nger and continue on the caval side.
While you dissect the liver parenchyma, hold the right hemiliver with your left hand or a
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band for optimal exposure and protection of the cava.
z Acknowledgments
We would like to acknowledge Panco Georgiev, who co-authored this chapter in the rst edition
of this Atlas.
Left Hemihepatectomy
Christopher Soll, Pierre-Alain Clavien
Procedure
Step1
Access and mobilization of the left hemiliver
e abdomen is opened through a subcostal incision, and the round and falciform ligaments
are divided. e le hemiliver is mobilized by dividing the le triangular and coronary ligament
(
. Fig. 47.1). Once the le hemiliver is mobilized, the liver can be evaluated by ultrasound. Aer
conrmation of resectability, the Pringle maneuver is prepared for by opening the hepatogastric
ligament, as shown in
Caval Resection in Liver Surgery.” At this point, an aberrant le hepatic artery can be isolated for
later clamping with a bulldog clamp.
▶ Chap. 41, “Techniques of Vascular Clamping, Vascular Exclusion, and
. Fig.47.1
In contrast to the right side, the anterior and posterior leafs of the le coronary ligaments are attached to each other and are separated close to the cava. e ligaments can be divided easily by
electrocautery while the posterior structures (spleen, stomach, esophagus) are protected with a
wet gauze swab (or a nger) placed behind the ligament (
can be divided over a right-angle clamp.
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_47, © Springer-Verlag Berlin Heidelberg 2016
. Fig. 47.2). Alternatively, the ligament