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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_819_Библиотеки_им_академика_М_И_Перельмана
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Five Important Anatomical Structures
inRight or Left Hepatectomy
8
8.1 Anatomy andSurgery
Surgery should be carried out based on a solid foundation of
anatomy, for without anatomy, there is no surgery. Liver surgery is no exception. There are several anatomical structures
that are especially relevant to liver surgery. The correct application of knowledge on these anatomical structures not only
leads surgeons to safer and easier liver surgery but can also
lead surgeons to design new approaches and new
operations.
8.2 Important Anatomical Structures
inRight or Left Hepatectomy
There are ve important anatomical structures in right or left
hepatectomy:
I. Hepatic intervenous fossa
II. Hepato-caval ligament
III. Ligamentum venosum
IV. Hepatic hilar plate
V. Short hepatic veins
Right or left hepatectomy is the most basic type of anatomical liver resection. With the exception of the left lateral
sectionectomy, these two anatomical liver resections are the
easiest and the most commonly performed anatomical liver
resections. To carry out either right or left hepatectomy, or
left sectionectomy, there is no need to have any knowledge
on the Couinaud’s liver segments in the main liver.
8.2.1 (I) Hepatic Intervenous Fossa
The hepatic intervenous fossa is found at a point where the
two leaves of the falciform ligament reect to join the diaphragm. It is covered by the coronary ligament anteriorly.
The fossa is situated between the right hepatic vein and the
common trunk of the middle/left hepatic veins. At its back is
the inferior vena cava (Fig.8.1).
As the hepatic veins join the inferior vena cava at a
slight angle that runs anterior to posterior, these veins form
a protuberance on the two sides of an area of depression.
We, therefore, call this area of depression a fossa. Before
dissection, this fossa is lled with connective tissues
(Fig.8.2).
Dissection of the connective tissues in the fossa leads to
the anatomical structure called the hepatic intervenous ssure. This ssure measures 1.5–2cm long and 1–1.5cm
wide. It is situated in the gap between the right hepatic
vein and the common trunk of the middle/left hepatic
veins. Anterior is segment 8 of the liver. Posterior is the
anterior wall of the inferior vena cava. Inside it contains
moderately dense connective tissues which lead inferiorly
to the loose connective tissues between the posterior wall
of the liver and the anterior wall of the inferior vena cava
(Fig.8.3).
8.2.2 Dissection ofHepatic Intervenous
Fossa andFissure
After dividing the coronary ligament, the fossa is identied. The moderately dense connective tissues in the fossa
are dissected using a combination of sharp and blunt dissection. This is followed by blunt dissection using the index
nger in the ssure and pushing inferiorly. This is technically possible because there is no vessel in the connective
tissues in the fossa and the ssure. The push using the index
nger should be gentle and as the nger moves inferiorly,
the tip of the nger should be closely applied anteriorly to
the posterior wall of the liver. This method is safe and reliable and it does not lead to a tear of the inferior vena cava
if carried out properly. When the tip of the nger reaches
the loose connective tissues, there is a sudden ‘breaking
© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House Co. Ltd. 2021
W. Y. Lau, Applied Anatomy in Liver Resection and Liver Transplantation, https://doi.org/10.1007/978-981-16-0800-1_8
67
68
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8 Five Important Anatomical Structures inRight or Left Hepatectomy
Fig. 8.1 Hepatic intervenous Fossa
a
Fig. 8.3 (a) Hepatic intervenous Fossa and Fissure. (b) Fossa/Fissure after dissection (with sling around common Trunk of middle/left hepatic
veins)
through’ sensation and the dissection should end at this
point (Fig.8.4).
Fig. 8.2 Hepatic intervenous Fossa before dissection
b
2. Used in selective hepatic vascular outow occlusion to
either occlude the right hepatic vein or the common trunk
of the middle/left hepatic veins by:
8.2.2.1 Clinical Applications
1. Easy separation of the right hepatic vein from the common trunk of the middle/left hepatic veins in piggy-back
liver transplantation in the recipient operation (Fig.8.5)
(a) Vascular clamps (Fig.8.6a)
(b) Slings (Fig.8.6b)
3. To use Belghiti’s hanging liver technique in liver resection (Fig.8.7)
8.2 Important Anatomical Structures inRight or Left Hepatectomy
Caudate
lobe
IVC
Portal v
69
Fig. 8.5 Separation of right hepatic vein from common trunk of middle/left hepatic vein in piggy-back liver recipient operations
Fig. 8.4 Blunt dissection of Fossa/Fissure
a
Fig. 8.6 (a) Vascular clamp on right hepatic vein. (b) Slings around right hepatic vein, and around common trunk of middle/left hepatic veins
b
70
8 Five Important Anatomical Structures inRight or Left Hepatectomy
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a
Right
hepatic vein
Fissure
c
Common trunk
b
d
Fig. 8.7 (a) A dissecting forcep to establish a tunnel. (b) Establishing the tunnel. (c) Sling. (d) Using Belghiti’s hanging technique in the liver
section
8.3 (II) Hepato-Caval Ligament
intervenous fossa and ssure so as to dissect the anterior and
the medial sides of the right hepatic vein (see Sect. 8.2). This
The detailed anatomy is described in Sect. 3.5.
The Japanese surgeons call this ligament the Makuuchi
ligament. Although Professor Makuuchi is not the rst one
who described this ligament, he was the rst one to point to
the important application of this ligament in the identication and isolation of the right hepatic vein.
is followed by dissection and division of the hepato-caval
ligament on the lateral and inferior sides of the right hepatic
vein. The nal step is to dissect between the anterior wall of
the inferior vena cava and the right hepatic vein to put a sling
around the right hepatic vein. Division of the small hepatic
veins along the right border of the inferior vena cava facilitates this nal step of isolation (Fig.8.8).
8.3.1 Clinical Importance ofHepato-caval
Ligament
For extrahepatic dissection, isolation and control of the right
hepatic vein, the safest method is to rst dissect the hepatic
8.4 (III) Ligamentum Venosum
The detailed Anatomy is described in Sect. 3.1, and Sects.
6.6 and 6.10.
a Hopato-caval ligament Division of short hepatic veinb
8.4 (III) Ligamentum Venosum
71
c
Fig. 8.8 (a) Hepato-caval ligament. (b) Division of short hepatic vein. (c) Dissection of hepato-caval ligament. (d) Isolation of right hepatic vein
The ligamentum venosum is also called the Arantius ligament as it was rst described by the Italian anatomist, Giulio
C. Arantius (1530–1589). It is the remains of the ductus
venosus of the foetus (Fig.8.9). After birth, it is represented
d
by a thin brous cord lying in the ssure of the ligamentum
venosum. Its position is therefore constant and in every individual, it connects the left portal vein with the posterior of
the common trunk of the middle/left hepatic veins (Fig.8.10).
72
reverse flow after birth
Hepatic portion of
Ductus venosus
n
n
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Fig. 8.9 Ductus venosus in
the foetus
patic vain
Hepatic vain
t vitelline)
(right vitelline)
8 Five Important Anatomical Structures inRight or Left Hepatectomy
inferior vena cava
Hepatic vein
Hepatic vein
Portal vein
ortal vei
Sup-mesenteric vein
mesenteric vei
8.4.1 Clinical Importance ofLigamentum
Venosum
For extrahepatic dissection, isolation and control of the common trunk of the middle/left hepatic veins, the safest method
is to rst dissect the hepatic intervenous fossa and ssure so
as to dissect the anterior and the medial sides of the common
trunk (see Sect. 8.2). The left triangular ligament is dissected
to free the lateral side of the left hepatic vein. This is followed by dissection of the ligamentum venosum from the
liver and the lesser omentum. The ligamentum verosum is
Segment of vin with
rev
Left umbilical
vein
Splenic vein
lenic vein
divided, the upper end is lifted upwards and dissected
towards the head of the patient while the lower end is left
behind. The dissection of the ligmentum venosum superiorly
leads to dissection of the back of the common trunk of the
middle/left hepatic veins. After this dissection, it becomes
easy to put a clamp around the common trunk of the middle/
left hepatic veins or to put a sling around the common trunk
(Fig.8.11).
An easier way to control the extrahepatic right hepatic
vein or the common trunk of the middle/left hepatic veins is
to free the coronary and left triangular ligaments to the edges
ab
Pa
ab
8.4 (III) Ligamentum Venosum
73
Right hepatic
vein
racaval
portion
Candate process
c
Inferior vena cava
Middle hepatic vein
Left portal vein
Ligamentum venosumMiddle hepatic vein
Left hepatic vein
Ligamentum
venosum
Spiegelian lobe
Right portal
vein
Portal vein
d
Inferior vena cava
Middle hepatic vein
Left hepatic vein
Ligamentum
venosum
Spiegelian lobe
Inferior vena cava
Left portal vein
Lesser omentum
Paracaval
portion
Inferior vena cava
Spiegelian lobe
Fig. 8.10 (a, b) Ligamentum venosum. (c) Relationship of ligamentum venosum and lesser omentum. (d) Operative photograph of ligamentum
venosum
Fig. 8.11 Dissection of the common trunk of middle/left hepatic vein by tracing the ligamentum venosum
74
a
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Fig. 8.12 A simpler way to extrahepatic control the right hepatic vein
and the common trunk of the middle/left hepatic vein using vascular
clamps
umbilical plate
8 Five Important Anatomical Structures inRight or Left Hepatectomy
of the right hepatic vein and the left hepatic vein, dissect the
hepatic intervenous fossa and ssure and to use two vascular
clamps to separately control the right hepatic vein and the
common trunk of the middle/left hepatic veins (Fig.8.12).
8.5 (IV) Hepatic Hilar Plate
The detailed anatomy is described in Chap. 4.
The hepatic hilar plate consists of four parts: the hilar
plate, the cystic plate, the umbilical plate and the plate of
Arantius (Fig.8.13).
cystic plate
hilar
plate
Plate of Arantius
cystic
plate
hilar plate
Plate of
Arantius
umbilical plate
b
Gallbladder
5
Hilar Plate
Round ligament
4a
6
7
Rouviere sulcus
Fig. 8.13 (a) Hepatic Hilar plate. (b) The four parts of the hepatic Hilar plate
Plate of Arantius
Umbilical plate
8.6 (V) Short Hepatic Veins
75
8.5.1 Clinical Application oftheHepatic Hilar
Plate
The hilar plate can be lowered (Fig.8.14):
1. To extrahepatically isolate the left duct for bypass in
patients with biliary stricture or carcinoma affecting the
conuence of the hepatic ducts
a
Line of incision of hilar plate
to expose left hepatic duct
Segment 4
Glisson’s capsule
Ligamentum teres
Umbilical fissure
2. To either isolate the right, the left, or both the right and
the left hepatic pedicles after lowering of the hilar plate
(see Sect. 4.3). This facilitates right or left hemihepatectomy or the use of hemihepatic vascular inow control
(see Chap. 13) (Fig.8.15).
c
Cystic plate
Hilar plate
b
Fig. 8.14 Lowering of hilar plate
Hilar
plate
Hilar
plate
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8 Five Important Anatomical Structures inRight or Left Hepatectomy
a
b
c
Fig. 8.15 (a) Lower of Hilar plate. (b) Isolation of right hepatic pedicle. (c) Sling around left hepatic pedicle
8.6 (V) Short Hepatic Veins
The short hepatic veins drain directly from the back of the
liver into the inferior vena cava. The detailed anatomy is
described in Sect. 3.3.
8.6.1 Clinical Application oftheAnatomy
oftheShort Hepatic Veins
1. To extrahepatically dissect, isolate and control the right
hepatic vein, we have described that it is easier to rst
dissect the hepatic intervenous fossa and ssure (Sect.
8.2) and to divide the hepato-caval ligament (Sect. 8.3).
Dissection and division of the small hepatic veins along
the right border of the inferior vena cava facilitates isolation of the hepato-caval ligament.
2. The short hepatic veins mainly drain from the back of the
caudate lobe of the liver into the inferior vena cava along
its right and left borders. This explains why the Belghiti
liver hanging technique can go through a tunnel that is
avascular (Fig.8.16).
3. In liver resection, if one of the short hepatic veins is torn
because of too much anterior traction onto the liver in an
attempt to better expose the liver, torrential bleeding can
result.
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