clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Under a right hemihepatic vascular occlusion, hepatic parenchymal transection along the right intersectional plane is started (A). The anterior section is lifted with the operator’s left hand and the portal pedicle for the anterior section (Pant) is ligated and divided (B)

The RHV is exposed and a thick venous branch draining the anterior section is divided.

After removal of the anterior section, landmarks including MHV, RHV, and the stump of

Pant are exposed.

Left Lateral Sectionectomy

(Anatomical Resection of Segments 2 and 3)

The Figure depicts the important anatomical structures for this procedure.

Left Medial Sectionectomy

(Anatomical Resection of Segment 4)

Figure A depicts the important anatomical structures for this procedure.

Hepatic parenchymal transection is done along the midplane of the liver and the right side of the umbilical portion of the portal vein (the left intersectional plane). After removal of the left lateral section, landmarks including MHV and stumps of P4s are exposed (B).

388 SECTION 3 Liver

Central Hepatectomy

(Anatomical Resection of Segments 4, 5, and 8)

Figure A depicts the important anatomical structures for this resection.

Hepatic parenchymal transection is done along the right and left intersectional plane (i.e., the umbilical portion of the portal vein). The MHV is divided at its root. After removal of the left lateral section, landmarks including RHV and stumps of Pant and P4s are exposed (B).

For preparation of the right and anterior portal vein/right hepatic artery, and identification of the right intersectional plane, see also steps for anterior sectionectomy above.

Wedge Resection (Limited Resection)

The aim of this procedure is a non-anatomical complete removal of the tumor with sufficient margin. A wide surgical margin (e.g., wider than 10mm) is not necessary, but care should be taken not to expose the tumor on the cut surface.

Tricks of the Senior Surgeon

■Complete exposure of major hepatic veins, the landmarks for the intersegmental planes, is the key for successful segmentectomy and sectionectomy.

■Before starting hepatic parenchymal transection, branching patterns of the major hepatic veins in each patient should be examined thoroughly with intraoperative ultrasound.

■Major hepatic veins are first exposed at their root and distal edge in the cut surface. Then the middle part of the venous trunks is exposed from both ends.

■A tip of the Metzenbaum scissors is useful for dissecting hepatic veins, and all venous branches larger than 1mm should be ligated.

■Very tiny branches can be pulled out from the parenchyma (not from the venous wall) with vascular pickups.

■CVP should be kept low (<3 mm Hg) to reduce blood loss during the parenchymal transection.

Laparoscopic Liver Resection

Daniel Cherqui, Elie Chouillard

Introduction

Unroofing of symptomatic simple liver cysts was the first laparoscopic liver procedure to be performed followed by resection of superficial, small-sized benign tumors. The first laparoscopic anatomical liver resection, a left lateral sectionectomy, was reported in 1996. More recently, larger hepatectomies and liver resections for malignant tumors have been described. Today, about 15–20% of liver resections might be considered for a laparoscopic approach.

Indications and Contraindications