acs surgery: principles and practice€¦ · unit that possesses its own nutrient blood supply and...

Clifford S. Cho, M.D., James Park, M.D., and Yuman Fong, M.D., F.A.C.S.

23 HEPATIC RESECTION

Liver resections were first described centuries ago, but until thelatter half of the 20th century, the majority of such resections wereperformed for management of either injuries or infections.Today,these procedures are performed not only for treatment of acuteemergencies (e.g., traumatic injuries or abscesses) but also aspotentially curative therapy for a variety of benign and malignanthepatic lesions.1-5

The first planned anatomic resection of a lobe of a liver is cred-ited to Lortat-Jacob, who in 1952 performed a right lobectomy astreatment for metastatic colon cancer.6 It was not until the 1980s,however, that major hepatectomies became commonplace. Sincethen, the safety of these operations has improved dramatically, andas safety has improved, the indications for hepatic resection havebecome better refined as well. Currently, resection of as much as85% of the functional liver parenchyma is being performed atnumerous centers with an operative mortality of less than 2%.Theduration of hospitalization is typically less than 2 weeks, andalmost all individuals regain normal hepatic function.7

In this chapter, we focus on the technical aspects of hepaticresection, emphasizing efficiency and safety and taking intoaccount recent developments, current controversies, and specialoperative considerations (e.g., the cirrhotic patient and repeat liverresection). Detailed discussions of the indications for hepaticresection are available elsewhere.8-10

Hepatic Anatomy

Familiarity with the surgical anatomy of the liver is essential forsafe performance of a partial hepatectomy.11 In 1998, as aresponse to the confusion created by the various anatomic nomen-clatures applied to the liver, the International Hepato-Pancreato-Biliary Association (IHPBA) appointed a committee that wascharged with deriving a universal terminology for hepatic anatomyand hepatic resections. In 2000, the recommendations of thiscommittee were accepted at the IHPBA’s biannual meeting inBrisbane. Accordingly, this system for naming the anatomic divi-sions of the liver and the corresponding resections has come to beknown as the Brisbane 2000 terminology.12

In the Brisbane 2000 system, the anatomy of the liver may bethought of in terms of first-order, second-order, and third-orderdivisions, all of which are based on the underlying vascular and bil-iary anatomy rather than on surface features [see Figure 1]. At thefirst level, the liver is divided into two hemilivers (right and left).At the second level, it is divided into four sections (right posterior,right anterior, left medial, and left lateral). At the third level, it isdivided into nine segments, each of which is a discrete anatomicunit that possesses its own nutrient blood supply and venous andbiliary drainage.

The right hemiliver consists of segments 5 through 8 and isnourished by the right hepatic artery and the right portal vein; theleft hemiliver consists of segments 2 through 4 and is nourished bythe left hepatic artery and the left portal vein. (The caudate lobe,a portion of the liver that is separate from the two hemilivers, con-sists of segments 1 and 9.) The anatomic division between theright hemiliver and the left is not at the falciform ligament (the

most readily apparent visual landmark on the anterior liver) butfollows a line projected through a plane (the principal plane, orCantlie’s line) that runs posterosuperiorly from the medial marginof the gallbladder to the left side of the vena cava.

The venous drainage of the liver consists of multiple small veinsdraining directly from the back of the right hemiliver and the cau-date lobe to the vena cava, along with three major hepatic veins.These major hepatic veins occupy three planes, known as portalscissurae.The three scissurae divide the liver into the four sections,each of which is supplied by a portal pedicle; further branching ofthe pedicles subdivides the sections into their constituent segments.The right hepatic vein passes between the right anterior section(segments 5 and 8) and the right posterior section (segments 6 and7) in the right scissura.This vein empties directly into the vena cavanear the atriocaval junction. The middle hepatic vein passesbetween the right anterior section and the left medial section (seg-ment 4, sometimes subdivided into segments 4a and 4b) in thecentral, or principal, scissura, which represents the divisionbetween the right hemiliver and the left.The left hepatic vein runsin the left scissura between segments 2 and 3 (which together makeup the left lateral section). In most persons, the left and middlehepatic veins join to form a common trunk before entering the venacava. Occasionally, a large inferior right hepatic vein is present thatmay provide adequate drainage of the right hemiliver after resec-tion of the left even when all three major hepatic veins are ligated.13

The portal vein and the hepatic artery divide into left and rightbranches below the hilum of the liver. Unlike the major hepaticveins, which run between segments, the portal venous and hepat-ic arterial branches, along with the hepatic ducts, typically runcentrally within segments [see Figure 1]. On the right side, thehepatic artery and the portal vein enter the liver substance almostimmediately after branching. The short course of the right-sideextrahepatic vessels and the variable anatomy of the biliary treemake these vessels vulnerable to damage during dissection.14 Incontrast, the left branch of the portal vein and the left hepatic ducttake a long extrahepatic course after branching beneath segment4.When these vessels reach the base of the umbilical fissure, theyare joined by the left hepatic artery to form a triad, which thenenters the substance of the left hemiliver at this point. It must beemphasized that proximal to the base of the umbilical fissure, theleft-side structures are not a triad. A consequence of the longextrahepatic course of the left-side structures is that for tumorsthat involve the hilum (e.g., Klatskin tumors), when a choice existsbetween an extended right hepatectomy and an extended lefthepatectomy [see Operative Technique, below], most surgeonschoose the former because the greater ease of dissection on the leftside facilitates preservation of the left-side structures. Knowledgeof the relative anatomic courses of the portal veins, the hepaticarteries, and the hepatic ducts is the basis of the classical extrahep-atic dissection for control of hepatic inflow [see OperativeTechnique, Right Hepatectomy, Step 6 (Extrahepatic Dissectionand Ligation), below].

The fibrous capsule surrounding the liver substance wasdescribed by Glisson in 1654.15 It was Couinaud,16 however, whodemonstrated that this fibrous capsule extends to envelop the por-

© 2007 WebMD, Inc. All rights reserved.5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice23 Hepatic Resection — 1



tal triads as they pass into the liver substance. Thus, within theliver, the portal vein, the hepatic artery, and the hepatic duct run-ning to each segment of the liver lie within a substantial sheath.This dense sheath allows rapid control of inflow vessels to specif-ic anatomic units within the liver and permits en masse ligation ofthese vascular structures in a maneuver known as pedicle ligation[see Operative Technique, Right Hepatectomy, Step 6—Alternative (Intrahepatic Pedicle Ligation), below].17

Preoperative Evaluation

Cross-sectional imaging modalities such as computed tomog-raphy, magnetic resonance imaging, and ultrasonography play animportant role in enhancing the safety and efficacy of hepaticresection. These modalities, along with biologic scanning tech-niques such as positron emission tomography (PET), are alsoinvaluable for staging malignancies so as to improve patient selec-tion and thereby optimize long-term surgical outcome.3

At a minimum, all candidates for hepatic resection shouldundergo either CT or MRI.These imaging tests not only identifythe number and size of any mass lesions within the liver but alsodelineate the relations of the lesions to the major vasculature—data that are crucial for deciding whether to operate and whichoperative approach to follow.

Use of contrast enhancement during CT scanning is vital foraccurate definition of the vascular anatomy. In fact, data from

thin-slice (1 to 2 mm) images captured by current spiral (helical)CT scanners can be reconstructed to provide angiographic pic-tures whose level of detail rivals that of direct angiograms [seeFigure 2]. Triple-phase scans (including a noncontrast phase, anarterial phase, and a venous phase) are recommended: these yieldthe best definition and characterization of intrahepatic lesions. Forexample, some vascular tumors become isodense with liverparenchyma after contrast injection. By first obtaining noncon-trast scans and then obtaining contrast scans at two differenttimes after contrast injection, the examiner stands a better chanceof visualizing such tumors.

For small tumors, a CT variant known as CT portography isrecommended. In this technique, contrast material is injectedthrough the superior mesenteric artery, and images are obtainedduring the portal venous phase. The normal liver receives themajority of its nutrient blood from the portal vein and is thereforecontrast-enhanced in this phase.Tumors, on the other hand, usu-ally derive their nutrient blood from the hepatic artery and there-fore appear as exaggerated perfusion defects. CT portography isthe most sensitive test available for identifying small hepatictumors.18

MRI may also be valuable for characterizing lesions and defin-ing them vis-à-vis the vasculature. It is particularly helpful in diag-nosing benign lesions such as hemangiomas, focal nodular hyper-plasia, and adenomas.Whenever any of these benign lesions is sus-pected, MRI is usually indicated. With regard to surgical plan-

Inferior Vena Cava

Right Hemiliver (Right Liver)

Right PosteriorSection

Right AnteriorSection

Left MedialSection

Left LateralSection

Left Hemiliver (Left Liver)

Right Hepatic Vein

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1, 9

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FalciformLigament

Portal Vein

Common Bile Duct

Common Hepatic Artery

Left Hepatic Vein

Middle Hepatic Vein

Figure 1 The liver is separated into nine anatomic segments, each with an independentnutrient blood supply and venous and biliary drainage. Appreciation of this segmentalanatomy is the basis of anatomic resection of the liver.



ning, magnetic resonance angiography (MRA) is useful for iden-tifying the major hepatic veins and clarifying their relations to anytumor masses.19

Over the past decade, biologic scanning, in the form of 18F-flu-orodeoxyglucose positron emission tomography (FDG-PET), hasemerged as an invaluable technique for preoperative staging ofpatients with hepatic malignancies. In patients with metastases tothe liver who are being considered for hepatic resection, FDG-PET allows better determination of candidacy for operative man-agement, thereby both reducing the incidence of nontherapeuticlaparotomy20 and improving long-term survival in cases whereresection is indicated.21 The role of FDG-PET in the workup ofpatients with primary hepatocellular carcinoma (HCC) is lessclear, in that many tumors cannot be distinguished from the sur-rounding liver through assessment of glucose metabolism alone.

Imaging recommendations may be summed up as follows. Atriple-phase CT should be obtained for most patients under con-sideration for hepatic resection. If diagnostic doubt remains afterCT, particularly if the differential diagnosis includes an asympto-matic benign tumor, MRI should be performed. If questionsremain after CT as to the extent of hepatic venous or major biliaryinvolvement, MRI or duplex ultrasonography should be consid-ered.22 If small tumors are encountered, CT portography shouldbe performed. Duplex ultrasonography, by demonstrating the vas-cular hilar structures, the hepatic veins, and the inferior vena cava,renders angiography unnecessary in many cases.19,23 For patientswith liver metastases from a primary colorectal cancer,4 breastcancer, or melanoma, an FDG-PET scan should be performedbefore hepatic resection. Direct hepatic angiography is rarelyrequired, and inferior vena cavography is almost never needed.

Operative Planning

PREPARATION

In general, preparation for hepatic resection is much the sameas that for other major abdominal procedures.All patients who areolder than 65 years or have a history of cardiopulmonary diseaseundergo a full cardiopulmonary assessment. It was once common-ly believed that patients 70 years of age or older were poor candi-dates for major liver resection,24,25 but this notion has been dis-

pelled by more recent data.26-28 Advanced chronologic age is not acomplete contraindication to hepatectomy.

Anemia and coagulopathy, if present, are corrected. All patientsare now encouraged to donate two units of autologous bloodbefore a major hepatectomy. As an alternative, hemodilution,whereby a portion of the patient’s blood volume is withdrawnintraoperatively and reinfused immediately after the completion ofthe hepatectomy, may be considered.

Appropriate single-dose antibiotic prophylaxis is administered[see 1:2 Prevention of Postoperative Infection].

ANESTHESIA

Decisions regarding anesthesia should take into account thepossibility of baseline hepatic dysfunction, as well as the postoper-ative hepatic functional deficits resulting from resection of a majorportion of the hepatic parenchyma.

The most important consideration, however, is the possibility ofmajor intraoperative hemorrhage. Suitable monitoring and suffi-cient vascular access to permit rapid transfusion should be inplace. At some centers, fluid resuscitation and blood transfusionare begun early in the course of resection to increase intravascularvolume as a buffer against sudden blood loss. At Memorial Sloan-Kettering Cancer Center (MSKCC), we favor the oppositeapproach, whereby a low central venous pressure is maintainedduring resection.The rationale for our preference is that general-ly, most of the blood lost during hepatic resection comes from themajor hepatic veins or the vena cava.29,30 If central venous pressureis kept below 5 mm Hg, there is less bleeding from the hepaticvenous radicles during dissection. Reduction of intrahepaticvenous pressure can be facilitated by performing the dissectionwith the patient in a 15° Trendelenburg position, which increasesvenous return to the heart and enhances cardiac output. Centralvenous pressure is maintained at the desired level through a com-bination of anesthesia and early intraoperative fluid restriction.The minimal acceptable intraoperative urine output is 25 ml/hr.

The need for intraoperative blood transfusion can be minimizedby accepting hematocrits lower than the common target figure of30%: 24% in patients without antecedent cardiac disease and29% in patients with cardiac disease. If blood loss is estimated toreach or exceed 20% of total volume or the patient becomeshemodynamically unstable, transfusion is indicated.29,30

Figure 2 (a) The arterial anatomy of the celiac axis is reconstructed from thin-slice CTimages. (b) The hepatic venous anatomy is similarly reconstructed, with the tumor superim-posed on the vascular reconstruction.

a b



PATIENT POSITIONING

The patient should be supine: to date we have not found a lat-eral position to be necessary even for the largest of tumors.Electrocardiographic leads should be kept clear of the right chestwall and the presternal area in case a thoracoabdominal incision isnecessitated by the position of a tumor or by intraoperative hem-orrhage. Preparation and draping should therefore also allow forexposure of the lower chest and the entire upper abdomen downpast the umbilicus. A crossbar or a similar device that holds self-retaining retractors should be used to elevate the costal margin.Some surgeons prefer ring-based self-retaining retractors. In ourexperience, although these retractors are adequate for most resec-tions, the rings tend to restrict lateral access, thereby potentiallyhindering posterior dissection, particularly of the vena cava.

ANATOMIC VERSUS NONANATOMIC RESECTION

The key decision in planning a hepatectomy is whether theresection should be anatomic or nonanatomic. For treatment ofmalignant disease, anatomic resection is usually favored becausethe long-term outcome is better. Anatomic resections permit exci-sion of parenchymal areas distal to the index tumors, where thereis a high incidence of vascular micrometastases. In addition, theyare significantly less likely to have positive margins thannonanatomic resections are. In a large series of hepatectomies formetastatic colorectal cancer, wedge or nonanatomic resectionswere associated with a 19% rate of positive margins.31 In oneexamination of the increasing preference for anatomic resections

over wedge resections, wedge resections were associated with a16% rate of positive margins, compared with a 2% rate foranatomic resections.32

There are two oncologic settings where nonanatomic resectionsare favored. In patients with HCC, viral hepatitis and cirrhosis areoften complicating factors. Cirrhotic patients tolerate resection ofmore than two segments of functional parenchyma poorly. Forthese patients, the smallest resection that will achieve completetumor excision is favored, even if it is a wedge resection. For man-agement of metastatic neuroendocrine tumors, in which resec-tions are merely debulking procedures designed to alleviate symp-toms, nonanatomic resections are accepted because cure is highlyunlikely.

Hepatic resections for benign hepatic tumors are usually per-formed for one of three reasons: (1) to relieve symptoms (e.g.,pain or early satiety), (2) because the diagnosis is uncertain, or(3) to prevent malignant transformation. A goal of such resec-tions should be to spare as much normal parenchyma as possi-ble. Consequently, lesions such as hemangiomas, adenomas,complex cysts, and focal nodular hyperplasia are often excised bymeans of enucleation or another nonanatomic resection withlimited margins.

Operative Technique

Theoretically, any hepatic segment can be resected in isolation.For practical purposes, however, there are six major types ofanatomic resection. Until comparatively recently, most authorshave followed the commonly used terminology of Goldsmith andWoodburne in referring to these procedures.33 Some authors havepreferred other systems of nomenclature, based on the anatomicdescriptions of Couinaud16 or Bismuth.34 In this chapter, howev-er, we use the Brisbane 2000 terminology for hepatic resections[see Figure 3].

The essential principles of all anatomic hepatectomies are thesame: (1) control of inflow vessels, (2) control of outflow vessels,and (3) parenchymal transection.To illustrate these principles, webegin by outlining the steps in a right hepatectomy [see Figure 3a]in some detail, describing both extrahepatic vascular dissectionand ligation and the alternative approach to inflow control, intra-hepatic pedicle ligation. Left hepatectomy [see Figure 3b] and othercommon anatomic resections [see Figures 3c, d, e, f] share a num-ber of steps with right hepatectomy; accordingly, we discuss themin somewhat less detail. Further detail on these procedures is avail-able in other sources.35,36

RIGHT HEPATECTOMY

Step 1: Laparoscopic Inspection

Experience from MSKCC37,38 and other centers39,40 indicatesthat laparoscopy allows detection of unresectable disease and pre-vents the morbidity associated with a nontherapeutic laparotomy.We generally perform laparoscopy immediately before laparotomyduring the same period of anesthesia.The laparoscopic port sitesare placed in the upper abdomen along the line of the intendedincision [see Step 2, below].The first two ports are usually 10 mmports placed in the right subcostal area along the midclavicular lineand along the anterior axillary line.These ports allow inspection ofthe abdomen and of the entire liver, including the dome and seg-ment 7.The port along the right anterior axillary line is particular-ly suitable for laparoscopic ultrasound devices. If additional portsare necessary, a left subcostal midclavicular port is usually the bestchoice.

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1, 92

3

Cantlie'sLine

a Right Hepatectomy b Left Hepatectomy

c Right Trisectionectomy (Extended Right Hepatectomy)

e Left Trisectionectomy (Extended Left Hepatectomy)

d Left Lateral Sectionectomy

f Right Posterior Sectionectomy

Figure 3 Shown are schematic illustrations of standard hepaticresections, with the shaded areas representing the resected por-tions: (a) right hepatectomy, (b) left hepatectomy, (c) right trisec-tionectomy (extended right hepatectomy), (d) left lateral sec-tionectomy, (e) left trisectionectomy (extended left hepatectomy),and (f) right posterior sectionectomy.

Step 2: Incision

For the majority of hepatic resections, most surgeons use abilateral subcostal incision extended vertically to the xiphisternum[see Figure 4]. Our own preference, however, is to use an uppermidline incision extending to a point approximately 2 cm abovethe umbilicus, with a rightward extension from that point to apoint in the midaxillary line halfway between the lowest rib andthe iliac crest [see Figure 4]. We find that this incision providessuperb access for either right- or left-side resection, without thewound complications often encountered with trifurcated incisions(e.g., ascitic leakage and incisional hernia). On rare occasions(e.g., in the resection of large, rigid posterior tumors of the righthemiliver), a right thoracoabdominal incision may be required. Ina series of nearly 2,000 resections at MSKCC, however, a thora-coabdominal incision proved necessary in only 3% of patients; themost common indication was repeat liver resection after previousright hepatectomy [see Repeat Hepatic Resection, below].

Step 3: Abdominal Exploration and IntraoperativeUltrasonography

The liver is palpated bimanually. Intraoperative ultrasonogra-phy is systematically performed to identify all possible lesions andtheir relations to the major vascular structures. This modality iscapable of identifying small lesions that preoperative imagingstudies and palpation of the liver may miss.41 The lesser omentumis incised to allow palpation of the caudate lobe and inspection ofthe celiac region for nodal metastases. A finger is passed from thelesser sac inferior to the caudate lobe through the foramen of

Winslow to permit identification of the portal vein and palpationof the portocaval lymph nodes.The hilar lymph nodes are palpat-ed, and any suspicious nodes are removed for frozen-sectionexamination. The entire abdomen is inspected for evidence ofextrahepatic tumor if the operation is being done to treat cancer.

Step 4: Mobilization of Liver

Once the decision is made to proceed with hepatic resection, theliver is fully mobilized by detaching all ligamentous attachments onthe side to be resected. (Some surgeons defer completion of mobi-lization to a later stage in the procedure.) In particular, the supra-hepatic inferior vena cava and the hepatic veins above the liver aredissected to facilitate the subsequent approach to the hepatic veins[see Step 7, below]. Once the liver is mobilized, further palpation isdone to detect any small lesions that may have been obscured ini-tially. This additional palpation is particularly important on theright side because before mobilization, the posterior parts of theliver cannot be effectively palpated, and intraoperative ultrasonog-raphy may fail to detect small lesions in this area.41

If, in the course of mobilization, tumor is found to be attachedto the diaphragm, the affected area of the diaphragm may beexcised and subsequently repaired.

Step 5: Identification of Arterial Anomalies

Any hepatic arterial anomalies present should be identifiedbefore resection is begun. With good preoperative imaging, thearterial anatomy is usually defined with sufficient exactitudebefore laparotomy. It is also possible to gain a clear picture of thearterial anatomy intraoperatively by means of simple maneuversthat do not involve major dissection.

The lesser omentum should be examined to determine whetherthere is a vessel coursing through its middle to the base of theumbilical fissure, and the hepatoduodenal ligament should be pal-pated with an index finger within the foramen of Winslow to seewhether there is an artery in the gastropancreatic fold on its medi-al aspect.The usual bifurcation of the hepatic arteries occurs lowand medially in the hepatoduodenal ligament, and the left hepaticartery normally travels on the medial aspect of the ligament toreach the base of the umbilical fissure.Thus, if an artery is palpa-ble in the medial upper portion of the hepatoduodenal ligament, itis the main left hepatic artery. Any vessel seen in the lesser omen-tum must therefore be an accessory left artery. If no pulse is foundin the medial upper portion of the hepatoduodenal ligament, thevessel in the lesser omentum must be a replaced left hepatic artery.The right hepatic artery usually travels transversely behind thecommon bile duct (CBD) to reach the base of the cystic plate. Avertically traveling artery on the lateral hepatoduodenal ligamentmust therefore be either a replaced or an accessory right hepaticartery, probably arising from the superior mesenteric artery.

Step 6 (Extrahepatic Dissection and Ligation): Control ofInflow Vessels

The classic approach to extrahepatic control of the inflow ves-sels in a right hepatectomy involves extrahepatic dissection andligation [see Figure 5].The cystic duct and the cystic artery are lig-ated and divided. The gallbladder may be either removed or leftattached to the right hemiliver, according to the surgeon’s prefer-ence. The usual practice is to ligate first the right hepatic duct,then the right hepatic artery, and finally the right portal vein,working from anterior to posterior. Our preference, however, is towork from posterior to anterior, as follows.

The sheath of the porta hepatis is opened laterally. Dissection isthen performed in the plane between the CBD and the portal



A

F

D

CB

E

Figure 4 Right hepatectomy. A right subcostal incision (A) with amidline extension to the xiphoid (D) is the most common choice;an extension to the left subcostal area (C) is sometimes added toprovide further operative exposure. We prefer a long midline inci-sion from the xiphoid (D) to a point approximately 2 to 3 cmabove the umbilicus (B) along with a rightward extension (A)because this incision provides superb exposure of both the rightside and the left without the wound complications of a trifurcatedincision. The chest can be entered through either a median ster-notomy (E) or an anterolateral right thoracoabdominal incision(F).

vein.To facilitate this dissection, the CBD is elevated by applyingforward traction to the ligated cystic duct.The portal vein is thenfollowed cephalad until its bifurcation into the left and right por-tal veins is visible. In a small percentage of patients, the left portalvein arises from the right anterior branch of the portal vein. If the

main right portal vein is ligated in a patient who exhibits thisanatomic variant, the portion of the liver remaining after resectionwill lack any portal flow.There is usually a small portal branch thatpasses from the main right portal vein to the caudate process.Ligation of this branch untethers another 1 to 2 cm of the right



a b

c

Figure 5 Right hepatectomy. For control of the inflow vessels of the right hemiliver, the liver is retractedcephalad to allow exposure of the porta hepatis. (a) The gallbladder is resected to allow access to the bile ductand hepatic vessels. (b) The right hepatic duct is ligated to allow access to the hepatic artery and the portalvein. (c) After the right hepatic artery is divided, the right portal vein is controlled and divided. Alternatively,the vessels may be approached from a posterolateral direction and the portal vein and hepatic artery may bedivided first, with the hepatic duct left intact until the parenchymal transection.

Glisson's Sheath

Sheath cut awayfrom this point

Figure 6 Right hepatectomy. Glisson’s sheath is avascular and biliary pedicle that contains the portaltriad. If this sheath is not violated, the entire pedi-cle can be suture-ligated or staple-ligated with con-fidence and safety.

portal vein, thereby allowing safer dissection and ligation. Theright portal vein is usually clamped with vascular clamps, divided,and oversewn with nonabsorbable sutures. Once this is done, theright hepatic artery is visible behind the CBD and can easily besecured and ligated with nonabsorbable sutures. Because of themultitude of biliary anatomic variations, we usually leave the righthepatic duct intact until parenchymal dissection [see Step 8, below]is begun, when this structure can be secured higher within thehepatic parenchyma and divided with greater safety.

Staple ligation Vascular staplers may be used for staplingthe right or the left portal vein during extrahepatic vascular dissec-tion42,43; however, suture ligation of the extrahepatic portal veins issuch a straightforward technical exercise that staplers add littleexcept cost.

Step 6—Alternative (Intrahepatic Pedicle Ligation): Control ofInflow Vessels

The observations of Glisson and Couinaud (see above) that thenutrient vessels to the liver are contained within a thick connec-tive tissue capsule [see Figure 6] were the basis for the initial pro-posal by Launois and Jamieson that intrahepatic vascular pedicleligation could serve as an alternative to extrahepatic dissection andligation for controlling vascular inflow to the liver.17 This alterna-tive technique has the advantages of being rapid and of beingunlikely to cause injury to the vasculature or the biliary drainageof the contralateral liver. Given adequate intrahepatic definitionand control of the portal triads supplying the area of the liver tobe resected, one can readily isolate the various major pedicles byusing simple combinations of hepatotomies at specific sites on theinferior surface of the liver [see Figure 7].

The right hemiliver is completely mobilized from the retroperi-toneum.The most inferior small hepatic veins are ligated, and theinferior right hemiliver is mobilized off the vena cava. Incisions arethen made in the liver capsule at hepatotomy sites A and B [seeFigure 7].The first incision is made though the caudate lobe.Thefull thickness of the caudate lobe is divided with a combination ofdiathermy, crushing, and ligation. The second incision is madealmost vertically in the medial part of the gallbladder bed. Both

incisions must be fairly substantial and reasonably deep. Caremust be taken to avoid the terminal branches of the middle hepat-ic vein, which are the most common source of significant bleed-ing. By means of either finger dissection or the passage of a largecurved clamp, a tape is then placed around the right main sheath[see Figure 8]. This tape can be pulled medially to provide betterexposure of the intrahepatic right pedicle and to retract the left bil-iary tree and portal vein away from the area to be clamped anddivided. Clamps are then applied, the right pedicle is divided, andthe stumps are suture-ligated.

In practice, for right hepatectomies, we prefer to isolate theright anterior and posterior pedicles separately [see Figure 8] andligate them individually. This measure ensures that the left-sidestructures cannot be injured. Any minor bleeding from a hepato-tomy usually ceases spontaneously or else stops when Surgicel isplaced into the wound.

Staple ligation The use of staplers is now well establishedfor liver resections,42-47 and we find that staple ligation greatlyincreases the speed with which intrahepatic portal pedicle liga-tions can be performed.To control the intrahepatic portal pediclesfor a right hepatectomy, incisions are made at hepatotomy sites Aand B [see Figure 7]. Ultrasonography directed from the inferioraspect of the liver helps determine the depth at which the rightpedicle lies, which is usually 1 to 2 cm from the inferior surface.The right main pedicle is then secured either digitally or with acurved blunt clamp (e.g., a renal pedicle clamp), and an umbilicaltape is placed around it [see Figure 9a].The hilar plate in the backof segment 4 is lowered via an incision at hepatotomy site C [seeFigure 7] to ensure that the left-side vascular and biliary structuresare mobilized well away from the area of staple ligation. A trans-verse anastomosis (TA) vascular stapler is applied to the rightmain pedicle while firm countertraction is being applied to theumbilical tape to pull the hilum to the left [see Figure 9a].The sta-pler is fired, and the pedicle is divided [see Figure 9b].

Troubleshooting There are several important guiding prin-ciples that should be followed in deciding on and performingintrahepatic pedicle ligation.The most important principle is that



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Figure 7 Right hepatectomy. Depicted aresites where hepatotomies can be made to per-mit isolation of various vascular pedicles.Incisions at sites A and B allow isolation ofthe right main portal pedicle. Incisions atsites A and D allow isolation of the right pos-terior portal pedicle. Incisions at sites B andD allow isolation of the right anterior pedicle.Incisions at sites C and E allow isolation ofthe left main portal pedicle; if the caudatelobe is to be removed, incisions are made atsites C and F.

in patients undergoing operation for cancer, an intrahepatic pedi-cle approach should not be used when a tumor is within 2 cm ofthe hepatic hilum. In such cases, extrahepatic dissection should beperformed to avoid violation of the tumor margin.

From a technical standpoint, removal of the gallbladder greatlyfacilitates isolation and control of right-side vascular pedicles in a

right hepatectomy. Application of the Pringle maneuver decreasesbleeding during hepatotomy and isolation of the pedicle. Finally,the lowest hepatic veins behind the liver should be dissected beforeany attempt is made to isolate the right-side portal pedicles: incis-ing the caudate lobe without dividing the small hepatic veinsdraining this portion of the liver to the vena cava can lead to sig-nificant hemorrhage.

Step 7: Control of Outflow Vessels

Control of the outflow vasculature begins with division of thehepatic veins passing from the posterior aspect of the righthemiliver directly to the vena cava. After the right hemiliver iscompletely mobilized off the retroperitoneum by dividing the righttriangular ligament, it is carefully dissected off the vena cava.Dissection proceeds upward from the inferior border of the liveruntil the right hepatic vein is exposed. Complete mobilization ofthe right hemiliver is particularly critical for tumors close to thevena cava. The right hepatic vein is then isolated, cross-clamped,divided, and oversewn [see Figure 10]. Unless the tumor or lesioninvolves the middle hepatic vein close to its junction with the venacava, the middle hepatic vein usually is not controlled extrahepat-ically for right-side resections and is easily secured during paren-chymal transection.

If there is a large tumor residing at the dome of the liver, gain-ing control of the hepatic veins and the vena cava may prove verydifficult. If so, one should not hesitate to extend the incision to thechest by means of a right thoracoabdominal extension.The mor-bidity of a thoracoabdominal incision is preferable to the poten-tially catastrophic hemorrhage that is sometimes encounteredwhen the right hepatic vein is torn during mobilization of a rigidright hemiliver containing a large tumor.

Staple ligation Staple ligation has proved useful for outflowcontrol during hepatectomy. When the tumor is in proximity to



Left Main Sheath

Lesser Omentum

Portal Vein

Caudate Process

Inferior Vena Cava

Right Main Sheath

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6

58

Figure 8 Right hepatectomy. Depicted is isolation of the main rightportal pedicle.The pedicle is controlled with a vascular tape andretracted from within the liver substance.This tape can be used forcountertraction when a vascular clamp or stapler is applied.Themain right portal pedicle has anterior and posterior branches.Theright anterior pedicle consists of pedicles to segments 5 and 8.Theright posterior pedicle usually consists of only the segment 6 pediclebut may also give rise to the segment 7 pedicle.

Figure 9 Right hepatectomy. Shown is staple ligation of the right portal pedicle. (a) After the liver isincised across the caudate lobe and along the gallbladder bed, the right main pedicle is isolated and heldwith an umbilical tape. Countertraction is placed on the umbilical tape while a TA vascular stapler isplaced across the pedicle, allowing the left hepatic duct and the left vascular structures to be retractedaway from the line of stapling. (b) After the stapler is fired, the pedicle is clamped and divided.

a b

the hepatic vein–vena cava junction, extrahepatic control of thehepatic veins is essential for excision of the tumor with clear mar-gins, and it limits blood loss during parenchymal transection.48

Ligating the hepatic veins, particularly with a large and rigidtumor in the vicinity, can be a technically demanding and danger-ous exercise.Tearing the hepatic vein or the vena cava during thismaneuver is the most common cause of major intraoperativehemorrhage.36 The endoscopic gastrointestinal anastomosis(GIA) stapler is well suited for ligation of the major hepatic veins,in that it has a low profile and is capable of simultaneously sealingboth the hepatic vein stump on the vena cava side and the one onthe specimen side.

For staple ligation of the right hepatic vein, the right hemiliveris mobilized off the vena cava. Any large accessory right hepaticvein encountered can be staple-ligated, as can the tongue of livertissue that often passes from the right hemiliver behind the venacava to the caudate lobe.The right hepatic vein is then identifiedand isolated. It is the practice of some authors to introduce thestapler from the top of the liver downward,43 but we find that inmost patients, the liver is sufficiently high in the surgical wound torender this angle of introduction technically impracticable.Accordingly, we introduce the stapler parallel to the vena cava anddirect it from below upward [see Figure 11].To ensure that the sta-pler does not misfire, care should be taken to confirm that no vas-cular clips are near the site where the stapler is applied.

Step 8: Parenchymal Transection

Inflow to the left hemiliver is temporarily interrupted by clamp-ing the hepatoduodenal ligament (the Pringle maneuver) [see 7:6Injuries to the Liver,Biliary Tract,Spleen, and Diaphragm].The safe-ty of temporary occlusion of the vessels supplying the hepatic rem-

nant is well documented. Even in patients with cirrhosis, the warmischemia produced by continuous application of the Pringlemaneuver is well tolerated for as long as 1 hour.49 Our practice isto apply the Pringle maneuver intermittently for periods of 10minutes, with 2 to 5 minutes of perfusion between applications toallow decompression of the gut.

Parenchymal division is then begun along the line demarcatedby the devascularization of the right hemiliver.The line of transec-tion along the principal plane is marked with the electrocauteryand then cut with scissors. Stay sutures of 0 chromic catgut areplaced on either side of the plane of transection and used for trac-tion, separation, and elevation as dissection proceeds.

Many special instruments have been proposed for use inparenchymal transection, including electrocauteries, ultrasonicdissectors, and water-jet dissectors. We find that for the majorityof hepatic resections, blunt clamp dissection is the most rapidmethod and is quite safe. In essence, a large Kelly clamp is usedto crush the liver parenchyma [see Figure 12]. The relatively softliver substance dissects away, leaving behind the vascular and bil-iary structures, which are then ligated. With this technique, theprincipal plane of the liver can usually be transected in less than30 minutes.

In cirrhotic patients, the clamp-crushing technique may notwork as well because of the firmness of the liver substance: the ves-sels often tear before the parenchyma does. Accordingly, in cir-rhotic patients, ultrasonic dissectors that coagulate while transect-ing the parenchyma may be a better choice. Water-jet dissectorsmay be useful in defining the major intrahepatic vascular pediclesor the junction of the hepatic vein and the vena cava, particularlyif tumor is in close proximity.

After the specimen is removed, the raw surface of the hepaticremnant is carefully examined for hemostasis and biliary leakage.Any oozing from the raw surface may be controlled with the argon



Vena Cava

Figure 10 Right hepatectomy. Once the small perforating vesselsto the vena cava have been ligated, further dissection cephaladleads to the right hepatic vein. This vessel is controlled with vascu-lar clamps and divided.

DiaphragmVena Cava

Right Lobe

Figure 11 Right hepatectomy. As an alternative to clamping anddivision, the right hepatic vein may be staple-ligated. Once thesmall perforating tributaries from the right hemiliver to the venacava have been divided, the right hepatic vein is isolated and ligat-ed with an endoscopic GIA vascular stapler. The safest method forintroducing this stapler is to retract the liver cephalad and to theleft while advancing the stapler cephalad in the direction of thevena cava.

beam coagulator. Biliary leaks should be controlled with clippingor suture ligation. The retroperitoneal surfaces should also beexamined carefully for hemostasis, and the argon beam coagulatorshould be used where necessary.

Step 9: Closure and Drainage

The abdominal wall is closed in one or two layers with contin-uous absorbable monofilament sutures. The skin is closed withstaples or with subcuticular sutures. Drains are unnecessary inmost routine cases50; sometimes, in fact, they may exert harmfuleffects by leading to ascending infection or fluid managementproblems if ascites develops. There are four clinical situations inwhich we routinely place a drain: (1) clear biliary leakage, (2) aninfected operative field, (3) a thoracoabdominal incision, and (4)biliary reconstruction. In the case of the thoracoabdominal inci-sion, a drain is placed to ensure that biliary leakage does not devel-op into a fistula into the chest.

LEFT HEPATECTOMY

Steps 1 through 5

Left hepatectomy involves removal of segments 2, 3, and 4, andsometimes 1 and 9 as well.The first five steps of the procedure aremuch the same as those of a right hepatectomy.

Step 6 (Extrahepatic Dissection and Ligation): Control ofInflow Vessels

Extrahepatic control of vascular inflow vessels can be achievedin essentially the same fashion as in a right-side resection. Ourpreference is to start the dissection at the base of the umbilical fis-sure.The left hepatic artery is divided first.The left branch of theportal vein is then easily identified at the base of the umbilical fis-sure. The point at which the left portal vein is to be divideddepends on the extent of the planned parenchymal resection [seeFigure 13]: if the caudate lobe is to be preserved, the left portal veinis ligated just distal to its caudate branch (line B); if the caudatelobe is to be removed, the left portal vein is ligated proximal to theorigins of the portal venous branches to this structure (line A).

Step 6—Alternative (Intrahepatic Pedicle Ligation): Control ofInflow Vessels

If the hepatectomy is being done to treat benign disease or toremove a malignancy that is remote from the base of the umbilicalfissure, we highly recommend performing stapler-assisted pedicleligation in preference to extrahepatic dissection and ligation.

The left portal pedicle is identified at the base of the umbilicalfissure.The hilar plate is lowered through an incision at hepatoto-my site C [see Figure 7], and a second incision is made in the backof segment 2 at hepatotomy site E [see Figure 7], thereby allowingisolation of the left portal pedicle with minimal risk of injury to the



Figure 12 Right hepatectomy. The parenchymacan be quickly and safely transected by means ofthe clamp-crushing technique. Large vessels andbiliary radicles are visualized and ligated orclipped. This is usually done in tandem withinflow occlusion (i.e., the Pringle maneuver).Alternatively, the parenchyma can be bluntlydissected away by means of the finger-fracturetechnique.

A

BF

DE

C

Figure 13 Left hepatectomy. Ligation of vascular pedicles at spe-cific sites in the left hemiliver interrupts inflow to specific areas.Ligation at A interrupts inflow to the entire left hemiliver, as wellas the caudate lobe. Ligation at B interrupts blood flow to the leftliver while sparing the caudate lobe. Ligation at C devascularizessegment 2, and ligation at D devascularizes segment 3. Ligation atE and F devascularizes segment 4.

hilum. If the caudate lobe is to be removed as well, incisions shouldbe made at hepatotomy sites C and F [see Figure 7] to allow isola-tion of the main left portal pedicle proximal to the vessels nourish-ing the caudate.The portal pedicle is isolated and secured with anumbilical tape.There is some risk that in the course of securing theleft portal pedicle, the middle hepatic vein, which lies immediatelylateral to the left portal pedicle, may be injured.To minimize thisrisk, firm downward traction is applied to the umbilical tape, anda TA-30 vascular stapler is placed across the left portal pedicle [seeFigure 14].The pedicle is then stapled and divided.

Step 7: Control of Outflow Vessels

The left hemiliver is retracted to the patient’s right, and theentire lesser omentum is divided. The ligamentum venosum isidentified between the caudate lobe and the back of segment 2and is then divided near its attachment to the left hepatic vein; thismeasure facilitates identification and dissection of the left andmiddle hepatic veins anterior to the inferior vena cava. The leftand middle hepatic veins are isolated in preparation for division.

Control of the left hepatic vein is quickly and safely accom-plished with staple ligation. In approximately 60% of patients, theleft and middle hepatic veins join to form a single trunk beforeentering the vena cava. In a left hepatectomy, the middle hepaticvein is often left intact; accordingly, if this is the surgeon’s intent,it is vital to protect the middle hepatic vein while ligating the left.After the left hepatic vein is identified, an endoscopic GIA-30 vas-cular stapler is directed from above downward [see Figure 15] toligate this vessel.The liver is retracted to the right to permit visu-alization of the junction of the left and middle hepatic veins. If lig-ation of the middle hepatic vein is desired as well, as is the casewhen there is tumor in proximity to the vessel, this can be accom-plished with a stapler directed along the same path used for lefthepatic vein ligation.

Steps 8 and 9

Parenchymal transection and closure are accomplished inmuch the same manner in a left hepatectomy as in a right hepatec-tomy (see above).

OTHER ANATOMIC RESECTIONS

In the ensuing review of the other major anatomic resections,we focus primarily on the major points in which they differ fromright and left hepatectomy. More detailed discussions of theseoperations are available in specialty texts on liver resection.35,36

Right Trisectionectomy (Extended Right Hepatectomy)

A right trisectionectomy (extended right hepatectomy) involvesremoval of the right hemiliver along with segment 4—that is, allliver tissue to the right of the falciform ligament [see Figure 3c].The initial steps of this operation are the same as those of a righthepatectomy, up through division of the right inflow vessels andthe right hepatic vein.

The next step is devascularization of segment 4.The umbilicalfissure is dissected to permit identification of the vascular pediclesto segments 2, 3, and 4, which lie within this fissure [see Figure 13].In most cases, the lower part of the umbilical fissure is concealedby a bridge of liver tissue fusing segments 2 and 3 to segment 4.After this tissue bridge is divided with diathermy, the ligamentumteres is retracted caudally to reveal the vascular pedicles from theumbilical fissure to segment 4 (lines E and F [see Figure 13]).Wegenerally suture-ligate these pedicles before dividing them.

The liver tissue is then transected immediately to the right ofthe falciform ligament, from the anterior surface back toward



Ligamentum Teres

Caudate Lobe

Vena Cava

Figure 15 Left hepatectomy. Staple ligation of the left hepaticvein. After the left hemiliver is completely mobilized through divi-sion of the left triangular ligament and the lesser omentum, theleft hepatic vein is isolated and ligated with an endoscopic GIAvascular stapler. The best angle for introducing the stapler is fromthe xiphoid posteriorly and caudad.

Figure 14 Left hepatectomy. After hepatotomies in segment 4and in the back of segment 2, the left portal pedicle is isolated,stapled, and divided.

the divided right hepatic vein.The middle hepatic vein is gener-ally left intact until it is encountered in the upper part of the dis-section, at which point it is controlled and either suture- or staple-ligated.

Left Lateral Sectionectomy

A left lateral sectionectomy involves removal of only segments 2and 3—that is, all liver tissue to the left of the falciform ligament[see Figure 3d].These segments are mobilized by dividing the leftfalciform and triangular ligaments. As this is done, care must betaken not to injure the left hepatic and phrenic veins, which lie onthe medial portion of the left triangular ligament.

The falciform ligament is retracted caudally, and the bridge ofliver tissue between segment 4 and segments 2 and 3 is dividedwith diathermy. Dissection is then performed within the umbilicalfissure to the left of the main triad. The vascular pedicles to seg-ments 2 and 3 usually are then readily dissected and controlled(lines C and D [see Figure 13]). Control of these pedicles withinthe umbilical fissure is particularly important for tumor clearanceif tumor is in proximity to the umbilical fissure: if the condition isbenign or if tumor is remote from the umbilical fissure, the livermay be split anteroposteriorly just to the left of the ligamentumteres and the falciform ligament, and the vascular pedicles may beidentified and ligated as they are encountered in the course ofparenchymal transection.

Once the inflow vessels have been ligated, the left hepatic veinis identified and then divided either before parenchymal transec-tion or as the vessel is encountered near the completion ofparenchymal transection. If there is tumor near the dome, it is par-ticularly important for tumor clearance that the left hepatic vein becontrolled and ligated early and outside the liver.

Left Trisectionectomy (Extended Left Hepatectomy)

A left trisectionectomy (extended left hepatectomy) involvesresection of segments 2, 3, 4, 5, and 8, and sometimes 1 and 9 aswell [see Figure 3e]. In essence, it is a left hepatectomy combinedwith a right anterior sectionectomy; it may or may not includeexcision of the caudate lobe. This complex resection is usuallyundertaken to excise large tumors that occupy the left hemiliverand cross the principal scissura into the right anterior section.

In this procedure, it is essential to preserve the right hepaticvein, which constitutes the sole venous drainage of the hepaticremnant. Usually, however, parenchymal transection must be per-formed along the course of this vein; thus, the major potential dan-ger in the operation is injury to the vessel, which could lead tohemorrhage or hepatic failure from venous congestion of thehepatic remnant. In addition, because the blood supply to seg-ment 7 often arises from the right anterior portal pedicle or fromthe junction of the right anterior and posterior pedicles [see Figure8], there is a risk that the operation may result in devascularizationof a large portion of the hepatic remnant. Finally, because of thegreat variability of the biliary anatomy and the extensive intrahep-atic dissection required in this procedure, there is a significant riskof biliary complications.51 For all of these reasons, left trisectionec-tomies are rarely performed outside major centers.52

In the planning of a left trisectionectomy, particularly close atten-tion must be paid to preoperative imaging investigations so that theright-side intrahepatic vessels and biliary structures can be accurate-ly delineated.Thin-slice CT or MRI images in the form of arterial,portal venous, and hepatic venous reconstructions [see Figure 2] arequite helpful in this regard. For large tumors encroaching on thehepatic hilum or on the junction of the right anterior and posteriorpedicles, direct angiography may still be necessary.

The liver is fully mobilized by dividing not only the left triangu-lar ligament but also the ligaments on the right.This step is essen-tial for identifying the correct plane of parenchymal dissection andfor ensuring safe dissection along the right hepatic vein.

The initial dissection is the same as for a left hepatectomy.Theliver is turned to the right side and the portal triad approached.The inflow vessels to the left hemiliver are ligated, and the lefthepatic vein and the subdiaphragmatic inferior vena cava are dis-sected free. The left and middle hepatic veins are controlled andligated in the extrahepatic portions of their courses.52 The lefthemiliver is thereby freed, and dissection on the right hemiliver isgreatly facilitated.

Next, the plane of transection within the right hemiliver isdefined.This plane is horizontal and lies lateral to the gallbladderfossa and just anterior to the main right hepatic venous trunk inthe right scissura, halfway between the right anterior pedicle andthe right posterior pedicle. The plane can be approximated bydrawing a line from just anterior to the right hepatic vein at itsinsertion into the vena cava to a point immediately behind the fis-sure of Gans.This line can be accurately defined by clamping theportal pedicle to the right anterior section of the liver.52 If thetumor is remote from the junction of the right anterior and poste-rior portal pedicles, the anterior pedicle is controlled as outlinedearlier [see Right Hepatectomy, Step 6—Alternative (IntrahepaticPedicle Ligation), above]. A vascular clamp is placed on the pedi-cle and the line of demarcation on the liver surface inspectedbefore the pedicle is divided. If segment 7 appears to be ischemicas well, further dissection must be done to identify and protect theorigins of the vessels supplying segment 7.

Parenchymal dissection is then carried out from below upward,with bleeding controlled by means of low central venous pressureanesthesia and intermittent application of the Pringle maneuver. Ifthe caudate lobe is to be removed as part of the total resection, theveins draining the caudate must be controlled before parenchymaltransection.

Segment-Oriented Resection

Each segment of the liver can be resected independently. Inaddition, resections involving only the right posterior section (seg-ments 6 and 7) [see Figure 3f] or the right anterior section (seg-ments 5 and 8) are not uncommon. Extensive and excellentdescriptions of so-called segment-oriented hepatic resection areavailable elsewhere.53,54

Postoperative Care

I.V. fluids administered postoperatively should include phos-phorus for support of liver regeneration. For large-volume hepat-ic resections, electrolyte levels, blood count, and prothrombintime (PT) are checked after the operation and then daily for 3 to4 days. Packed red blood cells are administered if the hemoglo-bin level falls to 8 mg/dl or lower, and fresh frozen plasma isgiven if the PT is longer than 17 seconds. Postoperative paincontrol is best achieved with patient-controlled analgesia (PCA).Because of the decreased clearance of liver-metabolized drugsafter a major hepatectomy, selection and dosing of pain medica-tions should be adjusted accordingly. An oral diet can beresumed as early as postoperative day 3 unless a biliary-entericanastomosis was performed.

Peripheral edema is common after major hepatic resections andmay be treated with spironolactone. If an unexplained fever occursor the bilirubin level rises when other hepatic function parametersare normal, an intra-abdominal bile collection may be present, and



a CT scan should be obtained. Percutaneous drain placementusually brings about resolution of such collections after a few days;reoperation is rarely necessary.

Special Considerations

TOTAL VASCULAR ISOLATION FOR CONTROL OF BLEEDING

For control of bleeding during liver parenchymal transection, atechnique known as total vascular isolation can be used as an alter-native to the Pringle maneuver. In this technique, the liver is isolat-ed by controlling the inferior vena cava (both above and below theliver), the portal vein, and the hepatic artery.This approach is basedon techniques developed for liver transplantation and on the obser-vation that the liver is capable of tolerating total normothermicischemia for as long as 1 hour.55 Its primary advantage is that whilethe liver is isolated, little or no bleeding occurs. It does, however,have disadvantages as well. In some patients, temporary occlusionof the inferior vena cava causes hemodynamic instability as a con-sequence of reduced cardiac output coupled with increased sys-temic vascular resistance.56 Cardiac failure with marked hypoten-sion, cardiac arrhythmia, and even cardiac arrest may ensue. Inaddition, when hepatic perfusion is restored, the sudden return ofstagnant potassium-rich blood to the systemic circulation canaggravate the situation. For these reasons and because bleeding isgenerally well controlled with low central venous pressure anesthe-sia, we believe that total vascular isolation is useful only in rarecases. The clinical data published to date support this view. Aprospective study from 1996 found that total vascular isolation hadno major advantages over the approach described earlier [seeOperative Technique, Right Hepatectomy, Step 8, above] and wasactually associated with greater blood loss.48

The one setting where we believe that total vascular isolationmay have a significant role to play is in the surgical managementof hepatic tumors, particularly very large tumors that compromisethe vena cava or the hepatic veins.To extend the duration of vas-cular isolation in this setting, a venovenous bypass that vents thesplanchnic blood into the systemic circulation may be used.57 Tofurther minimize parenchymal injury during vascular isolation,the liver may be perfused with cold organ preservation solutions.For extensive vascular invasion that necessitates major vena cavalor hepatic venous reconstruction, some authors have suggestedthat the liver can be removed during venovenous bypass andresection and reconstruction performed extracorporeally.58

Although there are clinical situations that call for venovenous bypassand ex vivo resection, in practice, these techniques are very rarely nec-essary: short-length vena caval resection and reconstruction can beperformed quite safely without resort to them. In fact, involvementof the retrohepatic vena cava at a level below the major hepaticveins can generally be treated with simple excision of the affectedsegment without replacement,59 particularly if complete obstruc-tion at this level has already led to established collateral circulation.

HANGING MANEUVER IN MAJOR HEPATECTOMY

The classic technique for a right hepatectomy (see above)involves complete mobilization of the right hemiliver before vascu-lar control and parenchymal transection. In cases where the tumorhas invaded the retroperitoneum or diaphragm, however, suchmobilization may be difficult. Moreover, in cases where the tumoris a large, soft, vascular one such as HCC, the earlier mobilizationof the right hemiliver may increase the risk of tumor rupture.Finally, division of the vascular inflow and outflow vessels before

manipulation of the tumor has the theoretical advantage of pre-venting vascular dissemination of cancer cells caused by compres-sion of the tumor. For these reasons, some authors proposed ananterior approach whereby the liver parenchyma is transectedfrom the anterior surface to reach the vena cava, with ligation ofthe inflow and outflow vasculature carried out before mobilizationof the right hemiliver.60 This approach is now widely followed forresection of HCC.

Subsequently, other authors proposed a modification of thistechnique whereby dissection is performed along the anterior sur-face of the vena cava and a tape passed in this plane to lift the liverand thereby facilitate transection of the parenchyma and ligationof the vasculature [see Figure 16].61 The first step in this so-calledhanging maneuver is to dissect the space between the right andmiddle hepatic veins downward for approximately 2 cm. Next,dissection is performed between the vena cava and the caudatelobe on the left side of the inferior right hepatic vein. A clamp isthen passed along this plane in the notch between the right andmiddle hepatic veins, and an umbilical tape is passed for suspen-sion of the liver.Transection of the parenchyma is performed in ananterior-to-posterior direction until the vena cava is reached.Theright side of the vena cava is then dissected, and the right hepaticvein and the inferior hepatic veins are ligated.The triangular liga-ment and the retroperitoneal attachments are transected, and thespecimen is removed.

THE CIRRHOTIC PATIENT

Cirrhotic patients, by definition, have reduced hepatic function-al capacity and reserve. Accordingly, these patients are at higherrisk from hepatectomy and require careful assessment of liverfunction, appropriate selection for surgery and choice of opera-tion, and greater attention to perioperative care.

Operative Planning

Selection of patients Hepatic failure is the major cause ofhospital death and long-term morbidity after hepatic resection incirrhotic patients.62-66 Consequently, determination of a cirrhoticpatient’s candidacy for hepatectomy is based on preoperativeassessment of baseline liver function.

A variety of tests have been proposed for assessment of hepaticreserve, including measurement of clearance of various dyes andmetabolic substrates (e.g., indocyanine green67,68 and aminopy-rine62). Measurement of the urea-nitrogen synthesis rate has alsobeen suggested as a way of predicting outcome after resection.65

Another functional test involves administering lidocaine and mea-suring levels of monethylglycinexylidide (a metabolite of lidocainethat is generated mostly through the cytochrome P-450 enzymesystem in the liver) as a gauge of liver function.69 Measurement ofthe hepatic portal venous pressure gradient via invasive radiologictechniques has been found to predict postoperative hepatic fail-ure.70 Assessment of portal venous hemodynamics by means ofnoninvasive Doppler ultrasonography has also been found to pre-dict outcome after hepatectomy.71

Currently, none of these functional tests are routinely done atmost major liver resection centers. In practice, the Child-Pughscore [see 5:3 Jaundice] is the most commonly employed clinicaltool for selection of surgical candidates. A Child-Pugh score high-er than 8 is generally accepted as a contraindication to majorhepatic resection.64,66,72-75

Choice of procedure The appropriate extent of resection forcirrhotic patients may be quite different from that for noncirrhotic



patients. In cirrhotic patients, the majority of hepatectomies areperformed to eradicate HCC.5 A prime consideration in suchresections is the margin needed to ensure tumor clearance. Mostclinicians aim for a tumor-free margin of 1 cm.A 1989 study, how-ever, found that in cirrhotic patients with HCC, as long as thetumor margin was microscopically clear of cancer, the exact size ofthe margin was not correlated with the incidence of recurrence.76

In fact, the acceptance of limited margins, coupled with the accep-tance of nonanatomic resections aimed at preserving as much func-tional parenchyma as possible, is the single change in technicalpractice that is most responsible for the great improvements in thesafety of hepatic resection observed worldwide in cirrhotic patients.

The guiding principle for hepatectomy in cirrhotic patients isthat limited resections should be favored, with as much function-al parenchyma spared as possible. In general, even for patientswith well-compensated Child’s grade A cirrhosis, we try to limitresections to less than two segments of functional liver. Patientswith large tumors are more likely to tolerate a major resectionbecause little functional parenchyma must be removed along withthe tumor. Major hepatic resections involving removal of at leastone hemiliver are now reported to carry an operative mortality ofless than 10% in cirrhotic patients.77,78 Such procedures are usu-ally performed in cirrhotic patients who have large tumors replac-ing most of one hemiliver, acceptable liver function, and no atro-phy of the uninvolved hemiliver. Small tumors are often more dif-ficult to manage. For patients with small, deeply placed tumorswhose resection would necessitate removal of a large amount offunctional parenchyma, an ablative alternative or even transplan-tation might be more suitable.

In an attempt to preserve as much functional liver as possible,many surgeons resort to more technically challenging operations.Most will perform multiple limited resections in order to avoid per-forming a full hemihepatectomy.79,80 Some go so far as to recon-

struct the right hepatic vein for the purpose of preserving venousoutflow in segments 5 and 6 after resection of segments 7 and 8.

Operative Technique

Hepatic resection in cirrhotic patients is associated with certainspecific technical difficulties that substantially increase the com-plexity of the operation. The liver parenchyma is hard, whichmakes retraction of the liver difficult. In addition, anatomic land-marks are distorted and difficult to find as a consequence of fibro-sis and atrophy-hypertrophy. Finally, portal hypertension and tis-sue friability contribute to increased blood loss during mobiliza-tion and parenchymal transection.

Exposure and mobilization Trifurcated incisions and tho-racoabdominal incisions should be avoided in cirrhotic patientsbecause of the potential for ascitic leakage externally or into thechest.The increased firmness of the cirrhotic liver and the conse-quent difficulty of retraction can lead to significant blood loss fromretroperitoneal or phrenic collateral vessels during mobilization.To prevent such bleeding, it may be preferable to use an anteriorapproach in which the liver parenchyma is split within the princi-pal scissura down to the anterior surface of the vena cava beforethe right hemiliver is mobilized off the retroperitoneum.60 Theright hemiliver is then mobilized in a medial-to-lateral direction,and the right hepatic vein is secured during mobilization of theright hemiliver off the vena cava.

Inflow control At one time, it was widely doubted whetherthe Pringle maneuver was safe in cirrhotic patients. Subsequently,however, many studies verified that this maneuver can be per-formed for extended periods in cirrhotic patients without increas-ing either morbidity or mortality.81-86 Nevertheless, it is advisableto employ the Pringle maneuver sparingly in this population so as



a

b

Figure 16 Illustrated is clamp dissection in prepa-ration for the hanging maneuver. (a) A long vascu-lar clamp is passed between the vena cava and thecaudate lobe. This clamp is directed at the notchbetween the right and middle hepatic veins, whichhas been dissected from above. (b) An umbilicaltape is then passed to suspend the plane ofparenchymal transection.

to minimize ischemic stress. Our practice is to clamp the portaltriad with a vessel loop tourniquet for 10-minute periods with 5-minute breaks in between. We have not found additional protec-tive maneuvers (e.g., topical cooling87,88) to be necessary.

Parenchymal transection In patients with normal liverparenchyma, most experienced hepatic surgeons use blunt dissec-tion, with either the clamp-crushing technique or the finger-frac-ture technique, to transect the liver tissue.89 In patients with cir-rhosis, however, the firmness of the parenchyma makes the clamp-crushing technique less than ideal: because the parenchyma isoften harder than the underlying vasculature and biliary radicles,blunt dissection is likely to tear these vessels. Accordingly, ultra-sonic dissectors that coagulate and seal vessels during dissectionare more suitable for parenchymal transection in this population.

Closure and drainage Because of the likelihood of postop-erative ascites, the abdominal wall is closed with a heavy continu-ous absorbable monofilament suture to create a watertight clo-sure. To prevent major fluid and protein losses and ascendinginfections, abdominal drains generally are not used.50 Reportsspecifically examining the role of drainage in cirrhotic patientsdocumented a much lower incidence of postoperative complica-tions and a shorter hospital stay for patients in whom no drainswere placed.90,91

Postoperative Care

The focus of postoperative care in cirrhotic patients is on man-agement of cirrhosis and portal hypertension [see 5:10 PortalHypertension]. In most such patients who undergo hepatic resec-tion, transient hepatic insufficiency develops postoperatively, withhyperbilirubinemia, ascites formation, hypoalbuminemia, edema,and worsening of the baseline coagulopathy.

In the first 24 hours after the procedure, crystalloid must beadministered at a level sufficient to maintain adequate portal per-fusion.92 If patients are stable after the first 24 hours, they are sub-jected to water and sodium restriction and receive liberal amountsof salt-poor albumin for volume expansion if needed.Spironolactone is started in all patients as soon as oral diet isresumed, and furosemide is added as needed. On rare occasions,a peritoneovenous shunt may have to be employed to controlpostoperative ascites,93 but this measure is usually unnecessary ifpatients were properly selected. The PT is checked twice dailyduring the immediate postoperative period; a PT longer than 17seconds is corrected by administering fresh frozen plasma.

CHEMOTHERAPY-ASSOCIATED STEATOHEPATITIS

One of the most important advances in the treatment ofmetastatic colon cancer over the past few years has been the devel-opment and approval of a number of newer chemotherapeuticagents, such as irinotecan, oxaliplatin, cetuximab (C225), andbevacizumab (Avastin).These agents target the cancer cell cycle,paracrine growth factors, and angiogenic factors, and they haveled to substantial improvements in survival for patients withhepatic colorectal metastases. They are currently being used notonly to allow effective palliative treatment to be provided in caseswhere resection is not feasible but also, by downstaging certainhepatic tumors, to allow surgical treatment to be provided for apercentage of patients who were previously thought to have unre-sectable disease. Consequently, it is now common for patients tobe subjected to a number of chemotherapies before being consid-ered for hepatectomy.94 Along with the benefits of these advancesin chemotherapy, however, has come the challenge posed by post-

operative management of the hepatic damage that can result fromthe use of these newer agents.95

The hepatic surgeon must therefore be vigilant for the condi-tion commonly known as chemotherapy-associated steatohepati-tis (CASH).96 This disease is associated with a characteristic clin-ical triad consisting of (1) hepatic steatosis, (2) splenomegaly, and(3) thrombocytopenia. Fatty infiltration of the liver can beassumed if hepatic attenuation is found to be lower than splenicattenuation. Splenomegaly is a sign of portal hypertension, as isrefractory consumptive thrombocytopenia that is not related tobone marrow suppression and therefore is not corrected evenwhen chemotherapy is stopped.

When CASH is documented, patients should be selected forhepatectomy according to the same criteria used for patients withearly cirrhosis. Consideration should also be given to preoperativeportal vein embolization (PVE) (see below) before hepatectomy toincrease the size of the hepatic remnant.

PREOPERATIVE PORTAL VEIN EMBOLIZATION

Most liver surgeons would be reluctant to resect more than theequivalent of two segments of functional liver in a patient withdocumented cirrhosis.97 Consequently, many cirrhotic patientswith technically resectable tumors are relegated to noncurativeablative therapy out of concern over possible postoperative hepat-ic failure.The situation may be changing, however, with the grow-ing use of preoperative PVE, which may extend surgeons’ abilityto resect tumor in cirrhotic patients.

In PVE, access to the portal vein on the side of the liver to beresected is gained via a percutaneous transhepatic approach.Thevein is embolized approximately 1 month before the plannedresection so as to produce ipsilateral atrophy along with compen-satory hypertrophy of the contralateral future hepatic remnant.98

The degree of compensatory hypertrophy can be dramatic [seeFigure 17] and may modulate postoperative hepatic dysfunction.PVE is also employed in patients with normal parenchyma inwhom extensive resection may result in a very small hepatic rem-nant. In patients undergoing right trisectionectomy, particularlythose with congenitally small left lateral sections, the entire area ofthe extended right hepatectomy, including the main right portalvein and the segmental branches supplying segment 4, can beembolized.99

There is substantial evidence that preoperative PVE can be suc-cessfully used in patients with cirrhotic livers or impaired hepaticfunction and that such use is generally well tolerated.100-103 Oneimmediate benefit of PVE is that it may act as a kind of stress testfor the liver, allowing preoperative determination of the likelihoodof liver regeneration. If no compensatory hypertrophy is seen 4weeks after PVE, the decision to perform a major hepatectomyshould be reconsidered.

Repeat Hepatic Resection

Since 1984, when one of the first reports of repeat hepaticresection was published,104 a number of reports from around theworld have demonstrated that repeat resection can be done safelyand with good long-term results even for recurrent malignancies.The morbidities and mortalities reported after repeat hepatecto-my for metastatic colorectal cancer105-117 and hepatocellular carci-noma118-125 are comparable to those reported after initial hepatec-tomy. Extended survival has been demonstrated, and in selectedcases, survival is equivalent to or even better than that observedafter initial resection.106,113,120,126 In the following section, we con-centrate on the key technical aspects of repeat hepatic resection;



discussions of indications, patient selection, and outcome areavailable in other sources.106,113,120,126

Repeat hepatic resection poses certain technical difficulties thatare not commonly encountered during initial resection.105,127,128

First, adhesions at the previous line of parenchymal transectioncan make reexposure of the liver difficult. Mobilizing the liver offthe vena cava and reexposing the porta hepatis and the hepaticveins can be extremely hazardous if dissection was previously donein these areas. Second, liver regeneration and systemic chemother-apy can induce accumulation of fat within the liver, thereby ren-dering it more friable106; the increased friability further increasesthe difficulties of reexposure and predisposes to tearing ofGlisson’s capsule.127 Third, regeneration alters the normalanatomic configuration of the portal structures [see Figure 18].129

For example, after a right hepatectomy, the porta hepatis is rotat-ed posteriorly and to the right. The normal anatomic relationsamong the portal structures are altered, with the bile duct dis-placed posteriorly and the portal vein displaced anteriorly.

Preoperative imaging is even more important for repeat resec-tions than for primary resections; the reason is that scarring limitsaccess to the liver for intraoperative assessment via palpation orultrasonography. Before embarking on a repeat resection, it isessential to know the exact number and locations of the lesions tobe treated within the regenerated parenchyma. Preoperative imag-ing also facilitates operative planning by accurately delineating thevasculature within the regenerated liver.

In a repeat resection after a previous major right hepatectomy,it is important to be prepared to convert the incision into a thora-coabdominal incision if necessary. Access through the right chestmay be required for mobilization of the liver because of adherenceof the previous resection margin to the diaphragm, or it may berequired for access to the rotated CBD and portal vasculature atthe porta hepatis.

In the dissection of the right upper quadrant after a previousright hepatectomy, three landmarks are particularly helpful indefining the anatomic structures within the regenerated lefthemiliver.The first landmark is the remnants of the ligamentumteres, which defines the demarcation between the left lateral sec-tion (segments 2 and 3) and the left medial section (segment 4);

these should be found early on. The ligamentum teres may befollowed to the base of the umbilical fissure to define the loca-tion of the left hepatic artery.Whether this artery arises from thecommon hepatic artery or from the left gastric artery, it passesinto the liver parenchyma at the base of the umbilical fissure.Thesecond landmark is the caudate lobe. The lesser omentumshould be opened early on to reveal this lobe. An index fingershould then be passed in front of the caudate toward the obliter-ated foramen of Winslow to define the porta hepatis and thelocation of the portal vein.The third landmark is the vena cava.Performing the Kocher maneuver to mobilize the duodenum offthe vena cava allows this vessel to be dissected, thus further



Figure 17 Liver atrophy and hypertrophy occur after right portal vein embolization. Shown areimages of the liver (a) at baseline and (b) 6 weeks after PVE. The right hemiliver is outlined in white.

a b

Left

2 + 3

Right

Hepatic Artery

Portal Vein

Common Bile Duct Normal

Atrophied/Hypertrophied

4

Figure 18 Repeat hepatic resection. Depicted are the changes inthe relations of the portal structures that occur as a result ofright-liver atrophy or resection and left-side hypertrophy. Thestructures in the porta hepatis rotate to the right, with the CBDcoming to rest laterally rather than anteriorly.

defining the portocaval plane. Definition of this plane leads tothe correct plane for dissection and mobilization of the liver offthe vena cava; it also allows isolation of the hepatoduodenal lig-ament for application of the Pringle maneuver and for extrahe-patic dissection of the inflow vessels.

In a repeat resection after a previous left hepatectomy, the mainconcern with regard to mobilization of the liver is the anteriorposition of the portal vasculature after right-side hypertrophy. It istherefore prudent to mobilize the right hemiliver, perform aKocher maneuver, and follow the vena cava caudally to identifythe portal vein from the right.The stomach and the colon usuallyare adherent to the edge of the previous resection and must becarefully dissected free to allow access to the liver. If the middlehepatic vein was preserved in the earlier left hepatectomy, it will lieimmediately deep to the plane of the stomach or the colon andthus may be a source of hemorrhage during dissection.

Control of the inflow or outflow vasculature may be compro-mised by the scarring resulting from the previous operation. Ifextensive extrahepatic dissection was performed for control ofinflow vasculature in the earlier procedure, control of these ves-sels in the repeat resection is more safely accomplished via intra-hepatic pedicle ligation [see Operative Technique, RightHepatectomy, Step 6—Alternative (Intrahepatic PedicleLigation), above].

A major concern with repeat hepatectomy is that it is some-times necessary to perform more limited resections than wouldotherwise be indicated. Normally, for removal of liver tumors, weavoid wedge excisions because these nonanatomic resections aremore often associated with greater blood loss and positive marginsthan anatomic resections are.112,130 In a repeat hepatectomy, how-ever, anatomic considerations arising in the regenerated liver maymake a wedge resection the best choice.

With appropriate patient selection and careful operative plan-ning, very favorable perioperative and long-term results can beachieved after repeat hepatic resection. It is noteworthy that stud-ies addressing repeat resection have not documented any substan-tial increases in blood loss, duration of operation, or rate of com-plications in comparison with the initial resection.106-110,131

Laparoscopic Hepatic Resection

In addition to revolutionizing treatment of gallstone disease,132

laparoscopic techniques are increasingly used for fenestration ofbenign cysts of the liver133,134 and for staging of hepatobiliarymalignancies to prevent unnecessary laparotomies.38,135-137 Untilcomparatively recently, however, laparoscopic resection of livertumors was described only in case reports or small series.133,138-142

Perhaps the main reason for the strong resistance to laparoscopichepatic resection has been fear of catastrophic bleeding. If inad-vertent damage to a major hepatic vein or the vena cava occursduring an open operation, the bleeding can be controlled withdirect manual compression until the vessel is repaired; however, ifsuch damage occurs during a laparoscopic operation, control ofthe bleeding is considerably more difficult. In addition, damage toa hepatic vein or the vena cava during a laparoscopic procedurecan theoretically result in CO2 embolism. Another concern is thatthe loss of tactile sensation characteristic of laparoscopic surgerymay lead to inadequate tumor clearance. Finally, whereas thereare many liver retractors designed to hold the liver in one position,there is no good retractor for repeatedly moving the liver from sideto side, as would be necessary during a laparoscopic hepatectomy.The human hand is still the best tool for this purpose.

Laparoscopic hepatic resection has been greatly facilitated byseveral recent technologic advances, including laparoscopic sta-plers143 and ultrasonic dissectors,144 which can be used for ligationof the hepatic vasculature and transection of liver parenchyma.The most important advance, however, is the hand access port, asmall port through which one hand can be introduced into theabdomen for a hand-assisted laparoscopic resection [see Figure19].145-147With this approach, the surgeon not only regains a mea-sure of tactile sensation but also is able to employ the best liverretractor available. Moreover, direct manual compression of anybleeding vessels is once again possible, and the incision made forthe hand access port is also used for extraction of the resectedspecimen.

Appropriate patient selection is essential for safe laparoscopicresection of liver tumors. Resection of any two segments along thelower edge of the liver is easily accomplished laparoscopically. At



Figure 19 Laparoscopic hepatic resection: hand-assisted.Introduction of the hand within the abdomen restores tac-tile sensation to the surgeon and facilitates resection of theliver. The hand is the best liver retractor available and canbe used to dissect the parenchyma. The specimen can beextracted through the hand access port.

MSKCC, we have laparoscopically resected lesions from all seg-ments.47 In the following section, we provide a general overview oflaparoscopic hepatic resection; more in-depth discussions of thetechnical aspects of these procedures and the results reportedfrom various centers are available elsewhere.148

OPERATIVE TECHNIQUE

The patient is placed on the operating table in the supine posi-tion, with the arm on the side of the resection out from the bodyat a 60° angle and the contralateral arm tucked. The patient issecurely strapped down to allow for rotation of the table. For aright hepatectomy or resection of segments 7 and 8 (bisegmentec-tomy 7, 8), the patient may be positioned in the left lateral decu-bitus position.The surgeon stands on the side opposite the side ofthe resection.

A left lateral sectionectomy typically requires the placement offive ports [see Figure 20a]. Pneumoperitoneum is achieved via aninitial port placed at the umbilicus; to prevent gas embolism duringliver transection, it is maintained at the lowest pressure possible(typically 10 to 12 mm Hg). Subsequent ports are then placedalong the subcostal line. A second 5–12 mm port is placed at theintersection of the subcostal and midclavicular lines to permit dis-section of the triangular ligament, the hepatic vein, and the inferiorvena cava. A third 5–12 mm port is placed between the previoustwo ports to permit dissection of the porta hepatis.The fourth 5–12mm port is placed in the right midclavicular line to permit theintroduction of an endovascular stapler for division of the portalstructures and liver parenchyma.We prefer using 5–12 mm ports inthe beginning, so that the camera and the staplers can be passedthrough any of the ports. If a 5 mm camera is available, 5 mm tro-cars can be placed at certain spots, usually at the most lateral posi-tions.This step frees up the 12 mm ports that are used to pass theendoscopic GIA stapler.We generally use the 45 mm rotating artic-ulated stapler loaded with the white 2.5 mm cartridge.

Some situations call for the use of a hand access port, which canbe of great help in several ways. First, the hand access port allowsthe surgeon to retract and compress the liver manually if bleeding isencountered, thereby increasing the overall speed of the procedure.Second, large resected liver specimens can be removed through thehand access port, without any need for a separate extraction site.Third, if intracorporeal suturing is required to manage bleeding orbile leakage, the surgeon can use the right hand to place the sutureand the left hand, placed through the hand access port, to tie theknots. A disadvantage of the hand access port, however, is that itmay get in the way of the other trocars, especially in a small patient.Hence, knowing when and where to place the hand access portrequires a measure of experience. For a left-side resection, the handaccess port should be placed through a transverse incision in the leftupper quadrant [see Figure 19]. For a right-side resection, the portmay be placed in the right lower quadrant [see Figure 20b].Alternatively, the port may be placed in the upper midline; tractionis then provided by the hand used to retract the left hemiliver medi-ally while the triangular ligament provides countertraction.

The procedure starts with the placement of a 10 mm port, usu-ally in the right or left upper quadrant on the side opposite that onwhich the hand access port will be placed. After staging is per-formed to confirm that the lesion is resectable, a 5 to 6 cm inci-sion is made for placement of the hand access port.The port siteshould be chosen so as to allow manual retraction of the part ofthe liver to be resected, with the falciform and triangular ligamentsused to provide countertraction. Once the access port is in place,the abdomen is fully palpated under laparoscopic vision. A laparo-tomy sponge is placed into the abdomen to facilitate retractionand absorb blood, and a long bulldog clamp is inserted for use inthe Pringle maneuver. A long umbilical tape is tied to the bulldogclamp beforehand so that the instrument can be easily locatedthroughout the procedure. Additional ports are then placed asnecessary for introduction of the stapler or the ultrasonic scalpel.



5 mm

5 mm

5 mm

12 mm12 mm 5 mm

5 mm

5 mm

12 mm12 mm

Hand port

a b

Figure 20 Shown are the recommended port placements for (a) laparoscopic left lateral sectionectomyand (b) hand-assisted laparoscopic right hepatectomy.

The area to be resected is outlined with the electrocautery.Theliver is manually retracted, intermittent application of the Pringlemaneuver is initiated, and the parenchyma is transected. Liverparenchyma remote from the major portal pedicles and hepaticveins may be transected either with the ultrasonic dissector or bymeans of finger fracture. Near the major portal pedicles andhepatic veins, an endoscopic GIA vascular stapler may be used.After removal of the specimen, the laparoscopic argon beam coag-

ulator (Conmed Corporation, Utica, New York) and hemostaticagents may be used.

The laparoscopic approach is suitable for both minor andmajor hepatic resections. At present, however, it remains unclearwhether this approach constitutes a significant advance in liversurgery.To clarify this issue, further study of laparoscopic hepaticresection with respect to perioperative outcome, quality of life,and long-term survival is required.



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Acknowledgment

Figures 1, 3 through 15, 18, 19 Tom Moore.Figure 16 Thom Graves, CMI.



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