© 2007 WebMD, Inc. All rights reserved.
ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN
23 HEPATIC RESECTION
Clifford S. Cho, M.D., James Park, M.D., and Yuman Fong, M.D., F.A.C.S.
Liver resections were first described centuries ago, but until the
latter half of the 20th century, the majority of such resections were
performed for management of either injuries or infections. Today,
these procedures are performed not only for treatment of acute
emergencies (e.g., traumatic injuries or abscesses) but also as
potentially curative therapy for a variety of benign and malignant
hepatic 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 as
treatment for metastatic colon cancer.6 It was not until the 1980s,
however, that major hepatectomies became commonplace. Since
then, the safety of these operations has improved dramatically, and
as safety has improved, the indications for hepatic resection have
become better refined as well. Currently, resection of as much as
85% of the functional liver parenchyma is being performed at
numerous centers with an operative mortality of less than 2%.The
duration of hospitalization is typically less than 2 weeks, and
almost all individuals regain normal hepatic function.7
In this chapter, we focus on the technical aspects of hepatic
resection, emphasizing efficiency and safety and taking into
account recent developments, current controversies, and special
operative considerations (e.g., the cirrhotic patient and repeat liver
resection). Detailed discussions of the indications for hepatic
resection are available elsewhere.8-10
Hepatic Anatomy
Familiarity with the surgical anatomy of the liver is essential for
safe performance of a partial hepatectomy.11 In 1998, as a
response 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 was
charged with deriving a universal terminology for hepatic anatomy
and hepatic resections. In 2000, the recommendations of this
committee were accepted at the IHPBA’s biannual meeting in
Brisbane. Accordingly, this system for naming the anatomic divi-
sions of the liver and the corresponding resections has come to be
known as the Brisbane 2000 terminology.12
In the Brisbane 2000 system, the anatomy of the liver may be
thought of in terms of first-order, second-order, and third-order
divisions, all of which are based on the underlying vascular and bil-
iary anatomy rather than on surface features [see Figure 1]. At the
first 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 is
divided into nine segments, each of which is a discrete anatomic
unit that possesses its own nutrient blood supply and venous and
biliary drainage.
The right hemiliver consists of segments 5 through 8 and is
nourished by the right hepatic artery and the right portal vein; the
left hemiliver consists of segments 2 through 4 and is nourished by
the 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 the
right hemiliver and the left is not at the falciform ligament (the
23 Hepatic Resection — 1
most readily apparent visual landmark on the anterior liver) but
follows a line projected through a plane (the principal plane, or
Cantlie’s line) that runs posterosuperiorly from the medial margin
of the gallbladder to the left side of the vena cava.
The venous drainage of the liver consists of multiple small veins
draining 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 portal
scissurae.The three scissurae divide the liver into the four sections,
each of which is supplied by a portal pedicle; further branching of
the 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 and
7) in the right scissura.This vein empties directly into the vena cava
near the atriocaval junction. The middle hepatic vein passes
between the right anterior section and the left medial section (seg-
ment 4, sometimes subdivided into segments 4a and 4b) in the
central, or principal, scissura, which represents the division
between the right hemiliver and the left.The left hepatic vein runs
in the left scissura between segments 2 and 3 (which together make
up the left lateral section). In most persons, the left and middle
hepatic veins join to form a common trunk before entering the vena
cava. Occasionally, a large inferior right hepatic vein is present that
may 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 right
branches below the hilum of the liver. Unlike the major hepatic
veins, which run between segments, the portal venous and hepat-
ic arterial branches, along with the hepatic ducts, typically run
centrally within segments [see Figure 1]. On the right side, the
hepatic artery and the portal vein enter the liver substance almost
immediately after branching. The short course of the right-side
extrahepatic vessels and the variable anatomy of the biliary tree
make these vessels vulnerable to damage during dissection.14 In
contrast, the left branch of the portal vein and the left hepatic duct
take a long extrahepatic course after branching beneath segment
4. When these vessels reach the base of the umbilical fissure, they
are joined by the left hepatic artery to form a triad, which then
enters the substance of the left hemiliver at this point. It must be
emphasized that proximal to the base of the umbilical fissure, the
left-side structures are not a triad. A consequence of the long
extrahepatic course of the left-side structures is that for tumors
that involve the hilum (e.g., Klatskin tumors), when a choice exists
between an extended right hepatectomy and an extended left
hepatectomy [see Operative Technique, below], most surgeons
choose the former because the greater ease of dissection on the left
side facilitates preservation of the left-side structures. Knowledge
of the relative anatomic courses of the portal veins, the hepatic
arteries, and the hepatic ducts is the basis of the classical extrahep-
atic dissection for control of hepatic inflow [see Operative
Technique, Right Hepatectomy, Step 6 (Extrahepatic Dissection
and Ligation), below].
The fibrous capsule surrounding the liver substance was
described by Glisson in 1654.15 It was Couinaud,16 however, who
demonstrated that this fibrous capsule extends to envelop the por-
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
Right Hemiliver (Right Liver)
Inferior Vena Cava
Right Hepatic Vein
1, 9
7
5
6
Right Posterior Right Anterior
Section Section
Figure 1 The liver is separated into nine anatomic segments, each with an independent
nutrient blood supply and venous and biliary drainage. Appreciation of this segmental
anatomy is the basis of anatomic resection of the liver.
tal triads as they pass into the liver substance. Thus, within the
liver, 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 of
these 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 an
important role in enhancing the safety and efficacy of hepatic
resection. These modalities, along with biologic scanning tech-
niques such as positron emission tomography (PET), are also
invaluable 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 should
undergo either CT or MRI.These imaging tests not only identify
the number and size of any mass lesions within the liver but also
delineate the relations of the lesions to the major vasculature—
data that are crucial for deciding whether to operate and which
operative approach to follow.
Use of contrast enhancement during CT scanning is vital for
accurate definition of the vascular anatomy. In fact, data from
ACS Surgery: Principles and Practice
23 Hepatic Resection — 2
Left Hemiliver (Left Liver)
Middle Hepatic Vein
Left Hepatic Vein
Falciform
Ligament
Portal Vein
Common
Hepatic Artery
Common
Bile Duct
Left Medial Left Lateral
Section Section
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 [see
Figure 2]. Triple-phase scans (including a noncontrast phase, an
arterial phase, and a venous phase) are recommended: these yield
the best definition and characterization of intrahepatic lesions. For
example, some vascular tumors become isodense with liver
parenchyma after contrast injection. By first obtaining noncon-
trast scans and then obtaining contrast scans at two different
times after contrast injection, the examiner stands a better chance
of visualizing such tumors.
For small tumors, a CT variant known as CT portography is
recommended. In this technique, contrast material is injected
through the superior mesenteric artery, and images are obtained
during the portal venous phase. The normal liver receives the
majority of its nutrient blood from the portal vein and is therefore
contrast-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 is
the most sensitive test available for identifying small hepatic
tumors.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-
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
ning, magnetic resonance angiography (MRA) is useful for iden-
tifying the major hepatic veins and clarifying their relations to any
tumor masses.19
Over the past decade, biologic scanning, in the form of 18F-flu-
orodeoxyglucose positron emission tomography (FDG-PET), has
emerged as an invaluable technique for preoperative staging of
patients with hepatic malignancies. In patients with metastases to
the 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 nontherapeutic
laparotomy20 and improving long-term survival in cases where
resection is indicated.21 The role of FDG-PET in the workup of
patients with primary hepatocellular carcinoma (HCC) is less
clear, 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. A
triple-phase CT should be obtained for most patients under con-
sideration for hepatic resection. If diagnostic doubt remains after
CT, particularly if the differential diagnosis includes an asympto-
matic benign tumor, MRI should be performed. If questions
remain after CT as to the extent of hepatic venous or major biliary
involvement, MRI or duplex ultrasonography should be consid-
ered.22 If small tumors are encountered, CT portography should
be 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 patients
with liver metastases from a primary colorectal cancer,4 breast
cancer, or melanoma, an FDG-PET scan should be performed
before hepatic resection. Direct hepatic angiography is rarely
required, and inferior vena cavography is almost never needed.
Operative Planning
PREPARATION
In general, preparation for hepatic resection is much the same
as that for other major abdominal procedures. All patients who are
older than 65 years or have a history of cardiopulmonary disease
undergo 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-
a b
Figure 2 (a) The arterial anatomy of the celiac axis is reconstructed from thin-slice CT
images. (b) The hepatic venous anatomy is similarly reconstructed, with the tumor superim-
posed on the vascular reconstruction.
ACS Surgery: Principles and Practice
23 Hepatic Resection — 3
pelled by more recent data.26-28 Advanced chronologic age is not a
complete contraindication to hepatectomy.
Anemia and coagulopathy, if present, are corrected. All patients
are now encouraged to donate two units of autologous blood
before a major hepatectomy. As an alternative, hemodilution,
whereby a portion of the patient’s blood volume is withdrawn
intraoperatively and reinfused immediately after the completion of
the 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 the
possibility of baseline hepatic dysfunction, as well as the postoper-
ative hepatic functional deficits resulting from resection of a major
portion of the hepatic parenchyma.
The most important consideration, however, is the possibility of
major intraoperative hemorrhage. Suitable monitoring and suffi-
cient vascular access to permit rapid transfusion should be in
place. At some centers, fluid resuscitation and blood transfusion
are begun early in the course of resection to increase intravascular
volume as a buffer against sudden blood loss. At Memorial Sloan-
Kettering Cancer Center (MSKCC), we favor the opposite
approach, whereby a low central venous pressure is maintained
during resection. The rationale for our preference is that general-
ly, most of the blood lost during hepatic resection comes from the
major hepatic veins or the vena cava.29,30 If central venous pressure
is kept below 5 mm Hg, there is less bleeding from the hepatic
venous radicles during dissection. Reduction of intrahepatic
venous pressure can be facilitated by performing the dissection
with the patient in a 15° Trendelenburg position, which increases
venous return to the heart and enhances cardiac output. Central
venous 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 minimized
by accepting hematocrits lower than the common target figure of
30%: 24% in patients without antecedent cardiac disease and
29% in patients with cardiac disease. If blood loss is estimated to
reach or exceed 20% of total volume or the patient becomes
hemodynamically unstable, transfusion is indicated.29,30
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
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 chest
wall and the presternal area in case a thoracoabdominal incision is
necessitated by the position of a tumor or by intraoperative hem-
orrhage. Preparation and draping should therefore also allow for
exposure of the lower chest and the entire upper abdomen down
past 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 our
experience, although these retractors are adequate for most resec-
tions, the rings tend to restrict lateral access, thereby potentially
hindering posterior dissection, particularly of the vena cava.
ANATOMIC VERSUS NONANATOMIC RESECTION
The key decision in planning a hepatectomy is whether the
resection should be anatomic or nonanatomic. For treatment of
malignant disease, anatomic resection is usually favored because
the long-term outcome is better. Anatomic resections permit exci-
sion of parenchymal areas distal to the index tumors, where there
is a high incidence of vascular micrometastases. In addition, they
are significantly less likely to have positive margins than
nonanatomic resections are. In a large series of hepatectomies for
metastatic colorectal cancer, wedge or nonanatomic resections
were associated with a 19% rate of positive margins.31 In one
examination of the increasing preference for anatomic resections
a Right Hepatectomy b Left Hepatectomy
4
8 2
7 1, 9
3 The essential principles of all anatomic hepatectomies are the
5
4
6 Cantlie's
Line
c Right Trisectionectomy
(Extended Right Hepatectomy) d Left Lateral Sectionectomy
e Left Trisectionectomy
(Extended Left Hepatectomy) f Right Posterior Sectionectomy
Figure 3 Shown are schematic illustrations of standard hepatic
resections, 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.
ACS Surgery: Principles and Practice
23 Hepatic Resection — 4
over wedge resections, wedge resections were associated with a
16% rate of positive margins, compared with a 2% rate for
anatomic resections.32
There are two oncologic settings where nonanatomic resections
are favored. In patients with HCC, viral hepatitis and cirrhosis are
often complicating factors. Cirrhotic patients tolerate resection of
more than two segments of functional parenchyma poorly. For
these patients, the smallest resection that will achieve complete
tumor 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 highly
unlikely.
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 by
means of enucleation or another nonanatomic resection with
limited margins.
Operative Technique
Theoretically, any hepatic segment can be resected in isolation.
For practical purposes, however, there are six major types of
anatomic resection. Until comparatively recently, most authors
have followed the commonly used terminology of Goldsmith and
Woodburne in referring to these procedures.33 Some authors have
preferred other systems of nomenclature, based on the anatomic
descriptions of Couinaud16 or Bismuth.34 In this chapter, howev-
er, we use the Brisbane 2000 terminology for hepatic resections
[see Figure 3].
same: (1) control of inflow vessels, (2) control of outflow vessels,
and (3) parenchymal transection.To illustrate these principles, we
begin by outlining the steps in a right hepatectomy [see Figure 3a]
in some detail, describing both extrahepatic vascular dissection
and ligation and the alternative approach to inflow control, intra-
hepatic pedicle ligation. Left hepatectomy [see Figure 3b] and other
common anatomic resections [see Figures 3c, d, e, f] share a num-
ber of steps with right hepatectomy; accordingly, we discuss them
in 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 indicates
that laparoscopy allows detection of unresectable disease and pre-
vents the morbidity associated with a nontherapeutic laparotomy.
We generally perform laparoscopy immediately before laparotomy
during the same period of anesthesia. The laparoscopic port sites
are placed in the upper abdomen along the line of the intended
incision [see Step 2, below]. The first two ports are usually 10 mm
ports placed in the right subcostal area along the midclavicular line
and along the anterior axillary line.These ports allow inspection of
the 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 ports
are necessary, a left subcostal midclavicular port is usually the best
choice.
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
E
D Once the decision is made to proceed with hepatic resection, the
F
B C
A tially. This additional palpation is particularly important on the
Figure 4 Right hepatectomy. A right subcostal incision (A) with a
midline extension to the xiphoid (D) is the most common choice;
an extension to the left subcostal area (C) is sometimes added to
provide further operative exposure. We prefer a long midline inci-
sion from the xiphoid (D) to a point approximately 2 to 3 cm
above the umbilicus (B) along with a rightward extension (A)
because this incision provides superb exposure of both the right
side and the left without the wound complications of a trifurcated
incision. The chest can be entered through either a median ster-
notomy (E) or an anterolateral right thoracoabdominal incision
(F).
Step 2: Incision
For the majority of hepatic resections, most surgeons use a
bilateral subcostal incision extended vertically to the xiphisternum
[see Figure 4]. Our own preference, however, is to use an upper
midline incision extending to a point approximately 2 cm above
the umbilicus, with a rightward extension from that point to a
point in the midaxillary line halfway between the lowest rib and
the iliac crest [see Figure 4]. We find that this incision provides
superb access for either right- or left-side resection, without the
wound 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 right
hemiliver), a right thoracoabdominal incision may be required. In
a series of nearly 2,000 resections at MSKCC, however, a thora-
coabdominal incision proved necessary in only 3% of patients; the
most common indication was repeat liver resection after previous
right hepatectomy [see Repeat Hepatic Resection, below].
Step 3: Abdominal Exploration and Intraoperative
Ultrasonography
The liver is palpated bimanually. Intraoperative ultrasonogra-
phy is systematically performed to identify all possible lesions and
their relations to the major vascular structures. This modality is
capable of identifying small lesions that preoperative imaging
studies and palpation of the liver may miss.41 The lesser omentum
is incised to allow palpation of the caudate lobe and inspection of
the celiac region for nodal metastases. A finger is passed from the
lesser sac inferior to the caudate lobe through the foramen of
ACS Surgery: Principles and Practice
23 Hepatic Resection — 5
Winslow to permit identification of the portal vein and palpation
of the portocaval lymph nodes.The hilar lymph nodes are palpat-
ed, and any suspicious nodes are removed for frozen-section
examination. The entire abdomen is inspected for evidence of
extrahepatic tumor if the operation is being done to treat cancer.
Step 4: Mobilization of Liver
liver is fully mobilized by detaching all ligamentous attachments on
the 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 are
dissected to facilitate the subsequent approach to the hepatic veins
[see Step 7, below]. Once the liver is mobilized, further palpation is
done to detect any small lesions that may have been obscured ini-
right side because before mobilization, the posterior parts of the
liver 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 attached
to the diaphragm, the affected area of the diaphragm may be
excised and subsequently repaired.
Step 5: Identification of Arterial Anomalies
Any hepatic arterial anomalies present should be identified
before resection is begun. With good preoperative imaging, the
arterial anatomy is usually defined with sufficient exactitude
before laparotomy. It is also possible to gain a clear picture of the
arterial anatomy intraoperatively by means of simple maneuvers
that do not involve major dissection.
The lesser omentum should be examined to determine whether
there is a vessel coursing through its middle to the base of the
umbilical fissure, and the hepatoduodenal ligament should be pal-
pated with an index finger within the foramen of Winslow to see
whether there is an artery in the gastropancreatic fold on its medi-
al aspect. The usual bifurcation of the hepatic arteries occurs low
and medially in the hepatoduodenal ligament, and the left hepatic
artery normally travels on the medial aspect of the ligament to
reach the base of the umbilical fissure. Thus, if an artery is palpa-
ble in the medial upper portion of the hepatoduodenal ligament, it
is the main left hepatic artery. Any vessel seen in the lesser omen-
tum must therefore be an accessory left artery. If no pulse is found
in the medial upper portion of the hepatoduodenal ligament, the
vessel in the lesser omentum must be a replaced left hepatic artery.
The right hepatic artery usually travels transversely behind the
common bile duct (CBD) to reach the base of the cystic plate. A
vertically traveling artery on the lateral hepatoduodenal ligament
must therefore be either a replaced or an accessory right hepatic
artery, probably arising from the superior mesenteric artery.
Step 6 (Extrahepatic Dissection and Ligation): Control of
Inflow Vessels
The classic approach to extrahepatic control of the inflow ves-
sels in a right hepatectomy involves extrahepatic dissection and
ligation [see Figure 5].The cystic duct and the cystic artery are lig-
ated and divided. The gallbladder may be either removed or left
attached 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 to
work from posterior to anterior, as follows.
The sheath of the porta hepatis is opened laterally. Dissection is
then performed in the plane between the CBD and the portal
© 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 23 Hepatic Resection — 6

a b

Figure 5 Right hepatectomy. For control of the inflow vessels of the right hemiliver, the liver is retracted
cephalad to allow exposure of the porta hepatis. (a) The gallbladder is resected to allow access to the bile duct
and hepatic vessels. (b) The right hepatic duct is ligated to allow access to the hepatic artery and the portal
vein. (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 be
divided first, with the hepatic duct left intact until the parenchymal transection.

vein. To facilitate this dissection, the CBD is elevated by applying
forward traction to the ligated cystic duct. The portal vein is then
followed cephalad until its bifurcation into the left and right por-
tal veins is visible. In a small percentage of patients, the left portal
vein arises from the right anterior branch of the portal vein. If the
main right portal vein is ligated in a patient who exhibits this
anatomic variant, the portion of the liver remaining after resection
will lack any portal flow.There is usually a small portal branch that
passes from the main right portal vein to the caudate process.
Ligation of this branch untethers another 1 to 2 cm of the right

Glisson's Sheath
Figure 6 Right hepatectomy. Glisson’s sheath is a
Sheath cut away vascular and biliary pedicle that contains the portal
from this point triad. If this sheath is not violated, the entire pedi-
cle can be suture-ligated or staple-ligated with con-
fidence and safety.
© 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 23 Hepatic Resection — 7

4
5 3

C Figure 7 Right hepatectomy. Depicted are

E sites where hepatotomies can be made to per-
B mit isolation of various vascular pedicles.
Incisions at sites A and B allow isolation of
D the right main portal pedicle. Incisions at
F sites A and D allow isolation of the right pos-
A
terior portal pedicle. Incisions at sites B and
6 2
D allow isolation of the right anterior pedicle.
Incisions at sites C and E allow isolation of
1 the left main portal pedicle; if the caudate
lobe is to be removed, incisions are made at
sites C and F.

portal vein, thereby allowing safer dissection and ligation. The
right portal vein is usually clamped with vascular clamps, divided,
and oversewn with nonabsorbable sutures. Once this is done, the
right hepatic artery is visible behind the CBD and can easily be
secured and ligated with nonabsorbable sutures. Because of the
multitude of biliary anatomic variations, we usually leave the right
hepatic duct intact until parenchymal dissection [see Step 8, below]
is begun, when this structure can be secured higher within the
hepatic parenchyma and divided with greater safety.
Staple ligation Vascular staplers may be used for stapling
the right or the left portal vein during extrahepatic vascular dissec-
tion42,43; however, suture ligation of the extrahepatic portal veins is
such a straightforward technical exercise that staplers add little
except cost.
Step 6—Alternative (Intrahepatic Pedicle Ligation): Control of
Inflow Vessels
The observations of Glisson and Couinaud (see above) that the
nutrient 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 pedicle
ligation could serve as an alternative to extrahepatic dissection and
ligation for controlling vascular inflow to the liver.17 This alterna-
tive technique has the advantages of being rapid and of being
unlikely to cause injury to the vasculature or the biliary drainage
of the contralateral liver. Given adequate intrahepatic definition
and control of the portal triads supplying the area of the liver to
be resected, one can readily isolate the various major pedicles by
using simple combinations of hepatotomies at specific sites on the
inferior 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 the
inferior right hemiliver is mobilized off the vena cava. Incisions are
then made in the liver capsule at hepatotomy sites A and B [see
Figure 7]. The first incision is made though the caudate lobe. The
full thickness of the caudate lobe is divided with a combination of
diathermy, crushing, and ligation. The second incision is made
almost vertically in the medial part of the gallbladder bed. Both
incisions must be fairly substantial and reasonably deep. Care
must 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 large
curved clamp, a tape is then placed around the right main sheath
[see Figure 8]. This tape can be pulled medially to provide better
exposure of the intrahepatic right pedicle and to retract the left bil-
iary tree and portal vein away from the area to be clamped and
divided. Clamps are then applied, the right pedicle is divided, and
the stumps are suture-ligated.
In practice, for right hepatectomies, we prefer to isolate the
right anterior and posterior pedicles separately [see Figure 8] and
ligate them individually. This measure ensures that the left-side
structures cannot be injured. Any minor bleeding from a hepato-
tomy usually ceases spontaneously or else stops when Surgicel is
placed into the wound.
Staple ligation The use of staplers is now well established
for liver resections,42-47 and we find that staple ligation greatly
increases the speed with which intrahepatic portal pedicle liga-
tions can be performed.To control the intrahepatic portal pedicles
for a right hepatectomy, incisions are made at hepatotomy sites A
and B [see Figure 7]. Ultrasonography directed from the inferior
aspect of the liver helps determine the depth at which the right
pedicle lies, which is usually 1 to 2 cm from the inferior surface.
The right main pedicle is then secured either digitally or with a
curved blunt clamp (e.g., a renal pedicle clamp), and an umbilical
tape is placed around it [see Figure 9a].The hilar plate in the back
of segment 4 is lowered via an incision at hepatotomy site C [see
Figure 7] to ensure that the left-side vascular and biliary structures
are mobilized well away from the area of staple ligation. A trans-
verse anastomosis (TA) vascular stapler is applied to the right
main pedicle while firm countertraction is being applied to the
umbilical 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 performing
intrahepatic pedicle ligation.The most important principle is that
© 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 23 Hepatic Resection — 8

Right Main Sheath Left Main Sheath
8
5 draining this portion of the liver to the vena cava can lead to sig-
7
6
Lesser Omentum
Portal Vein
Caudate Inferior
Process Vena Cava
Figure 8 Right hepatectomy. Depicted is isolation of the main right
portal pedicle. The pedicle is controlled with a vascular tape and
retracted from within the liver substance. This tape can be used for
countertraction when a vascular clamp or stapler is applied. The
main right portal pedicle has anterior and posterior branches. The
right anterior pedicle consists of pedicles to segments 5 and 8. The
right posterior pedicle usually consists of only the segment 6 pedicle
but may also give rise to the segment 7 pedicle.
in patients undergoing operation for cancer, an intrahepatic pedi-
cle approach should not be used when a tumor is within 2 cm of
the hepatic hilum. In such cases, extrahepatic dissection should be
performed to avoid violation of the tumor margin.
From a technical standpoint, removal of the gallbladder greatly
facilitates isolation and control of right-side vascular pedicles in a
right hepatectomy. Application of the Pringle maneuver decreases
bleeding during hepatotomy and isolation of the pedicle. Finally,
the lowest hepatic veins behind the liver should be dissected before
any attempt is made to isolate the right-side portal pedicles: incis-
ing the caudate lobe without dividing the small hepatic veins
nificant hemorrhage.
Step 7: Control of Outflow Vessels
Control of the outflow vasculature begins with division of the
hepatic veins passing from the posterior aspect of the right
hemiliver directly to the vena cava. After the right hemiliver is
completely mobilized off the retroperitoneum by dividing the right
triangular ligament, it is carefully dissected off the vena cava.
Dissection proceeds upward from the inferior border of the liver
until the right hepatic vein is exposed. Complete mobilization of
the right hemiliver is particularly critical for tumors close to the
vena cava. The right hepatic vein is then isolated, cross-clamped,
divided, and oversewn [see Figure 10]. Unless the tumor or lesion
involves the middle hepatic vein close to its junction with the vena
cava, 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 very
difficult. If so, one should not hesitate to extend the incision to the
chest 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 encountered
when the right hepatic vein is torn during mobilization of a rigid
right hemiliver containing a large tumor.
Staple ligation Staple ligation has proved useful for outflow
control during hepatectomy. When the tumor is in proximity to

a b

Figure 9 Right hepatectomy. Shown is staple ligation of the right portal pedicle. (a) After the liver is
incised across the caudate lobe and along the gallbladder bed, the right main pedicle is isolated and held
with an umbilical tape. Countertraction is placed on the umbilical tape while a TA vascular stapler is
placed across the pedicle, allowing the left hepatic duct and the left vascular structures to be retracted
away from the line of stapling. (b) After the stapler is fired, the pedicle is clamped and divided.
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
Vena Cava
Figure 10 Right hepatectomy. Once the small perforating vessels
to the vena cava have been ligated, further dissection cephalad
leads to the right hepatic vein. This vessel is controlled with vascu-
lar clamps and divided.
the hepatic vein–vena cava junction, extrahepatic control of the
hepatic 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 rigid
tumor in the vicinity, can be a technically demanding and danger-
ous exercise.Tearing the hepatic vein or the vena cava during this
maneuver is the most common cause of major intraoperative
hemorrhage.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 sealing
both the hepatic vein stump on the vena cava side and the one on
the specimen side.
For staple ligation of the right hepatic vein, the right hemiliver
is mobilized off the vena cava. Any large accessory right hepatic
vein encountered can be staple-ligated, as can the tongue of liver
tissue that often passes from the right hemiliver behind the vena
cava to the caudate lobe. The right hepatic vein is then identified
and isolated. It is the practice of some authors to introduce the
stapler from the top of the liver downward,43 but we find that in
most patients, the liver is sufficiently high in the surgical wound to
render this angle of introduction technically impracticable.
Accordingly, we introduce the stapler parallel to the vena cava and
direct 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 7:6
Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm].The safe-
ty of temporary occlusion of the vessels supplying the hepatic rem-
ACS Surgery: Principles and Practice
23 Hepatic Resection — 9
nant is well documented. Even in patients with cirrhosis, the warm
ischemia produced by continuous application of the Pringle
maneuver is well tolerated for as long as 1 hour.49 Our practice is
to apply the Pringle maneuver intermittently for periods of 10
minutes, with 2 to 5 minutes of perfusion between applications to
allow decompression of the gut.
Parenchymal division is then begun along the line demarcated
by the devascularization of the right hemiliver.The line of transec-
tion along the principal plane is marked with the electrocautery
and then cut with scissors. Stay sutures of 0 chromic catgut are
placed 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 in
parenchymal transection, including electrocauteries, ultrasonic
dissectors, and water-jet dissectors. We find that for the majority
of hepatic resections, blunt clamp dissection is the most rapid
method and is quite safe. In essence, a large Kelly clamp is used
to crush the liver parenchyma [see Figure 12]. The relatively soft
liver substance dissects away, leaving behind the vascular and bil-
iary structures, which are then ligated. With this technique, the
principal plane of the liver can usually be transected in less than
30 minutes.
In cirrhotic patients, the clamp-crushing technique may not
work 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 dissectors
may be useful in defining the major intrahepatic vascular pedicles
or the junction of the hepatic vein and the vena cava, particularly
if tumor is in close proximity.
After the specimen is removed, the raw surface of the hepatic
remnant is carefully examined for hemostasis and biliary leakage.
Any oozing from the raw surface may be controlled with the argon
Right
Lobe
Diaphragm
Vena Cava
Figure 11 Right hepatectomy. As an alternative to clamping and
division, the right hepatic vein may be staple-ligated. Once the
small perforating tributaries from the right hemiliver to the vena
cava have been divided, the right hepatic vein is isolated and ligat-
ed with an endoscopic GIA vascular stapler. The safest method for
introducing this stapler is to retract the liver cephalad and to the
left while advancing the stapler cephalad in the direction of the
vena cava.
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
beam coagulator. Biliary leaks should be controlled with clipping
or suture ligation. The retroperitoneal surfaces should also be
examined carefully for hemostasis, and the argon beam coagulator
should 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 with
staples or with subcuticular sutures. Drains are unnecessary in
most routine cases50; sometimes, in fact, they may exert harmful
effects by leading to ascending infection or fluid management
problems if ascites develops. There are four clinical situations in
which we routinely place a drain: (1) clear biliary leakage, (2) an
infected 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, and
sometimes 1 and 9 as well.The first five steps of the procedure are
much the same as those of a right hepatectomy.
Step 6 (Extrahepatic Dissection and Ligation): Control of
Inflow Vessels
Extrahepatic control of vascular inflow vessels can be achieved
in essentially the same fashion as in a right-side resection. Our
preference is to start the dissection at the base of the umbilical fis-
sure. The left hepatic artery is divided first. The left branch of the
portal vein is then easily identified at the base of the umbilical fis-
sure. The point at which the left portal vein is to be divided
depends on the extent of the planned parenchymal resection [see
Figure 13]: if the caudate lobe is to be preserved, the left portal vein
is ligated just distal to its caudate branch (line B); if the caudate
lobe is to be removed, the left portal vein is ligated proximal to the
origins of the portal venous branches to this structure (line A).
ACS Surgery: Principles and Practice
23 Hepatic Resection — 10
Figure 12 Right hepatectomy. The parenchyma
can be quickly and safely transected by means of
the clamp-crushing technique. Large vessels and
biliary radicles are visualized and ligated or
clipped. This is usually done in tandem with
inflow occlusion (i.e., the Pringle maneuver).
Alternatively, the parenchyma can be bluntly
dissected away by means of the finger-fracture
technique.
Step 6—Alternative (Intrahepatic Pedicle Ligation): Control of
Inflow Vessels
If the hepatectomy is being done to treat benign disease or to
remove a malignancy that is remote from the base of the umbilical
fissure, we highly recommend performing stapler-assisted pedicle
ligation in preference to extrahepatic dissection and ligation.
The left portal pedicle is identified at the base of the umbilical
fissure. The hilar plate is lowered through an incision at hepatoto-
my site C [see Figure 7], and a second incision is made in the back
of segment 2 at hepatotomy site E [see Figure 7], thereby allowing
isolation of the left portal pedicle with minimal risk of injury to the
E D
F C
B
A
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 well
as the caudate lobe. Ligation at B interrupts blood flow to the left
liver while sparing the caudate lobe. Ligation at C devascularizes
segment 2, and ligation at D devascularizes segment 3. Ligation at
E and F devascularizes segment 4.
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
Figure 14 Left hepatectomy. After hepatotomies in segment 4
and in the back of segment 2, the left portal pedicle is isolated,
stapled, and divided.
Ligamentum Teres Vena Cava
Caudate Lobe
Figure 15 Left hepatectomy. Staple ligation of the left hepatic
vein. After the left hemiliver is completely mobilized through divi-
sion of the left triangular ligament and the lesser omentum, the
left hepatic vein is isolated and ligated with an endoscopic GIA
vascular stapler. The best angle for introducing the stapler is from
the xiphoid posteriorly and caudad.
ACS Surgery: Principles and Practice
23 Hepatic Resection — 11
hilum. If the caudate lobe is to be removed as well, incisions should
be 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 an
umbilical tape.There is some risk that in the course of securing the
left portal pedicle, the middle hepatic vein, which lies immediately
lateral to the left portal pedicle, may be injured. To minimize this
risk, firm downward traction is applied to the umbilical tape, and
a TA-30 vascular stapler is placed across the left portal pedicle [see
Figure 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 the
entire lesser omentum is divided. The ligamentum venosum is
identified between the caudate lobe and the back of segment 2
and is then divided near its attachment to the left hepatic vein; this
measure facilitates identification and dissection of the left and
middle hepatic veins anterior to the inferior vena cava. The left
and 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, the
left and middle hepatic veins join to form a single trunk before
entering the vena cava. In a left hepatectomy, the middle hepatic
vein 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] to
ligate 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 case
when there is tumor in proximity to the vessel, this can be accom-
plished with a stapler directed along the same path used for left
hepatic vein ligation.
Steps 8 and 9
Parenchymal transection and closure are accomplished in
much 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 from
right and left hepatectomy. More detailed discussions of these
operations are available in specialty texts on liver resection.35,36
Right Trisectionectomy (Extended Right Hepatectomy)
A right trisectionectomy (extended right hepatectomy) involves
removal of the right hemiliver along with segment 4—that is, all
liver tissue to the right of the falciform ligament [see Figure 3c].
The initial steps of this operation are the same as those of a right
hepatectomy, up through division of the right inflow vessels and
the right hepatic vein.
The next step is devascularization of segment 4. The umbilical
fissure is dissected to permit identification of the vascular pedicles
to segments 2, 3, and 4, which lie within this fissure [see Figure 13].
In most cases, the lower part of the umbilical fissure is concealed
by a bridge of liver tissue fusing segments 2 and 3 to segment 4.
After this tissue bridge is divided with diathermy, the ligamentum
teres is retracted caudally to reveal the vascular pedicles from the
umbilical fissure to segment 4 (lines E and F [see Figure 13]). We
generally suture-ligate these pedicles before dividing them.
The liver tissue is then transected immediately to the right of
the falciform ligament, from the anterior surface back toward
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
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 2
and 3—that is, all liver tissue to the left of the falciform ligament
[see Figure 3d]. These segments are mobilized by dividing the left
falciform and triangular ligaments. As this is done, care must be
taken not to injure the left hepatic and phrenic veins, which lie on
the medial portion of the left triangular ligament.
The falciform ligament is retracted caudally, and the bridge of
liver tissue between segment 4 and segments 2 and 3 is divided
with diathermy. Dissection is then performed within the umbilical
fissure 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 within
the umbilical fissure is particularly important for tumor clearance
if tumor is in proximity to the umbilical fissure: if the condition is
benign or if tumor is remote from the umbilical fissure, the liver
may be split anteroposteriorly just to the left of the ligamentum
teres and the falciform ligament, and the vascular pedicles may be
identified and ligated as they are encountered in the course of
parenchymal transection.
Once the inflow vessels have been ligated, the left hepatic vein
is identified and then divided either before parenchymal transec-
tion or as the vessel is encountered near the completion of
parenchymal transection. If there is tumor near the dome, it is par-
ticularly important for tumor clearance that the left hepatic vein be
controlled and ligated early and outside the liver.
Left Trisectionectomy (Extended Left Hepatectomy)
A left trisectionectomy (extended left hepatectomy) involves
resection of segments 2, 3, 4, 5, and 8, and sometimes 1 and 9 as
well [see Figure 3e]. In essence, it is a left hepatectomy combined
with a right anterior sectionectomy; it may or may not include
excision of the caudate lobe. This complex resection is usually
undertaken to excise large tumors that occupy the left hemiliver
and cross the principal scissura into the right anterior section.
In this procedure, it is essential to preserve the right hepatic
vein, which constitutes the sole venous drainage of the hepatic
remnant. 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 to
hemorrhage or hepatic failure from venous congestion of the
hepatic remnant. In addition, because the blood supply to seg-
ment 7 often arises from the right anterior portal pedicle or from
the junction of the right anterior and posterior pedicles [see Figure
8], there is a risk that the operation may result in devascularization
of a large portion of the hepatic remnant. Finally, because of the
great variability of the biliary anatomy and the extensive intrahep-
atic dissection required in this procedure, there is a significant risk
of 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 the
right-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] are
quite helpful in this regard. For large tumors encroaching on the
hepatic hilum or on the junction of the right anterior and posterior
pedicles, direct angiography may still be necessary.
ACS Surgery: Principles and Practice
23 Hepatic Resection — 12
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 and
for ensuring safe dissection along the right hepatic vein.
The initial dissection is the same as for a left hepatectomy. The
liver is turned to the right side and the portal triad approached.
The inflow vessels to the left hemiliver are ligated, and the left
hepatic vein and the subdiaphragmatic inferior vena cava are dis-
sected free. The left and middle hepatic veins are controlled and
ligated in the extrahepatic portions of their courses.52 The left
hemiliver is thereby freed, and dissection on the right hemiliver is
greatly facilitated.
Next, the plane of transection within the right hemiliver is
defined. This plane is horizontal and lies lateral to the gallbladder
fossa and just anterior to the main right hepatic venous trunk in
the right scissura, halfway between the right anterior pedicle and
the right posterior pedicle. The plane can be approximated by
drawing a line from just anterior to the right hepatic vein at its
insertion into the vena cava to a point immediately behind the fis-
sure of Gans. This line can be accurately defined by clamping the
portal pedicle to the right anterior section of the liver.52 If the
tumor is remote from the junction of the right anterior and poste-
rior portal pedicles, the anterior pedicle is controlled as outlined
earlier [see Right Hepatectomy, Step 6—Alternative (Intrahepatic
Pedicle Ligation), above]. A vascular clamp is placed on the pedi-
cle and the line of demarcation on the liver surface inspected
before the pedicle is divided. If segment 7 appears to be ischemic
as well, further dissection must be done to identify and protect the
origins of the vessels supplying segment 7.
Parenchymal dissection is then carried out from below upward,
with bleeding controlled by means of low central venous pressure
anesthesia and intermittent application of the Pringle maneuver. If
the caudate lobe is to be removed as part of the total resection, the
veins draining the caudate must be controlled before parenchymal
transection.
Segment-Oriented Resection
Each segment of the liver can be resected independently. In
addition, 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 excellent
descriptions of so-called segment-oriented hepatic resection are
available 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 prothrombin
time (PT) are checked after the operation and then daily for 3 to
4 days. Packed red blood cells are administered if the hemoglo-
bin level falls to 8 mg/dl or lower, and fresh frozen plasma is
given if the PT is longer than 17 seconds. Postoperative pain
control is best achieved with patient-controlled analgesia (PCA).
Because of the decreased clearance of liver-metabolized drugs
after a major hepatectomy, selection and dosing of pain medica-
tions should be adjusted accordingly. An oral diet can be
resumed as early as postoperative day 3 unless a biliary-enteric
anastomosis was performed.
Peripheral edema is common after major hepatic resections and
may be treated with spironolactone. If an unexplained fever occurs
or the bilirubin level rises when other hepatic function parameters
are normal, an intra-abdominal bile collection may be present, and
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
a CT scan should be obtained. Percutaneous drain placement
usually 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, a
technique 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 the
liver), the portal vein, and the hepatic artery.This approach is based
on techniques developed for liver transplantation and on the obser-
vation that the liver is capable of tolerating total normothermic
ischemia for as long as 1 hour.55 Its primary advantage is that while
the liver is isolated, little or no bleeding occurs. It does, however,
have disadvantages as well. In some patients, temporary occlusion
of 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. In
addition, when hepatic perfusion is restored, the sudden return of
stagnant potassium-rich blood to the systemic circulation can
aggravate the situation. For these reasons and because bleeding is
generally well controlled with low central venous pressure anesthe-
sia, we believe that total vascular isolation is useful only in rare
cases. The clinical data published to date support this view. A
prospective study from 1996 found that total vascular isolation had
no major advantages over the approach described earlier [see
Operative Technique, Right Hepatectomy, Step 8, above] and was
actually associated with greater blood loss.48
The one setting where we believe that total vascular isolation
may have a significant role to play is in the surgical management
of hepatic tumors, particularly very large tumors that compromise
the vena cava or the hepatic veins. To extend the duration of vas-
cular isolation in this setting, a venovenous bypass that vents the
splanchnic blood into the systemic circulation may be used.57 To
further minimize parenchymal injury during vascular isolation,
the liver may be perfused with cold organ preservation solutions.
For extensive vascular invasion that necessitates major vena caval
or hepatic venous reconstruction, some authors have suggested
that the liver can be removed during venovenous bypass and
resection and reconstruction performed extracorporeally.58
Although there are clinical situations that call for venovenous bypass
and ex vivo resection, in practice, these techniques are very rarely nec-
essary: short-length vena caval resection and reconstruction can be
performed quite safely without resort to them. In fact, involvement
of the retrohepatic vena cava at a level below the major hepatic
veins can generally be treated with simple excision of the affected
segment 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 tumor
has invaded the retroperitoneum or diaphragm, however, such
mobilization may be difficult. Moreover, in cases where the tumor
is a large, soft, vascular one such as HCC, the earlier mobilization
of the right hemiliver may increase the risk of tumor rupture.
Finally, division of the vascular inflow and outflow vessels before
ACS Surgery: Principles and Practice
23 Hepatic Resection — 13
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 an
anterior approach whereby the liver parenchyma is transected
from the anterior surface to reach the vena cava, with ligation of
the inflow and outflow vasculature carried out before mobilization
of the right hemiliver.60 This approach is now widely followed for
resection of HCC.
Subsequently, other authors proposed a modification of this
technique whereby dissection is performed along the anterior sur-
face of the vena cava and a tape passed in this plane to lift the liver
and thereby facilitate transection of the parenchyma and ligation
of the vasculature [see Figure 16].61 The first step in this so-called
hanging maneuver is to dissect the space between the right and
middle hepatic veins downward for approximately 2 cm. Next,
dissection is performed between the vena cava and the caudate
lobe on the left side of the inferior right hepatic vein. A clamp is
then passed along this plane in the notch between the right and
middle hepatic veins, and an umbilical tape is passed for suspen-
sion of the liver.Transection of the parenchyma is performed in an
anterior-to-posterior direction until the vena cava is reached. The
right side of the vena cava is then dissected, and the right hepatic
vein and the inferior hepatic veins are ligated.The triangular liga-
ment and the retroperitoneal attachments are transected, and the
specimen is removed.
THE CIRRHOTIC PATIENT
Cirrhotic patients, by definition, have reduced hepatic function-
al capacity and reserve. Accordingly, these patients are at higher
risk from hepatectomy and require careful assessment of liver
function, 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 of
hospital death and long-term morbidity after hepatic resection in
cirrhotic patients.62-66 Consequently, determination of a cirrhotic
patient’s candidacy for hepatectomy is based on preoperative
assessment of baseline liver function.
A variety of tests have been proposed for assessment of hepatic
reserve, including measurement of clearance of various dyes and
metabolic substrates (e.g., indocyanine green67,68 and aminopy-
rine62). Measurement of the urea-nitrogen synthesis rate has also
been 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 lidocaine
that is generated mostly through the cytochrome P-450 enzyme
system in the liver) as a gauge of liver function.69 Measurement of
the hepatic portal venous pressure gradient via invasive radiologic
techniques has been found to predict postoperative hepatic fail-
ure.70 Assessment of portal venous hemodynamics by means of
noninvasive Doppler ultrasonography has also been found to pre-
dict outcome after hepatectomy.71
Currently, none of these functional tests are routinely done at
most major liver resection centers. In practice, the Child-Pugh
score [see 5:3 Jaundice] is the most commonly employed clinical
tool for selection of surgical candidates. A Child-Pugh score high-
er than 8 is generally accepted as a contraindication to major
hepatic resection.64,66,72-75
Choice of procedure The appropriate extent of resection for
cirrhotic patients may be quite different from that for noncirrhotic
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
a ration for the hanging maneuver. (a) A long vascu-
patients. In cirrhotic patients, the majority of hepatectomies are
performed to eradicate HCC.5 A prime consideration in such
resections is the margin needed to ensure tumor clearance. Most
clinicians aim for a tumor-free margin of 1 cm. A 1989 study, how-
ever, found that in cirrhotic patients with HCC, as long as the
tumor margin was microscopically clear of cancer, the exact size of
the 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 technical
practice that is most responsible for the great improvements in the
safety of hepatic resection observed worldwide in cirrhotic patients.
The guiding principle for hepatectomy in cirrhotic patients is
that limited resections should be favored, with as much function-
al parenchyma spared as possible. In general, even for patients
with well-compensated Child’s grade A cirrhosis, we try to limit
resections to less than two segments of functional liver. Patients
with large tumors are more likely to tolerate a major resection
because little functional parenchyma must be removed along with
the tumor. Major hepatic resections involving removal of at least
one hemiliver are now reported to carry an operative mortality of
less 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 tumors
whose resection would necessitate removal of a large amount of
functional 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-
ACS Surgery: Principles and Practice
23 Hepatic Resection — 14
Figure 16 Illustrated is clamp dissection in prepa-
lar clamp is passed between the vena cava and the
caudate lobe. This clamp is directed at the notch
between the right and middle hepatic veins, which
has been dissected from above. (b) An umbilical
tape is then passed to suspend the plane of
parenchymal transection.
struct the right hepatic vein for the purpose of preserving venous
outflow in segments 5 and 6 after resection of segments 7 and 8.
Operative Technique
Hepatic resection in cirrhotic patients is associated with certain
specific technical difficulties that substantially increase the com-
plexity of the operation. The liver parenchyma is hard, which
makes 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 patients
because of the potential for ascitic leakage externally or into the
chest. The increased firmness of the cirrhotic liver and the conse-
quent difficulty of retraction can lead to significant blood loss from
retroperitoneal or phrenic collateral vessels during mobilization.
To prevent such bleeding, it may be preferable to use an anterior
approach in which the liver parenchyma is split within the princi-
pal scissura down to the anterior surface of the vena cava before
the right hemiliver is mobilized off the retroperitoneum.60 The
right hemiliver is then mobilized in a medial-to-lateral direction,
and the right hepatic vein is secured during mobilization of the
right hemiliver off the vena cava.
Inflow control At one time, it was widely doubted whether
the 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 advisable
to employ the Pringle maneuver sparingly in this population so as
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
to minimize ischemic stress. Our practice is to clamp the portal
triad 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 liver
parenchyma, 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 is
often 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 dissection
are 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 ascending
infections, abdominal drains generally are not used.50 Reports
specifically examining the role of drainage in cirrhotic patients
documented a much lower incidence of postoperative complica-
tions and a shorter hospital stay for patients in whom no drains
were 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 Portal
Hypertension]. In most such patients who undergo hepatic resec-
tion, transient hepatic insufficiency develops postoperatively, with
hyperbilirubinemia, ascites formation, hypoalbuminemia, edema,
and worsening of the baseline coagulopathy.
In the first 24 hours after the procedure, crystalloid must be
administered 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 amounts
of salt-poor albumin for volume expansion if needed.
Spironolactone is started in all patients as soon as oral diet is
resumed, and furosemide is added as needed. On rare occasions,
a peritoneovenous shunt may have to be employed to control
postoperative ascites,93 but this measure is usually unnecessary if
patients were properly selected. The PT is checked twice daily
during the immediate postoperative period; a PT longer than 17
seconds is corrected by administering fresh frozen plasma.
CHEMOTHERAPY-ASSOCIATED STEATOHEPATITIS
One of the most important advances in the treatment of
metastatic colon cancer over the past few years has been the devel-
opment and approval of a number of newer chemotherapeutic
agents, such as irinotecan, oxaliplatin, cetuximab (C225), and
bevacizumab (Avastin). These agents target the cancer cell cycle,
paracrine growth factors, and angiogenic factors, and they have
led to substantial improvements in survival for patients with
hepatic colorectal metastases. They are currently being used not
only to allow effective palliative treatment to be provided in cases
where resection is not feasible but also, by downstaging certain
hepatic tumors, to allow surgical treatment to be provided for a
percentage of patients who were previously thought to have unre-
sectable disease. Consequently, it is now common for patients to
be subjected to a number of chemotherapies before being consid-
ered for hepatectomy.94 Along with the benefits of these advances
in chemotherapy, however, has come the challenge posed by post-
ACS Surgery: Principles and Practice
23 Hepatic Resection — 15
operative management of the hepatic damage that can result from
the 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 be
assumed if hepatic attenuation is found to be lower than splenic
attenuation. Splenomegaly is a sign of portal hypertension, as is
refractory consumptive thrombocytopenia that is not related to
bone marrow suppression and therefore is not corrected even
when chemotherapy is stopped.
When CASH is documented, patients should be selected for
hepatectomy according to the same criteria used for patients with
early cirrhosis. Consideration should also be given to preoperative
portal vein embolization (PVE) (see below) before hepatectomy to
increase the size of the hepatic remnant.
PREOPERATIVE PORTAL VEIN EMBOLIZATION
Most liver surgeons would be reluctant to resect more than the
equivalent of two segments of functional liver in a patient with
documented cirrhosis.97 Consequently, many cirrhotic patients
with technically resectable tumors are relegated to noncurative
ablative 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’ ability
to resect tumor in cirrhotic patients.
In PVE, access to the portal vein on the side of the liver to be
resected is gained via a percutaneous transhepatic approach. The
vein is embolized approximately 1 month before the planned
resection 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 [see
Figure 17] and may modulate postoperative hepatic dysfunction.
PVE is also employed in patients with normal parenchyma in
whom extensive resection may result in a very small hepatic rem-
nant. In patients undergoing right trisectionectomy, particularly
those with congenitally small left lateral sections, the entire area of
the extended right hepatectomy, including the main right portal
vein and the segmental branches supplying segment 4, can be
embolized.99
There is substantial evidence that preoperative PVE can be suc-
cessfully used in patients with cirrhotic livers or impaired hepatic
function and that such use is generally well tolerated.100-103 One
immediate benefit of PVE is that it may act as a kind of stress test
for the liver, allowing preoperative determination of the likelihood
of liver regeneration. If no compensatory hypertrophy is seen 4
weeks after PVE, the decision to perform a major hepatectomy
should be reconsidered.
Repeat Hepatic Resection
Since 1984, when one of the first reports of repeat hepatic
resection was published,104 a number of reports from around the
world have demonstrated that repeat resection can be done safely
and 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 selected
cases, survival is equivalent to or even better than that observed
after initial resection.106,113,120,126 In the following section, we con-
centrate on the key technical aspects of repeat hepatic resection;
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
a b
Figure 17 Liver atrophy and hypertrophy occur after right portal vein embolization. Shown are
images of the liver (a) at baseline and (b) 6 weeks after PVE. The right hemiliver is outlined in white.
discussions of indications, patient selection, and outcome are
available in other sources.106,113,120,126
Repeat hepatic resection poses certain technical difficulties that
are not commonly encountered during initial resection.105,127,128
First, adhesions at the previous line of parenchymal transection
can make reexposure of the liver difficult. Mobilizing the liver off
the vena cava and reexposing the porta hepatis and the hepatic
veins can be extremely hazardous if dissection was previously done
in 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 increases
the difficulties of reexposure and predisposes to tearing of
Glisson’s capsule.127 Third, regeneration alters the normal
anatomic 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 relations
among 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 limits
access to the liver for intraoperative assessment via palpation or
ultrasonography. Before embarking on a repeat resection, it is
essential to know the exact number and locations of the lesions to
be treated within the regenerated parenchyma. Preoperative imag-
ing also facilitates operative planning by accurately delineating the
vasculature 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 chest
may be required for mobilization of the liver because of adherence
of the previous resection margin to the diaphragm, or it may be
required for access to the rotated CBD and portal vasculature at
the porta hepatis.
In the dissection of the right upper quadrant after a previous
right hepatectomy, three landmarks are particularly helpful in
defining the anatomic structures within the regenerated left
hemiliver. The first landmark is the remnants of the ligamentum
teres, which defines the demarcation between the left lateral sec-
tion (segments 2 and 3) and the left medial section (segment 4);
ACS Surgery: Principles and Practice
23 Hepatic Resection — 16
these should be found early on. The ligamentum teres may be
followed to the base of the umbilical fissure to define the loca-
tion of the left hepatic artery.Whether this artery arises from the
common hepatic artery or from the left gastric artery, it passes
into the liver parenchyma at the base of the umbilical fissure.The
second landmark is the caudate lobe. The lesser omentum
should be opened early on to reveal this lobe. An index finger
should then be passed in front of the caudate toward the obliter-
ated foramen of Winslow to define the porta hepatis and the
location of the portal vein. The third landmark is the vena cava.
Performing the Kocher maneuver to mobilize the duodenum off
the vena cava allows this vessel to be dissected, thus further
Left
Right
2+3
4
Hepatic Artery
Portal Vein
Normal
Common Bile Duct
Atrophied/
Hypertrophied
Figure 18 Repeat hepatic resection. Depicted are the changes in
the relations of the portal structures that occur as a result of
right-liver atrophy or resection and left-side hypertrophy. The
structures in the porta hepatis rotate to the right, with the CBD
coming to rest laterally rather than anteriorly.
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
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 the
liver. The hand is the best liver retractor available and can
be used to dissect the parenchyma. The specimen can be
extracted through the hand access port.
defining the portocaval plane. Definition of this plane leads to
the correct plane for dissection and mobilization of the liver off
the 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 main
concern with regard to mobilization of the liver is the anterior
position of the portal vasculature after right-side hypertrophy. It is
therefore prudent to mobilize the right hemiliver, perform a
Kocher maneuver, and follow the vena cava caudally to identify
the portal vein from the right.The stomach and the colon usually
are adherent to the edge of the previous resection and must be
carefully dissected free to allow access to the liver. If the middle
hepatic vein was preserved in the earlier left hepatectomy, it will lie
immediately deep to the plane of the stomach or the colon and
thus 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. If
extensive extrahepatic dissection was performed for control of
inflow 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, Right
Hepatectomy, Step 6—Alternative (Intrahepatic Pedicle
Ligation), above].
A major concern with repeat hepatectomy is that it is some-
times necessary to perform more limited resections than would
otherwise be indicated. Normally, for removal of liver tumors, we
avoid wedge excisions because these nonanatomic resections are
more often associated with greater blood loss and positive margins
than anatomic resections are.112,130 In a repeat hepatectomy, how-
ever, anatomic considerations arising in the regenerated liver may
make a wedge resection the best choice.
With appropriate patient selection and careful operative plan-
ning, very favorable perioperative and long-term results can be
achieved 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
ACS Surgery: Principles and Practice
23 Hepatic Resection — 17
Laparoscopic Hepatic Resection
In addition to revolutionizing treatment of gallstone disease,132
laparoscopic techniques are increasingly used for fenestration of
benign cysts of the liver133,134 and for staging of hepatobiliary
malignancies to prevent unnecessary laparotomies.38,135-137 Until
comparatively recently, however, laparoscopic resection of liver
tumors was described only in case reports or small series.133,138-142
Perhaps the main reason for the strong resistance to laparoscopic
hepatic resection has been fear of catastrophic bleeding. If inad-
vertent damage to a major hepatic vein or the vena cava occurs
during an open operation, the bleeding can be controlled with
direct manual compression until the vessel is repaired; however, if
such damage occurs during a laparoscopic operation, control of
the bleeding is considerably more difficult. In addition, damage to
a hepatic vein or the vena cava during a laparoscopic procedure
can theoretically result in CO2 embolism. Another concern is that
the loss of tactile sensation characteristic of laparoscopic surgery
may lead to inadequate tumor clearance. Finally, whereas there
are many liver retractors designed to hold the liver in one position,
there is no good retractor for repeatedly moving the liver from side
to 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 by
several recent technologic advances, including laparoscopic sta-
plers143 and ultrasonic dissectors,144 which can be used for ligation
of the hepatic vasculature and transection of liver parenchyma.
The most important advance, however, is the hand access port, a
small port through which one hand can be introduced into the
abdomen for a hand-assisted laparoscopic resection [see Figure
19].145-147 With this approach, the surgeon not only regains a mea-
sure of tactile sensation but also is able to employ the best liver
retractor available. Moreover, direct manual compression of any
bleeding vessels is once again possible, and the incision made for
the hand access port is also used for extraction of the resected
specimen.
Appropriate patient selection is essential for safe laparoscopic
resection of liver tumors. Resection of any two segments along the
lower edge of the liver is easily accomplished laparoscopically. At
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
a b
5 mm
5 mm
5 mm 12 mm
12 mm
Figure 20 Shown are the recommended port placements for (a) laparoscopic left lateral sectionectomy
and (b) hand-assisted laparoscopic right hepatectomy.
MSKCC, we have laparoscopically resected lesions from all seg-
ments.47 In the following section, we provide a general overview of
laparoscopic hepatic resection; more in-depth discussions of the
technical aspects of these procedures and the results reported
from 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 body
at a 60° angle and the contralateral arm tucked. The patient is
securely strapped down to allow for rotation of the table. For a
right 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 of
the resection.
A left lateral sectionectomy typically requires the placement of
five ports [see Figure 20a]. Pneumoperitoneum is achieved via an
initial port placed at the umbilicus; to prevent gas embolism during
liver transection, it is maintained at the lowest pressure possible
(typically 10 to 12 mm Hg). Subsequent ports are then placed
along the subcostal line. A second 5–12 mm port is placed at the
intersection of the subcostal and midclavicular lines to permit dis-
section of the triangular ligament, the hepatic vein, and the inferior
vena cava. A third 5–12 mm port is placed between the previous
two ports to permit dissection of the porta hepatis.The fourth 5–12
mm port is placed in the right midclavicular line to permit the
introduction of an endovascular stapler for division of the portal
structures and liver parenchyma.We prefer using 5–12 mm ports in
the beginning, so that the camera and the staplers can be passed
through 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 the
endoscopic GIA stapler.We generally use the 45 mm rotating artic-
ulated stapler loaded with the white 2.5 mm cartridge.
ACS Surgery: Principles and Practice
23 Hepatic Resection — 18
5 mm
12 mm
5 mm 12 mm
5 mm
Hand port
Some situations call for the use of a hand access port, which can
be of great help in several ways. First, the hand access port allows
the surgeon to retract and compress the liver manually if bleeding is
encountered, thereby increasing the overall speed of the procedure.
Second, large resected liver specimens can be removed through the
hand access port, without any need for a separate extraction site.
Third, if intracorporeal suturing is required to manage bleeding or
bile leakage, the surgeon can use the right hand to place the suture
and the left hand, placed through the hand access port, to tie the
knots. A disadvantage of the hand access port, however, is that it
may get in the way of the other trocars, especially in a small patient.
Hence, knowing when and where to place the hand access port
requires a measure of experience. For a left-side resection, the hand
access port should be placed through a transverse incision in the left
upper quadrant [see Figure 19]. For a right-side resection, the port
may be placed in the right lower quadrant [see Figure 20b].
Alternatively, the port may be placed in the upper midline; traction
is 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 on
which 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 site
should be chosen so as to allow manual retraction of the part of
the liver to be resected, with the falciform and triangular ligaments
used 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 retraction
and absorb blood, and a long bulldog clamp is inserted for use in
the Pringle maneuver. A long umbilical tape is tied to the bulldog
clamp beforehand so that the instrument can be easily located
throughout the procedure. Additional ports are then placed as
necessary for introduction of the stapler or the ultrasonic scalpel.
© 2007 WebMD, Inc. All rights reserved.
5 GASTROINTESTINAL TRACT AND ABDOMEN
The area to be resected is outlined with the electrocautery.The
liver is manually retracted, intermittent application of the Pringle
maneuver is initiated, and the parenchyma is transected. Liver
parenchyma remote from the major portal pedicles and hepatic
veins may be transected either with the ultrasonic dissector or by
means of finger fracture. Near the major portal pedicles and
hepatic veins, an endoscopic GIA vascular stapler may be used.
After removal of the specimen, the laparoscopic argon beam coag-
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Acknowledgment
Figures 1, 3 through 15, 18, 19 Tom Moore.
Figure 16 Thom Graves, CMI.