Left Lateral Liver Segmentectomy

1. Abdominal cavity approach

Substep Structure Actions Specification

1A Skin Mark Mark the skin in a curvilinear fashion, starting left lateral and extending to right paramedian, at
least 2.5 cm below the costal arch.

Incise Incise the skin following the marking. The incision can be extended to the right lateral side if
necessary.

1B Subcutaneous tissue Incise Incise the subcutaneous tissue in the same direction as the skin until the anterior rectus sheath is
reached.

1C Anterior rectus sheath Incise Incise the anterior rectus sheath along the length of the skin incision.

HAZARD: Distance from costal arch

While opening the anterior rectus sheath, one should keep at least 2.5 centimetres distance from
the costal margin, in order to be able to close the fascia again.

1D Rectus abdominis muscle Transect Transect the rectus abdominis muscle completely on the left and partially on the right side.

HAZARD: Superior epigastric vessels injury

During the rectus muscle transection, it is important to identify and transect the superior
epigastric artery and vein, which run through the rectus abdominis muscles, in order to avoid
postoperative hemorrhage.

1E Linea alba Incise Incise the linea alba, which is comprised of the merged anterior and posterior rectus sheaths.

1F Posterior rectus sheath Incise Incise the posterior rectus sheath and underlying peritoneum, using a clamp to protect the
underlying tissue and organs.

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2. Liver exposure

Substep Structure Actions Specification

2A Round ligament of the liver Transect Transect the round ligament as distally as possible, as it may form a route for metastasis from
the liver.

2B Falciform ligament Transect The falciform ligament is transected along the anterior abdominal wall.

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3. Liver mobilization

Substep Structure Actions Specification

3A Liver Inspect Inspect the liver for any lesions, by bimanual palpation.

TIP: Intraoperative ultrasound

Intraoperative ultrasonography can be performed to identify undetected lesions and vascular or
biliary anomalies. These anomalies can be found in almost 50% of patients.

3B Falciform ligament Transect Transect the falciform ligament along the diaphragm and the posterior side of the abdominal
wall, until the inferior vena cava is reached.

3C Triangular ligament Transect Transect the left triangular ligament between the diaphragm and the left lateral liver segment
horizontally.

TIP: Triangular ligament ligation

The left triangular ligament often contains small blood vessels. In order to prevent excessive
bleeding, following transection of the ligament, it is advised to ligate it.

HAZARD: Accessory left hepatic artery and phrenic vessels injury

Care should be taken not to injure the accessory left hepatic artery and phrenic vessels that
could be present inside the lesser omentum and on the medial portion of the left triangular
ligament, respectively.

3D Liver Retract Retract the liver cranially for a better exposure of the area posterior to the liver.

3E Lesser omentum Incise Incise the lesser omentum in the pars flaccidum which is the transparent part of the omentum.

3F Caudate lobe Inspect Inspect the caudate lobe and the celiac trunk for any additional lesions.

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4. Inflow control

Substep Structure Actions Specification

4A Hepatoduodenal ligament Encircle Encircle the hepatoduodenal ligament with a silicon sling as a preparation for the Pringle
maneuver.

TIP: Pringle maneuver

In the event of bleeding during the segmental inflow control step or parenchyma transection,
acute, temporary hemostasis can be achieved by retracting the hepatoduodenal ligament with
the silicon sling and placing a coated clamp over the ligament and vessels.

Examine Examine the ligament and surrounding tissue by palpation for enlarged lymph nodes. Any
encountered lymph nodes can be excised for pathological analysis.

4B Falciform ligament Retract Retract the falciform ligament to expose the bridge of liver tissue between the left lateral
segments (II and III) and the fourth and the umbilical fissure.

4C Umbilical fissure Incise Incise the umbilical fissure on the left lateral side, by extending the previous made opening in the
falciform ligament.

4D Segmental branches Isolate Isolate segmental arterial, portal and biliary branches to segment II and III, during opening of the
umbilical fissure.

Transect Transect all these segmental branches to segment II and III to stop the arterial and portal inflow
to segment 2 and 3.

TIP: Demarcation segment II and III

After transecting all the segmental arterial and portal branches to segments II and III, the
parenchyma corresponding with these segments will become ischemic and a clear color
demarcation will be visible. This indicates the parenchyma transection margin.

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5. Liver transection

Substep Structure Actions Specification

5A Liver Mark Mark the transection margin using electrocautery. The border follows the color demarcation and
usually extends from the left hepatic vein cranially, to the round ligament caudally.

5B Left hepatic vein Identify Identify the left hepatic vein, which is the leftmost vein of the venous trunk cranioposterior to the
left liver lobe.

TIP: Vascular anomalies

Most frequently seen is that the left and middle hepatic vein join together prior to inserting into
the inferior vena cava. Note, sometimes the middle hepatic vein has a separate insertion into the
inferior vena cava.

TIP: Identication of the left hepatic vein

If the left hepatic vein cannot be identified, first transect the liver parenchyma carefully until the
vein can be located and be identified.

Encircle Encircle the left hepatic vein with a vessel loop.

5C Liver Transect Transect the parenchyma from caudal to cranial, while maintaining hemostasis. The
crush-clamp technique can be used to easily transect the parenchyma, while leaving the crossing
vessels and bile ducts intact. These vessels and ducts are transected separately.

5D Left hepatic vein Transect Transect the previously identified left hepatic vein, after complete inflow control in order to
prevent congestion of segment II and III.

5E Liver segments II and III Remove Remove the specimen from the body and send it in for pathological analysis.

5F Left hepatic vein Close Close the left hepatic vein.

5G Liver Inspect Inspect the resection plane of the remaining part of the liver for hemostasis and biliary leakage.

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5. Liver transection

Substep Structure Actions Specification

TIP: Achieving hemostasis

To achieve hemostasis of the resection plan, various techniques can be used, such as closing the
falciform ligament over the plane, an omental interposition, or the use of fibrin spray or fibrin
containing patches.

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6. Abdominal wall closure

Substep Structure Actions Specification

6A Posterior rectus sheath Close Close the posterior rectus sheath with a continuous suture and close the linea alba in the same
layer.

TIP: Operating table adjustment

During abdominal closure, the operating table can be placed back in neutral or in a slightly
anteflexion-bended position.

6B Anterior rectus sheath Close Close the anterior rectus sheath, thereby approximating both ends of the transected rectus
abdominis muscle, with a continuous suture.

6C Skin Close Close the skin, using a continuous suture.

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