Surgical Anatomy of Liver

Approaches to liver
resection
 Liver : a unique organ

Regeneration

basis of liver surgery

Promatheus punished by his father – greek God Zeus,

for stealing fire and hope and giving to humans
 Liver : a Unique organ
Dual blood supply :

2 Afferent : Portal vein

Hepatic artery
3 Efferent : Hepatic veins

Segmental anatomy :

Each segment has its

Own inflow and outflow
 Segmental Anatomy
Couinaud 1954

“…singularity
of liver is
parting of
afferent and
efferent
vessels; two
independent
distributions
overlapping
according to
definite
rules…”
Peritoneal attachments and ligaments
 Glisson’s Sheath / Capsule

The hilar plate which has to be taken down

(dissect at base of quadrate lobe) to gain access
A fascial condensation in the to pedicles
form of a sheath continuing
intrahepatically.

The 3 elements at the porta

hepatis - the hepatic artery, the
portal vein & the bile duct are
encased within.

.
A paracaval condensation to the right of
the IVC released carefully to access the
right hepatic vein (RHV)

Hepato Caval ligament / Blumgart’s

liagment

Liver rotated to the left & dissection

proceeds from the Rt. triangular
ligament & from the inferior aspect–
without injuring the Rt. adrenal vein

Ligation of small venous tributaries ant.

to IVC
The 3 hepatic veins: locus superior to
expectation…

The liver hangs from these veins

No other major vasculature between

the anterior surface of IVC & the liver

“Liver hanging maneuver”

Reproduced from HPB (Oxford). 2009
June; 11(4): 296–305.
 An independent unit on the ant.
aspect of the IVC ; the caudate
process extends behind the portal triad

Receives independent supply from the

rt. & lt. portal veins

Unique blood flow – independent

drainage through small veins directly
into the IVC

Lies between major vascular

structures
 Principal plane – Cantlies Line from
GB fossa to IVC

Division of Right and Left lobe by middle hepatic veins

 Understanding
segmental anatomy

8
7 3 2

5 4
 Hepatocellular Carcinoma

0 MRI appearance DEPENDS ON-

0 Type of HCC
0 Degree of Fibrosis
0 Amount of Fat/ h’ge / necrosis
0 Hypo on T1W. Hyper on T2W.

0 Post contrast (CT / MRI) :

- Intense early Arterial phase Enhancement.
- Washout in portal venous phase- iso/hypointense
 Triphasic CecT scan

ARTERIAL VENOUS

Early Arterial phase enhancing lesion seen in Right lobe of

liver with washout in porto-venous phase.
ARTERIAL VENOUS
Portal
MR- Dynamic contrast sequences
Hcc: AASLD GUIDELINES
Identifying segments on CT scan

Upper cuts Lower cuts

 2
2
4a 4a
8 3
8
1
7
7

2
4b 3
3 4b
5/8 1
5

6/7
6
 3
4b
5
5

6
6
0

Fig. 2 First-order division. (From Strasberg SM. Nomenclature of hepatic anatomy and resections: a
review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 2005;12(5):354; with permission.)
Fig. 3 Second-order divisions. (From Strasberg SM. Nomenclature of hepatic anatomy and
resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 2005;12(5):354;
with permission.)
0 Fig. 5 Other sectional liver resections. (From Strasberg SM. Nomenclature of
hepatic anatomy and resections: a review of the Brisbane 2000 system. J
Hepatobiliary Pancreat Surg 2005;12(5):355; with permission.)
Type of resections
Non-anatomical

Anatomical / Segmental
oriented Liver resection:
safe resection with complete
tumor clearance with negative
margins
Right Hepatectomy
Right Extended Hepatectomy
Left Hepatectomy
Left Extended Hepatectomy
Median Hepatectomy
Segmental Resections
 Classification according to
Surgical Technique / approach

• Preliminary Vascular Section - Classical

• Primary Parenchymal Transection – the Anterior approach
• Hanging maneuver
• Total Vascular Exclusion
• Pedicular Clamping – Pringle manoeuver
• Glissonian approach / segmental resections
 Hepatectomy with
Preliminary Vascular Section
“Classical Method”
Described by Lortat Jacob & Robert, 1952
Typical Right hepatectomy
First step consists of ligation of glissonial pedicle, f/b ligation of right
hepatic vein before parenchymal transection.

Demarcation due to Unsuitable for bulky tumors in proximity

devascularization to the vena cava/ tumors with
diaphragmatic invasion
Reduced blood loss
Risk of injury to hepatic vein
Congestion due to outflow obstruction
 Hepatectomy with
Primary Parenchymal Transection
“Anterior approach”

Described by Ton That Tung, 1963

Ozawa, 1990
The technique is to begin with incision of
parenchyma along the line of the scissura
Hilar elements are dissected and ligated
intraparenchymally during transection.
Section of hepatic vein is performed at the
end
To avoid rotation & displacement of lobes
which impair circulation (Ozawa)

It excises an amount of parenchyma Lack of preliminary vascular control

‘a la demande’
Ligation of vessels not hampered by Increased blood loss
anatomic abnormalities
 Hepatectomy with Hanging
Maneuver
Described by Jacques Belghiti, 2001

The liver is lifted by a tape passed between

the anterior surface of vena cava and liver

Existence of a longitudinal avascular plane

between the IVC and liver makes this
maneuver feasible

Classical and Modified techniques

Makes anterior approach easier and
safer
Protects IVC
Vertical transection along the
shortest possible route
Unsuitable when the avascular plane is
infiltrated
Relative C/I : Cirrhosis, diaphragmatic
infiltration, large tumors
 Hepatectomy with
Total Vascular Exclusion

• Described by Heaney & Jacobson

• First, the liver has to be mobilized fully
• Total vascular exclusion is achieved by
clamping the portal pedicle and the
vena cava, above and below the liver.
• Normal liver parenchyma can tolerate
devascularization for 60 to 90 min

Anatomic margins are not visible, especially for extended hepatectomies

Injury to hepatic vein or retrohepatic vena cava can go unnoticed until

perfusion is re-established.
 Hepatectomy with
Glissonian approach
Described by Ken Takasaki, 1986
First, detachment of primary Glissonian pedicle from
liver parenchyma at the hilum
Selective clamping of the segmental branches to
achieve demarcation/devascularisation of affected
segments

Superselective segmental pedicle clamping feasible

Limits ischemia to the remnant liver ( specially in cirrhotics)

 Hepatectomy with
Pedicular Clamping
Described by Pringle, 1908

Interrupts all inflow to the liver but leaves

intact the outflow

In healthy, noncirrhotic liver, intermittent

clamping upto 15 min are well tolerated.

In cirrhotics, alternating cycles of 10 min

clamping and 5 min declamping.

Vascular control Ischemia to normal liver

Reduced blood loss Impaired hepatic function

The role of vascular occlusion techniques
J. Hogart Pringle described the technique nearly 100 years ago

Cochrane review (2009): 10 trials - 657 patients

No statistically significant differences in mortality, liver failure, or other
morbidity between any of the comparisons

Total vascular occlusion Portal triad clamping (inflow only)

Complete Selective (side to be resected only)
Continuous Intermittent
Ischemic preconditioning No preconditioning
Level 1 evidence - the routine use of Pringle maneuver does not offer any
benefit in perioperative outcome after liver resection.
Cannot be recommended as a standard procedure
Rahbari et al. Br J Surg 2008 (Metaanalysis : 8 RCTs – 558 patients)

Vascular occlusion techniques still have a role - should be used for

excessive blood loss during liver mobilisation and transection
 VASCULAR CONTROL
Portal Triad Clamping (PTC)
V/S Hemi-hepatic vascular exclusionexclusion
Hemihepatic vascular inflow occlusion
Right H D

Right Portal Vein

PTC

Right hepatic
Artery

Ligated Cystic Duct

 Extra capsular excision of
haemangioma
The space between the liver and
the hemangioma is an avascular
plane consisting of liver tissue
compressed by the growing
hemangioma.

No bile ducts and only a few blood

vessels traverse the capsule, and
these are easily controlled.

The amount of normal functioning

liver parenchyma removed is also
minimal
Minimal Invasive Approach

Laparoscopic hepatectomy

Robotic hepatectomy
 Laparoscopic Liver Resection
• Associated with long learning curve
• Patient selection, Careful planning is most important

The International Position on Laparoscopic Liver

Surgery – The Louisville Statement, 2008

Acceptable indications for laparoscopic liver resection

Solitary lesions, < 5 cm, site- seg 2 to 6.

Laparoscopic left lateral sectionectomy should be

considered standard practice
Annals of Surgery April 2015
 Principal Hazards of Liver resection

International Study Group for Liver Surgery (ISGLS) recognises

following as major complications affecting outcomes:

1 Haemorrhage

2 Bile Leak

3 Post Hepatectomy Liver Failure (PHLF)

Careful patient selection and correct operative appraoch is

imperative for better outcomes.

Rahbari et al, ISGLS, Surgery 2011

Digestive Surgery, 2012
Belghiti et al, annals of surgery, 2005
Parenchymal transection
Vascular Control :
Inflow and Outflow control

Dissection techniques and devices :

Finger-fracture method – historica2l
Clamp crushing / kelly–clysis
Ultrasonic dissection - CUSA
Hydro-jet dissection
Energy devices – Harmonic/Ligasure/Thunderbeat
Radiofrequency ablation-based devices (Habib knife)
Vascular staplers

In Absence of clear advantage of one device over another, Personal

preference and local availability are the main factors determining the
use of a device for transection.
Techniques for liver parenchymal transection in liver resection (Review) i
Copyright © 2009 The Cochrane Collaboration.
 Take Home Message

All approaches have their advantages and

disadvantages

Tailored approach best suited for individual patient and

tumour

May combine more than one approach for effective and

safe surgery.