The standard three-dimensional anatomy of Sg8 is shown below.
The portal venous branches in Sg8 consist of two main branches, i. e., the dorsal branch (P8dor) and the ventral branch (P8vent), in 92% of patients. P8vent and one to three branches of Segment 5 (P5) form a trunk in 62 % of patients. Between P8vent and P8dor, a thick branch of the middle hepatic vein (MHV) runs and drains Segment 8 (V8).
STEP 1 Access and identification of Sg8
A J-shaped thoracoabdominal incision is made entering via the 9th intercostal space. Using the operator's left hand, the right liver is easily lifted together with the diaphragm, and a wide surgical field for the right liver is obtained (A).
Under hepatic arterial occlusion with a soft jaw clamp, P8vent and P8dor are punctured with a 22G needle using intraoperative ultrasound. Approximately 5 ml of indigo carmine is slowly injected into each vessel (B). The liver surface of Sg8 is stained blue and the border is marked with electrocautery. Cholecystectomy and hilar dissection are performed when hemihepatic vascular occlusion is applied during hepatic parenchymal transection. No hilar dissection is needed when Pringle's maneuver is applied.
STEP 2 Hepatic parenchymal transection along the main portal fissure
Using a curved forceps, hepatic parenchymal transection begins along the main portal fissure following the burned mark on the liver surface (A).
The trunk of the MHV is exposed and its tributaries draining Segment 8 are carefully ligated and divided (B).
STEP 3 Division of the portal pedicles for Segment 8
The intersegmental plane between Sg8 and Sg5 is divided and the portal pedicle for the ventral part of Sg8 (P8vent) is isolated and divided. The dorsal portal pedicle (P8dor) is then ligated and divided. Hepatic parenchymal transection along the right portal fissure is done and the right hepatic vein (RHV) is exposed.
STEP 4 Exposure of RHV trunk
The root of the RHV is exposed and a thick venous tributary draining Sg8 is divided. The specimen can now be removed and the procedure is completed with careful hemo-stasis and suture-ligation of bile leaks. After removal of Segment 8, landmarks including MHV, RHV, and stumps of P8vent and P8dor are exposed.
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