Extended Left Hemihepatectomy Left Trisectionectomy

The extended left hemihepatectomy includes resection of segments 2,3,4,5 and 8.

This procedure should only be performed if the remnant liver (segments 1/9+6+7) provides sufficient liver function. Preoperative assessment of liver function, volumetric evaluation of the expected remnant liver volume and exclusion of liver fibrosis or even cirrhosis are essential.

Depending on the vascular anatomy, two different approaches can be used for the anatomic resection of segments 5 and 8 in addition to the left liver. The classical anatomic resection of segments 5 and 8 is performed by selective ligation of the pedicle to these segments prior to tissue transsection. Alternatively, tissue transsection can be performed with ligation of the pedicle to segments 5 and 8 during parenchymal transsection. Here, we describe the classical approach of resection. STEPS 1-7 are the same as for a left hemihepatectomy.

To prepare an extended left hemihepatectomy, the right liver must be mobilized as for a formal right hemihepatectomy including the division of the short hepatic veins (see chapter "Right Hemihepatectomy").

Liver Segments Right Left

STEP 8 Selective ligation of the pedicle to segments 5 and 8

The pedicle to segments 5 and 8 (right anterior pedicle) is identified by careful blunt dissection on the right portal sheath. The vessels are selectively ligated, while the right posterior pedicle needs to be preserved. For tumors involving the right portal sheath, the anterior pedicle should not be dissected in the hilum, but ligated during tissue transsection. Intraoperative ultrasound is a helpful tool to define the exact extent of the lesion and to identify vascular anatomy.

Hepatic Veins Anatomy

STEP 9 Exposure of the left and middle hepatic vein

The middle and left hepatic veins, which usually share a common trunk, are isolated by careful dissection from above and marked with a rubber band for later dissection, while the right hepatic vein is identified and preserved.

Staple Ligation Right Hepatic Vein

STEP 10 Parenchymal transsection

The resection is performed along the demarcation line, which can be seen after ligation of the pedicles to segments 5 and 8. Stay sutures allowing gentle traction are placed on each side of the demarcation. If the pedicle cannot be ligated first, the plane of transsection is about 1 cm to the left of the right hepatic vein as defined by intraoperative ultrasound.

Particular attention must be paid to the right hepatic vein and its course needs to be known during the whole period of tissue transsection. The left bile duct and the bile duct to segments 5 and 8 can be safely ligated at the end of parenchyma dissection.

Hepatic Trisectionectomy

STEP 11 Ligation and transsection of the left and middle hepatic veins

At the end of tissue transsection, the left and middle hepatic veins are transsected by means of a vascular stapler and the resected part is removed, leaving segments 6 and 7 and the caudate lobe. In addition to this formal extended left hemihepatectomy, the caudate lobe can be approached and resected en bloc, if needed (see Section 4).

Extended Left Hemihepatectomy

Tricks of the Senior Surgeon

■ Extended hemihepatectomies are typically performed for large tumors partially invading segment 4 (extended right hemihepatectomy) or segments 5/8 (extended left hemihepatectomy) or hilar cholangiocarcinoma. In these cases, we do not selectively ligate the pedicles to segments 4 or 5 and 8, respectively, but rather perform a formal hemihepatectomy and extend the resection margin into the contralateral liver (extended wedge resection). This approach may spare liver parenchyma and operative time.

■ In the case of tumor involvement of the hilum, dissection and selective ligation of segmental pedicles should be performed during tissue transsection.

■ Similarly, in some situations preparation and transsection of the hepatic veins may prove difficult. Two strategies should be considered:

- Transsection of the hepatic veins during parenchymal transsection without previous isolation.

- Total vascular exclusion (TVE).

■ Portal vein embolization with delayed hepatectomy (about 4weeks) should be considered prior to resection, if the remnant liver is judged too small.

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