Tricks of the Senior Surgeon

■ In performing the hilar dissection, start on the right lateral aspect when identifying the right portal vein and hepatic artery. This avoids excessive dissection and skeletonization of the right hepatic duct and bile duct.

■ Identification of the biliary anatomy by intraoperative cholangiography should be performed early in the operation. A radiopaque metal clip or small bulldog should be used to mark the area of the right hepatic duct during the cholan-giogram. An atraumatic bulldog can be placed on the distal bile duct to avoid passage of contrast into the lower bile duct.

■ Marking the pathway of the middle hepatic vein by intraoperative ultrasound helps decide the parenchymal transection line, which should be 1 cm to the right of the middle hepatic vein.

■ Central venous pressure should be maintained low by anesthesia as it helps to reduce blood loss.

■ The hanging maneuver makes the parenchymal dissection easier, particularly in the last part.

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