clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Left Hemihepatectomy

Panco Georgiev, Pierre-Alain Clavien

Procedure

STEP 1

Access and mobilization of the left hemiliver

The abdomen is opened through a subcostal incision and the round and falciform liga-

ments are divided. The left hemiliver is mobilized by dividing the left triangular and

coronary ligament (A). Once the left hemiliver is mobilized, the liver can be evaluated by

ultrasound. After confirmation of the resectability, the Pringle maneuver is prepared for

by opening the hepatogastric ligament as shown in the chapter “Techniques of Vascular

Exclusion and Caval Resection.”At this point an aberrant left hepatic artery can be

isolated for later clamping with a bulldog clamp.

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SECTION 3

Liver

STEP 1 (continued)

Access and mobilization of the left hemiliver

In contrast to the right side, the anterior and posterior leafs of the left coronary liga-

ments are attached to each other and separated close to the cava. The ligaments can

be divided easily by electrocautery while the posterior structures (spleen, stomach,

esophagus) are protected with a wet gauze swab (or a finger) placed behind the

ligament (B). Alternatively, the ligament can be divided over a right-angle clamp.

Left Hemihepatectomy

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STEP 2

Opening of the hepatoduodenal ligament

A cholecystectomy is usually performed, although not necessary. Next, the hepatoduo-

denal ligament is opened from the left by means of a Kelly clamp and electocautery as

illustrated. The common bile duct, the artery and the portal vein are visualized without

any attempt to secure the left hepatic duct.

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Liver

STEP 3

Identification and disconnection of the arterial blood supply to the left hemiliver

Left Hemihepatectomy

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STEP 4

Preparation and ligation of the left portal vein

As the left portal vein typically is situated behind the left branch of the hepatic artery it

is easily identified. Following convincing identification of the bifurcation, the left portal

vein should be freed from the adventitional tissue and the short branch to Sg1 on the

back-left side is divided between ties. The vein can now be ligated with a 1-0 silk suture

on both sides. The distance to the bifurcation should be at least 5mm to avoid stenosis

of the remaining right portal vein. Suture ligation with 5-0 Prolene or transsection by

means of a vascular stapler are alternatives to a simple ligation (illustrated in the

chapter “Right Hemihepatectomy”).

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Liver

STEP 5

Dissection of the Arantius’ ligament and exposure of the left hepatic vein

Left Hemihepatectomy

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STEP 6

Dissection of the liver parenchyma

As the blood supply to the left hemiliver is now interrupted, a clear demarcation

between the left and the right hemiliver is seen and identifies the line of resection along

the main portal plane. Two stay sutures (2-0 silk) are placed at the inferior margin of the

liver, one on each side of the demarcation line. At this point, verify that CVP is low

(below 3mmHg). The liver capsule is incised with diathermy a few millimeters on the

ischemic side. The Pringle maneuver for intermittent or continued inflow occlusion is

used as needed. The dissection starts on the inferior margin of the liver and is continued

first on the caudate lobe, then right onto the surface of the vena cava. During the

parenchyma dissection, care must be taken to protect the mid hepatic vein. The left bile

duct is isolated and carefully ligated within the parenchyma.

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Liver

STEP 7

Transsection of the left hepatic vein

Left Hemihepatectomy

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STEP 8

Situs at the end of the left hemihepatectomy with preservation of segment 1

A gauze swab is placed on the resection surface and a slight compression is maintained

for a few minutes or longer in the case of diffuse bleeding. Each instance of bleeding on

the cut surface should be suture-ligated. At the end of the procedure, the gauze swab is

removed and inspected carefully. Any bile leaks (yellow spots on the gauze swab) are

oversewn by PDS 4-0 or 5-0. Some groups routinely inject methylene blue into the

common bile duct to identify bile leaks.

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Liver

Tricks of the Senior Surgeon